SSI + wound dehiscence Flashcards
Classifications of surgical site infection
- Superficial SSI - limited to skin and subcutaneous tissue
- Deep SSI - affects fascial and muscular layers
- Cavity space infection - within abdominal or joint cavity
RF for SSI - patient factors
- Increasing age
- Poor glucose control
- Obesity
- Smoking
- Renal failure
- Immunosupression
RF for SSI - operation factors
- Pre-op shaving
- Length of operation
- Use of abx prophylaxis
- Appropriate skin prep
- Appropriate gowning and sterile equipment
Typical symptoms of SSI
- Usually 5-7 days post procedure, but can be up to 3 weeks after
- Spreading erythema
- Localised pain
- Pus/discharge
- Persistent pyrexia
What can occur secondary to SSI developing to wound?
Complete wound dehiscence
Investigations for SSI - bedside and bloods
- Wound swabs for culture
- Bloods - CRP, FBC, blood cultures if septic
Imaging for SSI
- If clinical picture does not match appearance of wound
- Could consider CT scan to assess for deeper collections or even necrotising fasciitis (this would show SC emphysema)
Management of SSI
- Removal of any sutures or clips - allow drainage of pus and wound packing if needed
- Abx - follow local guidelines
Preventing SSI - preop
- Do not remove hair routinely - if need to, do immediately before with electric clipper
- Prophylactic abx - if prosthesis, clean-contaminated or contaminated surgery
- Patient advice - weight loss, smoking cessation, optimise nutrition, good diabetic control
Preventing SSI - intraop
- Antiseptic prep skin
- Change gloves/gowns if contaminated
- Wound irrigation at closure and use of antibiotic impregnated sutures to close
Preventing SSI - postop
- Monitor wounds closely - esp those in difficult areas and under skin folds
- Refer to tissue viability nurse for appropriate dressings for surgical wounds healing via secondary intention (left open, packed)
What is wound dehiscence?
- Wound fails to heal
- Re-opens days following surgery
- Most common post abdo surgery
Two types of wound dehiscence
- Superficial - skin wound fails, rectus sheath is intact
- Full thickness - rectus sheath fails to heal and bursts with protrusion of abdominal content (aka burst abdomen)
Who does superficial vs full thickness dehiscence occur in?
- Superficial - secondary to local infection, poorly controlled diabetes or poor nutritional status
- Full thickness - raised intrabdominal pressure (eg ileus), poor surgical technique or if patient critically unwell
Most common cause surgical wound dehiscence
Surgical site infection
RF of wound dehiscence - patient
- Increasing age
- Diabetes mellitus
- Steroids
- Smoking
- Obesity/malnutrition
Intra-operative RF of wound dehiscence
- Emergency surgery
- Length of op >6hrs
- Wound infection
- Poor surgical technique
Post-op factors of wound dehiscence
- Prolonged ventilation
- Post op blood transfusion
- Poor tissue perfusion eg hypotensive
Symptoms of wound dehiscence - superficial
- Noticing a visible opening of wound
- 5-7 days post op
- Noticed it producing discharge/redness
Full thickness dehiscence signs/symptoms
- Skin may be intact
- But bulging of wound
- Increased seepage of pink serous or blood stained fluid coming from the wound
- Severe cases - visible protrusion of abdominal contents
What should you do if sudden increase in wound discharge>
- Removal of skin clips/sutures at area of maximal leakage
- Physically examine rectus sheath with finger or wound swab to check intact
Investigations wound dehiscence
- Wound swabs if concurrent infection
- Otherwise diagnosis is clinical
Management of superficial wound dehiscence
- Conservative
- Manage underlying cause eg if infected
- Simple wound care - regular packing and cleaning with sterile saline
How will wound heal if superficial dehisence
- Via secondary intention
- So inform patient can take several weeks
- Sometimes may need negative pressure wound therapy if extensive
Management of full wound dehiscence
- Analgesia
- Broad spec IV abx
- Cover wound and protruding viscera with saline soaked gauze temporarily
- Need urgent return too theatre
What is done in theatre for wound dehiscence
- Large interrupted sutures - avoid tension and close deep fascial layers
- Extensive washout wound
- Carefully inspect viscera for signs of injury
What is done if closure is inappropriate in full dehiscence eg due to gross abdo sepsis or necrotising fasciitis
- Managed as open abdomen eg using negative pressure dressing
- Or bridging mesh
Preventing wound dehiscence
- Optimise co-morbidities
- Treat surgical site infection promptly
- Avoid strenious activity in early post op period
- Ensure adequate post op nutrition
