Dumville Jo C, Gray Trish A, Walter Catherine J, Sharp Catherine A, Page Tamara, Macefield Rhiannon, Blencowe Natalie, Milne Thomas Kg, Reeves Barnaby C, Blazeby Jane
Division of Nursing, Midwifery & Social Work, School of Health Sciences, Faculty of Biology, Medicine & Health, University of Manchester, Manchester, UK, M13 9PL.
Colorectal Surgery, Gloucestershire NHS Foundation Trust, Cheltenham General, Sandford Road, Cheltenham, UK, GL53 7AN.
Cochrane Database Syst Rev. 2016 Dec 20;12(12):CD003091. doi: 10.1002/14651858.CD003091.pub4.
Surgical wounds (incisions) heal by primary intention when the wound edges are brought together and secured, often with sutures, staples, or clips. Wound dressings applied after wound closure may provide physical support, protection and absorb exudate. There are many different types of wound dressings available and wounds can also be left uncovered (exposed). Surgical site infection (SSI) is a common complication of wounds and this may be associated with using (or not using) dressings, or different types of dressing.
To assess the effects of wound dressings compared with no wound dressings, and the effects of alternative wound dressings, in preventing SSIs in surgical wounds healing by primary intention.
We searched the following databases: the Cochrane Wounds Specialised Register (searched 19 September 2016); the Cochrane Central Register of Controlled Trials (CENTRAL; the Cochrane Library 2016, Issue 8); Ovid MEDLINE (including In-Process & Other Non-Indexed Citations, MEDLINE Daily and Epub Ahead of Print; 1946 to 19 September 2016); Ovid Embase (1974 to 19 September 2016); EBSCO CINAHL Plus (1937 to 19 September 2016).There were no restrictions based on language, date of publication or study setting.
Randomised controlled trials (RCTs) comparing wound dressings with wound exposure (no dressing) or alternative wound dressings for the postoperative management of surgical wounds healing by primary intention.
Two review authors performed study selection, 'Risk of bias' assessment and data extraction independently.
We included 29 trials (5718 participants). All studies except one were at an unclear or high risk of bias. Studies were small, reported low numbers of SSI events and were often not clearly reported. There were 16 trials that included people with wounds resulting from surgical procedures with a 'clean' classification, five trials that included people undergoing what was considered 'clean/contaminated' surgery, with the remaining studies including people undergoing a variety of surgical procedures with different contamination classifications. Four trials compared wound dressings with no wound dressing (wound exposure); the remaining 25 studies compared alternative dressing types, with the majority comparing a basic wound contact dressing with film dressings, silver dressings or hydrocolloid dressings. The review contains 11 comparisons in total.
SSIIt is uncertain whether wound exposure or any dressing reduces or increases the risk of SSI compared with alternative options investigated: we assessed the certainty of evidence as very low for most comparisons (and low for others), with downgrading (according to GRADE criteria) largely due to risk of bias and imprecision. We summarise the results of comparisons with meta-analysed data below:- film dressings compared with basic wound contact dressings following clean surgery (RR 1.34, 95% CI 0.70 to 2.55), very low certainty evidence downgraded once for risk of bias and twice for imprecision.- hydrocolloid dressings compared with basic wound contact dressings following clean surgery (RR 0.91, 95% CI 0.30 to 2.78), very low certainty evidence downgraded once for risk of bias and twice for imprecision.- hydrocolloid dressings compared with basic wound contact dressings following potentially contaminated surgery (RR 0.57, 95% CI 0.22 to 1.51), very low certainty evidence downgraded twice for risk of bias and twice for imprecision.- silver-containing dressings compared with basic wound contact dressings following clean surgery (RR 1.11, 95% CI 0.47 to 2.62), very low certainty evidence downgraded once for risk of bias and twice for imprecision.- silver-containing dressings compared with basic wound contact dressings following potentially contaminated surgery (RR 0.83, 95% CI 0.51 to 1.37), very low certainty evidence downgraded twice for risk of bias and twice for imprecision. Secondary outcomesThere was limited and low or very low certainty evidence on secondary outcomes such as scarring, acceptability of dressing and ease of removal, and uncertainty whether wound dressings influenced these outcomes.
AUTHORS' CONCLUSIONS: It is uncertain whether covering surgical wounds healing by primary intention with wound dressings reduces the risk of SSI, or whether any particular wound dressing is more effective than others in reducing the risk of SSI, improving scarring, reducing pain, improving acceptability to patients, or is easier to remove. Most studies in this review were small and at a high or unclear risk of bias. Based on the current evidence, decision makers may wish to base decisions about how to dress a wound following surgery on dressing costs as well as patient preference.
当伤口边缘对合并固定（通常使用缝线、吻合钉或夹子）时，手术伤口（切口）通过一期愈合。伤口闭合后应用的伤口敷料可提供物理支撑、保护并吸收渗出液。有许多不同类型的伤口敷料可供选择，伤口也可以不覆盖（暴露）。手术部位感染（SSI）是伤口常见的并发症，这可能与使用（或不使用）敷料或不同类型的敷料有关。
评估伤口敷料与不使用伤口敷料相比的效果，以及不同伤口敷料在预防一期愈合的手术伤口发生SSI方面的效果。
我们检索了以下数据库：Cochrane伤口专业注册库（检索日期为2016年9月19日）；Cochrane对照试验中心注册库（CENTRAL；Cochrane图书馆2016年第8期）；Ovid MEDLINE（包括在研及其他非索引引用文献、MEDLINE每日更新文献和印刷版之前的电子版文献；1946年至2016年9月19日）；Ovid Embase（1974年至2016年9月19日）；EBSCO CINAHL Plus（1937年至2016年9月19日）。检索不受语言、出版日期或研究背景的限制。
比较伤口敷料与伤口暴露（不使用敷料）或不同伤口敷料用于一期愈合的手术伤口术后处理的随机对照试验（RCT）。
两位综述作者独立进行研究选择、“偏倚风险”评估和数据提取。
我们纳入了29项试验（5718名参与者）。除一项研究外，所有研究的偏倚风险均不明确或较高。研究规模较小，报告的SSI事件数量较少，且报告往往不清晰。有16项试验纳入了“清洁”分类手术伤口的患者，5项试验纳入了接受“清洁/污染”手术的患者，其余研究纳入了接受各种不同污染分类手术的患者。4项试验比较了伤口敷料与不使用伤口敷料（伤口暴露）；其余25项研究比较了不同类型的敷料，大多数研究将基本伤口接触敷料与薄膜敷料、银敷料或水胶体敷料进行比较。本综述共包含11项比较。
SSI
与其他研究的替代方案相比，伤口暴露或任何敷料是否会降低或增加SSI风险尚不确定：我们评估大多数比较的证据确定性为极低（其他为低），降级（根据GRADE标准）主要是由于偏倚风险和不精确性。我们在下面总结了使用Meta分析数据进行比较的结果：
清洁手术后薄膜敷料与基本伤口接触敷料比较（RR 1.34，95%CI 0.70至2.55），证据确定性极低，因偏倚风险降级一次，因不精确性降级两次。
清洁手术后水胶体敷料与基本伤口接触敷料比较（RR 0.91，95%CI 0.30至2.78），证据确定性极低，因偏倚风险降级一次，因不精确性降级两次。
可能污染手术后水胶体敷料与基本伤口接触敷料比较（RR 0.57，95%CI 0.22至1.51），证据确定性极低，因偏倚风险降级两次，因不精确性降级两次。
清洁手术后含银敷料与基本伤口接触敷料比较（RR 1.11，95%CI 0.47至2.62），证据确定性极低，因偏倚风险降级一次，因不精确性降级两次。
可能污染手术后含银敷料与基本伤口接触敷料比较（RR 0.83，95%CI 0.51至1.37），证据确定性极低，因偏倚风险降级两次，因不精确性降级两次。
关于瘢痕形成、敷料可接受性和去除难易程度等次要结局的证据有限且确定性低或极低，伤口敷料是否会影响这些结局尚不确定。
对于用伤口敷料覆盖一期愈合的手术伤口是否会降低SSI风险，或者任何特定的伤口敷料在降低SSI风险、改善瘢痕形成、减轻疼痛、提高患者可接受性或更易于去除方面是否比其他敷料更有效，目前尚不确定。本综述中的大多数研究规模较小，偏倚风险高或不明确。基于目前的证据，决策者在决定术后如何包扎伤口时，可能希望根据敷料成本以及患者偏好来做出决策。
