A strategy of tracheostomy before day 8 postinjury in this group of trauma patients did not reduce the number of days of mechanical ventilation, frequency of pneumonia or ICU length of stay as compared with the group with a tracheostomy strategy involving the procedure at 28 days postinjury or more.

ObjectiveTo determine the optimal method of wound closure for dirty abdominal wounds. Summary Background DataThe rate of wound infection for dirty abdominal wounds is approximately 40%, but the optimal method of wound closure remains controversial. Three randomized studies comparing delayed primary closure (DPC) with primary closure (PC) have not conclusively shown any advantage of one method over the other in terms of wound infection. MethodsFifty-one patients with dirty abdominal wounds related to perforated appendicitis, other perforated viscus, traumatic injuries more than 4 hours old, or intraabdominal abscesses were enrolled. Patients were stratified by cause (appendicitis vs. all other causes) and prospectively randomized to one of two wound management strategies: E/DPC (wound packed with saline-soaked gauze, evaluated 3 days after surgery for closure the next day if appropriate) or PC. In the E/DPC group, wounds that were not pristine when examined on postoperative day 3 were not closed and daily dressing changes were instituted. Wounds were considered infected if purulence discharged from the wound, or possibly infected if signs of inflammation or a serous discharge developed. ResultsTwo patients were withdrawn because they died less than 72 hours after surgery. The wound infection rate was greater in the PC group than in the E/DPC group. Lengths of hospital stay and hospital charges were similar between the two groups. ConclusionA strategy of DPC for appropriate dirty abdominal wounds 4 days after surgery produced a decreased wound infection rate compared with PC without increasing the length of stay or cost.Dirty surgical wounds are associated with a high rate of wound infection.1 Postoperative wound infections have a significant impact on health resources and costs, 2,3 and the sequelae of wound infections (wound dehiscence and resulting incisional hernias) can result in significant long-term problems. 4 -6 Of the many risk factors influencing postoperative wound infections, the method of skin closure has been implicated as an important factor. Delayed primary closure (DPC) and primary closure (PC) are two commonly used methods, but there is no consensus as to the optimal method. Cruse and Foord 1 found in a retrospective survey a wound infection rate of 40% among 2,093 dirty wounds, but they did not specify how skin closure was performed. Three prospective randomized studies 7-9 performed on appendectomy wounds only showed no advantage to DPC in terms of decreased wound infection compared with PC. We conducted a prospective randomized trial on patients with dirty abdominal wounds and hypothesized that a strategy of DPC of appropriate dirty abdominal wounds would result in a decreased rate of wound infection.