Page 20 - Medicine and Surgery

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16 Chapter 1: Principles and practice of medicine and surgery

present with painful swelling of the legs, low-grade Surgical site infection
pyrexia or with signs and symptoms of a pulmonary
embolism. Definition
Confusion due to hypoxia, metabolic disturbance, in- Surgical site infections include superficial site infections

fection, drugs, or withdrawal syndromes. (skin and subcutaneous tissues), deep site infections (in-
General infections include pneumonia secondary to volving fascia and muscle layers) and organ or space in-

poolingofsecretions,urinarytractinfectionsandcan- fections (such as abscess, bone infections, etc).
nula site infections.
Surgical site complications include paralytic ileus, Aetiology

anastomotic leaks, surgical site infections (with sec- Superficial and deep site infections occur due to Staphy-
ondary haemorrhage as a result of the infection), fis- lococcus aureus (including MRSA),Staphylococcus epi-
tula formation and wound dehiscence (total wound dermidis (specific association with prosthetic material
breakdown). Intestinal fistulae may be managed con- including cannulae) and Streptococci or mixed organ-
servatively with skin protection, replacement of fluid isms. The organisms responsible for organ or space
and electrolytes and parenteral nutrition. If such con- infections are dependent on the site and the nature
servative therapy fails the fistula may be closed surgi- of the surgical condition, e.g. anaerobic organisms in
cally. bowel perforation or anastomotic leaks, Streptococci and
Postoperative hypoxia is almost always initially due to Staphylococci in bone infections. The risk of surgical

perioperative atelectasis unless a respiratory infection site infection is dependent on the procedure performed.
was present preoperatively. Prophylaxis and treatment Contaminated wounds such as in emergency treatment
involves adequate analgesia, physiotherapy and hu- for bowel perforation carry a very high risk of infection.
midificationofadministeredgases.Respiratoryfailure Patients at particular risk include the elderly, mal-
may occur secondary to airway obstruction. Laryn- nourished, immunodeficient and those with diabetes
geal spasm/oedema may occur in epiglottitis or fol- mellitus.
lowing traumatic intubation. Tracheal compression
may complicate operations in the head and neck. In Clinical features
the absence of obstruction hypoxia may result from Superficial infections appear as a cellulitis (redness,
drugs causing respiratory depression, infection, pul- warmth, swelling and tenderness) around the wound
monary embolism or exacerbation of pre-existing margin, there may be associated lymphadenopathy. It
respiratory disease. Respiratory support may be may be of value to draw round the area of erythema to
necessary. monitor progression and response to treatment. Deeper
Acute renal failure may result from inadequate infections and collections may present as pyrexia with

perfusion, drugs, or pre-existing renal or liver disease. few external signs. Specific presentations depend on the
Once hypovolaemia has been corrected any remaining site, e.g. peritonitis or pus discharging from surgical
renal impairment requires specialist renal sup- drains.
port.
Prolonged immobility increases the risk of pressure Complications

sores especially in patients with diabetes or vascular Localised infections, especially in high-risk patients may
insufficiency.Skincare,hygiene,turningofthepatient spreadtocausegeneralisedsepticaemiaandsepticshock.
and the use of specialised mattresses should prevent Wound dehiscence (total wound breakdown) is rare. It
pressuresores.Treatmentinvolvesdebridement,treat- is preceded by a high volume serous discharge from the
ment of any infection, application of zinc paste and in wound site and necessitates surgical repair.
severe cases, plastic surgery.
Late postoperative complications, which may occur Investigations
weeksoryearsaftersurgery,includeadhesions,strictures Pyrexial patients require investigations. Paired aerobic
and incisional hernias. andanaerobicbloodculturesshouldbetaken(preferably