1
Q
Infection definition
A
- the growth of pathogenic microorganisms in living tissue; it refers to the disease-producing process, not the routine multiplication of normal flora.
- can have MOs without infection
2
Q
Review of Microbiology
A
- Pathogenic microorganisms are those that cause disease
- Sepsis: a severe, toxic, febrile condition resulting from infection with pathogenic microbes, usually pyogenic (pusforming)
- Bacterial infections most frequently cause “hospital-acquired” infections.
3
Q
MRSA
A
- Aerobic
- Gram-positive Staphylococcus
- Methicillin Resistant Staph Aureus
- 20-30 % carry this
4
Q
Group A Streptococcus
A
- Aerobic
- Gram positive streptococcus
- (may cause necrotozing fasciitis)
- not contagious
5
Q
Mycobacterium Tuberculosis
A
- Aerobic bacteria
- A hardy bacillus- can live in soil for a long time
- Most common transmission route/infection site: airborne/lungs
- May be present as a “cyst” elsewhere in the body
6
Q
- Escherichia coli
- Klebsiella sp.
- Proteus sp.
A
- Aerobic
- Gram-negative bacilli
- all normal flora of the GI tract
7
Q
Clostridium difficile
A
- Anaerobic
- Gram-positive bacilli
- pseudomembranous colitis
- common nosocomial
- contact precautions
- antibiotics wipe out all the good bugs
8
Q
Bacillus stearothermophilus
A
is used for testing autoclaves (AKA “Attest”)
9
Q
*Bacteroides sp.
A
- Anaerobic
- Gram-negative bacilli
- normal flora of the gut
- cause gingivitis and periodontal disease
10
Q
GRAM-NEGATIVE BACTERIA ARE THE PRIMARY CONTAMINANTS IN
A
NOSOCOMIAL INFECTIONS
11
Q
Candida albicans
A
- Fungi
- AKA “thrush” (mouth), AKA “yeast” (vagina)
- can be normal flora of the mouth
12
Q
Sources of Contamination
A
- Community-acquired infection:
- Spontaneous
- Traumatic
- Nosocomial
- Endogenous
- Exogenous
13
Q
Community-acquired infection
A
- Spontaneous – Appendicitis, cholecystitis, peritonitis (kinda like endogenous)
- Traumatic – Compound fractures, penetrating wounds (kinda like exogenous)
14
Q
Nosocomial Infections
A
- Endogenous:
- Develops from sources within the body
- This raises the issue of cross contamination, especially “bowel technique” (isolating, fix contaminations)
- Exogenous:
- Acquired from sources outside the body
- ex: healthcare worker didn’t wash hands
15
Q
FACTS about nosocomial infections
A
- About 35% of all nosocomial infections develop in surgical patients
- The majority of these are related to instrumentation of the urinary tract and the respiratory tract.– isolate
16
Q
Sepsis
A
- Definitions:
– A severe, toxic, febrile state resulting from infection.
– The presence of pathogenic microbes or their toxins in the blood or other tissues. - three stages:
– invasion
– localization
– either resolution leading to recovery, OR, spreading of the infection.
17
Q
Development of Infection
A
- Cellulitis (invasion)- diffuse inflammatory response
- Abscess formation (localization):
- the result of tissue liquefaction with pus formation
- body attempts to wall off an abscess by means of a membrane that produces surrounding induration
- An abscess should be promptly drained.
18
Q
Regional infection
A
- Occurs when localization does not contain the infection, and it spreads
- The spreading infection enters the lymphatic system, causing lymphangitis. lymphnodes can help
19
Q
Systemic infection
A
- Septicemia may develop if the lymph nodes fail to contain the infection
- Veins in the infected area form thrombophlebitis, which sloughs septic emboli into the circulatory system
- These emboli and pathogenic microbes seed abscess formation in remote tissues
- Bacterial septicemia is called “bacteremia”.
20
Q
Septic Shock
A
- Exists in a state of widely disseminated infection, usually borne by the bloodstream, ie septicemia
- last stage before death
- Early symptoms of septic shock:
- Hypotension
- Tachycardia
- Rapid breathing
- Symptoms of Advanced septic shock:–decompensation– NOT GOOD
- Respiratory insufficiency
- Cardiac decompensation
- Diminished urinary output
- DIC
21
Q
Clinical Factors contributing to infection:
A
- Pathogenic microbes
- Local factors
- Host Defense Mechanisms
22
Q
Pathogenic microbes
A
- Must reach the host to cause infection
- The size and virulence of the inoculum is VERY important.
- can we stop it from reaching a new host?
23
Q
Local factors
A
- Various body tissues have different powers of resistance
- The face, scalp, and chest are more resistant than the abdomen, thigh, calf, and buttocks
- Vascularity of the tissue is a major factor–more vascular= more able to fight off infection
24
Q
Host Defense Mechanisms
A
- The general health of the patient is very important- how sick is your pt?
- The virulence of the infecting organism is very important
- Proper treatment plays a big part
25
Diabetes and host defense mechanisms
* The DIABETIC PATIENT DOESN'T HEAL WELL
* Compromised vascular system
* develop peripheral vascular disease
* loss of sensation (can't feel the injury, then gets infected)
* Prone to infection
26
Adjuvant factors to infection
* Duration of pre-op hospitalization
* Contaminated wounds
* Procedures involving GI or GU tracts
* Duration of the procedure- the longer it goes, the more things could go wrong
* Surgical technique
* injured tissues-- don't retract super hard
* Implants
* Excessive use of electrocautery creates necrotic tissue
* Intravascular devices
* Catheters
* Drains- inspect
* Any Implantable device
27
Post-op Wound Infections
* Incisional :
* Infection occurs at the site of the incision
* Involves skin, subcutaneous fat, or muscle
* Deep :
* Infection occurs in the surgical area
* Involves tissues at or beneath the fascia
28
Intra-operative Complications
* Hemorrhage
* Friable Tissue
* Incidental Injury to other organs
29
Intra-operative Complications (Hemorrhage)
* Definitions:
* Shock: A state of inadequate blood perfusion to parts of the body (most likely intraoperatively) hypovolemic
* DIC: Disseminated Intravascular Coagulation -- a condition in which the normal clotting mechanisms do not function (most likely postoperatively)
* Treatment of intra-op hemorrhage (larger vessel)
* Surgeon locates source and applies digital pressure
* Clamps put in place
* Vessel is then ligated or sutured
* Blood volume may need to be replaced with transfusion, or with "Cell Saver"
30
Friable Tissue
* AKA: "Readily crumbled”
* Tend not to hold suture well
* Can be lacerated by vigorous retracting
* Treat with chemical hemostatic agents
* NSAIDS break down tissue
* also radiation, smokers
* **Tumors** (may be highly vascular): grow own blood supply
* Malignant tumors
* Hemangiomas
* **Friable Organs**:
* Liver, spleen, kidney, pancreas, thyroid
31
Incidental Injury to other organs
* Friable organs
* Major Vessels
* Ureters
* Bowel
* Urinary Bladder
32
Incidental injury to Friable Organs
* Injuries may result from:
* Retractors- don't retract hard
* Dissection- delicate, slow
* Sutures/ligatures- can tear through
33
Incidental Injury to Major Vessels
* Veins
* Thin; tear easily
* Difficult to suture effectively
* Arteries-- clamp off well
* High pressure
34
Incidental injury to Ureters
* Anatomic relationship to pelvic structures
* Surgeon must identify the ureters to prevent accidental clamping, ligating, or cutting- check for peristalsis
* Ennervated smooth muscle; to identify, use a forceps, etc.
35
Incidental injury to Bowel
* May be cut during lysis of adhesions
* May be torn by pulling and tugging-- we will be in charge of retracting
* Spillage of intestinal contents can cause infection & peritonitis (esp. large intest- colon)
36
Incidental injury to Urinary Bladder
* May be cut or torn, causing leakage of urine into the pelvic cavity, and bleeding
* thin walls-easy to cut/tear
* Hematuria: blood in the urine-- check UDB
37
Foreign material left in the patient
* **Sponges- worst thing-porous-MOs!**
* **Instruments and Needles**
* **Anything** accidentally left in the patient must be removed!
* all scrub's job
38
Post Operative Complications
* Hemorrhage
* Pain
* Scarring
* Keloids
* Adhesions
* Extravasation
* Wound Disruption
* Thrombosis
* Incisional Hernia
39
Post-op complications Hemorrhage
* May occur any time after the wound is closed
* Ties and hemoclips may slip off vessels
* Clots can become dislodged (from chemical hemostatic agents)
* Remember previous definitions
* DIC--bigger risk post-op
* Shock-- more likely to happen intraoperatively
40
Post-op complication **Pain**
* Local Anesthetic-very acidic- burning sensation
* Must be injected
* General Anesthetic -- many tradeoffs:
* Intra-op -- If improperly administered, patient may sometimes feel pain, but can be unable to respond
* Post-op -- nausea, vomiting, sore throat.
* Retractors -- bruising of tissues, tearing of muscles
* Knives
41
Post-op complication: Scarring
* Keloids: hypertrophic skin scarring
* Adhesions:
* Develop in response to:
* Previous abdominal or pelvic surgery
* abrasion
* Appendicitis or peritonitis.
* Ischemia.
* most common cause of post-op intestinal obstruction.
* can cause infertility and chronic abdominal pain.
* Lysis of adhesions: a common surgical procedure.
* "Once Adhesions, Always Adhesions"
42
Extravasation
* **Definition**:The passage of blood, serum, or lymph into tissues. (fluid outside a vessel)
* **Edema**: Abnormal accumulation of fluid in interstitial spaces of tissues. (plasma)
* **Hematoma**: A collection of extravasated blood in tissue. (blood)
43
Wound Disruption
* **Definition**: separation of wound edges.
* Occurs when:
* wound fails to heal, sometimes due to:
* suture material fails to secure wound
* Acute wound disruption most frequently follows abdominal laparotomy
* Wound Disruption is usually caused by distention (intra-abdominal pressure), or a sudden strain such as vomiting, coughing, or sneezing
44
Types of wound disruption
* **Dehiscence**: Splitting open of the layers of the wound.
* **Evisceration**: Protrusion of viscera completely through the abdominal incision.
45
Thrombosis
* **Definition**: the development of a thrombus
* **Thrombus def**: an aggregation (clump) of blood factors, especially platelets and fibrin; essentially, a "blood clot"
* **Thrombophlebitis def** : Inflammation of a vein, associated with thrombosis.
46
Venous Stasis
* Definition: stagnation of normal flow; ie static instead of dynamic
* The venous return of blood from the lower extremities can be slowed by:
* The effects of general or spinal anesthesia
* The position of the legs during prolonged surgical procedures.
47
Effects of Venous Stasis
* Thrombosis
* Thrombophlebitis
48
Deep Vein Thrombosis (DVT)
* The majority of thrombi occur in the deep veins of the legs and pelvis, (aka"Deep Vein Thrombosis“).
* These thrombi can become detached and be carried to the
* lungs (pulmonary embolism),
* heart (MI), or (heart attack)
* brain (CVA) (stroke)
49
Prevention of Thrombosis
* Anti-embolic stockings (TED hose)
* Elevation of legs
* Sequential Compression Devices- attach to a unit
50
Incisional Hernia
* After a surgical wound has completely healed, a weakness can develop in the fascia at the incision site.
* Segments of bowel can protrude through this weak spot, causing a hernia.
* This is usually the result of impaired healing of a previous surgical incision, usually a ventral midline abdominal incision.
* It must be surgically repaired .
SRGT 1509
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