An in-hospital workup of a 78-yrs-old hypertensive

Discussion in 'MRCS Forum' started by Lona., Oct 26, 2007.

  1. Lona.

    Lona. Guest

    An in-hospital workup of a 78-yrs-old hypertensive, mildly asthmatic man who is receiving chemotherapy for colon cancer reveals symptomatic gallstones. Preoperative laboratory results are notable for a hematocrit of 24% and a urinalysis with 18 to 25 WBCs and gram-negative bacteria. On call to the operating room, the patient receives intravenous penicillin. His abdomen is shaved in the operating room. An open cholecystectomy is performed and, despite a lack of indications, the common bile duct is explored. The wound is closed primarily with a Penrose drain exiting a separate stab wound. On postoperative day 3, the patient develops a wound infection.

    1. Which of the following changes could have made this wound a less favorable environment for infection?
    a- Decreasing the operative time and wound contamination by omitting the common bile duct exploration
    b- Placing Penrose drain exiting directly through the lateral corner of the wound
    c- Using oral rather than intravenous penicillin perioperatively
    d- Leaving a seroma in the closure to prevent desiccation of the tissues
    e- Reinforcing the wound closure with a sheet of prosthetic polypropylene mesh

    2. Which of the following characteristics of this patient might have increased the risk of a wound infection?
    a- History colon surgery
    b- Hypertension
    c- Male sex
    d- Receipt of chemotherapy
    e- Asthma

    3. Which of the following changes in the care of this patient could have decreased the chance of a postoperative wound infection?
    a- Increasing the length of the preoperative hospital stay to prophylacticaly treat the asthma with steroids
    b- Treating the urinary infection prior to surgery
    c- Shaving the abdomen the night prior to surgery
    d- Continuing the prophylactic antibiotics for three postoperative days
    e- Using a closed drainage system brought out through the operative incision
  2. Lona.

    Lona. Guest

    Answer: 1-a, 2-d, 3-b. (Schwartz, 7/e, pp 448-452) The determinants of postoperative wound infection include those related to the bacteria, the environment (i.e. the wound), and the host’s defense mechanisms. Within this triad there are factors predetermined by the status of the patient (e.g. age, obesity, steroid dependence, multiple diagnoses (more than three), and immunosuppression) and by the type of procedure (e.g. contaminated versus clean, emergent versus elective). However, there are several factors that can be optimized by the surgeon. Decreasing the bacterial inoculum and virulence by limiting the patient’s prehospital stay, clipping the operative site in the operating room, administering perioperative antibiotics (within a 24-h period surrounding operation) with an appropriate antimicrobial spectrum, treating remote infections, avoiding breaks in technique, using closed drainage systems (if needed at all) that exit the skin away from the surgical incision, and minimizing the duration of the operation have all been shown to decrease postoperative infection. Making a wound less favorable to infection requires attention to basic Halstadian principles of hemostasis, anatomic dissection and gentle handling of tissues as well as limiting the amount of foreign body and necrotic tissue in the wound. Although they are the most difficult factors to influence, host defence mechanisms can be improved by optimizing nutritional status, tissue perfusion, and oxygen delivery.

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