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Difficulty: MediumPreoperative and Postoperative Care

A 64-year-old woman is evaluated on postoperative day 6 following an open partial gastrectomy for a refractory peptic ulcer. She complains of increasing pain at her surgical incision site and feeling feverish since yesterday. Her medical history includes type 2 diabetes mellitus and hypertension. Her temperature is 38.5°C (101.3°F), blood pressure is 135/85 mmHg, pulse is 98/min, and respiratory rate is 18/min. Oxygen saturation is 96% on room air. Lung auscultation reveals mild, scattered bibasilar crackles that clear with coughing. Cardiac examination is unremarkable. The abdomen is soft and non-distended, with normal active bowel sounds. Examination of the midline surgical incision reveals a 5-cm area at the inferior aspect that is exquisitely tender, erythematous, indurated, and fluctuant. There is no spontaneous drainage. Which of the following is the most appropriate next step in management?

  1. A
    Initiate broad-spectrum intravenous antibiotics and reassess in 24 hours
  2. B
    Obtain blood cultures, a urine culture, and a chest radiograph
  3. Open the affected portion of the incision to allow for drainageAnswer
  4. D
    Insert a nasogastric tube and maintain nothing-by-mouth status
  5. E
    Administer intravenous furosemide and implement fluid restriction

Answer

Open the affected portion of the incision to allow for drainage
The patient's presentation of fever, erythema, induration, and a fluctuant mass at the surgical incision on postoperative day 6 is highly diagnostic of a superficial surgical site infection (SSI) complicated by an abscess. The cornerstone of management for a superficial SSI with a fluid collection is source control. The most appropriate next step is to remove the staples or sutures over the affected area to open the wound, allow for drainage of the purulent material, and pack the wound with sterile gauze. Systemic antibiotics are generally reserved for cases with significant surrounding cellulitis, deep space involvement, or systemic inflammatory response syndrome (SIRS), and they should only be given in conjunction with, not instead of, definitive drainage.

Step-by-Step Solution

1
Analyze the timing and clinical signs of the patient's presentation.
The patient developed fever and localized wound fluctuance on postoperative day 6.
Understanding the timeline of postoperative complications (the '5 Ws') helps isolate the likely etiology, with wound infections classically presenting between days 5 and 7.
2
Diagnose the specific complication based on physical examination.
The tender, erythematous, and fluctuant mass at the incision site indicates a superficial surgical site infection (SSI) complicated by an abscess.
Fluctuance represents a walled-off collection of purulent material beneath the skin.
3
Determine the definitive management for a superficial surgical abscess.
The most appropriate next step is bedside source control by opening the wound to drain the pus.
Antibiotics cannot effectively penetrate an abscess cavity; physical evacuation of the infected material is required for resolution.

Key Concept

Superficial surgical site infections presenting with fluctuance (abscess) require immediate source control via bedside opening, drainage, and packing as the primary intervention.
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Topics

Preoperative and Postoperative Care

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