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Difficulty: EasyPreoperative and Postoperative Care

A 52-year-old man is evaluated in the surgical ward on postoperative day 6 following an open ventral hernia repair. He complains of worsening pain at the surgical site and feeling warm since this morning. His temperature is 38.9°C (102.0°F), heart rate is 104/min, blood pressure is 130/85 mm Hg, and respiratory rate is 16/min. Physical examination of the abdomen reveals a localized 5-cm area of marked erythema, induration, and tenderness surrounding the lower half of the surgical incision. There is visible spontaneous drainage of thick, yellowish fluid from the wound edges. The patient's lungs are clear to auscultation bilaterally, and his calves are soft and non-tender. Which of the following are the most appropriate initial steps in the management of this patient?

  1. Open the affected portion of the incision to evacuate the purulent fluidAnswer
  2. Obtain a sample of the wound discharge for microbiological cultureAnswer
  3. C
    Administer broad-spectrum intravenous antibiotics while leaving the wound closed
  4. D
    Obtain a bedside chest radiograph to evaluate for postoperative pulmonary complications
  5. E
    Order bilateral lower extremity venous ultrasonography to rule out deep vein thrombosis

Answer

The correct steps are to open the affected portion of the incision to evacuate the purulent fluid and to obtain a sample of the wound discharge for microbiological culture.
The patient presents with a classic superficial surgical site infection (SSI), characterized by fever, wound erythema, and purulent drainage on postoperative day 6. The definitive management of an SSI involves source control by opening the incision to allow for adequate drainage. Additionally, because the patient has systemic signs of infection (fever and tachycardia), a sample of the drainage should be sent for microbiological culture to appropriately guide necessary antibiotic therapy.

Step-by-Step Solution

1
Identify the clinical problem from the patient's presentation.
The patient has a superficial surgical site infection (SSI) presenting on postoperative day 6 with fever, localized erythema, and purulent drainage.
Purulent drainage from a surgical incision, accompanied by surrounding erythema and systemic fever, is diagnostic of an SSI.
2
Determine the most critical initial therapeutic intervention.
The incision must be partially or fully opened to evacuate the pus.
Antibiotics alone cannot penetrate a fluid collection; physical drainage (source control) is required for resolution.
3
Determine the role of adjunctive testing and medical therapy.
A sample of the purulent fluid should be sent for Gram stain and culture.
Because the patient exhibits systemic signs (fever, tachycardia), systemic antibiotics will be necessary, and cultures are needed to ensure targeted, narrow-spectrum therapy.

Key Concept

The primary management of a superficial surgical site infection with purulence is source control (opening the wound for drainage), accompanied by obtaining wound cultures and starting antibiotics if systemic signs of infection are present.
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Topics

Preoperative and Postoperative Care

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