Wound Packing Change Frequency in Tunneled Wounds
Remove any existing packing within 24 hours and do not replace it—instead, transition to external absorbent dressings only or place a drain that exits to an external dressing. 1, 2, 3
Evidence Against Routine Packing
The highest-quality guideline evidence demonstrates that traditional wound packing provides no therapeutic benefit for wound healing, recurrence prevention, or fistula formation, while significantly increasing patient pain and healthcare costs. 1, 3
- The World Society of Emergency Surgery (WSES) and Infectious Diseases Society of America (IDSA) state that packing adds no measurable benefit to the healing process and should be avoided. 1, 3
- A multicenter observational study of 141 patients confirmed that packing is costly, painful, and offers no advantage. 1, 2
- Recurrence rates remain high (15-44%) regardless of packing use—inadequate initial drainage, not absence of packing, is the primary risk factor for recurrence. 1, 2, 3
Recommended Management Approach
Initial 24-48 Hours
- Keep the wound clean and dry with a sterile external absorbent dressing only—do not place internal packing material. 1, 3
- Change the external dressing whenever it becomes saturated with drainage. 1
- If packing was already placed, remove it within 24 hours and transition to external dressing management. 1, 2, 3
Alternative Drainage Strategy
- Consider placing a catheter or drain into the wound cavity that exits to an external dressing, leaving it in place until output falls below 30-50 mL per 24 hours (typically 5-7 days). 1, 3
- This approach maintains adequate drainage while eliminating painful packing changes. 3
After 24-48 Hours
- Begin warm water soaks or sitz baths to promote continued drainage and healing. 1, 2, 3
- Allow healing by secondary intention (from inside out)—do not allow skin edges to close prematurely. 1, 3
- Continue external dressing changes until drainage ceases and the wound has fully healed. 1
Special Considerations for High-Risk Patients
Elderly, Diabetic, and Immunocompromised Patients
- These patients require the same packing avoidance strategy, but monitor more closely for signs of infection or delayed healing. 1, 3
- Initiate antibiotics if high-risk features develop: fever >38.5°C, heart rate >110 bpm, erythema extending >5 cm beyond wound margins, systemic inflammatory response syndrome (SIRS) criteria, or signs of organ failure. 1, 3
- Ensure adequate initial drainage, as inadequate drainage—not absence of packing—is the primary cause of complications in all patient populations. 1, 3
Dressing Type Selection
- Use gauze dressings if there is significant bleeding or drainage from the wound site, changing every 2 days until drainage resolves. 4
- Transparent dressings can be used once drainage decreases, with changes at least every 7 days or sooner if soiled, loose, or damp. 4
- Consider hydrogel dressings changed weekly as a cost-effective option that provides a moist healing environment once initial drainage subsides. 1
Critical Pitfalls to Avoid
- Do not continue packing beyond 24 hours—prolonged packing increases pain, cost, and infection risk without any clinical benefit. 1, 2, 3
- Do not probe for fistulas unless clinically evident, as unnecessary probing causes iatrogenic injury. 1, 3
- Do not allow premature skin closure, which prevents drainage from inside out and increases complications. 1, 3
- Recognize that inadequate initial drainage, not absence of packing, is the primary cause of recurrence and complications. 1, 3
Warning Signs Requiring Immediate Evaluation
- Fever >38.5°C (101.3°F) 1, 2
- Rapidly spreading erythema around the wound 1, 2
- Increasing pain, swelling, or purulent discharge after initial improvement 1, 2
- Systemic infection signs: tachycardia, hypotension, altered mental status 1, 3