wound dehiscence + surgical site infection Flashcards
what is wound dehiscence
where a wound fails to heal, often re-opening a few days after surgery
(most common in abdominal surgery)
patient risk factors for wound dehiscence
Increasing age Male gender Co-morbidities, especially diabetes mellitus Steroids Smoking Obesity or malnutrition
intra operative risk factors for wound dehiscence
Emergency surgery Abdominal surgery Length of operation (>6hrs) Wound infection Poor surgical technique
post operative factors for wound dehiscence
Prolonged ventilation Post-operative blood transfusion Poor tissue perfusion (e.g. post-operative hypotension) Excessive patient coughing Radiotherapy
what are the clinical features of wound dehiscence
visible opening of the wound
pink serous or blood stained fluid from wound
5-7 days post operatively
You are called to see a patient who is 5 days post-laparotomy. He has pink serous fluid seeping from his wound. You assess him and his observations are normal. What is your next step in his management?
remove clips/sutures where the leakage is at its maximal and digitally examine the rectus sheath - ensure in tact
what investigations are required for wound dehiscence
clinical
management of superficial wound dehiscence
washing out the wound with saline and then simple wound care (e.g. packing the wound with absorbent ribbon gauze).
The patient should be advised the wound will now be required to heal by secondary intention and that this can take several weeks.
More extensive wounds may be treated with a Vacuum-Assisted Closure device to speed healing
management of full dehiscence
analgesia
broad spectrum IV abx
cover wound with saline soaked gauze and arrange urgent return to theatre for re closure of wound
describe prevention of wound dehiscence
Optimisation of co-morbidities and treating any surgical site infections
Avoiding heavy lifting and encouraging adequate post-operative nutrition will reduce the risk further.
You are called to see a patient who’s wound has dehisced and he now has bowel protruding from his abdomen. What is your next step in the patient’s management?
call senior and arrange an urgent return to theatre
cover the wound with moist dressing, re-close the abdomen (either with sutures or a vacuum wound closure device)
give iv fluid resus and administer dose of broad spectrum iv antibiotics
what is a surgical site infection
an infection that occurs in the incision created by an invasive surgical procedure.
what are the complications of SSI
hospital morbidity, resulting in prolonged hospital stay, increased hospital costs, higher rates of re-operation, and even increased mortality rates.
what is the primary prevention for SSI
good surgical technique and patient optimisation.
patient factors for SSI
Increasing age Poor glucose control Obesity Smoking Renal Failure Immunosuppression
operative factors for SSI
Preoperative shaving
Length of operation
Use of antimicrobial prophylaxis (protective)
Appropriate skin preparation (protective)
Appropriate gowning and sterile equipment (protective)
common clinical features of vSSI
Spreading erythema
Localised pain
Pus or discharge from the wound
Persistent pyrexia
investigations for SSI
wound swabs taken for culture at the wound site
Blood tests for infection markers (FBC, CRP) should be taken, alongside blood cultures if any evidence of systemic involvement or sepsis.
consider cross-section imaging to assess for deeper collections or even necrotising fasciitis.
management of SSI
sutures or clips present should be removed, allowing for the drainage of any pus and the opportunity for wound packing if required.
follow local empirical antibiotic guidelines.
prevention of SSI
pre op phase
- prophylactic abx
- do not remove hair routinely
- pt weight loss, smoking cessation, optimise nutrition, ensure good diabetic control
intra operative phase
- prepare the skin before incision
- change gloves or gown if contaminated
- wound irrigation at closure and use of abx impregnated sutures to close
post operative phase
- monitor wounds closely
- refer to tissue viability nurse for appropriate dressings for management of surgical wounds
