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Zorluk: OrtaPreoperative and Postoperative Care

During surgical ward rounds, a physician evaluates a patient who is currently on day 5 of recovery following an urgent laparotomy for a perforated duodenal ulcer. The primary nurse reports a new onset of fever. The patient's temperature is 38.9∘C38.9^\circ\text{C} (102.0∘F102.0^\circ\text{F}), heart rate is 98/min98/\text{min}, and blood pressure is 128/82 mmHg128/82\text{ mmHg}. The patient complains of severe, throbbing pain at the abdominal incision that has worsened significantly over the past 24 hours. Physical examination reveals an abdominal midline incision closed with surgical staples. There is a 4-cm4\text{-cm} area of expanding erythema, induration, and marked tenderness around the lower half of the incision, accompanied by spontaneous drainage of thick, purulent fluid. Which of the following is the most appropriate next step in management?

  1. Removal of staples and bedside wound explorationCevap
  2. B
    Initiation of intravenous piperacillin-tazobactam
  3. C
    Computed tomography of the abdomen and pelvis with contrast
  4. D
    Return to the operating room for exploratory laparotomy
  5. E
    Administration of acetaminophen and reassessment in 24 hours

Cevap

The most appropriate next step is the removal of staples and bedside wound exploration to drain the infection.
The correct intervention is the removal of staples and bedside wound exploration. This patient is presenting with classic signs of a surgical site infection (SSI) on postoperative day 5, including fever, marked erythema, induration, and spontaneous purulent drainage. The standard of care for a superficial SSI is to open the wound (removing sutures or staples) to allow for complete drainage of the infected fluid. The wound is then typically packed and allowed to heal by secondary intention.

Adım Adım Çözüm

1
Analyze the timeline and clinical findings to determine the cause of the fever.
Fever on postoperative day 5 accompanied by localized erythema, induration, and purulent drainage strongly indicates a surgical site infection (SSI).
Matching the timeline ('Wound' typically presents on days 5-7) with physical exam findings provides the clinical diagnosis without needing advanced imaging.
2
Determine the standard of care for a superficial surgical site infection.
The primary treatment is adequate drainage (source control) by opening the wound.
Purulent collections cannot be effectively sterilized by antibiotics alone or definitively treated with observation; they must be mechanically drained and allowed to heal by secondary intention.

Anahtar Kavram

The primary treatment for a superficial surgical site infection (typically presenting on postoperative days 5-7) is source control through the removal of sutures or staples, bedside wound exploration, and adequate drainage.
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Preoperative and Postoperative Care

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