Clinical Officer Training MALAWI SURGERY OF SEPSIS King 5 + 6.

Clinical Officer Training

MALAWI

SURGERY OF SEPSIS

King 5 + 6


The “surgery of sepsis” What is that?

HOW to DRAIN PUS Has to do with INFECTION Most commonest operation developing world Can collect almost everywhere in the body Where?

Could be 1, could be more abscesses Some small, some more than 3 liters of pus

Your experience?

2013 Clinical Officer Training Malawi



COMMON SITES of SEPSIS, names?


The Surgery of Sepsis

Particular important sites Muscles: pyomyositis Bones: osteomyelitis Joints: septic arthritis Hand: f.e paronychia Breast: mastitis Pleura: empyema Peritoneum: peritonitis



WHAT CAUSES “SEPTIC INFECTIONS”?

Not well understood Anaemia Malnutrition Poor hygiene More in children/young adults

IMMUNE SYSTEM Predisposition: HIV



Most common bacteria in surgical sepsis?

Staphylococcus aureus (Skin)

E Coli and anaerobics (Peri-anal)

TB

Salmonella, Gonococcal

2013


BODY RESPONSES

INFLAMMATION

Is the natural response of the body (vascular tissues) to protect itself from harmful stumuli such as “irritants”, damaged cells. It is the initiation of the healing system.

Examples: sun burn, fracture, insect bite etc

Classical signs: pain, heat, swelling (oedema), redness (hyperaemia), los of function

INFECTION is the invasion of disease causing organism such as germs, viruses and fungus, and the reaction of host tissues to these organisms and the toxins they produce. Hosts can fight using their immune system.




TYPES OF INFECTION

Localized inf (Body managed to localize infection)

example: BOIL, CARBUNCEL

Spreading inf (Invador seems to be stronger ) Spreading cellulitis: skin + subcutis Lymphangitis: along lymphatics Bacteraemia is the presence of bacteria in

the blood and may or may not be symptomatic

What most serious complication is? Signs?



What is an abscess?

a non previously existing cavity filled with PUS

It is the outcome of the body management to imprison the intruders by a wall of defense forces!


WHAT IS PUS?

Damaged tissue, necrosis, bacteria, autolized white blood cells,

as a result of the infectious process



When to SUSPECT ABSCESS?

LOCAL SIGNS- Pain (throbbing pain: the tighter the space…f.e finger) - swelling- red- hot- impaired function - Fluctuation?? GENERAL SIGNS- General impression patient? Weak?- Abscess temperature? - Signs of toxaemia? - Septic shock?




NOT SURE PUS ?

What to do?

Aspirate with needleFailure to aspirate pus does not mean there is no pus

Ultrasound scanning

specifically for the abdomen

Done that yourself?



What TO DO ABSCESS?

As soon as possible!why?

SO OPERATE


TO TREAT AN ABSCESS


by ANTIBIOTICS?

usually NOT NEEDED or even USELESS and DANGEROUS!

why?

Useless why?

Because antibiotics will not enter the abscess in which the pressure is high


ANTIBIOTICS in septic infections

BUT GIVE

1. Signs of SPREADING INFECTION increasing erythema, cellulitis, lymphangitis /

lymphadenitis

2. GENERALIZED symptoms with fever toxaemia (Bacteriaemia? Sepsis?)



1. ANAESTHESIA

ETHYL CHLORIDE for very small superficial LOCAL for small superficial Usually KETAMINE GENERAL anaesthesia, with muscle relaxants

for deep intra peritoneal


PROCEDURE DRAINING ABSCESS



2. SURGERY

Superficial abscess

Skin incision

site MAXIMUM tenderness

parallel to nerves and

blood vessels




DRAINING DEEPER ABSCESSb) Surgery by the “Hilton’s method” to prevent deeper

structures from being injuredA. Incise skin at lowest point B. Push blunt haemostat into

softest, prominent partC. Open haemostat inside the

abscessD. Enlarge by blunt dissection

inside the tissue by fingerE. Insert drain


How to DRAIN?

Provide FREE drainage: Open wide Use corrugated drain if abscess is deep and fix Do not use curette

Immediate Complications Bleeding What to do?

Post op measures Raise Analgetics Attention when to REMOVE drain. Why?

Clinical Officer Training Malawi



LATE COMPLICATIONS

Pus remains coming out. Cause?

Foreign body? Gauze? Procedure rightly done? Patient does not improve: Cause? HIV?

TB? More abscesses develop. Cause?

Due to Pyaemia!

Treatment?

Now give antibiotics. Patient very ill and several abscesses. What now?

Will not tolerate operation. ABSTAIN

2013



BOILS - CARBUNCLES



BOIL: aggressive infection skin+subcutis originating from hair follicle by staphylococci

CARBUNCLE: collection of boils with extensive subcutaneous necrosis.

TREATMENTBOIL: Lift out central necrosis +/- small incision.

Do not squeeze CARBUNCLE: lift off slough, cut down on pus and

necrosis and drain. Give antibiotics

BOIL - CARBUNCLE


SPECIAL ABSCESSES

Examples?

1. PERINEPHRIC ABSCESS 2. ILIAC ABSCESS

3. EMPYEMA

4. ABSCESSES IN PERITONEAL CAVITY

5. SUBPHRENIC ABSCESS

6. PELVIC ABSCESS




SPECIAL ABSCESSES 1. PERINEPHRIC ABSCESS

Fever, tender swollen loin /subhepatic.

Pus must be drained!

Approach extra peritoneal

as for nephrostomy. AB 2. ILIAC ABSCESS

Fever, painful flexed hip, swelling inguinal regio. Ex. under anaesth. Punctate for pus. Explore “extra peritoneal” for drainage



3. EMPYEMA

Febrile Limited movement chest affected side Dull on percussion

X-ray: dense area lung base

Diagnose: Aspirate to confirm the diagnosis. How? Cause?

TB? How to diagnose?MANAGEMENT Give antibiotics. Repeat aspiration 3 times a week, until pus stops

forming. If aspiration becomes difficult closed drainage

for at least 2 weeks.



Pleura aspiration & Closed drainage


4. ABSCESSES IN PERIT. CAVITY

Can be the result of: General Peritonitis

with primary focus of infection f.e -- appendicitis – salpingitis (PID) – perf gastric.u – perf typhoid ulcer

An abdominal injury (trauma)

- gut perforation Any laparotomy

- Contamination? Why?

- Aseptic theatre technique? (Chikwawa)

- Infection rate in yr H? And yours? Higher 5%?

- Audit?! How in yr hospital?

Clinical Officer Training Malawi


HIGH POST OPERATIV INFECTION RATE?

- Check what? ASEPTIC THEATRE TECHNIQUE,

includes YOU too Was indication good? How preparation of patient in ward, in theatre, scrubbing, gowning, draping, shaving, counting gauzes? and your surgical technique? Like: tissue handling, wound closure, making proper knots, etc CO project study post op inf rate: 21%- 8.6%!! It can be done! Clinical Officer Training Malawi


Ward rounds. Diagnose? Cause?


Skills: like making knots !

•Thoraxdrains

•debridement wounds

•skingrafts etc.



ABSCESSES IN PERITONEAL CAVITY

Symptoms? For example POST LAPAROTOMY Temperature doesn’t fall Sepsis/Abscess temperature Pat not well, looses weight WB count is raised

On examination? Abdomen tender Decreased or absent bowel sounds? Shallow breathing? Dehydrated? Hypotensive? (septic shock)



HOW TO DIAGNOSE INTRA- ABD ABSCESS?

IPPA Patient

- Swelling to feel?/ Tender/ Fluctuation?

What not to forget?

+ Rectal / Vag examination!!! Why?

Ultrasound Aspiration


Management intra abd abscess OPERATION decided. 1. Preferraby EXTRA peritoneal. Why?If you can’t, do: 2. Laparatomycareful for bowels, use fingers, drain pus, use saline, decide: “to drain or not to drain”, close fascia

- with what? - what to do if you can’t close?

“Bogota Bag” - leave skin open!! - Antibiotics iv (cephalo, genta, metro)



“TO DRAIN OR NOT TO DRAIN”

Tubes: lead fluids from somewhere to somewhere.

Pleural cavity, naso- gastric tube, feeding tubes Drains: to let blood, pus, intestinal contents, bile

and other fluids escape from a wound while it heals, without letting the bacteria getting in

Open/closed drainage system Risk: bacteria and spreading infection

eroding tissue and blood vessels.

Trend: not to drain unless good reasons


Clinical Officer Training THE USE OF A DRAIN INTRA ABD ABSCESS

- Use SEPARATE incision, as wide as drain- Fix drain to skin

Open drainage - Penrose tube (soft latex) 1-2 cm - Corrugated rubber drain Preferred

Semi or Closed tube drainage systems - Sump Suction drain, cont. suction by vacuum Removal - as soon is feasible, max 3- 4 days

2013



5. SUB PHRENIC ABSCESSThoracic signs: cough,

diminished breath sounds, tenderness, oedema+redness loin/below ribs.

X-ray essential: raised fuzzy looking diaphragm, fluid costo phrenic angle.

Incision for drainage in loin below ribs (site of max oedema redness)



6. PELVIC ABSCESS

Follows- appendicitis - generalized peritonitis

- female genital tract infection

(PID) Drained preferably

extra peritoneally by vaginal or by rectal drainage.

Suprapubic Drainage


Pelvic Inflammatory Disease (PID)

1. PID unrelated to pregnancy gonococci, chlamydia, mycoplasma

2. PID related to pregnancy

2.1 Post abortion 2.2 Infected obstructed labour2.3 Puerperal sepsis (septic thrombo flebitis)2.4 Post Caesarian



1. About PID unrelated to pregnancy

Infection starts from vagina/cervix2 ways:A: ascending- Endometrium: endometritis- Fallopian tubes: salpingitis- Tubes/ovaries: tubo ovarian abscess- Pelvic cavity: Pelvic peritonitis- abscess- Peritoneal cavity: generalized peritonitis

B: through uterine wall to broad ligaments - parametritis/abscess - septic thrombophlebitis




ACUTE/CHRONIC PID

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Clinical Officer Training MALAWI SURGERY OF SEPSIS King 5 + 6.

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