A 60-year-old man undergoes a laparotomy for intestinal obstruction secondary to postoperative adhesions from a cholecystectomy 2 years ago. His other medical problems include type 2 diabetes mellitus, hypothyroidism, and hypertension. On postoperative day 3, he complains of intense pain around his laparotomy wound. His temperature is 38.3 C (101 F), blood pressure is 121/76 mm Hg, pulse is 100/min, and respirations are 16/min. Examination of the wound shows abundant cloudy-gray discharge and dusky, friable subcutaneous tissue. Sensation is decreased at the wound edges. His serum glucose level is 312 mg/dL. Which of the following is the most appropriate next step in management of this patient?

Question

A 60-year-old man undergoes a laparotomy for intestinal obstruction secondary to postoperative adhesions from a cholecystectomy 2 years ago.  His other medical problems include type 2 diabetes mellitus, hypothyroidism, and hypertension.  On postoperative day 3, he complains of intense pain around his laparotomy wound.  His temperature is 38.3 C (101 F), blood pressure is 121/76 mm Hg, pulse is 100/min, and respirations are 16/min.  Examination of the wound shows abundant cloudy-gray discharge and dusky, friable subcutaneous tissue.  Sensation is decreased at the wound edges.  His serum glucose level is 312 mg/dL.  Which of the following is the most appropriate next step in management of this patient?

Quizplus · Accepted Answer

Explanation: This patient has the following signs and symptoms suggestive of necrotizing surgical site infection: Pain, edema, or erythema spreading beyond the surgical site Systemic signs such as fever, tachycardia, or hypotension Paresthesia or anesthesia at the edges of the wound Purulent, cloudy-gray discharge ("dishwater drainage") Subcutaneous gas or crepitus Necrotizing surgical site infections occur more commonly in patients with diabetes and are usually polymicrobial. These infections are considered emergencies if they involve the fascial plane and develop into necrotizing fasciitis. The most important step in management of this condition is early surgical exploration to assess the extent of the process and debride necrotic tissues. Adjunctive therapies, including broad-spectrum antibiotics, adequate hydration, and tight glycemic control, are also important but are secondary to surgical exploration. (Choice A) Appropriate wound dressing and tight glucose control play a key role in adequate surgical wound healing in diabetics. However, once infection is established, definitive therapy with surgical exploration and antibiotic therapy is needed. (Choice B) Negative-pressure wound therapy (ie, vacuum-assisted wound closure) is a wound-dressing system that applies sub-atmospheric pressure to a wound to accelerate the healing process. It is reserved for healthy, granulating wounds. It is not used initially when the wound is infected or necrotic. (Choice C) Intravenous antibiotics alone are sufficient therapy for wound infections limited to cellulitis, but surgical debridement is required when the infection penetrates the deeper skin layers and adjacent tissue, as in this patient. (Choice E) Topical antimicrobial agents do not have a clear role in surgical site infections. They are not useful for prevention as they may inhibit wound healing, and they are not a substitute for parenteral therapy once infection has been established. Educational objective: Necrotizing surgical infection is characterized by intense pain in the wound, decreased sensitivity at the edges of the wound, cloudy-gray discharge, and sometimes crepitus. Early surgical exploration is essential. References: Necrotizing soft-tissue infection: diagnosis and management (http://www.ncbi.nlm.nih.gov/pubmed/17278065) Necrotizing soft tissue infections. (http://www.ncbi.nlm.nih.gov/pubmed/24094377) Morbidity and mortality of diabetes with surgery. (http://www.ncbi.nlm.nih.gov/pubmed/23834046)

A 60-Year-Old Man Undergoes a Laparotomy for Intestinal Obstruction Secondary