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CFB > WCS28 Surgical Infection > Flashcards

WCS28 Surgical Infection Flashcards

1
Q

Infection and Pathogenesis during Surgery

A

Infection:

  • Invasion + Multiplication of microorganism in body tissues
  • Causing local cellular injury due to Competitive metabolism, Toxins, Intracellular multiplication, Ag-Ab response

Pathogenesis:

  1. Infectious agent
  2. Susceptible host
  3. Closed unperfused space
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2
Q

Systemic Inflammatory Response Syndrome (SIRS)

A

> =2 criteria met:

  1. Body temp >=38oC / <36oC
  2. HR >90
  3. RR >20 / PaCO2 <32
  4. WBC >12 (Leukocytosis) / <4 (Leukopenia)

Sepsis:
- SIRS + Infection

Severe Sepsis:
- Sepsis associated with Organ dysfunction, Systemic hypoperfusion, Hypotension

Septic shock
- Sepsis (SIRS + Infection) + Arterial hypotension

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3
Q

Clinical approach to Septic patients

A
  1. Recognise septic patients
    - Changes in core temperature
    - **Unexplained hypotension
    - **    Oliguria
    - Confusion
  2. Locate source of infection
    - Abdomen
    - Skin
    - Joints
    - Respiratory
    - CVS
    - CNS
    - Haematological
  3. Identify underlying cause of infection + Investigations
    - Blood tests
    - Radiological tests
    - Microbiological tests
  4. Management
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4
Q

Abdomen

A
  1. GI tract
    - IBD, perforation, anastomotic leakage, abscess
  2. Hepato-biliary and pancreatic system
    - Cholecystitis, Cholangitis, Pancreatitis, Hepatitis, abscess
  3. Genito-urinary
    - UTI, Pyelonephritis
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5
Q

Skin and Joints

A

Skin:
- Surgical wound infection, Percutaneous line (IV access), Soft tissue infection

Joints:
- Septic arthritis, Prosthetic infection

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6
Q

Respiratory, CVS, CNS, Haematological

A

Respiratory:
- Pneumonia, Empyema

CVS:
- Endocarditis

CNS:
- Meningitis, Encephalitis, Abscess

Haematological:
- Recent travel (malaria)

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7
Q

Investigations

A
  1. Blood tests
    - CBC: **leukocytosis (neutrophil + leukocyte)
    - RFT
    - LFT: ductal + parenchymal enzymes
    - **    Arterial blood gases: **metabolic acidosis (e.g. ischaemic bowel)
    - Clotting screening: **    DIC
    - Inflammatory markers: ***CRP, ESR
    - Others: fasting glucose, HbA1c
  2. Radiological tests
    - X-ray
    - USG
    - CT
    - Cardiac ECHO (look for cardiac function, vegetation on valves)
  3. Microbiological tests
    - Wound swab
    - Urine: msu, csu
    - Stool: culture, C. difficile toxin
    - Blood
    - Sputum
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8
Q

Management principles

A
  1. Excise / Drain any septic foci amenable to surgical therapy
    - abscess
  2. Antibiotics
    - Infections that are likely to spread / persist after surgical therapy
    - Immunocompromised
    - ***Empirical
  3. Organ support
    - Fluids / nutrition
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9
Q

Folliculitis / Furuncle / Carbuncle

A

Folliculitis:

  • 1 mm perifollicular red papule / pustule
  • areas of sweat / abrasion

Furuncle (Boil):

  • 1 cm tender red papule / fluctuant nodule
  • areas of sweat / abrasion

Carbuncle:
- several cm diameter red plaque
- nape of neck
- necrotising infection of skin + SC tissue composed of cluster of furuncles with **multiple draining sinuses (S. aureus)
—> poorly controlled DM
—> **Excision (Remove all necrotic sources / draining sinuses) + **Antibiotics + **DM control

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10
Q

Necrotising fasciitis

A
  • Infection that spreads along ***fascial planes
  • ***Polymicrobial
  • Portal of entry via skin
  • 30% mortality

Signs:

  • Erythema
  • SC edema
  • Dermal gangrene
  • Foul smelling (Dishwater) discharge
  • ***Venous thrombosis
  • ***Crepitus during palpation (∵ anaerobes)
  • ***Fournier’s gangrene —> dermal gangrene of scrotum and penis

Management:

  1. Rapid aggressive ***resuscitation
  2. ***Debridement of necrotic tissue
  3. ***Broad-spectrum antibiotics (∵ polymicrobial)
  4. Colostomy (if perineum is involved, to prevent faecal soiling)
  5. Foley catheter (prevent urinary contamination of debrided wound)
  6. Nutritional support
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11
Q

Cholecystitis

A

Management:

  1. Cholecystectomy
    - laparoscopic
    - open
  2. Cholecystostomy
    - incise a hole to drain all pus
  3. Antibiotics
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12
Q

Appendicitis

A

Management:

  1. Appendectomy
    - laparoscopic
    - open
  2. Antibiotics
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13
Q

Pyelonephritis

A

Pus in calyces

Management:
1. Drainage using nephrostomy

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14
Q

Parapharyngeal space abscess

A
  • Secondary to foreign body ingestion

- Concerns of airways

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15
Q

Post-op infection

A

Identify source

  1. ***Surgical site infection
  2. ***Respiratory infection
  3. UTI
  4. ***Line-associated infection
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16
Q

***Surgical site infection

A
  1. Clean
    - operative incisional wounds through non-inflamed tissue
    - skin commensals (S. epidermidis, S. aureus, S. enterobacteria)
    - very low infection rate (< 2%)
  2. Clean contaminated
    - perforation of clean viscus, ***entry into hollow viscus other than colon, with minimal, controlled contamination
    - e.g. Gastrostomy, Cystotomy (relatively sterile)
    - infection rate (~8-10%)
  3. Contaminated
    - ***breaching of hollow viscus with more spillage (opening the colon, open fractures, penetrating bites)
    - e.g. Perforated peptic ulcer (PPU)
    - infection rate (~20%)
  4. Dirty wounds
    - gross pus, perforated viscus (e.g. faecal peritonitis), traumatic wounds unattended >4 hours
    - e.g. Ruptured diverticulum, Leakage from colonic anastomosis
    - infection rate (~25%)

Management:

  1. Wound swab
  2. Blood culture
  3. Empirical antibiotics
  4. Drainage
  5. Debridement
17
Q

Extensive skin wound: Burn

A

Eschar: tough leathery tissue remaining after a full-thickness burn has been termed eschar
—> following a full-thickness burn, as the underlying tissues are rehydrated, they become constricted due to the eschar’s **loss of elasticity
—> leading to **impaired circulation distal to the wound

Management:
1. ***Eschartomy: incision through the eschar to expose the fatty tissue below. Due to the residual pressure, the incision will often widen substantially

  1. Skin graft on wound bed
18
Q

Respiratory infection

A

Causes:

  1. General anaesthetics + Basal atelectasis
  2. Prolonged ventilation
  3. Immunosuppression

4 types:

  1. Community acquired
  2. Nosocomial (usually gram -ve: **Klebsiella, **E. coli due to long term ventilation)
  3. Empyema (usually ***S. pneumoniae)
  4. Lung abscess (aspiration pneumonia, TB)
19
Q

UTI

A

Causes:

  1. Community acquired
    - **E. coli
    - **    Proteus
    - Klebsiella
  2. Renal abnormalities
    - ***Pseudomonas
  3. Catheterisation
    - ***S. epidermidis
    - E. faecalis
20
Q

Line sepsis

A

Incidence ↑ with duration

Common organisms:

  • Staphylococcus
  • Streptococci
  • Enterococci
  • Gram -ve species

Management:

  1. Re-site the line if infection documented
  2. Blood culture
    - ***infected line
    - distant peripheral site
  3. Antibiotics
21
Q

Prevention of infection

A
  1. Infection control
    - Identify patients at risk
    - Infection control teams + Hospital policy
    —> multidisciplinary
    —> audit
    —> implement hospital policy
    - Patient isolation + Ward discipline
  2. Measures to reduce infection
    - Environmental factors
    - Patient factors
    - Surgeon factors
    - Surgical technique
    - ***Prophylactic antibiotics
22
Q

***Measures to reduce infection

A
  1. Pre-operation skin preparation
    - Shower
    - Clipping of hair immediately pre-operation
    - Antiseptics
    —> **Betadine
    —> **    Chlorhexadine
    —> Alcoholic (flammable)
  2. Preparation of theatre
    - Cleaniness
    - Personnel movements
    - Airflow
    —> **PPFV (positive pressure filtered ventilation)
    —> **    Laminar flow
    —> Ultraclean air systems
  3. Preparation of surgical team
    - Scrub-up (↓ bacterial skin count)
    - Clothing (bacteria-impermeable fabrics)
    - Caps (    S. aureus on scalp)
    - Masks
    - Gloves
    - Shoes
  4. Asepsis and Sterilisation
    - Asepsis: Prevent introduction of bacteria
    —> skin preparation
    —> bowel preparation
    —> **draping to surround sterile field
    —> **    scrub up
    —> ***sterile instrumentation
    —> no-touch technique
    —> good operative technique
  • Sterilisation: Complete destruction of all viable microorganisms by means of heat, chemicals, irradiation
    —> ***Autoclave sterilisation
  1. Prophylactic antibiotics
    - Reduce surgical site infection
    - Given pre-operation
    - High levels of systemic antibiotics at the time of procedure and throughout surgery
    - Must be **Broad spectrum and appropriate to likely organisms
    - Indications:
    —> procedures which commonly lead to infection
    —> reducing post-op infections from endogenous sources
    —> if results of sepsis would be devastating
    —> **    NO value in clean procedures (e.g. sebaceous cyst, abscess)
23
Q

Antibiotic control of infection

A

Principles:

  1. Indication
  2. Microorganism
  3. Type / Class of antibiotics
  4. Route of administration
  5. Dosage
  6. Duration
  7. Reassessment

Beware:

  1. Allergy
  2. SE
  3. Toxicity (e.g. Hepatotoxicity / Renal toxicity)
  4. Microbial resistance
    - MRSA
    - VRE
24
Q

Microbial resistance

A
  1. Inappropriate prescription
  2. Failure to complete full course of antibiotics
  3. Addition of antibiotics to food chain
  4. Extensive use of antibiotics in sick patients with multiple organisms may promote resistance and transmission between individuals
  5. Natural evolution of bacteria
25
Q

Prevention of MRSA transmission

A
  1. Hand hygiene
  2. Patient screening
  3. ***Isolation of carriers
  4. Removal of colonised catheters
  5. Eradication of carriage

CFB (43 decks)

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