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Open wound management for treatment of

postoperative infections in eight dogs
Michael S. Bauer, Audrey M. Remedios and Bryden J. Stanley
Postoperative infections are major contributing factors to increased morbidity, prolonged hospitalization, added expense, and surgical failures. Treatment
options include systemic antibiotics alone, surgical
debridement and primary or delayed primary closure,
various drainage techniques, and open wound management followed by secondary closure or second intention healing (1,2). Management is based on clinical
judgement regarding the severity of infection, condition of tissues, presence of foreign materials, and failure of response to less aggressive management. Not
all infected wounds require open management, but
when indicated, benefits include optimal drainage, and
daily inspection, debridement and lavage of the tissues.
The eight dogs in this case series were treated at the
Western College of Veterinary Medicine (WCVM)
between September 1986 and April 1988 (Table 1).
Postoperative infections developed either while
hospitalized at WCVM or while animals were under
the care of a referring veterinarian. Six infections
developed following orthopedic surgery, one followed
delayed primary closure of a soft tissue wound, and
one followed jejunal resection and anastomosis.
Wound management following diagnosis of infection
was similar in all dogs.
Dog 1 developed an infection of the left stifle joint
and surrounding soft tissues two months following
extracapsular repair of a ruptured cranial cruciate ligament. Number 5 polyester fiber suture (American
Cyanamid Co., Pearl River, New York) had been used
to perform a lateral retinacular imbrication. A draining tract and local swelling had been unsuccessfully
treated with systemic antibiotics for one month by the
referring veterinarian. Initial management at WCVM
consisted of removal of the suture material, surgical
debridement, bacterial culture, antibiotic sensitivity determination, and open wound management. The
infection extended into the joint
Dog 2 sustained a distal femoral fracture which was
repaired using a 6-hole, 3.5 mm bone plate one year
prior to the development of a draining tract. Systemic
antibiotics, given for one month, were unsuccessful in
decreasing drainage. The dog subsequently developed
an acute nonweight bearing lameness and was referred.
Can Vet J 1989; 30: 46-49

Department of Veterinary Anesthesiology, Radiology and

Surgery, Western College of Veterinary Medicine, University of Saskatchewan, Saskatoon, Saskatchewan S7N OWO.
46

Radiography revealed a midshaft femoral fracture at

the proximal end of the plate and osteolysis around
the proximal screw. The plate was removed and tissue
and screws were submitted for bacterial culture and
antibiotic sensitivity determination. The fracture was
repaired using a 10-hole, 3.5 mm bone plate. Cefazolin
(30 mg/kg, tid, IV) (Eli Lilly Inc., Toronto, Ontario)
was administered after harvesting the tissue and
implant for culture. Eight days after surgery, the incision site appeared grossly infected.
Dog 3 sustained a 12 cm laceration in the left flank
which was treated as an open wound for two days
followed by delayed primary closure. The wound
appeared infected on the sixth postoperative day.
The remaining five dogs developed infections following routine surgical procedures (Table 1).

I'igure 1. Lavage of an open wound of the left lateral thigh

with tap water using a sterile hand-held nozzle (case 8).
The dog is in right lateral recumbency. S: Stifle.
Wound management was similar in all dogs. As
soon as infection was suspected, material for culture
was obtained by fine needle aspiration or by swabbing
of purulent discharge. Appropriate systemic antibiotics, based on sensitivity studies, were begun (Table 1).
Under general anesthesia, each wound was opened and
lavaged using a sterile hand-held spray nozzle that
delivered warm (20-25C) tap water at a pressure of
1-2 psi (6.9-13.8 kPa) and volume of approximately
2 L/min. The procedure was performed in an operating room equipped with a surgery table that drained
into a sink (Figure 1). Following an initial 10-30 min
lavage period, remaining debris and necrotic-appearing
tissues were excised. The wounds were bandaged with
Can Vet J Volume 30, January 1989

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wet-to-dry dressings (3) using sterile gauzes and

0.05% chiorhexidine (Ayerst Laboratories, Montreal,
Quebec) covered by cotton, gauze and tape. Orthopedic
stockinettes, tied over the animal's back, were used
to secure dressings involving the limbs. In areas not
suitable for application of secure bandages, 2-0 nylon
(Cyanamid Canada Inc., Montreal, Quebec) was used
to construct numerous looped eyelets around the
defect. Gauze sponges were held in place with umbilical
tape laced through the eyelets (Figure 2). Collars were
used to prevent self mutilation. Bandages were
changed daily and the wounds lavaged for 5-20 min
as previously described. Intravenous oxymorphone

(0.1I mg/kg, IV) (Dupont Pharmaceuticals, Dupont

Canada Inc., Mississauga, Ontario) was used for
analgesia and restraint for the initial bandage changes.
All wounds healed completely. Two wounds (cases 3
and 5) healed by second intention. Each wound began
to produce granulation tissue after 3-5 days of manCan Vet J Volume 30, January 1989

agement. The wounds allowed to heal by second intention were covered with healthy granulation tissue
after six days and completely closed within 30 days.
In case 3, the wound healed by second intention and
the dog had decreased range of motion in the left
coxofemoral joint due to wound contraction.
The remaining six wounds were closed 6-9 days
after the onset of open wound management. In each
case, granulation tissue covered the wound and
necrotic-appearing tissue was absent. There was
no growth on routine (cases 2,6,7) or quantitative
(cases 1,8) bacterial cultures prior to closure. Four
of six wounds treated by secondary closure healed
without additional complication or treatments. The
distal 2 cm of one wound (case 1) dehisced. Antibiotics
were continued and the defect healed by second intention in 14 days. One dog (case 2) developed a small
subcutaneous abscess containing Pseudomonas
aeruginosa, and was successfully treated with systemic
47

:?-

Figure 2. A dressing over the open wound in case 8 held

securely by use of umbilical tape laced through preplaced
nylon eyelets.

gentamicin (2 mg/kg, tid, IM) (Schering Canada Inc.,

Pointe Claire, Quebec). This animal had been treated
with a closed suction drain at the time of closure.
The drain was left in place for five days and gentamicin
was given for ten days.
Successful management of wound infection is
dependent on decreasing the bacterial load within the
wound and providing an optimal environment for host
resistance (4). Bacterial load can be decreased with
appropriate systemic antibiotics, wound lavage and
continual drainage (4). Host defenses are dependent
on systemic as well as local wound factors. Systemic
host defense mechanisms can be optimized by managing such factors as hypovolemia, hypoproteinemia,
malnutrition, or diabetes mellitus. Enhancement of
local host resistance consists of removing foreign
debris, necrotic tissue and establishing drainage (1,4).
The decision to use open wound management instead
of drains or medical management alone in our dogs
was based on clinical judgement involving the severity
of infection, presence of existing foreign material,
presence of necrotic tissues, and lack of response to
less aggressive treatment. Chlorhexidine was chosen
for the wet-to-dry dressing because of its bactericidal
and nonirritating properties (5). Saline or tap water
might have been equally effective.
Wound lavage is effective in removing bacteria and
infection-promoting debris (1,2,4). A multitude of
lavage solutions and delivery systems exist (1,2,4-8).
An ideal lavage solution is sterile, isotonic and
isosmotic (2). Tap water does not meet these requirements. However, we felt the potential benefits and
48

higure

3. Healthy appearing granulation tissue seven days

following open wound management with tap water lavage
(case 8).

positive clinical results at our hospital, outweighed

the facts that tap water is hypotonic and nonsterile.
Tap water effectively reduces surface bacterial numbers, removes debris, and is minimally irritating to
tissues (7,8). The use of tap water lavage as a solution
is convenient and inexpensive, and the use of large
volumes is practical.
High pressure (25-60 psi) versus low pressure (0.510 psi) lavage has been investigated (6,8-10). The
speculation that high pressure lavage may drive
bacteria into deeper tissue has been disproven (6).
However, high pressure lavage may cause tissue
damage resulting in infection (6). High pressure wound
lavage has been shown to be more effective in decreasing bacterial numbers than low pressure lavage (8-10).
However, these investigations involved single lavage
of experimentally infected wounds with immediate
closure (8,10). One advantage of open wound management was daily lavage. The effectiveness and ideal
pressure for repeated lavage has not been established.
Single, low pressure lavage decreases soil material
Can Vet J Volume 30, January 1989

capable of promoting infection by up to 48Wo (10).

The number of bacteria removed is proportional to
lavage volume (1,1 1). We hoped to decrease bacterial
load and remove exudate and debris on a daily basis
using multiple, low pressure, large-volume lavage.
Low pressure lavage was selected for two reasons.
High pressure lavage systems deliver a small stream
making lavage of massive wounds impractical, and,
because of the apparent pain associated with high
pressure lavage, general anesthesia is usually required.
Using low pressure, we were able to lavage large
wounds by initially using narcotics for analgesia, and
found that dogs tolerated lavage without any analgesic
on subsequent sessions.
The development of nosocomial infection during
open wound management was a potential complication. However by using sterile techniques during lavage
and bandage changes, adequately securing the bandages, and promoting drainage and host defence mechanisms, nosocomial infection was avoided in seven of
eight cases. The only dog in our study that developed
an infection following secondary closure was treated
by use of a drain; the drain may have provided a route
for bacteria to ascend.

Open wound management is an effective

method of treating selected postoperative
infections
Closure options following open wound management
include delayed primary closure, secondary closure,
and second intention healing (1,2). Delayed primary
closure is usually performed within five days of
wounding and precedes the development of granulation tissue (2). We believe this type of closure is usually
inappropriate and may have led to postoperative infection in case 3. Secondary closure usually is performed
after five days, once necrotic-appearing tissue is absent
and granulation tissue develops (2). Second intention
healing involves formation of granulation tissue,
epithelialization and contraction without surgical
closure (2).
The closure technique chosen in our dogs was based
on owner compliance, appearance of the wound, and
bacterial cultures (five dogs). Secondary closure was
used in six of eight cases. Healthy appearing granulation tissue was present in each case. Bacteria were not
isolated from routine (three cases) or quantitative
cultures (two cases) obtained prior to closure. Quantitative bacterial cultures are advocated prior to wound
closure in people (4). Our lab requires 1 cm3 of tissue

Can Vet J Volume 30, January 1989

which is often impractical or impossible to harvest

from canine wounds. In our series we used bacterial
cultures as an ancillary test once we felt closure was
indicated. Quantitative bacterial cultures were not performed in all dogs because of insufficient amounts of
tissue. Visual inspection and clinical judgement, based
on the presence of healthy appearing granulation tissue
and absence of necrotic-appearing tissue, appear to be
accurate indications for safe closure.
Two wounds were left to heal by second intention
because of lack of owner compliance (case 3) and to
avoid a second general anesthetic in a dog with a
rapidly closing wound (case 5). Wound contraction
may result in disfigurement or, as demonstrated in
case 3, decreased limb mobility (2). In retrospect,
secondary closure would have been an appropriate
alternative to second intention healing.
In summary, open wound management is an effective method of treating selected postoperative infections. We felt that wound lavage was an important
aspect of treatment; however, controlled studies are
needed to compare the effectiveness of multiple, low
pressure tap water lavage to other treatment
Cvi
modalities.

References
1. Swaim SF. Surgery of Traumatized Skin: Management and
Reconstruction in the Dog and Cat. Philadelphia: WB Saunders
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2. Daly WR. Wound infection. In: Slatter DH, ed. Textbook of
Small Animal Surgery. Philadelphia: WB Saunders Co., 1985:
37-51.
3. Swaim SF, Wilhalf D. The physics, physiology, and chemistry
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4. Tobin GR. Closure of contaminated wounds. Symposium on
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