Clinical Officer Training MALAWI

1
Clinical Officer TrainingMALAWI

• SURGERY OF SEPSIS
• King 5 6

2
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?

3
COMMON SITES of SEPSIS, names?
4
The Surgery of Sepsis

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

5
WHAT CAUSES SEPTIC INFECTIONS?

• Not well understood
• Anaemia
• Malnutrition
• Poor hygiene
• More in children/young adults
• IMMUNE SYSTEM
• Predisposition HIV

6
Most common bacteria in surgical
sepsis?

• Staphylococcus aureus (Skin)
• E Coli and anaerobics (Peri-anal)
• TB
• Salmonella, Gonococcal

7
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.

8
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?

9
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!
10
WHAT IS PUS?

• Damaged tissue, necrosis, bacteria, autolized
  white blood cells,
• as a result of the infectious process

11
When to SUSPECT ABSCESS?LOCAL SIGNS- Pain
(throbbing pain the tighter the spacef.e
finger) - swelling- red- hot- impaired function -
Fluctuation?? GENERAL SIGNS- General
impression patient? Weak?- Abscess
temperature?
- Signs of toxaemia? - Septic shock?
12
NOT SURE PUS ?

• What to do?
• Aspirate with needle
• Failure to aspirate pus does not mean there is no
  pus
• Ultrasound scanning
• specifically for the abdomen
• Done that yourself?

13
What TO DO ABSCESS?
where there is pus, let it out !

• As soon as possible!
• why?
• SO OPERATE

14
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
15
ANTIBIOTICS in septic infections

• BUT GIVE
• 1. Signs of SPREADING INFECTION
  increasing erythema, cellulitis, lymphangitis /
  lymphadenitis
• 2. GENERALIZED symptoms with fever
  toxaemia (Bacteriaemia? Sepsis?)

16
PROCEDURE DRAINING ABSCESS

• 1. ANAESTHESIA
• ETHYL CHLORIDE for very small superficial
• LOCAL for small superficial
• Usually KETAMINE
• GENERAL anaesthesia, with muscle relaxants for
  deep intra peritoneal

17
PROCEDURE DRAINING ABSCESS

• 2. SURGERY
• Superficial abscess
• Skin incision
• site MAXIMUM tenderness
• parallel to nerves and
• blood vessels

18
DRAINING DEEPER ABSCESS

• b) Surgery by the
• Hiltons method
• to prevent deeper structures
• from being injured
• A. Incise skin at lowest point
• B. Push blunt haemostat into softest, prominent
  part
• C. Open haemostat inside the abscess
• D. Enlarge by blunt dissection inside the tissue
  by finger
• E. Insert drain

19
PROCEDURE DRAINING ABSCESS

• 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?

20
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

21
BOILS - CARBUNCLES
22
BOIL - CARBUNCLE

• BOIL aggressive infection skinsubcutis
  originating from hair follicle by staphylococci
• CARBUNCLE collection of boils with extensive
  subcutaneous necrosis.
• TREATMENT
• BOIL Lift out central necrosis /- small
  incision. Do not squeeze
• CARBUNCLE lift off slough, cut down on pus and
  necrosis and drain. Give antibiotics

staphylococcus aureus
23
SPECIAL ABSCESSES

• Examples?
• 1. PERINEPHRIC ABSCESS
  2. ILIAC ABSCESS
• 3. EMPYEMA
• 4. ABSCESSES IN PERITONEAL CAVITY
• 5. SUBPHRENIC ABSCESS
• 6. PELVIC ABSCESS

24
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

25
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.

26
Pleura aspiration Closed drainage
27
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?

28
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!
29
(No Transcript)
30
Ward rounds. Diagnose? Cause?
31
Skills like making knots !

• Thoraxdrains
• debridement wounds
• skingrafts etc.

32
(No Transcript)
33
ABSCESSES IN PERITONEAL CAVITY

• Symptoms?
• For example POST LAPAROTOMY
• Temperature doesnt 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)

34
HOW TO DIAGNOSE INTRA- ABD ABSCESS?

• IPPA Patient
• - Swelling to feel?/ Tender/ Fluctuation?
• What not to forget?
• Rectal / Vag examination!!! Why?
• Ultrasound
• Aspiration

35
(No Transcript)
36
Management intra abd abscess OPERATION decided.
1. Preferraby EXTRA peritoneal. Why?If you
cant, 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 cant close?
Bogota Bag - leave skin
open!! - Antibiotics iv (cephalo, genta, metro)

37
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

38
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
39
5. SUB PHRENIC ABSCESS

• Thoracic signs cough, diminished breath sounds,
  tenderness, oedemaredness 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)

40
6. PELVIC ABSCESS

• Follows- appendicitis - generalized
  peritonitis
• - female genital tract infection
• (PID)
• Drained preferably extra peritoneally by
  vaginal or by rectal drainage.
• Suprapubic Drainage

41
Pelvic Inflammatory Disease (PID) 1.
PID unrelated to pregnancy gonococci,
chlamydia, mycoplasma2. PID related to
pregnancy2.1 Post abortion 2.2 Infected
obstructed labour2.3 Puerperal sepsis (septic
thrombo flebitis)2.4 Post Caesarian
42
1. About PID unrelated to
pregnancyInfection starts from vagina/cervix2
waysA 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
43
ACUTE/CHRONIC PID

• MORE INFORMATION
• by
• Gynecologists

44
ZIKOMO KWAMBIRI
45
(No Transcript)