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MANAGEMENT OF POST OPERATIVE WOUND INFECTION
(SURGICAL SITE INFECTION)
DR BASHIR YUNUS
20/11/14
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INTRODUCTION DEFINITION EPIDIMIOLOGY CLASSIFICATION PATHOGENESIS RISK FACTORS MICROBIOLOGY
MANAGEMENT HISTORY PHYSICAL EXAMINATION INVESTIGATION TREATMENT
PREVENTION CONCLUSION REFERENCES
OUTLINE
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It is defined as infection present in any location along the surgical tract after a surgical procedure within 30days of procedure or up to 1 year after a procedure that has involved an implant.
INTRODUCTION
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Incidence vary from center to center.
About 2-5% develop SSI in US accounting for about 300,000-500,000 patient per annum
2nd most common type of Hospital Associated infection.
INTRODUCTION
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CLASSIFICATION
INCISIONAL
Superficial (skin and subcutaneous )
Deep (fascia and muscle)
ORGAN/SPACE
Involves any part of anatomy in organs and spaces other than the incision which was opened or manipulated during operation.
INTRODUCTION
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CRITERIA The above classification, each class is accompanied by at
least one of the following; Purulent discharge with or without laboratory
confirmation.
Organism isolated from aseptically obtained culture
At least one of the signs of inflammation
Spontaneous wound dehiscence or delibrate opening by the attending surgeon
Diagnosis by the attending surgeon
INTRODUCTION
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RISK FACTORS
GENERAL/ PATIENT FACTORS
LOCAL FACTORS
MICROBIAL FACTORS
INTRODUCTION
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PATIENT FACTORS Age; elderly
malnutrition
Obesity
DM
Malignancy
Prolonged steroid use
Immunosuppressive diseases
Anaemia
Chronic inflammatory diseases
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LOCAL FACTORS
Poor skin preparation
Bridge of asepsis
Contaminated instrument
Prolong procedure(>2hrs)
Poor surgical technique
Operation on an infected organ: TIP, perforated appendicitis
Foreign body
Local tissue necrosis
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MICROBIAL FACTOR
Virulence
Bacterial resistance
Dose of inoculum
Pre-existing remote body site infection
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Depends on the type of surgical procedure
Clean : staph aureus (commonest) Exogenous source
Skin flora
Clean-contaminated, contaminated and dirty wound : polymicrobial- anaerobes and aerobes
E. coli
Proteus
Psedomonas
bacteroides
MICRO-ORGANISMS
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History
Pain, fever, discharge usually about 5th day postoperatively (5-7days)
However, infection can be seen within 48hours(within 6-8hrs) with organisms such as clostridium, bacteriodes, β-hemolytic streptococcus and coliforms.
History of risk factors as mentioned,co-morbidities.
MANAGEMENT
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Physical examination
GPE
Wasted
Obese
febrile
Anaemic
Dehydrated
Pedal oedema
MANAGEMENT
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Systemic Systemic involvement- septicemia
Pre-existing remote infection
LOCAL Oedema
Hyperamia
Discharge
Gapping wound edges
tenderness
MANAGEMENT
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WOUND SWAB MCS
WOUND BIOPSY
FBC- leukocytosis, or leukopenia
U/Ecr – hyponatremia in necrotising fasciitis
USS- intra abdominal uss
CTSCAN
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INVESTIGATION
Sutures in the infected part are removed for free drainage of pus, expressed
Wound swab is taken for MCS (other investigations are requested base on the assessment of the attending surgeon) FBC, U/E, USS, serum protein, wound biopsy-mcs
Placed on broad spectrum antibiotics pending the result of mcs
Wound dressing(frequency depends on degree of infection) and debridement of necrotic tissues.
Correction of anaemia if present other derangements
Treatment
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It is better prevented than treated
Prevention starts pre-operatively, intra and post-operatively
PREVENTION
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PRE-OPERATIVE Short pre-operative hospital stay
Pre-op antiseptic shower
Pre-op hair removal
Pre-op bowel preparation
Pre-op antibiotics
Tight glucose control
Optimize nutrition
Stop smoking
PREVENTION
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INTRA-OPERATIVE Strict asepsis Skin preparation Gowning and draping Good surgical technique
Dead space Appropriate sutures Debridement Approximate not strangulate Justify use of drain
Delay primary closure when indicated Supplemental O₂, adequte fluid resuscitation,
PREVENTION
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POST-OPERATIVE
Protect wound for 1st 48hrs then inspect, however if dressing is soaked, change dressing.
Early enteral nutrition
Tight glucose control
Surveillance programme
PREVENTION
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Abscess
Septicemia
Sinus
Synergistic gangrene
Wound dehiscence
Weak and ugly scar
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COMPLICATIONS
SSI is a common preventable post operative complication which prolong hospital stay, hence cost medical care as well as other complications.
Risk factors should taken into consideration for appropriate prevention and prompt treatment went it occur.
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CONCLUSION
E.A. Badoe, E.Q. Arcampompong, J.T Rocha; “Principles and Practice of surgery including pathology in the tropics”. 4th edition, Assembly of God Literature Center ltd 237-238
F Charles et tal “schwart’s principles of surgery” tenth edition, McGraw Hill Education.
www.wikipedia.com
www.slideshare.net
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REFERENCES
