Addressing the Pain: Silicone Sheeting as an Alternative to Elastic Bandages in Dressing Lower Extremity Amputations
Amputation of the lower limb is generally seen as an ominous event, with the potential for poor survival. Four-year survival rates have been estimated from 22% to 76% depending on a variety of factors.1 In a study of 1997 hospital discharge rates for nontraumatic amputations, 131,218 patients had a discharge diagnosis code of lower extremity amputation; nearly 88,000 of these were patients with diabetes.2
Other diagnoses and conditions that may lead to this calamitous event include renal disease, cardiovascular disease (including congestive heart failure), cerebrovascular disease, Hansen's disease, and peripheral vascular disease.1 Clinicians must address quality-of-life issues of pain and anxiety for the patient who faces this dramatic experience. In a large study conducted across the US between October 1994 and April 1996 by the Veterans' Administration among patients with diabetes, between 31.5% and 35.9% of patients undergoing this procedure already had at least one amputation.3
Standard dressings on amputations usually include four-by-four (dressing sponges), circumferential wrapped gauze, and elastic bandages. These items create circumferential constrictive pressure in order to create adequate pressure and friction to support loops or wraps around the actual stump or incision below. Physically, this circumferential craniad pressure must be greater than that supplied below or the wrap will shift downward. This likewise decreases distal arterial flow and increases ischemia. It also decreases venous outflow; thereby, increasing tissue edema, which further increases the ischemic component.
To decrease the trauma and pain of this type of post-amputation bandaging, silicone perforated sheeting (Mepitel®, Molnlycke Health Care, Newtown, Pa.) can be placed immediately post-op on patients' stumps instead of the classic elastic bandages. This product is preferred for its elastic quality, perforations, translucency, and adherence to dry skin. Two large pieces are usually required. One is placed medially and the other laterally in either sequence. The first piece is clipped posteriorly by raising up the stump, then brought over the incision and drain (if one is in place) under some tension, which is held as the opposite end of the silicone perforated sheeting is clipped under tension. The second piece is slightly overlapped on the first; it is also clipped posteriorly and brought around anteriorly over the incision and likewise clipped under tension. This creates pressure on the incision with almost no proximal constriction created by standard elastic dressings. A force vector is created in the craniocaudad direction with no circumferential constrictive force. A sheet of Mefilm® (Molnlycke Health Care, Newtown, Pa.) is placed over the silicone perforated sheeting. Of note: tape is avoided with this procedure, which provides pain reduction as well as less constriction to the stump.
Using this bandaging option in 15 major lower extremity and several lesser amputations has produced no significant swelling, no significant development of flap hematomas or seromas, no flap necrosis, and no necrosis of clip insertion sites to date. The incisions are easily visualized through the sheeting and drains are easily removed either directly from under the sheeting or by making a short incision through it. One episode of bleeding occurred from the drain site, which was treated by packing and applying an elastic bandage for approximately 10 hours; once the elastic bandage was removed, no further significant bleeding reoccurred. This bleeding was deemed a suture failure and not that of the dressing.
The only notable problem is that many clips need to be removed. Also, clinicians must ensure that the clip lines do not lie directly in contact with the bed or other points of pressure; otherwise, additional pain is created.
Mr. C was an 85-year-old Caucasian man referred to the wound care center with multiple wounds on his left foot. His vascular status and his medical conditions precluded any attempt at revascularization radiographically or surgically. His past medical history included hypertension, cerebral vascular accident with left-sided hemiplegia, cardiomegaly, congestive heart failure, bradycardia, esophagitis, hiatal hernia with reflux, organic brain syndrome, arthritis, and remote alcohol abuse. His past surgical history included an appendectomy. On admission, Mr. C was dehydrated, moderately demented, and had multiple pressure ulcers that were exceptionally severe on his left foot. His lab studies indicated anemia with an Hgb of 10.0, elevated BUN and creatinine, and a low albumin. Transcutaneous oxygen measurements below the knee were very hypoxic. Clinicians decided to proceed with an above-the-knee amputation, which was performed on the third day, post admission.
Following surgery, the wound was dressed with the silicone perforated sheeting. The first piece was stapled to the back of Mr. C's leg and pulled around to the front surface and stapled anteriorly directly over the drain (see Figure 1). A second piece was similarly stapled back to front overlapping in the middle of the stump and placed over the opposite drain (see Figure 2). Regular dressing sponges were placed over the drains, which came out bilaterally, and a large Mefilm® was placed on top to secure the dressing (see Figure 3).
The patient healed his amputation site with no necrosis, hematomas, seromas, nor infection. He healed without complication.
The elastic properties of the silicone perforated sheeting provide an effective pressure dressing without causing further trauma or pain over the amputation stump. The inherent elasticity also allows the dressing to conform in shape to most body surfaces. This dressing technique also has been used on toe and partial foot amputations with similar success. The perforations provide adequate drainage and coupled with the dressing's translucency allow for adequate visualization of the wound without difficulty. Also, no problems occurred at any of the clip sites. As dressing sponges can be simply tucked under the edges or through a simple slit in the silicone perforated sheeting at the drain sites, tape usage is also avoided; this decreases both pain on tape removal and skin irritation or ulceration. The dressing also seems to stay on without difficulty. This method of dressing amputation stumps appears to have fewer complications than those associated elastic bandages.
Addressing the Pain is made possible through the support of Mölnlycke Health Care, Newtown, Pa.