Examkin

Question

Difficulty: MediumPreoperative and Postoperative Care

During her sixth day of recovery following an open abdominal hysterectomy for symptomatic uterine fibroids, a 45-year-old woman develops a fever. The surgical procedure was uncomplicated, and her postoperative course has been otherwise unremarkable. She is currently ambulating in the ward and tolerating a solid diet. Her temperature is 38.8°C (101.8°F), blood pressure is 120/78 mmHg, and pulse is 96/min. The patient reports localized throbbing pain at her abdominal incision but denies dysuria, cough, or shortness of breath. Physical examination demonstrates a 12-cm lower midline incision. The inferior 4 centimeters of the wound are notably erythematous, indurated, and exquisitely tender. Gentle pressure applied adjacent to this area produces a small amount of thick, purulent discharge emerging from between the surgical staples. Auscultation of the lungs reveals clear breath sounds bilaterally. Which of the following is the most appropriate next step in the management of this patient's current condition?

  1. Removal of the affected surgical staples and bedside wound packingAnswer
  2. B
    Initiation of empiric intravenous vancomycin and cefepime
  3. C
    Cross-sectional abdominal imaging with intravenous contrast
  4. D
    Intensive deep-breathing exercises and chest physiotherapy
  5. E
    Urinalysis, urine culture, and oral ciprofloxacin therapy

Answer

The most appropriate next step is the removal of the affected surgical staples and bedside wound packing to achieve source control of the surgical site infection.
The patient is presenting with a fever on postoperative day 6, accompanied by erythema, induration, and purulent discharge at her incision site. These findings are diagnostic of a superficial surgical site infection (SSI). The timing classically aligns with the 'Wound' etiology of postoperative fever, which typically arises between days 5 and 7. For a superficial SSI with localized purulence in a patient who is otherwise hemodynamically stable without extensive surrounding cellulitis, the cornerstone of management is mechanical source control. This is achieved by removing the staples or sutures at the affected area, exploring the wound to ensure the fascia is intact, and packing the wound to allow it to drain and heal by secondary intention. Antimicrobial therapy alone is inadequate without proper drainage and is often unnecessary if adequate source control is achieved.

Step-by-Step Solution

1
Analyze the patient's postoperative timeline and vital signs.
The patient has developed a new-onset fever (38.8°C) on postoperative day 6.
Identifying the timing of postoperative fever helps narrow the differential diagnosis using the classic '5 Ws' mnemonic.
2
Evaluate the physical examination findings.
The patient has a localized area of erythema, induration, and purulent discharge at the surgical incision with no other focal signs of infection.
These are classic signs of a superficial surgical site infection (SSI), which characteristically manifests between postoperative days 5 and 7 ('Wound').
3
Determine the optimal intervention for the identified condition.
The primary treatment for a superficial SSI with purulence is mechanical source control rather than isolated pharmacotherapy or further diagnostic imaging.
Opening the wound, draining the pus, and allowing it to heal by secondary intention is necessary and often sufficient for healthy, hemodynamically stable patients.

Key Concept

The cornerstone of management for a superficial surgical site infection (typically occurring on postoperative days 5-7) is mechanical source control via wound opening and packing.
Rate this question

Topics

Preoperative and Postoperative Care

More questions from this topic