Examkin

Question

Difficulty: MediumPreoperative and Postoperative Care

A 62-year-old man is evaluated on postoperative day 2 following an elective low anterior resection for rectal cancer. He reports severe, continuous pain at the abdominal incision site that has worsened over the past 6 hours and is disproportionate to his previous postoperative pain. His temperature is 39.4∘C39.4^\circ\text{C} (102.9∘F102.9^\circ\text{F}), blood pressure is 88/58 mmHg88/58 \text{ mmHg}, pulse is 122/min122/\text{min}, and respiratory rate is 22/min22/\text{min}. Physical examination reveals significant edema and violaceous discoloration of the skin surrounding the midline incision. Removal of the dressing reveals a thin, grayish fluid leaking from the wound edges. Palpation around the incision elicits exquisite tenderness, though sensation to light touch is decreased near the wound margins. Which of the following is the most appropriate next step in the management of this patient?

  1. Immediate surgical exploration and debridementAnswer
  2. B
    Initiation of empiric broad-spectrum antibiotics and serial clinical observation
  3. C
    Bedside opening of the incision and packing with wet-to-dry dressings
  4. D
    Computed tomography scan of the abdomen and pelvis
  5. E
    Chest radiography and initiation of incentive spirometry

Answer

Immediate surgical exploration and debridement
The correct option is immediate surgical exploration and debridement. The patient exhibits classic signs of a necrotizing surgical site infection (NSTI), including severe pain out of proportion to the physical exam, violaceous skin discoloration, thin grayish ('dishwater') drainage, and hemodynamic instability early in the postoperative course. Furthermore, the decreased sensation near the wound margins indicates nerve destruction from the rapidly spreading necrotic process. NSTIs are surgical emergencies. The definitive and most critical step in management is immediate operative exploration and aggressive debridement of all necrotic tissue until healthy, bleeding tissue is reached. While broad-spectrum antibiotics and aggressive fluid resuscitation are essential adjuncts, they must not delay surgical source control.

Step-by-Step Solution

1
Analyze the clinical presentation and timeline.
The patient is on postoperative day 2 with a high fever, hemodynamic instability (hypotension, tachycardia), severe pain out of proportion to exam, violaceous skin, and grayish 'dishwater' drainage.
Identifying these classic signs differentiates a benign postoperative course from a life-threatening complication.
2
Formulate a diagnosis.
The findings are highly specific for a necrotizing surgical site infection (necrotizing fasciitis).
Pain out of proportion, early shock, and dishwater fluid are hallmark signs of rapidly spreading fascial necrosis.
3
Determine the next best step in management.
Immediate operative debridement is required.
Necrotizing soft tissue infections are surgical emergencies. Delaying surgery for imaging or relying exclusively on antibiotics leads to near 100% mortality.

Key Concept

Necrotizing surgical site infections present with pain out of proportion to exam, violaceous skin changes, early hemodynamic instability, and 'dishwater' drainage. They require emergent surgical exploration and debridement.
Estimated Time:1m 15s
Rate this question

Topics

Preoperative and Postoperative Care

More questions from this topic