Better Health: Smart Health Commentary Better Health (TM): smart health commentary

Article Comments

Are You Allergic To Stitches (Sutures)?

This past week I was once again asked about suture allergy.  It has prompted me to revisit the issue which I have posted about twice now. (photo credit).

Sutures by their very nature of being foreign material will cause a reaction in the tissue.  This tissue reactivity is NOT necessarily a suture allergy.

Many factors may contribute to suture reactivity.

  • The length of time the sutures remain.  The longer the sutures are in, the more reactivity occurs.
  • The size of the sutures used.  The larger the caliber of the suture, the more reactivity.  The increase of one suture size results in a 2- to 3-fold increase in tissue reactivity.
  • The type of suture material used.  Synthetic or wire sutures are much less reactive than natural sutures (eg, silk, cotton, catgut).  Monofilament suture is less reactive than a braided suture.
  • The region of the body the suture is used affects tissue reactivity.  The chest, back, extremities, and sebaceous areas of the face are more reactive.

In general, accepted time intervals for superficial suture removal vary by body site, 5-7 days for the face and the neck, 7-10 days for the scalp, 7-14 days for the trunk, and 14 days for the extremities and the buttocks.  The deeper placed sutures will never be removed.

Sutures meant to dissolve (ie vicryl sutures) placed too high in the dermis (which happens often when the dermis is thin) can “spit” several weeks to several months after surgery. This is a reactive process, NOT a suture allergy.  It usually presents as a noninflammatory papule (looks very much like a pimple) and progresses with extrusion of the suture through the skin. The suture material may be trimmed or removed if loose, and it is not needed for maintaining wound strength.  Rarely does this affect the scar outcome.

The remaining portion is a “repost” about suture allergies:

Allergic reactions to suture materials are rare and have been specifically associated with chromic gut. However, Johnson and Johnson mention known triclosan allergy as a contraindication for use of certain sutures (see below). Contact allergy to triclosan is uncommon.

Surgical gut suture (Plain and Chromic) is contraindicated in patients with known sensitivities or allergies to collagen or chromium, as gut is a collagen based material, and chromic gut is treated with chromic salt solutions.

MONOCRYL Plus Antibacterial suture should not be used in patients with known allergic reactions to Irgacare MP(triclosan).

PDS Plus Antibacterial suture should not be used in patients with known allergic reactions to Irgacare MP (triclosan).

VICRYL*suture should not be used in patients with known allergic reactions to Irgacare MP (triclosan).  [In rechecking facts, I found that only Vicryl Plus has the triclosan, so simple vicryl or coated vicryl should be okay.]

Surgical Stainless Steel Suture may elicit an allergic response in patients with known sensitivities to 316L stainless steel, or constituent metals such as chromium and nickel. Skin staples are surgical steel so should be used with the same precautions.

Dermabond — Tissue glues should not be used in patients with a known hypersensitivity to cyanoacrylate or formaldehyde.

SO WHAT IS LEFT TO USE

So what is left to use in a patient who may have or has a proven allergy to suture or closure material?

Silk, Dexon, Nylon (monofilament or braided), Prolene, INSORB (absorbable staples), and any of the above listed (in the allergy section) to which the patient in question doesn’t react negatively.

The choice of a particular suture material will have to based further on the wound, tissue characteristics, and anatomic location. Understanding the various characteristics of available suture materials will be even more important to make an educated selection.

The amount of suture placed in a wound, particularly with respect to the knot volume, affects inflammation. The suture size contributes more to knot volume than the number of throws. The volume of square knots is less than that of sliding knots, and knots of monofilament sutures are smaller than those of multifilament sutures.

REFERENCES

Allergic Suture Material Contact Dermatitis Induced by Ethylene Oxide: G. Dagregorio, G. Guillet; Allergy Net Article

Johnson and Johnson Product Information

Current Issues in the Prevention and Management of Surgical Site Infection – Part 2; MedScape Article

MECHANICS OF BIOMATERIALS: SUTURES AFTER THE SURGERY; Raúl De Persia, Alberto Guzmán, Lisandra Rivera and Jessika Vazquez

Materials for Wound Closure by Margaret Terhune, MD; eMedicine Article

Product Allergy Watch: Triclosan; MedScape Article by Lauren Campbell; Matthew J. Zirwas

New References

  • Surgical Complications; eMedicine Article, May 29, 2009; Natalie L Semchyshyn, MD, Roberta D Sengelmann, MD
  • Engler RJ, Weber CB, Turnicky R. Hypersensitivity to chromated catgut sutures: a case report and review of the literature. Ann Allergy. Apr 1986;56(4):317-20. [Medline].
  • Fisher AA. Nylon allergy: nylon suture test. Cutis. Jan 1994;53(1):17-8. [Medline].

Related Posts

Allergies from Suture Material (September 7, 2007)

Suture Allergies Revisited (April 30, 2008)

Suture (June 7, 2007)

Basic Suture Techniques (June 8, 2007)

*This blog post was originally published at Suture for a Living*


You may also like these posts

Read comments »


Comments are closed.

Return to article »

Latest Interviews

How To Make Inpatient Medical Practice Fun Again: Try Locum Tenens Work

It s no secret that most physicians are unhappy with the way things are going in healthcare. Surveys report high levels of job dissatisfaction burn out and even suicide. In fact some believe that up to a third of the US physician work force is planning to leave the profession…

Read more »

Caring For Winter Olympians In Sochi: An Interview With Team USA’s Chief Medical Officer Dr. Gloria Beim

I am a huge fan of the winter Olympics partly because I grew up in Canada where most kids can ski and skate before they can run and partly because I used to participate in Downhill ski racing. Now that I m a rehab physician with a reconstructed knee I…

Read more »

See all interviews »

Latest Cartoon

Richmond, VA – In an effort to simplify inpatient medical billing, one area hospitalist group has determined that “altered mental status” (ICD-9 780.97) is the most efficient code for use in any patient work up.

“When you enter a hospital, you’re bound to have some kind of mental status change,” said Dr. Fishbinder, co-partner of Area Hospitalists, PLLC. “Whether it’s confusion about where your room is located in relationship to the visitor’s parking structure, frustration with being woken up every hour or two to check your vital signs, or just plain old fatigue from being sick, you are not thinking as clearly as before you were admitted. And that’s all the justification we need to order anything from drug and toxin screens, to blood cultures, brain MRIs, tagged red blood cell nuclear scans, or cardiac Holter monitoring. There really is no limit to what we can pursue with our tests.”

Common causes of mental status changes in the elderly include medicine-induced cognitive side effects, disorientation due to disruption in daily routines, age-related memory impairment, and urinary tract infections.

“The urinalysis is not a very exciting medical test,” stated Dr. Fishbinder. “It doesn’t matter that it’s cheap, fast, and most likely to provide an explanation for strange behavior in hospitalized patients. It’s really not as elegant as the testing involved in a chronic anemia or metabolic encephalopathy work up. I keep it in my back pocket in case all other tests are negative, including brain MRIs and PET scans.”

Nursing staff at Richmond Medical Hospital report that efforts to inform hospitalists about foul smelling urine have generally fallen on deaf ears. “I have tried to tell the hospitalists about cloudy or bloody urine that I see in patients who are undergoing extensive work ups for mental status changes,” reports nurse Sandy Anderson. “But they insist that ‘all urine smells bad’ and it’s really more of a red herring.”

Another nurse reports that delay in diagnosing urinary tract infections (while patients are scheduled for brain MRIs, nuclear scans, and biopsies) can lead to worsening symptoms which accelerate and expand testing. “Some of my patients are transferred to the ICU during the altered mental status work up,” states nurse Anita Misra. “The doctors seem to be very excited about the additional technology available to them in the intensive care setting. Between the central line placement, arterial blood gasses, and vast array of IV fluid and medication options, urosepsis is really an excellent entré into a whole new level of care.”

“As far as medicine-induced mental status changes are concerned,” added Dr. Fishbinder, “We’ve never seen a single case in the past 10 years. Today’s patients are incredibly resilient and can tolerate mixes of opioids, anti-depressants, anti-histamines, and benzodiazepines without any difficulty. We know this because most patients have been prescribed these cocktails and have been taking them for years.”

Patient family members have expressed gratitude for Dr. Fishbinder’s diagnostic process, and report that they are very pleased that he is doing everything in his power to “get to the bottom” of why their loved one isn’t as sharp as they used to be.

“I thought my mom was acting strange ever since she started taking stronger pain medicine for her arthritis,” says Nelly Hurtong, the daughter of one of Dr. Fishbinder’s inpatients. “But now I see that there are deeper reasons for her ‘altered mental status’ thanks to the brain MRI that showed some mild generalized atrophy.”

Hospital administrators praise Dr. Fishbinder as one of their top physicians. “He will do whatever it takes to figure out the true cause of patients’ cognitive impairments.” Says CEO, Daniel Griffiths. “And not only is that good medicine, it is great for our Press Ganey scores and our bottom line.”

As for the nursing staff, Griffiths offered a less glowing review. “It’s unfortunate that our nurses seem preoccupied with urine testing and medication reconciliation. I think it might be time for us to mandate further training to help them appreciate more of the medical nuances inherent in quality patient care.”

Dr. Fishbinder is in the process of creating a half-day seminar on ‘altered mental status in the inpatient setting,’ offering CME credits to physicians who enroll. Richmond Medical Hospital intends to sponsor Dr. Fishbinder’s course, and franchise it to other hospitals in the state, and ultimately nationally.

***

Click here for a musical take on over-testing.

See all cartoons »

Latest Book Reviews

The Spirit Of The Place: Samuel Shem’s New Book May Depress You

When I was in medical school I read Samuel Shem s House Of God as a right of passage. At the time I found it to be a cynical yet eerily accurate portrayal of the underbelly of academic medicine. I gained comfort from its gallows humor and it made me…

Read more »

Eat To Save Your Life: Another Half-True Diet Book

I am hesitant to review diet books because they are so often a tangled mess of fact and fiction. Teasing out their truth from falsehood is about as exhausting as delousing a long-haired elementary school student. However after being approached by the authors’ PR agency with the promise of a…

Read more »

Unaccountable: A Book About The Underbelly Of Hospital Care

I met Dr. Marty Makary over lunch at Founding Farmers restaurant in DC about three years ago. We had an animated conversation about hospital safety the potential contribution of checklists to reducing medical errors and his upcoming book about the need for more transparency in the healthcare system. Marty was…

Read more »

See all book reviews »