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Chapter 26 / Shock 169 |
What are the signs/ |
Hypotension and bradycardia, |
symptoms? |
neurologic deficit |
Why are heart rate and BP |
Loss of sympathetic tone |
decreased? |
(but hypovolemia [e.g., hemoperitoneum] |
|
must be ruled out) |
What are the associated |
Neurologic deficits suggesting cord injury |
findings? |
|
What MUST be ruled out in |
Hemorrhagic shock! |
any patient where spinal |
|
shock is suspected? |
|
What is the treatment? |
IV fluids (vasopressors reserved for hypo- |
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tension refractory to fluid resuscitation) |
What percentage of patients |
About 67% (two thirds) of patients |
with hypotension and spinal |
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neurologic deficits have |
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hypotension of purely |
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neurogenic origin? |
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What is spinal shock? |
Complete flaccid paralysis immediately |
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following spinal cord injury; may or may |
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not be associated with circulatory shock |
What is the lowest reflex available to the examiner?
What is the lowest level voluntary muscle?
What are the classic findings associated with spinal cord shock?
MISCELLANEOUS
Bulbocavernous reflex: checking for contraction of the anal sphincter upon compression of the glans penis or clitoris
External anal sphincter
Hypotension
Bradycardia or lack of compensatory tachycardia
What is the acronym for |
“BASE”: |
treatment options for |
Benadryl |
anaphylactic shock? |
Aminophylline |
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Steroids |
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Epinephrine |
170 Section I / Overview and Background Surgical Information
C h a p t e r 27 Surgical Infection
What are the classic signs/ symptoms of inflammation/ infection?
Define:
Bacteremia
SIRS
Tumor (mass swelling/edema) Calor (heat)
Dolor (pain)
Rubor (redness erythema)
Bacteria in the blood
Systemic Inflammatory Response Syndrome (fever, tachycardia, tachypnea, leukocytosis)
Sepsis
Septic shock
Cellulitis
Documented infection and SIRS
Sepsis and hypotension
Blanching erythema from superficial dermal/epidermal infection (usually strep more than staph)
Abscess |
Collection of pus within a cavity |
Superinfection |
New infection arising while a patient is |
|
receiving antibiotics for the original |
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infection at a different site (e.g., C. difficile |
|
colitis) |
Nosocomial infection |
Infection originating in the hospital |
Empiric |
Use of antibiotic based on previous |
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sensitivity information or previous |
|
experience awaiting culture results in |
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an established infection |
Prophylactic |
Antibiotics used to prevent an infection |
What is the most common |
Urinary tract infection (UTI) |
nosocomial infection? |
|
What is the most common |
Respiratory tract infection (pneumonia) |
nosocomial infection causing |
|
death? |
|
|
Chapter 27 / Surgical Infection 171 |
URINARY TRACT INFECTION (UTI) |
|
|
|
What diagnostic tests are |
Urinalysis, culture, urine microscopy for |
used? |
WBC |
What constitutes a POSITIVE |
Positive nitrite (from bacteria) |
urine analysis? |
Positive leukocyte esterase (from WBC) |
|
10 WBC/HPF |
|
Presence of bacteria (supportive) |
What number of colonyforming units (CFU) confirms the diagnosis of UTI?
On urine culture, classically 100,000 or 105 CFU
What are the common |
Escherichia coli, Klebsiella, Proteus |
organisms? |
(Enterococcus, Staphylococcus aureus) |
What is the treatment? |
Antibiotics with gram-negative spectrum |
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(e.g., sulfamethoxazole/trimethoprim |
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[Bactrim™], gentamicin, ciprofloxacin, |
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aztreonam); check culture and sensitivity |
What is the treatment of bladder candidiasis?
CENTRAL LINE INFECTIONS
1.Remove or change Foley catheter
2.Administer systemic fluconazole or amphotericin bladder washings
What are the signs of a central line infection?
Unexplained hyperglycemia, fever, mental status change, hypotension, tachycardia S shock, pus, and erythema at central line site
What is the most common cause of “catheter-related bloodstream infections”?
When should central lines be changed?
What central line infusion increases the risk of infection?
Coagulase-negative staphylococcus (33%), followed by enterococci, Staphylococcus aureus, gram-negative rods
When they are infected; there is NO advantage to changing them every 7 days in nonburn patients
Hyperal (TPN)
172 Section I / Overview and Background Surgical Information
What is the treatment for central line infection?
1.Remove central line (send for culture)/ IV antibiotics
2.Place NEW central line in a different site
When should peripheral IV |
Every 72 to 96 hours |
short angiocatheters be |
|
changed? |
|
WOUND INFECTION (SURGICAL SITE INFECTION) |
|
|
|
What is it? |
Infection in an operative wound |
When do these infections |
Classically, PODs #5 to #7 |
arise? |
|
What are the signs/ |
Pain at incision site, erythema, drainage, |
symptoms? |
induration, warm skin, fever |
What is the treatment? |
Remove skin sutures/staples, rule out |
|
fascial dehiscence, pack wound open, send |
|
wound culture, administer antibiotics |
What are the most common |
Staphylococcus aureus (20%) |
bacteria found in postopera- |
Escherichia coli (10%) |
tive wound infections? |
Enterococcus (10%) |
|
Other causes: Staphylococcus epidermidis, |
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Pseudomonas, anaerobes, other |
|
gram-negative organisms, |
|
Streptococcus |
Which bacteria cause fever |
1. Streptococcus |
and wound infection in |
2. Clostridium (bronze-brown weeping |
the first 24 hours after |
tender wound) |
surgery? |
|
CLASSIFICATION OF OPERATIVE WOUNDS
What is a “clean” wound?
Elective, nontraumatic wound without acute inflammation; usually closed primarily without the use of drains
What is the infection rate of 1.5% a clean wound?
What is a clean-contaminated wound?
Without infection present, what is the infection rate of a clean-contaminated wound?
Chapter 27 / Surgical Infection 173
Operation on the GI or respiratory tract without unusual contamination or entry into the biliary or urinary tract
3%
What is a contaminated wound?
What is the infection rate of a contaminated wound?
What is a dirty wound?
What is the infection rate of a dirty wound?
What are the possible complications of wound infections?
Acute inflammation, traumatic wound, GI tract spillage, or a major break in sterile technique
5%
Pus present, perforated viscus, or dirty traumatic wound
33%
Fistula, sinus tracts, sepsis, abscess, suppressed wound healing, superinfection (i.e., a new infection that develops during antibiotic treatment for the original infection), hernia
What factors influence the |
Foreign body (e.g., suture, drains, grafts) |
development of infections? |
Decreased blood flow (poor delivery of |
|
PMNs and antibiotics) |
|
Strangulation of tissues with excessively |
|
tight sutures |
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Necrotic tissue or excessive local tissue |
|
destruction (e.g., too much Bovie) |
|
Long operations ( 2 hrs) |
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Hypothermia in O.R. |
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Hematomas or seromas |
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Dead space that prevents the delivery of |
|
phagocytic cells to bacterial foci |
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Poor approximation of tissues |
What patient factors |
Uremia |
influence the development |
Hypovolemic shock |
of infections? |
Vascular occlusive states |
|
Advanced age |
|
Distant area of infection |
174 Section I / Overview and Background Surgical Information
What are examples of an |
Immunosuppressant treatment |
immunosuppressed state? |
Chemotherapy |
|
Systemic malignancy |
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Trauma or burn injury |
|
Diabetes mellitus |
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Obesity |
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Malnutrition |
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AIDS |
|
Uremia |
Which lab tests are |
CBC: leukocytosis or leukopenia (as an |
indicated? |
abscess may act as a WBC sink), blood |
|
cultures, imaging studies (e.g., CT scan |
|
to locate an abscess) |
What is the treatment? |
Incision and drainage—an abscess must |
|
be drained (Note: fluctuation is a sign |
|
of a subcutaneous abscess; most |
|
abdominal abscesses are drained |
|
percutaneously) |
|
Antibiotics for deep abscesses |
What are the indications for |
Diabetes mellitus, surrounding cellulitis, |
antibiotics after drainage of |
prosthetic heart valve, or an immunocom- |
a subcutaneous abscess? |
promised state |
PERITONEAL ABSCESS |
|
|
|
What is a peritoneal |
Abscess within the peritoneal cavity |
abscess? |
|
What are the causes? |
Postoperative status after a laparotomy, |
|
ruptured appendix, peritonitis, any |
|
inflammatory intraperitoneal process, |
|
anastomotic leak |
What are the sites of |
Pelvis, Morison’s pouch, subphrenic, |
occurrence? |
paracolic gutters, periappendiceal, |
|
lesser sac |
What are the signs/ |
Fever (classically spiking), abdominal |
symptoms? |
pain, mass |
How is the diagnosis made? |
Abdominal CT scan (or ultrasound) |