Control the Effluent, Protect the Skin

 Control the Effluent, Protect the Skin

As WOCN nurses we pride ourselves in our ability to pouch stomas and draining fistulas.  This was not the case with Mrs. L.  This 41 year old patient came to our institution 5 months post incarcerated hernia with development of multiple enterocutaneous fistulas.  As her surgical wound healed it formed a mound of tissue on her abdomen containing 9 prolapsed fistulas.  The previous institution used frequent dry dressing changes to control the drainage which unfortunately left her perifistula skin severely denuded.  There was a deep crease around the fistulas which made pouching impossible, even for our team.
Our goals were to control the effluent and protect the skin.  Using a large wound manager we cut the opening to contain the fistulas.  We could not seal the system on the right due to the configuration of the abdomen and the deep creasing.  We applied skin barrier cream to the areas affected by leakage and covered the skin with highly absorbent dressings.  We changed the dressings and reapplied the cream bid and prn.  We attached the wound manager to bedside drainage and secured the entire system with an elastic netting.
The patient’s severely denuded skin started healing the next day and the pouching system had outputs of 700-1000ccs per shift.  The perifistula skin was healed within 7 days.  A Hohn catheter was placed for total parenteral nutrition and the patient was transferred to an ECF.   The follow up plan of care included losing weight, maintaining healed perifistula skin, containing the drainage, and repairing the fistulas with resection and reanastamosis of the small bowel.
Mrs. L. returned 10 months later after losing 75 lbs. for repair of the EC fistulas.  Amazingly,  the section of involved bowel was only 18 inches and the fistula takedown was a success.