SSI + wound dehiscence

Question 1

Classifications of surgical site infection

Answer 1

• Superficial SSI - limited to skin and subcutaneous tissue
• Deep SSI - affects fascial and muscular layers
• Cavity space infection - within abdominal or joint cavity

Question 2

RF for SSI - patient factors

Answer 2

• Increasing age
• Poor glucose control
• Obesity
• Smoking
• Renal failure
• Immunosupression

Question 3

RF for SSI - operation factors

Answer 3

• Pre-op shaving
• Length of operation
• Use of abx prophylaxis
• Appropriate skin prep
• Appropriate gowning and sterile equipment

Question 4

Typical symptoms of SSI

Answer 4

• Usually 5-7 days post procedure, but can be up to 3 weeks after
• Spreading erythema
• Localised pain
• Pus/discharge
• Persistent pyrexia

Question 5

What can occur secondary to SSI developing to wound?

Answer 5

Complete wound dehiscence

Question 6

Investigations for SSI - bedside and bloods

Answer 6

• Wound swabs for culture
• Bloods - CRP, FBC, blood cultures if septic

Question 7

Imaging for SSI

Answer 7

• 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)

Question 8

Management of SSI

Answer 8

• Removal of any sutures or clips - allow drainage of pus and wound packing if needed
• Abx - follow local guidelines

Question 9

Preventing SSI - preop

Answer 9

• 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

Question 10

Preventing SSI - intraop

Answer 10

• Antiseptic prep skin
• Change gloves/gowns if contaminated
• Wound irrigation at closure and use of antibiotic impregnated sutures to close

Question 11

Preventing SSI - postop

Answer 11

• 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)

Question 12

What is wound dehiscence?

Answer 12

• Wound fails to heal
• Re-opens days following surgery
• Most common post abdo surgery

Question 13

Two types of wound dehiscence

Answer 13

• 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)

Question 14

Who does superficial vs full thickness dehiscence occur in?

Answer 14

• 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

Question 15

Most common cause surgical wound dehiscence

Answer 15

Surgical site infection

Question 16

RF of wound dehiscence - patient

Answer 16

• Increasing age
• Diabetes mellitus
• Steroids
• Smoking
• Obesity/malnutrition

Question 17

Intra-operative RF of wound dehiscence

Answer 17

• Emergency surgery
• Length of op >6hrs
• Wound infection
• Poor surgical technique

Question 18

Post-op factors of wound dehiscence

Answer 18

• Prolonged ventilation
• Post op blood transfusion
• Poor tissue perfusion eg hypotensive

Question 19

Symptoms of wound dehiscence - superficial

Answer 19

• Noticing a visible opening of wound
• 5-7 days post op
• Noticed it producing discharge/redness

Question 20

Full thickness dehiscence signs/symptoms

Answer 20

• 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

Question 21

What should you do if sudden increase in wound discharge>

Answer 21

• Removal of skin clips/sutures at area of maximal leakage
• Physically examine rectus sheath with finger or wound swab to check intact

Question 22

Investigations wound dehiscence

Answer 22

• Wound swabs if concurrent infection
• Otherwise diagnosis is clinical

Question 23

Management of superficial wound dehiscence

Answer 23

• Conservative
• Manage underlying cause eg if infected
• Simple wound care - regular packing and cleaning with sterile saline

Question 24

How will wound heal if superficial dehisence

Answer 24

• Via secondary intention
• So inform patient can take several weeks
• Sometimes may need negative pressure wound therapy if extensive

Question 25

Management of full wound dehiscence

Answer 25

• Analgesia
• Broad spec IV abx
• Cover wound and protruding viscera with saline soaked gauze temporarily
• Need urgent return too theatre

Question 26

What is done in theatre for wound dehiscence

Answer 26

• Large interrupted sutures - avoid tension and close deep fascial layers
• Extensive washout wound
• Carefully inspect viscera for signs of injury

Question 27

What is done if closure is inappropriate in full dehiscence eg due to gross abdo sepsis or necrotising fasciitis

Answer 27

• Managed as open abdomen eg using negative pressure dressing
• Or bridging mesh

Question 28

Preventing wound dehiscence

Answer 28

• Optimise co-morbidities
• Treat surgical site infection promptly
• Avoid strenious activity in early post op period
• Ensure adequate post op nutrition