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Difficulty: MediumPreoperative and Postoperative Care

A 72-year-old woman is evaluated on postoperative day 5 following an elective sigmoid colectomy for recurrent diverticulitis. She has a history of chronic obstructive pulmonary disease (COPD) and heart failure with preserved ejection fraction. She reports increasing incisional pain, a productive cough, and mild shortness of breath. Temperature is 38.7°C (101.7°F), blood pressure is 135/85 mmHg, pulse is 102/min, and respirations are 18/min. Pulse oximetry shows 94% on room air. Lung auscultation reveals a prolonged expiratory phase and scattered expiratory wheezes bilaterally. Jugular venous pressure is 6 cm H2O, and there are no crackles or lower extremity edema. The surgical incision has a 4-cm area of fluctuance, erythema, and purulent discharge. The wound is swabbed for culture, and Gram stain of the purulent fluid shows only Gram-positive cocci in clusters. The local hospital antibiogram demonstrates a less than 1% prevalence of methicillin-resistant Staphylococcus aureus (MRSA). Which of the following are the most appropriate next steps in the management of this patient? (Select 2 answers)

  1. Open the infected portion of the surgical incisionAnswer
  2. Administer inhaled ipratropium and albuterolAnswer
  3. C
    Administer intravenous furosemide
  4. D
    Initiate intravenous piperacillin-tazobactam and vancomycin
  5. E
    Order a lower extremity venous duplex ultrasound

Answer

The most appropriate next steps are opening the infected portion of the surgical incision and administering inhaled short-acting bronchodilators (albuterol and ipratropium).
This patient has two concurrent postoperative issues: a surgical site infection (SSI) and a chronic obstructive pulmonary disease (COPD) exacerbation. SSIs typically present between postoperative days 5 and 7 (the 'Wound' of the 5 Ws of postoperative fever). The primary and most critical management for a superficial SSI is source control, which requires opening the infected portion of the incision, draining the purulent fluid, and packing the wound to heal by secondary intention. Additionally, the patient's respiratory symptoms (productive cough, wheezing, prolonged expiration) in the context of her COPD history strongly indicate an acute exacerbation, likely triggered by the physiological stress of surgery and infection. Inhaled short-acting bronchodilators (e.g., albuterol and ipratropium) are the appropriate initial therapy to relieve her bronchospasm.

Step-by-Step Solution

1
Evaluate the surgical wound and vital signs.
The patient has fever, tachycardia, and a fluctuant, erythematous, draining wound on postoperative day 5.
To identify the primary source of the postoperative fever, which aligns with a surgical site infection ('Wound').
2
Determine the primary intervention for the surgical site infection.
Opening the wound is identified as the necessary intervention.
Source control by opening the wound and allowing it to drain is the definitive management for superficial surgical site infections.
3
Assess the respiratory symptoms and lung examination findings.
The patient exhibits wheezing, a prolonged expiratory phase, and a productive cough, with a normal JVP and no crackles.
To differentiate between a COPD exacerbation and acute decompensated heart failure in a patient with a history of both.
4
Select the appropriate respiratory treatment.
Inhaled ipratropium and albuterol are selected.
Short-acting bronchodilators are the first-line treatment for an acute COPD exacerbation.

Key Concept

Surgical site infections typically present on postoperative days 5-7 and are primarily managed with wound opening and drainage. Concurrent postoperative respiratory decline must be carefully differentiated; COPD exacerbations present with wheezing and prolonged expiration and are treated with bronchodilators, whereas volume overload presents with crackles and elevated jugular venous pressure.
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Topics

Preoperative and Postoperative Care

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