How to achieve hemostasis after incision and drainage?

Achieving Hemostasis After Incision and Drainage

Direct pressure should be the primary method for achieving hemostasis after incision and drainage, with hemostatic dressings added when standard pressure techniques are insufficient to control bleeding. 1

Primary Hemostasis Techniques

Direct Pressure

• Apply firm, direct manual pressure over the bleeding area for at least 5 minutes 1
• Use sterile gauze pads to absorb blood while applying pressure
• Maintain pressure continuously until bleeding stops
• For persistent bleeding, continue pressure for up to 15 minutes 2

Pressure Dressings

• After achieving initial hemostasis with direct pressure, apply an elastic adhesive bandage over gauze pads 1
• Ensure the dressing is tight enough to maintain pressure but not restrictive enough to compromise circulation
• Avoid circumferential tight bandages around the neck, thorax, or abdomen as they may restrict breathing 3

Advanced Hemostasis Techniques

Hemostatic Dressings

When direct pressure is insufficient to control bleeding:

1. Indications for use:

   • Severe bleeding not controlled by standard pressure techniques 1
   • Bleeding in areas where tourniquets cannot be applied 1

2. Application technique:

   • Clean the wound area with gauze to remove excess blood
   • Apply the hemostatic dressing directly to the bleeding source
   • Maintain direct pressure over the dressing for at least 3-5 minutes 1
   • Complete cessation of bleeding can be achieved in most cases within 5 minutes 1

3. Types of hemostatic dressings:

   • Chitosan-coated gauze dressings have shown efficacy in achieving hemostasis within 5 minutes in 51.2% of cases compared to 32.5% with standard pressure dressings 1
   • Various commercial products are available with different active ingredients (collagen, cellulose, etc.)

Chemical Hemostatic Agents

• Ferric subsulfate solution (styptic): Apply to wound after wiping with gauze, while maintaining tension on the skin for approximately 15 seconds 2
• Typically achieves hemostasis in less than 20 seconds for dermal wounds 2

Special Considerations

For Larger Wounds

• Consider wound packing only if necessary for hemostasis
• Evidence suggests that many subcutaneous abscesses can be effectively managed without packing 4
• If packing is used, it can typically be removed after 24 hours 4

For Persistent Bleeding

• Consider negative pressure wound therapy (NPWT) for complex wounds or hematomas
• NPWT has been shown to decrease drainage time (1.6 days vs 3.1 days with standard dressings) 5

Pitfalls and Caveats

1. Avoid ice or ice water for cooling any associated burns as this may increase tissue damage 1

2. Avoid excessive pressure that could compromise circulation to the area

3. Monitor for complications of hemostatic dressings, which occur in approximately 3% of cases 1

4. Be aware of potential allergic reactions to hemostatic agents containing porcine or bovine constituents 6

5. Do not rely on pressure points (indirect pressure) as there is evidence against their effectiveness 1

By following this algorithmic approach to achieving hemostasis after incision and drainage, you can effectively control bleeding while minimizing complications and promoting optimal wound healing.