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Clinical Officer Training MALAWI

Clinical Officer Training MALAWI. SURGERY OF SEPSIS King 5 + 6. The “surgery of sepsis”. 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?

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Clinical Officer Training MALAWI

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  1. Clinical Officer TrainingMALAWI SURGERY OF SEPSIS King 5 + 6

  2. The “surgery of sepsis” What is that? HOW to DRAIN PUS • Has to do with INFECTION • Most commonest operation developing world • Can collect almost everywherein 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

  3. COMMON SITES of SEPSIS, names? Clinical Officer Training Malawi

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

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

  6. Most common bacteria in surgical sepsis? • Staphylococcus aureus (Skin) • E Coli and anaerobics (Peri-anal) • TB • Salmonella, Gonococcal

  7. 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 • 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. Clinical Officer Training Malawi

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

  9. 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! Clinical Officer Training Malawi

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

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

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

  13. What TO DO ABSCESS? where there is pus, let it out ! As soon as possible! why? SO OPERATE Clinical Officer Training Malawi

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

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

  16. PROCEDURE DRAINING ABSCESS 1.ANAESTHESIA • 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

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

  18. 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 Clinical Officer Training Malawi

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

  20. LATE COMPLICATIONS • 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

  21. BOILS - CARBUNCLES Clinical Officer Training Malawi

  22. BOIL - CARBUNCLE BOIL:aggressive infection skin+subcutis originating from hair follicle bystaphylococci 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 staphylococcus aureus Clinical Officer Training Malawi

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

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

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

  26. Pleura aspiration & Closed drainage Clinical Officer Training Malawi

  27. 4. ABSCESSES IN PERIT. CAVITY 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 hospital? Clinical Officer Training Malawi

  28. HIGH POST OPERATIV INFECTION RATE? - Check what? ASEPTIC THEATRE TECHNIQUE, includes YOU tooWasindication 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, etcCO project study post op inf rate: 21%- 8.6%!! It can be done! Clinical Officer Training Malawi

  29. Ward rounds. Diagnose? Cause?

  30. Skills: like making knots ! • Thoraxdrains • debridement wounds • skingrafts etc.

  31. Clinical Officer Training Malawi

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

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

  34. Clinical Officer Training Malawi

  35. Management intra abd abscessOPERATION decided. 1. PreferrabyEXTRA peritoneal. Why?If you can’t, do: 2. Laparatomycareful 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) Clinical Officer Training Malawi

  36. “TO DRAIN OR NOT TO DRAIN” • 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 Clinical Officer Training Malawi

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

  38. 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) Clinical Officer Training Malawi

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

  40. Pelvic Inflammatory Disease (PID)1. PID unrelated to pregnancy gonococci, chlamydia, mycoplasma2. PID related to pregnancy2.1 Post abortion 2.2 Infected obstructed labour2.3 Puerperal sepsis (septic thrombo flebitis)2.4 Post Caesarian Clinical Officer Training Malawi

  41. 1. About PID unrelated to pregnancyInfection starts from vagina/cervix2 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 Clinical Officer Training Malawi

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

  43. ZIKOMO KWAMBIRI Clinical Officer Training Malawi

  44. Clinical Officer Training Malawi

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