wound complications - Emily

Question 1

What affects wound healing?

Answer 1

-Wound factors
-Host factors
-External factors

Question 2

What is the most significant complication to wound healing?

Answer 2

Bacterial infection

Question 3

What are two ways bacteria can invade a surgical site?

Answer 3

1. Local route (patient surfaces, instruments, surgeon, environment)
2. Distant route (other site infection in patient, hematogenous spread)

Question 4

What is the approximate risk of SSI in a clean wound?

Answer 4

1-5%

Question 5

What is the approximate risk of SSI in a clean contaminated wound?

Answer 5

5-10%

Question 6

What is the approximate risk of SSI in a contaminated wound?

Answer 6

10-30%

Question 7

What is the approximate risk of SSI in a dirty wound?

Answer 7

> 30%

Question 8

Which tissue types are involved in superficial SSI?

Answer 8

Skin and subcutaneous

Question 9

Which tissue types are involved in deep incisional SSI?

Answer 9

Muscle and fascia

Question 10

Which tissue types are involved in organ or space SSI?

Answer 10

Peritoneum, pleural space, etc

Question 11

What is the infectious dose of bacteria?

Answer 11

> 10^5 bacteria/gram of tissue

Question 12

What bacterial factors can affect the infectious dose needed?

Answer 12

-High microbe virulence (adherence, antibiotic resistance, biofilms)
-Foreign material in wound or site
-Host site dependent (oral mucosa and tissues or mouth vs synovial fluid or CSF)

Question 13

What are important surgical risk factors?

Answer 13

-Duration of surgery (TIME)
-Aseptic technique
-Foreign material
-Surgical technique
-Emergency procedures

Question 14

What are Halstead’s principles of surgery?

Answer 14

-Gentle tissue handling
-Hemostasis
-Preservation of blood supply
-Strict aseptic technique
-Minimize tension
-Accurate apposition of tissue
-Eliminate dead space

Question 15

What are common symptoms of SSI?

Answer 15

-Fever, redness, swelling, pain
-Purulent discharge
-Wound dehiscence/delayed healing
-Usually within 30 days

Question 16

What are some ways to prevent SSI?

Answer 16

-Careful skin prep
-Minimize trauma (ex. scalpel vs laser)
-Minimize trash
-Minimize surgical time
-Peri-operative antibiotics if indicated

Question 17

What is prophylactic antibiotic use?

Answer 17

Given pre-operatively and possibly intra-op to prevent establishment of infection

Question 18

What is therapeutic antibiotic use?

Answer 18

Used post-operatively when indicated to treat an established infection

Question 19

When would it be a good idea to give prophylactic antibiotics?

Answer 19

-Fracture repair with implants
-Abdominal surgery
-“field” surgery
-Anything other than clean surgeries

Question 20

What are the principles of administration of surgical antibiotics?

Answer 20

-Bactericidal (1 dose given 30 mins before surgery)
-Maintain levels throughout surgery (2nd dose if surgery is >3 hours or 1-2x 1/2 life of drug)
-Not necessarily needed >24hrs post op

Question 21

What are routes of administration for antibiotics?

Answer 21

-Systemics (IM or IV)
-Regional (perfusion with tourniquet, antibiotic implants)
-Topical (tissue irrigation)

Question 22

What are some procedures where prophylactic antibiotics would be a good idea?

Answer 22

-Long surgeries (>90mins)
-Prosthetic (permanent) implants
-Patients with prostheses undergoing surgery
-Severely infected or traumatized wounds
-Orthopedic surgeries
-Respiratory surgeries
-GI surgeries
-Urogenital surgeries
-Systemically compromised patients

Question 23

What is dehiscence?

Answer 23

A complication of wound healing in which the wound ruptures along a previously closed surgical incision

Question 24

What are some wound factors that can lead to dehiscence?

Answer 24

-Infection
-Excessive tension
-Seroma/hematoma formation (dead space)
-Non-viable tissue or poor perfusion
-Saliva or synovial fluid in wound
-Foreign body
-Neoplasia

Question 25

What are some patient factors than can lead to dehiscence?

Answer 25

-Systemic disease -Nutrition -Medications -Neoplasia

Question 26

What are some environment factors than can lead to dehiscence?

Answer 26

-Post op wound trauma -Movement

Question 27

What are some signs of impending wound dehiscence?

Answer 27

-Discharge along suture line -Excessive swelling or fluid accumulation under skin -Evidence of suture failure -Evidence of tissue necrosis

Question 28

How many days post-op is dehiscence likely to happen?

Answer 28

7 days

Question 29

How can you prevent wound dehiscence?

Answer 29

-Prevent contamination -Minimize tension -Immobilize joints to minimize movement -Reduce dead space -Reduce swelling -Protect from trauma -Overall patient care (meds, nutrition)

Question 30

What are some things you would do to work up a wound that isn't healing well?

Answer 30

-Impression smears and culture -Biopsy and culture -Radiographs -Wound exploration

Question 31

What are some factors that contribute to delayed wound healing?

Answer 31

-Foreign body -Reduced local blood flow -Systemic factors (diseases) -Drugs (corticosteroids, chemotherapy, etc)

Question 32

What is a bone sequestrum and which species is it most common in?

Answer 32

A piece of dead bone in the wound. Most common in horses

Question 33

What causes a bone sequestrum?

Answer 33

-Loss of blood supply in periosteum -Bacteria invade and colonize dead bone

Question 34

Why does a bone sequestrum impair healing?

Answer 34

It acts as a foreign body and provides a place for bacteria to thrive

Question 35

What are some signs that a bone sequestrum might be present?

Answer 35

-Persistent soft tissue swelling -More pain than expected with palpation -Mild lameness -Persistent cleft in granulation tissue -Persistent drainage -Wound won't heal

Question 36

When is a bone sequestrum likely to occur?

Answer 36

3-4 weeks after initial injury

Question 37

What are 3 types of excessive wound healing?

Answer 37

-Fibroproliferative wound healing -Contracture -Adhesions

Question 38

What is fibroproliferative wound healing?

Answer 38

-Exuberant granulation tissue (proud flesh) - OPEN -Hypertrophic scar/keloid - CLOSED

Question 39

What type of wounds are at high risk of excessive wound contracture?

Answer 39

-Large wounds -Wounds in high motion areas -Wounds left to heal by second intention

Question 40

What can excessive wound contracture lead to?

Answer 40

Impaired function, pain and disability

Question 41

What are some ways to treat/prevent excessive wound contracture?

Answer 41

-Primary closure or delayed primary closure when possible -Reconstructive techniques -Physiotherapy -Scar revision procedures as treatment

Question 42

What is tissue adhesion?

Answer 42

Scar formation and contracture affects internal organs or tissue in a pathologic manner

Question 43

How can the risk of tissue adhesion be reduced?

Answer 43

-Good surgical technique and tissue handling -Anti-adhesion products for intraoperative use -Physiotherapy

Question 44

What is exuberant granulation tissue?

Answer 44

Excessive and prolonged proliferative phase where granulation tissue extends above epithelial margins

Question 45

What are consequences of granulation tissue above epithelial margins?

Answer 45

-Inhibits epithelialization and contraction -May cause expansion or enlargement of wound

Question 46

What are treatment options for excessive granulation tissue?

Answer 46

-Surgical excision -Local anti-inflammatories -Reduce inflammatory stimuli -Possibly a bandage -Skin grafting

Question 47

What are the 4 main wound healing complications?

Answer 47

-Infection, SSI -Delayed wound healing (dehiscence) -Bone sequestrum -Excessive wound healing