E nterocutaneous fistulas present a challenge to medical and nursing staff. If not adequately managed, a patient with a high-output fistula can develop fluid and electrolyte imbalance and metabolic acidosis in a relatively short period of time. Fistulas typically develop in a surgical incision or dehisced wound; the patient faces a 35% risk of dying. Spontaneous closure occurs in approximately 57% of all enteric fistulas within 8 weeks as along as adequate nutrition and fluid and electrolyte balance are maintained and the patient remains on bowel rest.1 Periwound skin is at great risk of breakdown due to proteolytic enzymes contained in small intestine effluent.2 Proper application of a wound pouch over an open incision with the presence of an enterocutaneous fistula can help ameliorate the likelihood of a good outcome.

Case Study
A 63-year-old male was admitted on November 13, 2001 for a colostomy reversal. Three days postoperatively, he developed cardiopulmonary complications with atrial fibrillation, dyspnea, nausea, and oxygen desaturation. His history included congestive heart failure, chronic obstructive pulmonary disease, myocardial infarction, hypertension, and previous colon resection due to diverticulitis.
He was transferred to the intensive care unit and treated with furosemide, diltiazem hydrochloride, albuterol, ipratropium bromide, azithromycin, and enoxaparin sodium. On November 19, he became hypotensive and had a large bloody stool. He was intubated and given packed red blood cells. An X-ray revealed free air in the abdomen. He returned to the operating room. Two other colonic perforations were found; a subtotal colectomy with ileostomy was performed. Postoperatively, his blood pressure was maintained with dopamine hydrochloride and norepinephrine with ventilator support.
On November 29, an enterocutaneous fistula developed in the lower abdominal wound. His total parenteral nutrition was increased with additional albumin. Intravenous fluid with electrolytes was used to replace the amount of fluid lost via fistula. At this time, he was treated with vancomycin, metronidazole, and fluconazole. The WOC nurse was consulted for wound management by pouch application to contain the effluent. The appliance chosen contains a hydrocolloid type backing that adheres to the skin, providing protection from wound drainage and effluent.
By December 19, the fistula effluent had markedly decreased. Total parenteral nutrition was tapered and tube feedings were started. Use of the wound appliance was discontinued on December 24 and moist saline dressings were applied. The abdominal wound was granulating nicely. The patient was transferred to a skilled nursing facility near his home on December 31 for further rehabilitation and care.

Supplies
To effect treatment in cases such as this one, the following supplies are required:
* Wound pouch appliance (size dependent on the size of the wound/fistula)
* Skin barrier/ostomy paste
* Skin cement (optional)
* Hydrocolloid wedges
* Adhesive remover wipes
* Skin protective wipes
* Waterproof tape
* Closed drainage unit
* Skin cleanser
* Normal saline for irrigation
* Gloves
* Scissors
* Marking pen

Application
Step 1. Cleanse the periwound skin with an appropriate product (eg, skin cleanser or sterile normal saline) as ordered by surgeon (see Figure 1).
Step 2. Make a pattern for the wound pouch by placing the wound guide or plastic covering from the wound pouch over the wound. Draw the outline of wound with a marking pen.
Step 3. Using the pattern, cut the backing of the wound pouch to the proper size of wound.
Step 4. Remove the paper backing from the wound pouch. Apply a thin coat of skin cement to the back of wound pouch. This is necessary only if obtaining a good seal or reasonable wear time is difficult. Set aside to dry (see Figure 2).
Step 5. Apply the skin protective wipe to periwound area and allow to dry.
Step 6. Apply a bead of ostomy paste to the wound edges (see Figure 3).
Step 7. Apply a thin coat of skin cement to the periwound skin. Allow this to dry 2 to 3 minutes. This will be necessary only if Step 4 was utilized (see Figure 4).
Step 8. If a crease is noted, place a wedge of a hydrocolloid skin barrier over the crease to smooth the surface. The wound may be lightly packed with normal saline-moistened gauze as needed (see Figure 5).
Step 9. Apply the wound pouch over the wound, pressing to adhere (see Figure 6).
Step 10. Create a picture frame with the waterproof tape.
Step 11. Connect the pouch to a closed drainage unit if the drainage is watery in consistency. If the drainage is thick, cut the end of the wound pouch and apply a clamp.
Step 12. Change the pouch one to two times per week or as needed.

Nursing Implications
Containment of wound drainage has several advantages over standard wound dressings. Because the output is accurately measured, fluid and electrolytes can be replaced adequately. The patient is more comfortable because dressing changes are fewer and a dry system is maintained. Any odor from the wound is contained; thus, promoting patient comfort. By protecting the periwound skin, the patient does not experience skin breakdown due to enzymes contained in the small bowel effluent. Nursing time is also saved with fewer dressing and linen changes.

Conclusion
The wound pouch has been effective in the management of high-output fistulas. With its ability to be modified and suction-enhanced as needed, the pouch protects the periwound skin, controls odor, and allows an accurate record for output. The wound pouch should be changed at least weekly or more frequently depending on the seal obtained. This is influenced by the location of the fistula, the contour of the perifistula skin, and the type of output. On this patient, the wound pouch was changed two times per week. The wound was thoroughly irrigated with sterile normal saline every 8 hours as ordered by the surgeon; a sterile Yankauer suction tip was used to suction drainage. Using the wound pouch promoted patient comfort and improved the quality of this patient's life. - OWM