This document discusses dead space management and wound dressings. It defines dead space as any area remaining devoid of tissue after wound closure. Dead space can lead to hematoma formation and increased risk of infection if not properly managed. Methods to eliminate dead space include suturing tissue planes, applying pressure dressings, packing wounds, and using surgical drains. The document then describes different types of drains and their classifications, as well as potential complications. It also discusses wound dressing materials, their purposes and properties.

1. DEAD SPACE MANAGEMENT
DR. JEFF ZACHARIA
POST GRADUATE STUDENT
DEPT. OF ORAL & MAXILLOFACIAL SURGERY
A.J. INSTITUTE OF DENTAL SCIENCES

2. CONTENTS
 Introduction
 How dead space is formed
 Methods of elimination of dead space
 Surgical drains
 Classification of drains
 Types of drains
 Complications of drains
 Removal of drain
 Wound dressing materials
 Purpose of wound dressing
 Properties of an ideal dressing material
 Classification of wound dressing materials
 Dressings used intraorally

3. INTRODUCTION
Dead space in a wound is any area that remains devoid of tissue after closure of the
wound
DEAD SPACE
FILLS WITH BLOOD
HEMATOMA
INCREASED RISK OF
INFECTION

4. HOW DEAD SPACE IS FORMED?
• When a space occupying mass (tumor, granuloma) is removed, defect created often
approximates that of the lesion
• Loose or elastic facial planes are potential areas of fluid accumulation: cases of facial
trauma or wide surgical dissection
• High velocity projectile wounds can cause significant tissue disruption & dead space
formation as a result of cavitation and tissue trauma secondary to fragmentation of bone.
• Bite wounds – crushing, stretching, tearing and laceration of skin and underlying tissues.

5. METHODS OF ELIMINATION OF DEAD SPACE
• Suturing tissue planes together to minimize post
operative void.
• Application of pressure dressing over repaired wound
(takes 12 – 18 hrs.)
• Packing into void until bleeding has stopped
• Use of drains

6. SURGICAL DRAINS
• A drain is a tube to remove pus, blood or other fluids from a wound
INDICATIONS
• Helps to eliminate dead space
• To evacuate existing accumulation of fluid or gas, to remove pus, blood, serous
exudates
• To form a controlled fistula
• Accurate recording of the volume of the drainage as well as the contents

7. CLASSIFICATION OF DRAINS
• Open drains & closed drains
• Active drains & passive drains

8. Open drains
• Drain fluids that collect in gauze pad or stoma bag
• They increase risk of infection
• E.g., Penrose drains, corrugated rubber
Closed drains
• Consists of tubes draining into a bag or bottle
• Risk of infection is reduced
• E.g.: Jackson-Pratt drain

9. ACTIVE DRAINS
• These are maintained under suction
• Can be under high or low pressure
E.g.: Open: Jackson-Pratt drain, hemovac drain
Closed: Sump drain
Advantages
• keeps wound dry
• Efficient fluid removal
• prevents bacterial ascension
• allows evaluation of volume and nature of fluid
Disadvantages
• High negative pressure may injure the tissue
• Drain clogged by tissue

10. PASSIVE DRAINS
• Have no suction
• Drains by means of overflow, gravity and pressure differentials between body
cavities and exterior
E.g., NGT, Foley’s, T – tube
Disadvantages
• Gravity dependent – affects location of the drain
• Easily clogged.

11. COMPARISON OF ACTIVE & PASSIVE DRAINS
ACTIVE PASSIVE
FUNCTION Works by negative pressure by
compressible drains or mechanical
evacuation system
Depends upon pressure
differentials & gravity
PRESSURE GRADIENT Negative pressure Normal
DRAIN EXIT SITE Dependent position not necessary Dependent position for best
function
RETROGRADE INFECTION Lower incidence Higher incidence
FLUID COLLECTION Decreased incidence because
negative pressure improves tissue
apposition & obliterates dead
space
Increased incidence because of
limited effect on dead space
OBSTRUCTION OF DRAIN More common Less common
PRESSURE NECROSIS Greater incidence Less common

12. TYPES OF DRAINS
• JACKSON PRATT DRAIN
• HEMOVAC DRAIN
• PIGTAIL DRAIN
• PENROSE DRAIN
• CORRUGATED RUBBER DRAIN
• DAVOL DRAIN
• T-TUBE
• CHEST TUBE
• NASOGASTRIC TUBE
• URINARY CATHETER
• NEGATIVE PRESSURE WOUND THERAPY

13. JACKSON-PRATT DRAIN
• It is a bulb shaped device connected to a tube.
• One end is placed inside the body during surgery while the
other end comes out through a small incision in the skin where
the bulb is connected.
• The drain removes fluids by creating suction in the tube. The
bulb is squeezed flat and connected to the tube that sticks out.
The bulb expands as it fills with fluid.
• Uses: Abdominal surgery, mastectomy, thoracic surgery

14. HEMOVAC DRAIN
• It is an active closed drain.
• Drains about 200cc, 400cc & 800cc
• It is a fine tube with numerous holes at
the end.
• It is attached to an evacuated glass/plastic
bottle providing suction
• It is used to drain the blood under the
skin.

15. PIG TAIL DRAINS
• Its sole purpose is to remove unwanted body fluids
from an organ, duct or abscess.
• They are inserted under strict radiological guidance
to ensure correct positioning.
• It is a sterile, thin, long universal catheter with a
locking tip that forms a pigtail shape. The tip has
several holes facilitating drainage process.
• They are inserted through the skin by a radiologist.
• It may be inserted to allow urine to drain directly
from a kidney, if ureter is diseased or blocked. This is
called nephrostomy.

16. PENROSE DRAIN
• It is an open drain
• soft and flexible
• It empties into absorptive dressing material
– does not have a collection device.
• The drainage moves from an area of high
pressure to low pressure.
• The drain acts like a straw, to pull fluids out
of the wound, and release them outside the
body.

17. CORRUGATED RUBBER DRAIN
• It is a rubber drain fixed by a suture at the
end of the wound & a safety pin must be
placed through the end to prevent it from
slipping inwards.
• It can be used for wound or for deep
drainage
• The rubber can cause a tissue reaction
• The drain track caused by this material
persists longer than when inert materials
are used.

18. DAVOL DRAIN
• It has a rubber bulb on top of drain that acts as a
pump to inflate balloon in drainage bottle.
• To establish suction, squeeze rubber bulb with
continuous pumping motion until balloon is
completely inflated. Replace plug in the drain
before balloon deflates, the inflated balloon
inside the bottle creates suction.
• Drains have a triple lumen configuration to
increase drain versatility & effectiveness. Large
centre lumen for maximum removal, filtered air
vent helps to reduce risk of infection. The third
lumen permits irrigation & instillation of
medication.

19. T – TUBE
• It consists of a stem and cross
head, is placed into the
common bile duct while the
stem is connected to a small
pouch.
• It is used as a temporary post
op drainage of common bile
duct.

20. CHEST TUBE
• It is used to drain
hemothorax, pneumothorax,
pleural effusion, chylothorax,
and empyema.
• It is placed in pleural space in
the 4th intercostal space
above upper border of the
rib.

21. NASOGASTRIC TUBE
It passes through the nostrils into stomach.
INDICATION
- Aspiration of gastric juice
- Lavage – in case of poisoning or overdose
medication
- Feeding
COMPLICATIONS
- Epistaxis
- Aspiration
- Erosions in nasal cavity and nasopharynx

22. URINARY CATHETER
• It is a hollow, flexible tube made of
rubber, silicone or latex used to collect
urine from the bladder
• Available in different sizes and types
• It leads to a drainage bag that holds
collected urine.
• It allows urine to drain in case of urinary
obstruction
• Allows patient to urinate – in case of
bladder weakness
• Drain bladder before, during and after
surgery

23. COMPLICATIONS OF DRAINS
Infection
- Ascension of bacterial invasion
- Foreign body reaction
- Fluid accumulation
- Poor post operative management
Discomfort/pain
- In case of chest tubes
- Stiff tubing
- Blockage

24. Inefficient drainage
- Obstruction
- Poor drain selection
Incision dehiscence
- Poor placement
Premature removal
- Results in accumulation of fluid

25. REMOVAL OF DRAIN
• Generally, drains should be removed once drainage has stopped or becomes
less than 25ml/day.
• They can be shortened by withdrawing it approximately 2cm/day allowing
the site to heal gradually.
• Drains that protect post operative sites from leakage form a tract and are
usually kept in place for a week

26. WOUNDDRESSINGS MATERIALS

27. DRESSING
• It is an artificial wound cover.
• It is a material applied to wound with or without medication to give protection
& assist in wound healing.

28. PURPOSE OF WOUND DRESSING
• To promote wound healing by primary intention
• To prevent infection
• To assess the healing process.
• To protect wound bed from mechanical trauma
• To absorb drainage.

29. PROPERTIES OF AN IDEAL DRESSING
• Absorbent, removes excess exudate
• Maintains moist environment
• Aid tissues to remove necrotic material.
• Promotes healing.
• Prevent trauma to underlying healing granulation tissue
• Prevent passage of organism to wound.
• Maintains temperature & gaseous exchange.
• Allow easy pain free dressing change
• Odorless
• Cosmetically acceptable
• Inexpensive

30. CLASSIFICATION OF DRESSINGS
Based on
function
Primary dressings
(plain gauze,
impregnated gauze)
Secondary dressings
(hydrogel dressings)
Based on origin
of dressings
Synthetic Dressings
(gauze and tulle
dressings)
Biological Dressings
(amniotic membrane
dressings, collagen
membrane)

31. CONVENTIONAL DRESSING
Dry to dry dressing (gauze)
• Inexpensive, reliable, widely available, highly absorbent.
• Used as a primary dressing over ointments & secondary dressing over wound fillers
& hydrogels.
• Permeable to exogenous bacteria & is associated with a higher infection rate.
Wet to dry dressing (gauze & saline)
• To debride tissue, fill cavities, absorb exudate & wick drainage
• Evaporation of the saline causes wound dessication
• Non selective debridement & injury to healthy tissue
• Used for full thickness & open wound

32. Impregnated dressings
• Gauze impregnated with petroleum jelly ( Vaseline),
Iodine or antibacterial compound.
• Non adhesive
• Help reduce bacterial proliferation
• Add moisture to wounds
• First degree & partial second degree burns wound
• Skin grafts & Donor sites with minimal to moderate
exudate, abrasions & lacerations.

33. SILVER SULFADIAZINE
• Most commonly used in second degree & third degree
burns.
• 1 g of ointment contains 10 mg micronized silver
sulfadiazine
• It has broad spectrum antimicrobial activity. It acts by
destroying the cell wall of bacteria.
• Sulfadiazine is a PABA inhibitor thereby inhibiting
bacterial replication
• It can cause skin necrosis, erythema multiforme, skin
discoloration, burning sensations, rashes & transient
leucopenia

34. BIOACTIVE WOUND CARE PRODUCTS
ALGINATES (Calcium salt of alginic acid)
They are non-woven, non adhesive pads and ribbons composed
of natural polysaccharide fibers or xerogel derived from
seaweed.
On contact with exudate, these dressings form a moist gel
through a process of ion exchange.
They are soft, conformable, easy to pack dressings
Used over wounds with moderate to heavy exudate such as
pressure ulcers, infected wounds & venous insufficiency ulcers.

35. FOAM DRESSING
• It is made of polyurethane with small open cells
capable of holding fluids.
• They may be impregnated or layered in
combination with other materials,
• Absorption capability depends on thickness &
composition.
• The area in contact of the wound is non
adhesive for easy removal.
• Indicated in partial and full thickness wounds.

36. HYDROFIBRES
• Consists of sodium carboxymethylcellulose.
• Manufactured as ribbons & sheets
• Structurally similar to alginates & have
similar properties
• Excellent ability to absorb exudate
• Requires secondary dressing
• It can be used for a period up to 7 days.

37. HYDROCOLLOIDS
• Available as wafers, powders or pastes composed of
gelatin, pectin or carboxymethylcellulose.
• Provides moist wound healing & promotes
debridement & formation of healthy granulation tissue.
• It is occlusive & water proof.
• On absorption of exudate, swells up to a gel & acts like
a sponge.
• It is advised for low to medium exudate wounds.
• Might have a slight odor on removal
• Are made especially for difficult-to-dress wound areas
such as elbows and heels

39. HYDROGELS (polyethylene membrane)
• Hydrogel wound dressing sheets are three dimensional
networks of cross linked hydrophilic polymers that are
insoluble in water & interact with aqueous solutions by
swelling.
• It has excellent biocompatibility
• Promotes debridement of eschar & slough
• It requires secondary dressing
Indications
 Partial & full thickness wounds
 Wounds with necrosis
 Minor burns
 Radiation tissue damage

40. COMPOSITE DRESSING
Composite dressings are the products obtained by
combining physically distinct components into single
dressing that provides multiple functions.
These include:
• A physical bacterial barrier that is present over the
entire dressing pad & extends out into the adhesive
border.
• An absorptive layer
• A semi adherent or non adherent layer over the
wound site.

41. TRANSPARENT FILMS
• They are polymer membranes of varying thickness
coated on one side with an adhesive.
• They are impermeable to liquid, water & bacteria but
permeable to moisture vapor & atmospheric gases.
• Transparency allows visualization of the wound.
Indications
Wounds with little or no exudate
Wounds with necrosis
Second degree burns
To cover IV sites, lacerations, abrasions & donor sites.

42. WOUND FILLER
• Wound fillers are beads, creams,
foams, gels, etc that are non-adherent.
• They may include a time released anti-
microbial.
• They function to maintain a moist
environment & manage exudate.
Indications
Partial or full thickness wounds
Infected wounds
Draining wounds
Deep wounds that require packing

43. COLLAGEN
• Obtained from bovine, porcine, avian collagen
• They are easy to apply and remove & are
conformable.
• Due to its chemotactic properties, it encourages
deposition & organization of newly formed
collagen thereby creating an environment that
fosters healing
• It also stimulates & recruits specific cells such as
macrophages & fibroblasts along the healing
cascade to enhance & influence the wound healing
process
• Indications: Partial & full thickness wounds
Minimal to moderate draining wounds

44. HUMAN AMNIOTIC MEMBRANE
• Amniotic membrane, or amnion, is the innermost layer of the placenta
and consists of a thick basement membrane and an avascular stromal
matrix.
• Properties: anti-inflammatory effects, bacteriostatic, wound protection,
decreased scarring, and pain reduction properties, as well as
epithelialization initialization capacities
• AM produces B defensins, elastase inhibitors, elastin, and lactoferrin that
contribute to its anti-inflammatory and antimicrobial effects.
• It expresses few antigens, which accounts for its good tolerability and the
absence of rejection reactions.
• AM expresses many neurotrophic and angiogenic factors: endothelin-2
and -3, vascular endothelial growth factor, vascular endothelial growth
factor-B, Tie-2 angiopoietin receptor, ephrin-A2, ephrin receptors A2, B1,
B3, B4, B5, neuropilin-2, nerve growth factor receptor, and semaphorin-
F19 as well as erythropoietin and its receptor that contribute to healing
of wounds. Marwin KW et al
Splichal et al

45. • Storage: 0.25% Sodium hypochlorite at -30 ⁰C to -90⁰C in deep
freezer for any length of time
• Immediate use: treated with gentamycin
Advantages
• Very thin/easily adherent/ easy to spread/ conforms to
contour
• Decreases pain
• Moist environment
• Helps in epithelization
• Exudation of discharge can occur
Disadvantages
• Cumbersome to separate
• Infection transmission

47. MULTILAYER DRESSING USING NEGATIVE
PRESSURE WOUND THERAPY
• It utilizes humidity control of a wound in the
proliferation phase to promote the intricate process of
wound healing.
• It uses a negative pressure source such as a vacuum
pump with an air tight seal, suction member and
biocompatible porous dressing.
• The negative pressure drains the excess fluids and
exudates & effectively promote blood flow to that area,
stimulate the formation of granulation tissue &
encourage migration of healthy tissue over the wound.

49. DRESSINGS USED INTRA ORALLY
 Some of the most commonly used intra orally are:
OXIDIZED REGENERATED CELLULOSE (SURGICEL)
• It forms a gelatinous mass when mixed with blood & functions as an artificial clot
• Due to its low pH, it may also have antimicrobial effects.
WHITEHEAD’S VARNISH
• Contains 10g Iodoform, 10g Benzoic acid, 7.5g Storax, 5g of Balsam of Tolu & 100
mL Ether
• It prevents capillary oozing & post op pain relief.
• Used in surgical extractions, cleft palate surgery, osteomyelitis & orbital floor
reconstruction
CARNOY’S SOLUTION
• Contains 3 mL Chloroform, 1mL glacial acetic acid, 1 g of Ferric Chloride & 6 mL
alcohol
• Used as a tanning agent to facilitate the removal of cystic linings

50. BISMUTH IODOFORM PARAFFIN PASTE
• It facilitates excellent healing & reduced infection rates in large open wounds
• Can be used in dry sockets, prevention of infection after reduction of nasal
bone fractures & epistaxis
• Toxicity is known to cause neurological impairment
ZINC OXIDE BASED DRESSINGS
• It reduces inflammation thereby reducing pain. (eugenol based)
• Eugenol based dressings is known to cause contact dermatitis & local
cytotoxicity.
• Non eugenol based products are known to cause inflammatory changes
• Mainly used in dry socket & periodontal dressings
ALVOGYL
• It contains Butamben, Iodoform & eugenol
• Used primarily in the treatment of alveolar ostitis
• Can be used to relieve pain in extraction sockets
• Studies show that it delays healing in extraction socket Syrjanean et al, 1979

51. EMBROIDARY TECHNOLOGY FOR WOUND DRESSING
• Developed by St. Gallen, Switzerland
• Used for treatment for chronically non healing
wounds.
• It has a textile architecture that uses pores for
stimulating angiogenesis & elements for local
mechanical stimulation of wound ground.
• They harden because of exudates emerging from
the wound & thus lose their flexibility.

52. MULTILAYER DRESSINGS USING NANOFIBRES
• Wound dressing with nano fibers contribute to improved
hemostasis, absorption of exudates from the wound,
flexibility in the designed dressing mat & maintenance of
moisture in the wound environment allowing for oxygen
& water permeability.
• These nano fibers have a large surface area to volume
ratios, high porosity containing small pores & a matrix
morphology that resembles natural extracellular matrix
of the human body.

53. • Electrospinning technology can produce biomimetic nanofibrous materials
from a wide variety of natural and synthetic polymers with biologically
relevant features.
• Electrospun nanofibers provide an excellent platform for local delivery of
therapeutic agents.
• The mechanical properties of electrospun nanofibers are easily altered by
selecting an appropriate raw material to meet wound healing
requirements.
• Electrospun nanofibers can regulate skin cell behavior via transmembrane
receptors or intracellular signaling pathways
Summary: Recent advances in electrospun nanofibers for wound healing,
Chen et al

54. CONCLUSION
Wound healing is a dynamic and complex process which requires suitable
environment to promote healing process. With the advancement in technology,
more than 3000 products have been developed to treat different types of
wounds by targeting various aspects of healing process, but still there is no
superior product that heals chronic wounds. Hence developing a dressing
material that addresses the major interfering factors of normal healing process
will help patients and wound care practitioners largely around the world.

55. THANK YOU