Clinical Officer Training MALAWI SURGERY OF SEPSIS King

Clinical Officer Training MALAWI SURGERY OF SEPSIS King 5 + 6

Clinical Officer Training The “surgery of sepsis” n n n 2013 What is that? HOW to DRAIN PUS Has to do with INFECTION Most commonest operation developing world Can collect almost everywhere in the body Where? Could be 1, could be more abscesses Some small, some more than 3 liters of pus Your experience? Clinical Officer Training Malawi

Clinical Officer Training COMMON SITES of SEPSIS, names? 2013 Clinical Officer Training Malawi

Clinical Officer Training The Surgery of Sepsis Particular important sites n Muscles: pyomyositis n Bones: osteomyelitis n Joints: septic arthritis n Hand: f. e paronychia n Breast: mastitis n Pleura: empyema n Peritoneum: peritonitis 2013 Clinical Officer Training Malawi

Clinical Officer Training WHAT CAUSES “SEPTIC INFECTIONS”? n n n n 2013 Not well understood Anaemia Malnutrition Poor hygiene More in children/young adults IMMUNE SYSTEM Predisposition: HIV Clinical Officer Training Malawi

Clinical Officer Training Most common bacteria in surgical sepsis? n Staphylococcus aureus (Skin) n E Coli and anaerobics (Peri-anal) n TB n 2013 Salmonella, Gonococcal

Clinical Officer Training BODY RESPONSES INFLAMMATION Is the natural response of the body (vascular tissues) to protect itself from harmful stumuli such as “irritants”, damaged cells. It is the initiation of the healing system. Examples: sun burn, fracture, insect bite etc Classical signs: pain, heat, swelling (oedema), redness (hyperaemia), los of function n INFECTION is the invasion of disease causing organism such as germs, viruses and fungus, and the reaction of host tissues to these organisms and the toxins they produce. Hosts can fight using their immune system. 2013 Clinical Officer Training Malawi n

Clinical Officer Training TYPES OF INFECTION n Localized inf (Body managed to localize infection) example: BOIL, CARBUNCEL n Spreading inf (Invador seems to be stronger ) Spreading cellulitis: skin + subcutis n Lymphangitis: along lymphatics n Bacteraemia is the presence of bacteria in the blood and may or may not be symptomatic What most serious complication is? Signs? n 2013 Clinical Officer Training Malawi

Clinical Officer Training What is an abscess? a non previously existing cavity filled with PUS It is the outcome of the body management to imprison the intruders by a wall of defense forces! 2013 Clinical Officer Training Malawi

Clinical Officer Training WHAT IS PUS? Damaged tissue, necrosis, bacteria, autolized white blood cells, as a result of the infectious process 2013 Clinical Officer Training Malawi

Clinical Officer Training When to SUSPECT ABSCESS? LOCAL SIGNS - Pain (throbbing pain: the tighter the space…f. e finger) - swelling- red- hotimpaired function - Fluctuation? ? GENERAL SIGNS - General impression patient? Weak? - Abscess temperature? - Signs of toxaemia? - Septic shock? 2013 Clinical Officer Training Malawi

Clinical Officer Training NOT SURE PUS ? What to do? n Aspirate with needle Failure to aspirate pus does not mean there is no pus Ultrasound scanning specifically for the abdomen n Done that yourself? 2013 Clinical Officer Training Malawi

Clinical Officer Training What TO DO ABSCESS? As soon as possible! why? SO 2013 OPERATE Clinical Officer Training Malawi

Clinical Officer Training TO TREAT AN ABSCESS by ANTIBIOTICS? usually NOT NEEDED or even USELESS and DANGEROUS! why? Useless why? Because antibiotics will not enter the abscess in which the pressure is high 2013 Clinical Officer Training Malawi

Clinical Officer Training ANTIBIOTICS in septic infections BUT GIVE 1. Signs of SPREADING INFECTION increasing erythema, cellulitis, lymphangitis / lymphadenitis 2. GENERALIZED symptoms with fever toxaemia (Bacteriaemia? Sepsis? ) 2005 Clinical Officer Training Malawi

Clinical Officer Training PROCEDURE DRAINING ABSCESS 1. ANAESTHESIA n n 2005 ETHYL CHLORIDE for very small superficial LOCAL for small superficial Usually KETAMINE GENERAL anaesthesia, with muscle relaxants for deep intra peritoneal Clinical Officer Training Malawi

Clinical Officer Training PROCEDURE DRAINING ABSCESS 2. SURGERY Superficial abscess Skin incision site MAXIMUM tenderness parallel to nerves and blood vessels 2005 Clinical Officer Training Malawi

Clinical Officer Training DRAINING DEEPER ABSCESS b) Surgery by the “Hilton’s method” to prevent deeper structures from being injured A. Incise skin at lowest point B. Push blunt haemostat into softest, prominent part C. Open haemostat inside the abscess D. Enlarge by blunt dissection inside the tissue by finger E. Insert drain 2005 Clinical Officer Training Malawi

Clinical Officer Training PROCEDURE DRAINING ABSCESS How to DRAIN? Provide FREE drainage: n Open wide n Use corrugated drain if abscess is deep and fix n Do not use curette Immediate Complications n Bleeding What to do? Post op measures n Raise n Analgetics n Attention when to REMOVE drain. Why? Clinical Officer Training Malawi

Clinical Officer Training LATE COMPLICATIONS n n 2013 Pus remains coming out. Cause? Foreign body? Gauze? Procedure rightly done? Patient does not improve: Cause? HIV? TB? More abscesses develop. Cause? Due to Pyaemia! Treatment? Now give antibiotics. Patient very ill and several abscesses. What now? Will not tolerate operation. ABSTAIN

Clinical Officer Training BOILS - CARBUNCLES 2013 Clinical Officer Training Malawi

Clinical Officer Training BOIL - CARBUNCLE BOIL: aggressive infection skin+subcutis originating from hair follicle by staphylococci CARBUNCLE: collection of boils with extensive subcutaneous necrosis. TREATMENT BOIL: Lift out central necrosis +/- small incision. Do not squeeze CARBUNCLE: lift off slough, cut down on pus and necrosis and drain. Give antibiotics 2013 Clinical Officer Training Malawi

Clinical Officer Training SPECIAL ABSCESSES Examples? 1. PERINEPHRIC ABSCESS 2. ILIAC ABSCESS 3. EMPYEMA 4. ABSCESSES IN PERITONEAL CAVITY 5. SUBPHRENIC ABSCESS 6. PELVIC ABSCESS 2013 Clinical Officer Training Malawi

Clinical Officer Training SPECIAL ABSCESSES n 1. PERINEPHRIC ABSCESS Fever, tender swollen loin /subhepatic. Pus must be drained! Approach extra peritoneal as for nephrostomy. AB n 2. ILIAC ABSCESS Fever, painful flexed hip, swelling inguinal regio. Ex. under anaesth. Punctate for pus. Explore “extra peritoneal” for drainage 2013 Clinical Officer Training Malawi

Clinical Officer Training 3. EMPYEMA n n n Febrile Limited movement chest affected side Dull on percussion n X-ray: dense area lung base Diagnose: Aspirate to confirm the diagnosis. How? Cause? TB? How to diagnose? MANAGEMENT n Give antibiotics. n Repeat aspiration 3 times a week, until pus stops forming. n If aspiration becomes difficult closed drainage for at least 2 Training Malawi weeks. 2013 Clinical Officer

Clinical Officer Training Pleura aspiration & Closed drainage 2013 Clinical Officer Training Malawi

Clinical Officer Training 4. ABSCESSES IN PERIT. CAVITY n n n Can be the result of: General Peritonitis with primary focus of infection f. e -- appendicitis – salpingitis (PID) – perf gastric. u – perf typhoid ulcer An abdominal injury (trauma) - gut perforation Any laparotomy - Contamination? Why? - Aseptic theatre technique? (Chikwawa) - Infection rate in yr H? And yours? Higher 5%? - Audit? ! How in yr. Officer Training Malawi hospital? Clinical

Clinical Officer Training HIGH POST OPERATIV INFECTION RATE? - Check what? ASEPTIC THEATRE TECHNIQUE, includes YOU too Was indication good? How preparation of patient in ward, in theatre, scrubbing, gowning, draping, shaving, counting gauzes? and your surgical technique? Like: tissue handling, wound closure, making proper knots, etc CO project study post op inf rate: 21%- 8. 6%!! It can be done! Clinical Officer Training Malawi

Clinical Officer Training

Clinical Officer Training Ward rounds. Diagnose? Cause?

Clinical Officer Training Skills: like making knots ! • Thoraxdrains • debridement wounds • skingrafts etc.

Clinical Officer Training 2005 Clinical Officer Training Malawi

Clinical Officer Training ABSCESSES IN PERITONEAL CAVITY Symptoms? For example POST LAPAROTOMY n Temperature doesn’t fall n Sepsis/Abscess temperature n Pat not well, looses weight n WB count is raised On examination? n Abdomen tender n Decreased or absent bowel sounds? n Shallow breathing? n Dehydrated? n Hypotensive? (septic shock) 2005 Clinical Officer Training Malawi

Clinical Officer Training HOW TO DIAGNOSE INTRA- ABD ABSCESS? n IPPA Patient - Swelling to feel? / Tender/ Fluctuation? What not to forget? + Rectal / Vag examination!!! Why? n n 2005 Ultrasound Aspiration Clinical Officer Training Malawi

Clinical Officer Training 2005 Clinical Officer Training Malawi

Clinical Officer Training Management intra abd abscess OPERATION decided. 1. Preferraby EXTRA peritoneal. Why? If you can’t, do: 2. Laparatomy careful for bowels, use fingers, drain pus, use saline, decide: “to drain or not to drain”, close fascia - with what? - what to do if you can’t close? “Bogota Bag” - leave skin open!! - Antibiotics iv (cephalo, genta, metro) 2013 Clinical Officer Training Malawi

Clinical Officer Training “TO DRAIN OR NOT TO DRAIN” n n n Tubes: lead fluids from somewhere to somewhere. Pleural cavity, naso- gastric tube, feeding tubes Drains: to let blood, pus, intestinal contents, bile and other fluids escape from a wound while it heals, without letting the bacteria getting in Open/closed drainage system Risk: bacteria and spreading infection eroding tissue and blood vessels. Trend: not to drain unless good reasons 2013 Clinical Officer Training Malawi

Clinical Officer Training THE USE OF A DRAIN INTRA ABD ABSCESS - Use SEPARATE incision, as wide as drain - Fix drain to skin Open drainage - Penrose tube (soft latex) 1 -2 cm - Corrugated rubber drain Preferred Semi or Closed tube drainage systems - Sump Suction drain, cont. suction by vacuum Removal - as soon is feasible, max 3 - 4 days 2013

Clinical Officer Training 5. SUB PHRENIC ABSCESS Thoracic signs: cough, diminished breath sounds, tenderness, oedema+redness loin/below ribs. X-ray essential: raised fuzzy looking diaphragm, fluid costo phrenic angle. Incision for drainage in loin below ribs (site of max oedema redness) 2013 Clinical Officer Training Malawi

Clinical Officer Training 6. PELVIC ABSCESS Follows - appendicitis - generalized peritonitis - female genital tract infection (PID) Drained preferably extra peritoneally by vaginal or by rectal drainage. Suprapubic Drainage 2013 Clinical Officer Training Malawi

Clinical Officer Training Pelvic Inflammatory Disease (PID) 1. PID unrelated to pregnancy gonococci, chlamydia, mycoplasma 2. PID related to pregnancy 2. 1 Post abortion 2. 2 Infected obstructed labour 2. 3 Puerperal sepsis (septic thrombo flebitis) 2. 4 Post Caesarian 2013 Clinical Officer Training Malawi

Clinical Officer Training 1. About PID unrelated to pregnancy Infection starts from vagina/cervix 2 ways: A: ascending - Endometrium: endometritis - Fallopian tubes: salpingitis - Tubes/ovaries: tubo ovarian abscess - Pelvic cavity: Pelvic peritonitis- abscess - Peritoneal cavity: generalized peritonitis B: through uterine wall to broad ligaments - parametritis/abscess - septic thrombophlebitis 2005 Clinical Officer Training Malawi

Clinical Officer Training ACUTE/CHRONIC PID MORE INFORMATION by Gynecologists 2005 Clinical Officer Training Malawi

Clinical Officer Training 2013 Clinical Officer Training Malawi

Clinical Officer Training 2005 Clinical Officer Training Malawi