Surgical site infections (SSIs) are the most common and the costliest of all hospital-acquired infections.1 Although most patients with an SSI recover, the infection itself accounts for 77% of mortality in these patients.1 A SSI on average adds more than $20,000 USD to each hospital admission.1 Patients with an SSI experience low quality of life with limitations in physical, social, and psychological functioning.2 The fictional case study that follows includes findings of a SSI and interventions.
CASE STUDY
Mr L is a 76-year-old man with diabetes mellitus Type 2. Fifteen days ago, he underwent emergent coronary artery bypass grafting for left main coronary artery dissection that occurred during percutaneous coronary angioplasty at an outside hospital. Mr L presented to the ED with complaints of shortness of breath. On further examination, he was found to have a moderate pleural effusion, fever of 38.3 oC, white blood cell count of 14.3 th/uL (reference range 4-10 th/uL), and random blood glucose of 226 mg/dL (reference range 60-200 mg/dL). Mr L was admitted to the medical service for further evaluation and medical management.
Upon the nurse's initial assessment, Mr L was comfortable with the head of the bed elevated to 45 degrees. His respirations were unlabored while receiving 2 liters of oxygen via nasal cannula. The sternal incision was clean, closed, dry, and well-approximated, without drainage or surrounding induration.
His left medial lower extremity incision had uniform periwound erythema along most of the incision line. While blanchable, the erythema extended 7.8 cm along the incision line below the knee and was 2.3 cm in width. The lower extremity wound edges were separated, leaving an open wound that measured 4.4 cm in length, 0.6 cm in width, and 0.4 cm in depth. The wound bed was moist with creamy slough adherent to the base of the wound (Figure). The nurse noted two trails of scant-to-moderate red-tinged, golden-tan drainage drying on Mr L's lower extremity extending from the incision line; odor was not present. On palpation, the reddened area was found to have increased warmth. When the nurse touched the erythematous area, Mr L exclaimed, "Oh! That is a sore spot!" Mrs L was at Mr L's bedside and reported that the lower extremity incision line reddened shortly after surgery but had started draining 2 days previously, on postoperative day 13. Staples were removed in the ED prior to his admission.
The nurse noted both lower extremities had pre-tibial pitting edema, but that the left lower extremity was visibly larger than the right lower extremity.
Dilemma: Should the Nurse Be Concerned about the Left Lower Extremity Incision?
The patient's intrinsic risk factors for an SSI included advanced age and diabetes, and an extrinsic factor was the emergent nature of the procedure.1 Local signs and symptoms of a SSI included erythema, warmth, swelling, pain, drainage, and separation of wound edges; systemic signs included fever and leukocytosis.
CASE STUDY (CONTINUED)
The nurse notified the attending physician immediately of concern for a SSI of the left lower extremity incision due to local signs on examination, as well as the patient's elevated temperature, blood glucose level, and white blood cell count. The attending physician gave the nurse orders for a surgical consultation for further surgical wound care recommendations. The attending physician also placed orders to check hemoglobin A1c and prealbumin levels. The patient was started empirically on a broad-spectrum antibiotic to cover common skin flora such as Staphylococcus epidermidis after a culture was obtained.
The wound surgeon's preference was a deep wound culture. The surgeon separated the wound edges and locally explored the wound so that the deepest portion of the wound bed could be cleaned and adequately swabbed. Opening the wound allowed infected fluid to drain and simplified wound care.
Dilemma: What Wound Dressing Could Be Used for the Lower Extremity Incision?
The dressing should be selected based on the amount of drainage, condition of the periwound skin, signs of local and systemic infection, and need for reassessment of the wound by healthcare providers. Based on the wound assessment, an absorbent antimicrobial dressing was deemed appropriate. The dressing type may change as the wound's attributes change.
CASE STUDY (CONTINUED)
The nurse consulted with the wound surgeon who recommended lower extremity elevation and dressing changes every other day. The wound was to be irrigated with 0.9% sodium chloride solution with each dressing change. Considering that the wound had indications of infection, the wound surgeon ordered a topical antimicrobial cadexomer iodine ointment, covered with 4 x 4-inch gauze dressings and secured with bandage wrap and paper tape.
The wound surgeon also ordered additional studies. Mr L's X-ray results showed soft tissue swelling without fluid accumulation or destruction of the tibia or fibula characteristic of osteomyelitis. The Doppler results were negative for superficial or deep venous thrombosis. Blood cultures were negative. The wound culture showed moderate methicillin-sensitive Staphylococcus aureus that was treated with cefazolin. After 2 days of treatment, Mr L's lower extremity incision had resolving erythema, decreased drainage, and visible granulation. His condition improved, and discharge was planned.
Dilemma: What Does the Patient Need to Know in Preparation for Discharge?
Providers should teach patients and caregivers how to care for the lower extremity incision at home and how to recognize an infection at the surgical site.3 A homecare referral was made so that a nurse could continue to evaluate Mr L's surgical incisions and provide education specific to the management of the wound in conjunction with close postoperative follow up with the patient's surgeon. Additional patient education regarding factors that may contribute to infection and delayed wound healing including nutrition, control of blood glucose, edema, and activity level were also provided to Mr L and his wife.
HOW CAN AN SSI BE PREVENTED IN THE FUTURE?
Practitioners need to consider perioperative factors to help prevent SSI occurrence.4 The effectiveness of presurgical bathing, limiting preoperative hair removal to clipping, perioperative antibiotics (as directed by Surgical Care Improvement Project protocols),5 and immediate postoperative site care all must be evaluated.
IMPLEMENTATION OUTCOMES
1. Consider perioperative factors to decrease the occurrence of SSIs.
2. Evaluate the effectiveness of practices such as presurgical bathing, perioperative antibiotics based on Surgical Care Improvement Project recommendations, and immediate postoperative site care.
3. Perform appropriate SSI assessments and interventions to prevent further morbidity, mortality, and healthcare costs.
CONCLUSIONS
The prevalence of SSIs can vary with the type of surgery and the degree of contamination. An SSI results in incisional exudate, dehiscence with delayed healing, pain, impaired quality of life, and overall increased patient and healthcare costs; however, assessment and appropriate interventions can prevent further morbidity, mortality, and healthcare costs.
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