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Difficulty: EasyPreoperative and Postoperative Care

A 58-year-old woman is evaluated in the surgical ward for a new-onset fever and worsening abdominal pain. She is currently on postoperative day 6 following an elective open abdominal hysterectomy for symptomatic uterine fibroids. Her temperature is 38.8°C (101.8°F), blood pressure is 122/78 mmHg, pulse is 98/min, and respirations are 16/min. Physical examination of the abdomen reveals a 10-cm midline surgical incision. The lower half of the incision is markedly erythematous, indurated, and warm to the touch. Gentle palpation of the surrounding skin yields a moderate amount of opaque, purulent fluid from the wound edges. The remainder of her physical examination is unremarkable. Which of the following is the most appropriate next step in management?

  1. Open the incision, drain the fluid, and pack the woundAnswer
  2. B
    Initiate empiric intravenous piperacillin-tazobactam therapy
  3. C
    Order a computed tomography scan of the abdomen and pelvis
  4. D
    Obtain a plain chest radiograph and encourage incentive spirometry
  5. E
    Perform bilateral lower extremity venous duplex ultrasonography

Answer

Open the incision, drain the fluid, and pack the wound.
This patient's presentation of fever, erythema, induration, and purulent drainage at the incision site on postoperative day 6 is highly characteristic of a superficial surgical site infection (SSI). In the timeline of postoperative fever (the '5 Ws'), wound infections classically manifest between postoperative days 5 and 7. The most appropriate next step in management is to remove the sutures or staples from the affected area, open the wound, drain the purulent collection, and pack the wound with sterile gauze. This allows the wound to heal gradually from the base upward by secondary intention. Antibiotics are typically reserved for cases complicated by systemic signs of sepsis (e.g., hypotension, altered mental status) or extensive surrounding cellulitis, neither of which are present in this localized infection.

Step-by-Step Solution

1
Analyze the patient's postoperative timeline and vital signs.
The patient is on postoperative day 6 and has a new-onset fever of 38.8°C (101.8°F).
Timing of postoperative fever helps narrow the differential diagnosis based on the '5 Ws' (Wind, Water, Wound, Walking, Wonder drugs).
2
Evaluate the physical examination findings.
There is pronounced erythema, induration, and purulent drainage originating directly from the midline surgical incision.
These are the hallmark clinical signs of a superficial surgical site infection (SSI).
3
Determine the definitive treatment for the identified pathology.
The primary intervention for a superficial SSI is source control by opening the infected portion of the wound, draining the purulence, and packing it to allow healing by secondary intention.
Mechanical drainage is strictly required; antibiotics alone cannot penetrate and clear a localized collection of pus.

Key Concept

The primary management of a superficial surgical site infection consists of opening the wound, draining the purulent material, and packing the site to allow healing by secondary intention.
Estimated Time:50s
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Topics

Preoperative and Postoperative Care

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