Transcript Surgical Infection. Acute Purulent Infection of The Skin

Surgical Infection.
Acute Purulent Infection Of
The Skin And Soft Tissues
A. Letch Kline, MD, FACS
Infections
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Skin And Soft Tissue Infections Are Common
In Our VA Population
Most Are Treated As Outpatients But Many
Patient Come In Late And Require Admission
Most Of The Hospitalized Infections Require
Surgical Drainage
Preoperative Preparation And Postoperative
Nursing Care Is Critical To Successful Outcome
Acute Purulent Aerobic Infections
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The Cause Of The Most Frequently Purulent
Surgical Infections:
Staphylococcal Infections.
 Streptococcal Infections.
 Gram - Negative Infections.
 Mixed Bacterial Infections.
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Five Classical Local Signs Of
Inflammation Are:
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Heat-the Inflamed Area Feels Warmer Than
The Surrounding Tissues.
Redness Of The Skin Over The Inflamed Area.
Tenderness, Due To The Pressure Of Exudate
On The Surrounding Nerves.
Swelling.
Loss Of Function
Boil (Furuncles)
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Boil Constitute One Of The Very Widespread Purulent
Diseases Of The Hair Follicle And Sebaceous
Boil (Furuncles)
Boil (Furuncles)
Complications
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Boils May Lead To Cellulitis, Particularly In
Those Whose Power Of Immunity Is Less.
Boils May Also Lead To Infection Of The
Neighboring Hair Follicles Where Numbers Of
Hair Follicles Are Too Many (E.G. Axilla)
Leading To Hidradenitis.
Boils Usually Secondarily Infect The Regional
Lymph Nodes.
Hidradenitis
Carbuncle
Carbuncles
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After Penetration Of Pyogenic Bacteria Under
The Skin Through Hair Follicles And Sebaceous
Glands The Process Spreads In Depth, If The
Conditions Are Unfavorable To The Body, And
Affects Considerable Sections Of Subcutaneous
Tissue. It Is An Infective Gangrene Of The
Subcutaneous Tissue Due To Staphylococcal
(Staphylococcus Aureus) Infection. Gramnegative Bacilli And Streptococci May Be Found
Coincidently.
Carbuncle
Treatment
Treat Medical Conditions
 Culture
 Antibiotic.
Operation May Be Required:
 Unresponsive To Antibiotic
 Carbuncle Is More Than 2 Inches In Diameter With
Fluctuance
 Ultrasound Can Be Used To Detect Abscess Cavity
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Abscess
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An Abscess Is A Cavity Filled With Pus And
Lined By A Pyogenic Membrane. This Pyogenic
Membrane Consists Of Dead Tissue Cells And
A Wall Of Granulation Tissue Consisting For
The Most Part Of Phagocytic Histiocytes.
Abscess
Abscess
Treatment
The Basic Principle Of Treatment Of An Abscess
Are:
 To Drain The Pus;
 To Send A Sample Of Pus For Culture And
Sensitivity Test;
 To Give Proper Antibiotic.
Erysipelas
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It Is An Acute Inflammation Of The Lymphatics
Of The Skin Or Mucous Membrane.
The Causative Organism Is Usually Streptococcus
Haemolyticus.
Erysipelas
Erysipelas
Erysipelas
Erysipelas
Lymphangitis
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A Spread Of Infection Along The Lymphatic
System Is Manifested In A Disease Of The
Lymphatic Vessels And Lymph Nodes.
Inflammation Of The Lymphatic Vessels
(Lymphangitis) Is One Of The Frequent
Complications Of Infected Wounds, Especially
During The First Weeks Following Injury, And
Of Local Purulent Diseases.
Lymphangitis
Treatment
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The Treatment Of Lymphangitis Consists
Primarily In Elimination Of Its Cause (Incision
Of The Abscess, Pockets Of The Wound, Etc.)
And In Giving The Affected Organ Complete
Rest.
Paraproctitis
Paraproctitis
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Is The Purulent Inflammation Of Around-rectal
Cellular Tissue.
Can Progress To Fournier’s Gangrene
Skin Abscess
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Require Incision And Drainage
Make Large Enough Incision To Drain Purulent
Collection
Greater Then 6 Cm Or Complex/Deep
Infection May Require General Anesthesia
Take Cultures Before Starting Antibiotics
Pack Wound Tightly To Prevent Bleeding In
First 6 Hours
Post Operative Care
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Leave Packing For 6-12 Hours
Pre And Postoperative Antibiotics
Monitor Fever, WBC, Associated Cellulitis
Return To The OR If Have Fasciitis Or
Advancing Infection
Start Wet To Dry Packing To Debride Surface
Of SQ Tissues And Create Granulation Tissue
Preoperative Care
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Antibiotics
Start As Soon As Diagnosis Made But
 Try To Get Cultures If Possible First
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Want To Cover Gram Positives In Routine Skin
Infections
Gram Positives, Gram Negatives/Anerobes If
Fasciitis Or Life/Limb Threatening Infection
Preoperative Care
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Antibiotics
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Skin Infections-mssa
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Po
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Dicloxicillin
Cephalexin
Iv
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Nafcillin/Oxacillin
Cefazolin
Preoperative Care
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Antibiotics
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Skin Infections-mrsa
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Po
Bactrim DS
Clindamycin
Doxycyline
Linezolid
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Iv
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Vancomycin
Linezolid
Preoperative Care
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Antibiotics
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Life Or Limb Threatening Infections
Diabetic Foot Infections
 Faciitis
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Cover Gram Negatives And Anerobes As Well As
Gram Positives
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Vancomycin And
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Unasyn
Timentin
Zosyn
Ertapenem/Imipenem/Meropenem
Post Operative Care
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Once Purulence Is Controlled, Consider Wound
Vacuum Assisted Closure (VAC)
Drains Wound
Lessens Need For Dressing Changes
Often Less Painful For Patients
Quickens Wound Closure
Clinical Benefits Of V.A.C. Therapy
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Maintenance Of Moist, Protected Environment
Removal Of Excess Interstitial Fluid From The Wound
Periphery
Increased Local Vascularity
Decreased Bacterial Colonization
Quantification/Qualification Of Wound Drainage
Increased Rate Of Granulation Tissue Formation
Increased Rate Of Contraction
Increased Rate Of Epithelialization
V.A.C. Therapy Indications
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Acute Wounds
Full-thickness Surgical Wounds
Chronic Wounds
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Stage 3 Pressure Ulcers
Stage 4 Pressure Ulcers
Diabetic Ulcers
Venous Stasis Ulcers
Traumatic Wounds
Dehisced Wounds
V.A.C. Therapy Contraindications
Active Infections
 Nearby Blood Vessels
 Malignancy In Wound
 Untreated Osteomyelitis
 Nearby Bowel
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Perioperative Care
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Broad Spectrum Antibiotics
Start Empiric (Best Guess) Coverage Then Use
Culture/Gram Stain Results
 Cover MRSA
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Control Blood Glucose
Patient/Wound Isolation
Pain Control
KT/Physical Therapy-prevent Contractures
Perioperative Care
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Dressing Changes
More Frequent If Trying To Debride
 Packing Should Be Loose But Want To Cover The
Surface Of The Cavity
 Start With Saline Soaked Gauze-avoid Betadine For
Repeated Wound Dressings
 Can Add Dakin’s Solution If Concerned For
Superficial Pseudomonas
 Best If Can Remove Dry, To Help Debride Surface
Of Cavity
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Perioperative Care
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Consider For Discharge
Afebrile
 Decreasing WBC
 Resolving Cellulitis
 No Evidence For Sepsis/SIRS
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Normal BP
 No Orthostatic Changes
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Adequate Pain Control
Appropriate Home Care
Necrotizing Fasciitis
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Life-threatening, Progressive, Rapidly Spreading, Inflammatory
Infection Located In The Deep Fascia.
Infection Rapidly Destroy The Skin And Soft Tissue Beneath It
Also Known As: “Flesh-eating” Bacteria.
Other Names: Β-hemolytic Streptococcal Gangrene, Meleney Ulcer,
Acute Dermal Gangrene, Hospital Gangrene, And Necrotizing
Cellulitis.
3 Types Of NF.
 Type I : A Polymicrobial Flora.
 Type II Group A Β-streptococcus Bacteria (Most Common
Case)
 Type III : Marine Vibrio Gram-negative Rods.
Cofactors That Increase Risks
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Diabetes
Alcoholism
Immuno-suppression
Severe Illnesses: Heart, Lung, Or Liver Disease
Obesity
Pathophysiology
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Bacteria Destroy Tissue Between Skin And Muscle
Increase In Sensitivity Or Anesthetic Feel To The
Skin Itself
Inflammatory Response By Immune System
Bacterial Toxins Released
Cytokines Impede Function Of Phagocytic Cells
 Anaerobes Thrive Speeding Up Necrotic
Process
Endothelial Cells Become Damaged;
 Increased Permeability Of The Lining Of
Vessels In The Body
Pathophysiology
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Poor Blood Supply Inhibit:
 Inflammatory Response Process
 Ability For The Immune System To Properly
Work
 Ability To Transfer Antibiotics To The Affected
Fascial Layer
Vasoconstriction And Thrombosis  Edema 
Hypoxia  Necrosis Of The Fascia, Skin, Soft
Tissue, And Muscles.
Additional Necrosis Involving The Subcutaneous
Nerves.
Early Symptoms And Signs Of
NF?
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Flu like symptoms that include
fever, chills, nausea, weakness,
dizziness, aches and a heat rate of
more than 100 beats per minute.
Skin becomes tender, warm, red in
color, and will start to swell.
Patients may experience pain
greater than expected from the
appearance of the wound.
Subcutaneous tissue may also have
a hard feel on palpation that goes
past the visibly infected area.
Clinically indistinguishable from
other possible soft tissue infections
with only the presentation of pain,
tenderness, and warm skin.
Advanced Symptoms…
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The advanced symptoms appear as
the disease progresses
The area of the body experiencing
pain begins to swell excessively.
Multiple discolored patches
develop to produce a large area of
gangrenous skin.
Initial necrosis appears as a massive
destruction of the skin and
subcutaneous layer.
The normal skin and subcutaneous
tissue are loosened.
Large, dark marks that become
blisters filled with a yellow-green
necrotic fluid appear.
Critical Symptoms…
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The Critical Symptoms Form In
The Last Stages Of NF.
30% Of Patient’s Develop
Hemorrhagic Bullae Which May
Cause Them To Become Anemic.
Vasculature Of The Skin Becomes
Inflamed And Thrombosed.
Resulting In Necrotic Eschars That
Look Like Deep Thermal Burns.
Without Treatment, Secondary
Involvement Of Deeper Muscle
Layers May Occur.
Critical Symptoms…
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Patients May Become Numb Because
Of Nerve Damage And Progressing
Gangrene In The Infected Area.
Unconsciousness Will Occur As The
Body Becomes Too Weak To Fight Off
The Infection Along With A Severe
Decrease In The Patient’s Blood
Pressure.
As Toxins Are Being Released, The
Body’s Organ May Go Into Septic
Shock While Contracting A High Fever,
High White Blood Count, And
Becoming Disoriented. This May Result
Into Respiratory Failure, Heart Failure
And Renal Failure.
Treating NF
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Early Diagnosis And Treatment Is Vital
Emergency Debridement
IV Antibiotic Treatment
Hyperbaric Oxygen Therapy Is Recommended For Anaerobic Organisms
Morphine Drip And A Patient-controlled Analgesia Pump To Control Pain
Soft Tissue Reconstruction
Monitor Nutrition
If Sepsis Has Set In, Vasoconstricting Medications Should Be Given.
Education And Counseling
Other Soft Tissue Infections
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Fournier’s Gangrene
Diabetic Foot Ulcers
Vascular Leg Ischemia
Post Operative Wound/Graft Infections
Primary Cellulitis
Conclusion
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Early Recognition And Treatment Is Critical To
The Prevention Of Complications Of Skin And
Soft Tissue Infections
Surgical I&D And Debridement With
Perioperative Directed Antibiotics Coverage Is
The Hallmark Of Treatment Of Progressive
Infections
Perioperative Nursing Care Is Critical To A
Successful Outcome