Surg - Secrets Ch 10,11 - Postop Fever and Surgical Wound Infection crc
Terms in this set (59)
Rare, life threatening response to inhaled anesthetics
Core temp rises >40 C
Abnormal Ca metabolism in skeletal muscle --> heat, acidosis, hypokalemia, muscle rigidity, coagulopathy, and circulatory collapse.
Malignant hyperthermia, what is it?
Give bicarb (2mEq/kg IV)
Give dantrolene (Ca channel blocker) at 2.5 mg/kg IV, and cont every 6 hours for
Cool patient with alcohol sponges and ice
How is malignant hyperthermia treated?
AD response but variable penetrance.
Malignant hyperthermia, is it inherited?
Core temp>40 C (>104)
Clinical manifestations of malignant hyperthermia
Macropahges activated by bacteria and endotoxin
Activated macrophages release IL-1, TNF, and IFNgamma ---> reset the hypothalamic thermoregulatory center
What causes fever?
Block formation of PGE2 in the hypothalamus --> effectively control fever
How do ASA, acetaminophen, and ibuprofen control fever?
Patients are more comfortable, but no improvement as far as clinical outcomes.
Should fever be treated?
urine gram stain and culture
Surgical incision inspection
Old and current IV sites evidence of septic thrombophlebitis
Breath sounds worrisome? GET A CXR
Fever work up
Traditional answer is atelectasis, but this is probably not the case.
Most common cause of fever during early postop period? 1-3 days.
Wind, pulmonary complaints
Walking - DVTs, PEs
Wonder --> iatrogenic? Drugs, infusion related
Mnemonic for causes of postop fever
YES -- VC was measured in patients 24 hours after various surgical procedures
Upper abdominal was the worst, followed by lower abdominal incision
and THEN thoractomy, median sternotomy, and extremity incisions.
Surgical incisions related to compromised spontaneous breathing patterns?
Incentive spirometry. Not to avoid fever, but to preserve VC.
How should postop atelectasis be treated?
>10^5 organisms per gram of tissue.
Wound infection strict definition
Human bites, each ml of human saliva contains >10^8 organisms aeronic and anaerobic, gram positive and gram negative.
All human bite wounds must be considered as contaminated.
Animal bite wounds are typically less contaminated.
What wounds are especially prone to infection?
>39 fever <12 hours postop
Foul-smelling, serous discharge in a particularly painful wound (all incisions hurt) with or without crepitus.
Gram stain --> gram positive rods confirms or excludes diagnosis of clostridial infection.
What are you looking for in a possible infected wound shortly after surgery?
Wound opened immediately, fluid resuscitation
Mainstay of therapy --> aggressive surgical debridement of necrotic tissue (skin, muscle, and fascia). Make a big hole, do not worry about closing it!
PCN 12 mil U/day IV for 1 week
Hyperbaric oxygen?? NOT HELPFUL
Therapy for clostridial gas gangrene?
Hemolytic strep gangrene
Idiopathic scrotal gangrene
Gram neg synergistic necrotizing cellulitis
What has been lumped together with necrotizing fasciitis?
Gram positive coverage --> ampicillin
Gram neg coverage --> gentamicin
Anaerobic coverage --> metronidazole
To avoid overgrowth of yeast and resistant bacteria, focus on culprit bacteria as soon as the cultures define it.
Triple antibiotics shotgun approach?
Clostiridial --> underlying muscle resulting in myonecrosis or gas gangrene
Nonclost --> infeciton involves SQ fascia, aka necrotizing fasciitis
Both have similar management!
Difference between clostridial infection vs nonclostridial necrotizing wound infections
Fluid and electrolyte resus
Antibiotics - high dose for clostridial infection, broad spectrum triples for necrotizing fasciitis
Aggresive surgical debridement of necrotic tissues
General management of necrotizing wound infections?
Ampicillin - 1g q6h IV in audlts, 40mg/kg q6h IV in children
Gentamicin - 7mg/klg IV q24h, SINGLE DAILY DOSEIS LESS NEPHROTOXIC
Metro - 500mg IV q6h adults, 7.5mg/kg IV q6h in children
Doses for triple antibiotics?
What covers gram neg organisms in shotgun antibiotics?
What covers gram pos organisms in shotgun antibiotics?
What covers anaerobes in shotgun antibiotics
GI procedures, esp if the colon is opened
What surgical procedures are predisposed to wound infections?
12h and 7 days postop
When do wound infections typically occur?
Opened and completely drained
General wound infection treatment
It is good, because it decreases bacterial load and promotes healing.
Alcohol --> toxic to tissues!! Sodium hydrochlorite (Dakin solution, AKA BLEACH) and hydrogen peroxide also kill fibroblasts and slow epithelization.
Do not put anything into a wound that you would not put into your eye.
Irrigation in wound infection treatment?
Longer the foley is in place, the more likely the UTI will happen.
Germs crawl up outside of catheter, by 5-7 days post op mos tpatients harbor infected urine.
Urologic instrumentation at the time of surgery may acelerate
When do UTIs post op happen?
UTI has a urine culture with >10^5 bact/ml
WBCs on urinalysis are highly suspicious.
How is a UTI diagnosed?
Septic thrombophlebitis from an IV line
Occult (usually intraabdominal) abscesses tend to present about 2 weeks out!!1
Most common causes of LATE postop fever?
20%, with 1/3 of these as infections at surgical sites. Complicate 1% to 12% of all operations
Increases risk of death by 4x, each infection costs 12k-30k to treat.
What percent of surgical patients acquire a nosocomial infection?
Inguinal herniorrhaphy 2%
Colectomy - 12%
Highest rates of surgical wound infection with what?
Surgical site infections
SSI stands for what
Superficial incisional infection
Deep incisional --> deep soft tissue layers, fascial or muscle layers of the incision
Organ space SSis --> anatomic structures opened or manipulated during the operative procedure
SSI three categories?
30 days of surgery
foreign body? Up to one year
SSI time frame?
Incisional signs of infection?
May require imaging studies
Organ space SSI signs
Warming the patient during perioperative period
What simple act has been shown ot decrease signifiicantly the incidence of SSIs?
Good blood supply
Why do facial wounds have a generally lower infection rate?
From the face in 4 to 5 days.
From the hands and arms in 5 to 10 days.
From the feet, legs, chest, abdomen, and back in 7 to 14 days.
Over a joint in 7 to 14 days.
When can sutures be removed?
Know your suspected organism
Staph most common skin organism, most common cause in SSIs
Cefazolin --> Ancef: first gen cephalosporin, usually antibiotic prophylaxis in clean surgical procedures.
If gut was entered --> enterobacteriaceae and anaerobes are common, biliary tract and esophageal incisions yield these organisms plus enterococci.
UT or vagina --> Group D strep, pseudomonas, Proteus species
How do you use antibiotics to prevent SSIs?
IV less than 1 hour before surgical incision. Late administration is actually similar to no administration
Special circumstances may call for other than IV doses.
How and when should antibiotics be used to prevent SSI
Clean wound infection rate?
Dirty wound infection rate?
Mupirocin intranasal for staph
PO antibiotics for elective colon surgery
Other routes for antibiotic prevention of sSIs?
High pressure pulsatile lavage --> 7x more effective in reducing bacteiral load than bulb syringe.
Inherent elastic recoil --> soft tissues
50-70 lb/sqinch optimal pressure, 800 pulses/min.
Adding antibiotics to lavage solutions --> not been shown to definitely improve outcome.
What has been proven to be seven times more effective than bulb syringe lavage for the purposes of redicing bacterial load?
Stop smoking. Leading preventable patient factor for SSIs.
Triples the risk of incisional wound breakdown. Tobacco decreases blood flow and oxygen delivery to wounds. Toxic tobacco byproducts also directly impede all stages of wound healing.
Number one thing that PATIENTs can do to help decrease SSIs
Drainage --> reopening the wound or, in the case of deep space infections, using techiniques that are guided by CT o rUS for drain placement or presurgical planning.
Antibiotics to control associated cellulitis and generalized sepsis
SSIs, first step in management?
untreated SSIs, what happens?
Rupture of abdominal wall, extrusion of the abdominal viscera
Increased intraabdominal pressure
Renal or hepatic insufficiency
Use of corticosteroids ro cytotoxic drugs
Radiation --> all have been implicated in wound dehiscence.
What factors predispose to dehiscence?
Transition zone between linea alba and rectus abdominis sheath.
Maximal strength when reattaching hte linea alba?
Any time postop, but msot commonly b/w 5-10th day postop, when wound strength is at a minimum. Macrophage infiltration at this point
When does wound dehiscence occur?
Absence of a healing ridge, which extends about 0.5 cm on each side of the incision within 1 week postop.
What might be a strong indicator of impending wound breakdown postop?
Absence of healing ridge
Leakage of serosanguinous fluid fro mwound
Sudden evisceration may be first indication of abdominal wound dehiscence
Patient may also describe a sensation of tearing or popping associated wtih coughing or retching.
First sign of impending wound breakdown?
If not infected, elective reclosure
If this is impossible, healing by second intention may be the way to go. Unstable scar or incisional hernia may be dealt with at a later, safer time.
Management of dehiscence?
10-20%, this is a surgical emergency. Initial treatment --> appropriate resuscitation while protecting the eviscerated organs with moist towels. Next step is prompt surgical closure.
Mortality of evisceration?
Covering exposed bowels with moist towels
Lavage exposed bowels and omentum thoroughly
Abdominal contents returned, wall closure
skin wound should be packed open
Vacuum-assisted wound closure may be valuable
Treatment for evisceration
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