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Difficulty: MediumPreoperative and Postoperative Care

An assessment is requested for a patient recovering in the surgical unit. The patient is a 58-year-old female who underwent an open abdominal hysterectomy six days ago for symptomatic uterine leiomyomas. Over the past 12 hours, she has developed new-onset chills and worsening pain at her incision site. Her medical history includes diet-controlled type 2 diabetes mellitus and heart failure with preserved ejection fraction. Current vital signs reveal a temperature of 38.9°C (102.0°F), blood pressure of 130/80 mmHg, heart rate of 96/min, and respiratory rate of 16/min. Pulse oximetry is 96% on room air. Upon physical examination, the lungs exhibit faint, scattered basilar crackles that clear completely with a cough. Abdominal examination demonstrates a 4-cm area of significant erythema, induration, and point tenderness at the inferior aspect of the midline surgical incision. Gentle palpation of this area produces a small amount of thick, purulent exudate between the surgical staples. Bowel sounds are active, and there is no rebound tenderness or guarding in the remaining abdominal quadrants. Which of the following is the most appropriate next step in management?

  1. Remove the staples at the affected site and pack the woundAnswer
  2. B
    Initiate broad-spectrum intravenous antibiotics without altering the incision
  3. C
    Order a computed tomography scan of the abdomen and pelvis
  4. D
    Obtain a duplex ultrasound of the bilateral lower extremities
  5. E
    Administer intravenous furosemide and elevate the head of the bed

Answer

Remove the staples at the affected site and pack the wound
This patient is presenting with classic signs of a superficial surgical site infection (SSI) on postoperative day 6. The most appropriate next step in management is to open the wound by removing the staples at the affected site and packing it with sterile gauze. This allows for mechanical drainage of the purulent material and facilitates healing by secondary intention. Source control is the cornerstone of SSI management. Systemic antibiotics are generally not required for superficial SSIs in the absence of extensive surrounding cellulitis, systemic inflammatory response syndrome (beyond a simple fever), or immunocompromise.

Step-by-Step Solution

1
Evaluate the patient's postoperative timeline and physical examination findings.
The patient is on postoperative day 6 with a new high fever and localized erythema, induration, and purulent drainage at the surgical incision site.
Identifying the specific signs of a surgical site infection (SSI) is critical for determining the source of the postoperative fever.
2
Determine the most appropriate initial management for a superficial surgical site infection.
The primary treatment is immediate source control achieved by opening the affected portion of the wound.
Superficial SSIs require mechanical drainage to remove infected fluid and promote healing by secondary intention; antibiotics or imaging cannot replace source control.

Key Concept

Management of superficial surgical site infections
Estimated Time:1m 15s
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Topics

Preoperative and Postoperative Care

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