CLINICAL CASES FOR THE EXAM 5 Wounds and Wound Healing PROBLEM 23 A 55 year old man with a history of severe asthma (treated with chronic steroids) and non-insulin dependent diabetes underwent an emergent sigmoid resection with end colostomy for perforated diverticulitis. There was gross contamination of the entire abdominal cavity with large intestine contents. During the operation his blood pressure fell to 80 systolic. After irrigation of the abdomen to clear debris, the abdominal fascia was closed with running #2 nylon suture material and the skin and subcutaneous tissue left open and packed with saline-moistened gauze. Study Questions: 1. What type of wound closure was used in this patient? 2. What is the sequence of wound healing events? 3. What specific factors about this patient will influence wound healing? Surgical Infections/Antibiotics PROBLEM 24 A 55 year old woman undergoes an emergency cholecystectomy and common duct exploration for acute cholecystitis and cholangitis. E. coli, Klebsiella, and enterococcus grow out of the intraoperative bile cultures. She receives ampicillin and gentamicin preoperatively and this is continued in the postoperative period through day four. On day five she complains of increased pain in the stapled skin closure site. She has fever to 39oC, and erythema and warmth are noted in the mid portion of the wound. Study Questions: 1. What type of wound (clean, clean-contaminated, contaminated, dirty) was present in this case? What is the relative risk of surgical site infection in these categories? 2. What type of surgical site infection (SSI) is likely in this patient? 3. What other risk factors can contribute to increased infection rates? 4. What organism(s) would you expect to culture from this wound? 5. How would you treat this patient’s surgical site infection? PROBLEM 25 A 65 year old male diabetic has had pain in the perianal region for three days. This morning his wife found him unresponsive and called an ambulance. Upon arrival to the emergency room he has a blood pressure of 90/50, pulse of 130, a temperature of 40oC and is foul-smelling. Examination of his perianal region reveals crepitus, bullae, and foul-smelling liquid draining from a spontaneously draining abscess just lateral to the right anal opening. A pelvic x-ray demonstrates air in the soft tissues of the perineum. Study Questions: 1. What types of infections can cause crepitus and air in the soft tissues? 2. What type of patients are more prone to these infections? 3. How is a specific microbiologic diagnosis made quickly? 4. What is the major mode of therapy for such infections? 5. What adjuncts are available in the management of such infections? PROBLEM 26 A 35 year old woman who was involved in a motor vehicle accident undergoes a splenectomy for a severely injured spleen. On postoperative day #1 she has a temperature to 38.5oC, with physical exam demonstrating tubulo-vesicular breath sounds and egophony at her left base. Preoperatively administered cephazolin is discontinued after two doses. Her temperature over the next four days never goes below 38oC and on day five increases to 39oC. Her physical exam is unchanged. Her abdomen is as distended as it was immediately postoperatively, and she has passed little flatus. Her wound looks normal. She has little appetite and still requires intravenous fluid. A urinary catheter is still in place. Her WBC fell from 15,000 immediately postoperatively to 10,000 on day three. On day five it is 18,000. Study Questions: 1. What were the likely etiologies of fever during the immediate postoperative period? What was most likely? 2. What test(s) besides physical exam would confirm this diagnosis? 3. What etiologies of fever are likely on post-operative day #5? What test(s) would help you make a diagnosis? PROBLEM 27 A 68 year old man with known COPD (FEV1 1.5 liters, pCO2 48 on room air) undergoes an uneventful resection of a 6cm abdominal aortic aneurysm. However, intubation was difficult and required three attempts. One dose of preoperative cephazolin was given. Central vascular access wad placed during surgery but a pulmonary artery catheter was not used. On postoperative day one he fails extubation because of vocal cord swelling and is urgently reintubated. Despite the presence of a nasogastric tube, some gastric contents are suctioned from the endotracheal tube. He had been on H2 blockers since surgery. His repeat chest x-ray shows bilateral pulmonary infiltrates. Blood gases on 50% FIO2, tidal volume 1000 and rate 12 are pO2 95 and pCO2 42. No antibiotics are given. Four days later he develops a temperature to 39oC with no drop in blood pressure but an increase in pulse to 120. His chest x-ray shows resolution of most of the infiltrates except for those in the right lower lung field. The central venous catheter is still in place. Urine output measured throughout with a bladder catheter is 30 cc to 40 cc per hour. His blood gases drawn through the arterial line placed in the operating room on 40% FIO2 and an IMV of 6 are pO2 of 105, pCO2 45. Study Questions: 1. What are the most likely etiologies of fever in this patient on postoperative day five? 2. What role does preoperative antibiotics have in preventing infections postoperatively? Which type of infections are prevented? 3. How does gastric acid neutralization affect postoperative infection risk? 4. What is the most common nosocomial infection?
Posted on: Tue, 25 Nov 2014 11:30:31 +0000
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