How often should packing be changed in a wound?

Wound Packing Change Frequency

For most wounds after incision and drainage, avoid traditional packing entirely—use only an external absorbent dressing or a drain that exits to an external dressing, eliminating the need for any packing changes. 1, 2, 3

Evidence Against Routine Packing

The World Society of Emergency Surgery (WSES) and Infectious Diseases Society of America (IDSA) guidelines explicitly state that traditional wound packing provides no therapeutic benefit while causing significant patient pain and increased healthcare costs without improving healing time, recurrence rates, or fistula prevention. 1, 2, 3

• A Cochrane review found it unclear whether packing influences healing time, wound pain, fistula development, or abscess recurrence. 1
• A multicenter observational study of 141 patients concluded that packing is costly, painful, and adds no benefit to the healing process. 1, 2
• Recurrence rates remain high (15-44%) regardless of packing status—inadequate initial drainage, not absence of packing, is the primary risk factor for recurrence. 1, 2, 3

Recommended Alternative Approach

For Simple Abscesses and Most Surgical Wounds

• Place no internal packing; cover with a sterile external absorbent dressing only. 2, 3
• Alternatively, use a catheter or drain placed into the cavity that drains to an external dressing, leaving it in place until drainage ceases (typically producing <30-50 mL per 24 hours). 1, 2, 3, 4
• Keep the wound clean and dry for the first 24-48 hours, then begin warm water soaks or sitz baths to promote drainage and healing. 2, 3
• Change the external dressing regularly as it becomes saturated. 2

If Packing Has Already Been Placed

Remove any existing packing within 24 hours and transition to the external dressing approach described above. 3 Prolonged packing beyond initial hemostasis offers no additional benefit and increases pain. 1, 3

Specific Wound Type Considerations

Anorectal Abscesses

• WSES guidelines make no recommendation for packing use, stating the evidence is insufficient. 1
• Common practice historically involved regular packing changes until cavity healing, but recent evidence shows this is costly and painful without benefit. 1
• One lower-quality study suggested packing wounds larger than 5 cm might reduce recurrence, but this conflicts with higher-quality guideline evidence showing no overall benefit. 3, 5

Vaginal/Vulvar Surgery

• Vaginal packing does not decrease postoperative bleeding or hematoma formation and does not increase pain. 1
• If packing is used, studies show no difference in outcomes between 3-hour and 24-hour packing duration. 1
• Packing longer than 24 hours may increase infection rates and requires prolonged catheterization with higher UTI risk. 1

Perineal Drains After Abdominoperineal Resection

• Leave drains in place until producing <30-50 mL per 24 hours, typically requiring at least 5-7 days postoperatively. 4
• This allows overlying skin flaps to adhere to underlying tissue and decreases lymphocyst formation. 4

Closed Surgical Wounds

• Remove dressings within 48 hours permanently for clean or clean-contaminated wounds—early removal has no detrimental effect and may reduce hospital stay and costs. 6

Post-Drainage Wound Care Algorithm

Days 0-2 (First 24-48 Hours)

• Keep wound clean and dry with external absorbent dressing only. 2, 3
• Change external dressing as it becomes saturated. 2
• Avoid occlusive dressings that promote excessive humidity and skin maceration. 2

Days 2+ (After 24-48 Hours)

• Begin warm water soaks or sitz baths to promote drainage and healing. 2, 3
• Monitor daily for bleeding, pain, erythema, induration, leakage, and inflammation. 2
• Clean with 0.9% saline solution, sterile water, or cooled boiled water. 2
• Consider hydrogel dressings (changed weekly) as a cost-effective alternative that provides a moist healing environment. 2

Ongoing Management

• Allow healing by secondary intention (from inside out); do not close skin edges prematurely. 3
• Continue external dressing changes until drainage ceases and wound heals. 2, 3

When Antibiotics Are Indicated

Antibiotics are not routinely required after adequate drainage unless high-risk features are present: 2, 3

• Fever >38.5°C (101.3°F) or heart rate >110 beats/min 3
• Erythema extending >5 cm beyond wound margins 3
• Systemic inflammatory response syndrome (SIRS) criteria met 3
• Diabetes, immunosuppression, or surrounding cellulitis 2, 3
• Signs of organ failure (hypotension, oliguria, decreased mental alertness) 2

Critical Pitfalls to Avoid

• Inadequate initial drainage is the primary cause of recurrence, not absence of packing. Risk factors include incomplete drainage, loculated collections not adequately broken up, and delayed incision after symptom onset. 1, 2, 3
• Do not probe for fistulas unless clinically evident—unnecessary probing causes iatrogenic injury. 1, 3
• Premature skin closure prevents drainage from inside out and increases complications. 3
• Prolonged packing beyond 24 hours increases pain, cost, and infection risk without benefit. 1, 3

Warning Signs Requiring Immediate Return

• Fever >38.5°C (101.3°F) 2
• Rapidly spreading redness around the wound 2
• Increasing pain, swelling, or pus after initial improvement 2
• Signs of systemic infection 2, 3