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MALAWI
SURGERY OF SEPSIS
King 5 + 6
Clinical Officer Training
The “surgery of sepsis”
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2013
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?
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COMMON SITES of SEPSIS, names?
2013
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The Surgery of Sepsis
Particular important sites
 Muscles: pyomyositis
 Bones: osteomyelitis
 Joints: septic arthritis
 Hand: f.e paronychia
 Breast: mastitis
 Pleura: empyema
 Peritoneum: peritonitis
2013
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Clinical Officer Training
WHAT CAUSES “SEPTIC INFECTIONS”?
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Not well understood
Anaemia
Malnutrition
Poor hygiene
More in children/young adults
IMMUNE SYSTEM
Predisposition: HIV
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Most common bacteria in surgical sepsis?
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Staphylococcus aureus (Skin)
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E Coli and anaerobics (Peri-anal)
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TB
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2013
Salmonella, Gonococcal
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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.
2013
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TYPES OF INFECTION
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Localized inf (Body managed to localize
infection)
example: BOIL, CARBUNCEL
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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?
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2013
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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!
2013
Clinical Officer Training Malawi
Clinical Officer Training
WHAT IS PUS?
Damaged tissue, necrosis, bacteria,
autolized white blood cells,
as a result of the infectious process
2013
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When to SUSPECT ABSCESS?
LOCAL SIGNS
- Pain (throbbing pain: the tighter the
space…f.e finger) - swelling- red- hotimpaired function - Fluctuation??
GENERAL SIGNS
- General impression patient? Weak?
- Abscess temperature?
- Signs of toxaemia?
- Septic shock?
2013
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NOT SURE PUS ?
What to do?
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Aspirate with needle
Failure to aspirate pus does not mean there is no pus
Ultrasound scanning
specifically for the abdomen
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Done that yourself?
2013
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What TO DO ABSCESS?
As soon as possible!
why?
SO
2013
OPERATE
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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
2013
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Clinical Officer Training
ANTIBIOTICS in septic infections
BUT GIVE
1. Signs of SPREADING INFECTION
increasing erythema, cellulitis, lymphangitis /
lymphadenitis
2. GENERALIZED symptoms with fever
toxaemia (Bacteriaemia? Sepsis?)
2005
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PROCEDURE DRAINING ABSCESS
1. ANAESTHESIA
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2005
ETHYL CHLORIDE for very small superficial
LOCAL for small superficial
Usually KETAMINE
GENERAL anaesthesia, with muscle relaxants
for deep intra peritoneal
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PROCEDURE DRAINING ABSCESS
2. SURGERY
Superficial abscess
Skin incision
site MAXIMUM tenderness
parallel to nerves and
blood vessels
2005
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DRAINING DEEPER ABSCESS
b) Surgery by the
“Hilton’s 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
2005
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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
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Raise
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Analgetics
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Attention when to REMOVE drain. Why?
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LATE COMPLICATIONS
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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
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BOILS - CARBUNCLES
2013
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BOIL - CARBUNCLE
BOIL: aggressive infection skin+subcutis 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
2013
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SPECIAL ABSCESSES
Examples?
1. PERINEPHRIC ABSCESS
2. ILIAC ABSCESS
3. EMPYEMA
4. ABSCESSES IN PERITONEAL CAVITY
5. SUBPHRENIC ABSCESS
6. PELVIC ABSCESS
2013
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SPECIAL ABSCESSES
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1. PERINEPHRIC ABSCESS
Fever, tender swollen loin
/subhepatic.
Pus must be drained!
Approach extra peritoneal
as for nephrostomy. AB
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2. ILIAC ABSCESS
Fever, painful flexed hip,
swelling inguinal regio.
Ex. under anaesth.
Punctate for pus.
Explore “extra peritoneal”
for drainage
2013
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3. EMPYEMA
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Febrile
Limited movement chest affected side
Dull on percussion
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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.
2013
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Pleura aspiration & Closed drainage
2013
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4.
ABSCESSES IN PERIT. CAVITY
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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 inClinical
yrOfficer
hospital?
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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!
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Ward rounds. Diagnose? Cause?
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Skills: like making knots !
•Thoraxdrains
•debridement wounds
•skingrafts etc.
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2005
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ABSCESSES IN PERITONEAL CAVITY
Symptoms?
For example POST LAPAROTOMY
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Temperature doesn’t fall
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Sepsis/Abscess temperature
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Pat not well, looses weight
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WB count is raised
On examination?
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Abdomen tender
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Decreased or absent bowel sounds?
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Shallow breathing?
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Dehydrated?
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Hypotensive? (septic shock)
2005
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HOW TO DIAGNOSE INTRA- ABD ABSCESS?
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IPPA Patient
- Swelling to feel?/ Tender/ Fluctuation?
What not to forget?
+ Rectal / Vag examination!!! Why?
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2005
Ultrasound
Aspiration
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2005
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Management intra abd abscess
OPERATION decided.
1. Preferraby EXTRA peritoneal. Why?
If you can’t, do:
2. Laparatomy
careful 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)
2013
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Clinical Officer Training
“TO DRAIN OR NOT TO DRAIN”
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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
2013
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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
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5. SUB PHRENIC ABSCESS
Thoracic 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)
2013
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6. PELVIC ABSCESS
Follows
- appendicitis
- generalized
peritonitis
- female genital
tract infection
(PID)
Drained preferably
extra peritoneally
by vaginal or by
rectal drainage.
Suprapubic
Drainage
2013
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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 labour
2.3 Puerperal sepsis (septic thrombo flebitis)
2.4 Post Caesarian
2013
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1. About PID unrelated to pregnancy
Infection starts from vagina/cervix
2 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
2005
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ACUTE/CHRONIC PID
MORE INFORMATION
by
Gynecologists
2005
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2013
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2005
Clinical Officer Training Malawi