Palliative Care PART – 11 Wound Care
(All the articles published in past are available at www.shyamhemoncclinic.com/blog/)
Question: Last time we covered few more aspects of palliative care. A large number of patients in very advance stages have large wounds. Much more of an issue in India and particularly in Gujarat, as we have a large number of head and neck cancer patients. Any particular advice about their care will be highly appreciated.
Ans: A very pertinent question. Head and neck cancer patients are the most common ones at Karunalay too. Wounds are also seen in some breast cancer patients with local chest wall recurrence or untreated large breast masses that are fungating. Most family doctors and even general surgeons are not comfortable with such wounds. Some patients have deep wounds in extremities, inguinal region etc. Large dressings are also very expensive for an average patient. Material cost alone can be Rs 500-1500 depending on wound size. Doctor charges could be around Rs 500. Dressing is required at least once, frequently two times per day in such patients, as they may have large amounts of discharge – serous, pus, bloody, sometimes lymphorrhea. A lot of smell in many cases makes it very difficult for the person doing dressing or family members.
As you are aware, we run a cancer palliative care center Karunalay for last about 9 years, where all the care is completely free. Many patients come to us on OPD basis for daily dressing. Not all patients are admitted in the center. Interested readers can call Karunalay for more information, guidance at 07926754002; 917405044001. Or send me a message. I will share some experiences from Karunalay. Many of these tips are from a very good handbook from IAPC – Indian Palliative Care Association. You may read this handbook for more details.
- When a new patient comes, we assess their wound and decide plan. For example, if patient has orocutaneous fistula, even if a very small one, we insert nasogastric tube. And strictly avoid any oral feeding. Even a small leak will not allow proper clearance of infection from the wound. If the wound has pus i.e. suppurative discharge, apart from dressing, we generally give oral levofloxacin for 5 days as most have anerobic infection.
- Suppurative wounds. Start dressing with cleaning by normal saline, then use betadine liquid (for significant pus discharge). Betadine ointment is used for dry wounds. We also frequently use powder made from 3-4 crushed metrogyl tablets in dressing, to clear infection.
In a few days, once pus has cleared, daily dressing is done with saline only, and covered at the end with a dry gauze. No antibiotic ointment is then required. We advise patients not to keep wounds open. That leads to re infection, and even maggots. Wounds should be cleaned using sterile material only. Gauze pad is not required, once there is no soakage. Simple gauze piece is sufficient. Makes dressing less bulky.
- Home care. Since dressing material is expensive, we teach them how to autoclave cotton cloth pieces, at home. Using pressure cooker. And sterile technique for dressing at home.
- Smell. Bad smell from infected wounds is a common concern, even for family members. First is use of tablet levofloxacin orally or amoxicillin-clavulanate for 5 days, as mostly smell is from anaerobic infection. Thorough dressing however is must to maintain this initial support from oral antibiotic. Additionally, we use 2-4 crushed charcoal tablets, placed between 2 gauze pieces, at the top of dressing, to absorb smell.
- Pain. Some patients are very anxious while opening the dressing due to severe pain. If very painful to open dressing, sprinkle some xylocaine liquid on the last gauze that is stuck to the wound. Wait for 2-3 minutes, then gently open.
- Maggots: wounds with maggots are very painful, as maggots actually bite patient.
Turpentine smell drives maggots out of wound. Sprinkle few drops of turpentine liniment (thicker than liquid). Wait for few minutes. For a deep wound, soak gauze with little bit of turpentine and place deep inside wound. Daily dressing for 2-3 days is sufficient to clear maggots. Remember to remove debris of dead maggots, especially from deep wounds. These patients also require betadine dressing as secondary bacterial infection is generally there.
- Oral hygiene is compromised frequently in oral cancer patients. Use metrogyl 5 tablets in 100 ml of hexidine gargle. Mix well. One teaspoon of this in one glass water for gargles. About three times a day. Some need every 3-4 hours if significant smell.
- Bleeding wounds: Frequently one or two main spots which are oozing – be careful with these specific spots during daily dressing. If dried gauze is stuck at this spot, soak in saline and then remove very gently. Use betadine ointment to avoid dry gauze sticking to these few spots. Or Vaseline jelly. Or readymade moist gauze for example Jelonet (less preferred due to cost).
- Antibiotics: we rarely need anything more than metronidazole, levofloxacin, amoxicillin-clavulanate. Occasionally Bactrim. Good quality thorough dressing is the more important than antibiotics. If dressing is not adequate, systemic infection with fever may be seen, then requiring higher antibiotics including injectable.
September 14, 2021 Dr Chirag A. Shah; M.D. Oncology/Hematology (USA), 9998084001. Diplomate American Board of Oncology and Hematology. Ahmedabad. firstname.lastname@example.org