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Difficulty: EasyPreoperative and Postoperative Care

During morning rounds on the surgical ward, a 62-year-old woman complains of new-onset pain around her incision and burning with urination. She is currently on postoperative day 6 following a total abdominal hysterectomy for symptomatic uterine fibroids. Her indwelling urinary catheter was removed 48 hours ago. Her temperature is 38.6°C (101.5°F), blood pressure is 122/78 mmHg, heart rate is 94/min, and respiratory rate is 16/min. Examination of the abdomen reveals significant erythema, induration, and a small amount of purulent drainage at the surgical incision site. Auscultation of the lungs reveals clear breath sounds bilaterally. Which of the following are the most appropriate next steps in the management of this patient? (Select all that apply)

  1. Open the surgical incision to allow for adequate drainageAnswer
  2. Perform a microscopic urinalysis and send a urine sample for cultureAnswer
  3. C
    Initiate empiric vancomycin and piperacillin-tazobactam therapy
  4. D
    Order a portable chest radiograph to evaluate for atelectasis
  5. E
    Provide symptomatic treatment with antipyretics and observe closely

Answer

The correct steps are to open the surgical incision to allow for adequate drainage AND perform a microscopic urinalysis while sending a urine sample for culture.
This patient presents with a fever on postoperative day 6 along with two distinct sources of infection: a surgical site infection (SSI) and a likely urinary tract infection (UTI). The definitive initial management for a superficial SSI with purulent drainage is to open the wound to allow for proper drainage and healing by secondary intention. Simultaneously, her dysuria following Foley catheter removal warrants a urinalysis and urine culture to confirm a UTI and guide specific antibiotic therapy.

Step-by-Step Solution

1
Analyze the timing of the fever and physical exam findings.
The patient has a fever on postoperative day 6 with a purulent abdominal wound and dysuria.
Postoperative fever etiologies correlate strongly with the timeline. POD 6 fevers are classically associated with wound infections or deep space infections, while the recent catheter removal and dysuria point to a urinary tract infection.
2
Determine the appropriate management for the wound finding.
The presence of purulence and induration indicates a surgical site infection. The primary treatment is source control.
Superficial surgical site infections are primarily managed by opening the incision, draining the purulent material, and packing the wound. Systemic antibiotics are often unnecessary unless there is overlying cellulitis or systemic toxicity.
3
Determine the appropriate diagnostic step for the urinary symptoms.
A urinalysis and urine culture must be obtained.
Catheter-associated urinary tract infections are a common cause of postoperative fever, and targeted antibiotic therapy requires identification of the offending organism via culture.

Key Concept

Diagnosis and management of common postoperative complications based on the timeline, specifically surgical site infections (POD 5-7) and urinary tract infections (POD 3-5).
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Topics

Preoperative and Postoperative Care

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