Surgery of the wound and infections

1. Surgery of the wound and infections

2. Wound healing processrestoration/regeneration • Collagen formation • finroblasts- protocollagen • hydroxylation • Epithelial coverage • Contraction in the tissues • Blood vessels • migration and division • Angiogenesis • Vasculogenesis, in situ.

3. Wound Healing: Stages • Hemostasis • platelets, endothelial cells, fibrin & fibronectin • Inflammation • neutrophils, macrophages, lymphocytes, growth factors and proteases and cytokines • Proliferation - fibroblasts, epithelial & endothelial • growth factors. • Remodeling - collagenase

4. Wound healing phases • Lag (24-48 h) • acute inflammatory response • Prolifaretive (4-5 weeks) • migration of fibroblasts, capillaries • wound strength: 1st month 50% 2nd month 75% 6th month 95% • Maturation: cross linking, remodelling, contraction

5. Clinical management • First intention healing • primary closure, epithelisation 48-72 h • 2nd intention- contaminated wounds • granulation tissue • 10 000 organism/mm3 • 3rd intention- delayed primary closure • 3-4 days observation, closure

7. Abnormal wound healing • Large, dead space that accumulates fluid, • excessive fat that obscures the fascia, BMI>52 • poor blood supply, • attenuated and weakened fascia, • excessive wound tension • chronic lung disease, chronic cough, and vomiting • malnutrition, old age, diabetes (neutrophil dysfunction, and microvascular disease) decreasing phagocytosis, chemotaxis, killing bacteria, adherence, impaired lymphocyte function, glycosylation of C3, which impairs phagocytosis, and an increased risk of bacterial and fungal infections. • cigarette smoking, chronic steroids, and prior surgery

8. Special wound healing problems • Gastrointestinal • stricture, anastomotic leak • Keloid, hypertrohpic scar • Marjolin ulcer-sqamous cell carcinoma • chronic wound • pressure ulcer • diabetec ulcer • venous stasis

9. Keloid and hypertrophic scar

10. Keloid and hypertrophic scar

11. Treatment of chronic wounds • Removal of non-viable tissue including: necrotic tissue, slough, foreign debris including residual material from dressings. • Removal of nonviable tissue is referred to as debridement. • Removal of foreign debris is referred to as cleansing. • 4 Types of Debridement Autolytic, Biochemical, Mechanical, Sharp

12. Wound etiologies • Arterial • Venous • Diabetic • Trauma • Surgical • Auto-immune • Pressure • Mixed

13. Chronic wound treatment • Debridement • Cleansing • Maintaining a moist environment • Preventing Further Injury

14. Debridement • Removal of ALL devitalized tissue • Not the Physical Therapy “Pick and Whittle” • Healthy bleeding tissue introduces beneficial platelets and Growth factors • Allows for thorough investigation of the wound • Remove potentially infected tissue • Obtain appropriate deep cultures

15. Debridement • Mechanical • Surgical – “Audible Bleeding ?” • Enzymatic • Autolytic = Hydrogels, hydrocolloids, saline

16. Is there adequate blood flow to the ulcer?Arterial based wounds • Feel the pulse • Segmental pressures • Doppler examination • Waveforms • Can you examine the microvascular circulation?

17. Is there adequate blood flow from the ulcer?Venous Stasis Ulcers • Skin discoloration • Hemosiderin deposition • Stasis dermatitis • Lipodermatosclerosis • Loss of hair on the legs • Shiny skin on the tibias

18. Diabetesmultifactorial • Increased risk of infection • Neuropathy (loss of protective sensation) • Vascular effects • Macrovascular ( trifurcation disease below the knee ) • Microvascular (affects medial layer to prevent vasodilatation) • Humeral (decreased NO)

19. Infections • Invasion by pathogenic microorganism • Nosocomial • Autoinfection • Virulence • Carriers • Opportunistic bacteria

20. Soft Tissue Infections • cellulitis, intact blood supply • Lymphangitis • Erysipelas- cellulitis+lymphangitis • subcutaneous abscess • Impetigo-multiple intraepithelial abscesses • Furuncle-sweet glands • Carbuncle- subcutaneous tissue • perirectal abscess-fistula at anal crypt • distal phalanx of the finger (felon)

21. Erysipelas It is acute, non suppurative, spreading inflammation of the skin dt invasion of its lymohatics • Rose pink • Hot • Tense • Tender • Smooth • Blanching on pressure • Marked edema dt lymphatic obstruction

22. Erysipelas • Course • Resolution • Erysipelas migrans • Lymph edema • Gangrene and sloughing • Death • Treatment • Isolation • Rest and elevation • Icthyol or lead subacetate • penicillin

23. It is a staphylococcal infection originating in a hair follicle but involve the sc tissue and adjacent hair follicle Painful induraed swelling, red, hot & dusky Grow in all directions, central become soft & boggy then break with multiple discharging sinuses

24. Carbuncle

25. Gas Gangrene • It is an acute fatal rapidly spreading infection caused by a mixture of gas forming organisms of clostridia group • Predisposing • Bad general conditions • Local ischemia • In-adequte surgical wound care • Clostridial soft tissue include cellulitis and myonecrosis. • Clostridium perfringens • Cl nevyi • Cl septicum • Cl sordelli

26. Gas Gangrene Powerful exotoxin • Skin and SC tissue • oedematous celluitis with gas that destroy local microcirculation • release RBCs and hemolysis • Early sacchrolytic----- hemolysis--- brick red • Late proteolytic--- H2 + Fe---- iron sulphide--- black color • Muscles toxins lead to necrosis • Toxins generally

27. Gas Gangrene ( Clinical picture) • IP = 1- 3 days • General • Toxemia and prostrtion • Stupor, delirium and death • Local • Brown watery discharge from wound and marked tenderness • Palpable crepitance. • Skin and muscle gangrene early brick red later black • X-rays show GAS

28. Gas Gangrene ( Clinical Types) • Fulminating • Massive ( whole limb) • Local ( muscle) • Gas edema • Gas abscess • Gas cellulites

29. Gas Gangrene Prophylaxis • Tetanus immunization • Anti gas gangrene serum 10 cm then 4 cm then 2 cm every 6 hours • Adequate surgical debridement prevents gangrene. • Immediate radical surgical Debridement. • Penicillin in massive doses

30. Gas Gangrene Active treatment • General • Blood transfusion • O2 therapy • Anti-gas gangrene serum 100 cm daily • Penicillin in massive doses or erythromycin • Local • Debridement • Amputation

31. Tetanus • caused by enterotoxin secreted by clostridium tetani • 2 days to several weeks incubation • Complex prodromal symptom • Tonic phase • Lockjaw. then Jaw stiffness • muscular contractions, tonic spasms • respiratory arrest • Clonic phase

32. Tetanus • Acute tentanus • Chronic • Latent • Cephalic • Splanchnic • Local • Cryptogenic • Post operative • Tetanus neonatorum

33. Tetanus (DD) • Meningitis • Erysipelas • Tetany • Rabies • Strychnine poisoning • Local cause of trismus

34. Tetanus immunotherapy • Adults should receive booster toxoid doses at 10-year intervals • Who do not have three prior toxoid injections-tetanus diphtheria toxoid (Td) • Tetanus immune globulin (TIG) • ATS 1500 unit • ATG 250 IU

35. Tetanus (treatment) • Nursing • Anti tetenic serum • ATS • 100.000 u ½ IV and ½ IM • 50.000 U after 7 days • ATG one dose only • Penicillin & streptomycin • Wound care • Other measure

36. Tetanus (treatment) • Stage I • Sedation by luminal or sparine • Stage II • Sedation • NG • Tracheotomy • Stage III • Muscle relaxant as curare 20 – 40 mg IV initial then IM • IPPV • NG tube • Continue till spasm disappear