1. Surgical Infection. Acute Purulent Infection Of The Skin And Soft Tissues
A. Letch Kline, MD, FACS

2. Infections
Skin And Soft Tissue Infections Are Common In Our VA Population
Most Are Treated As Outpatients But Many Patient Come In Late And Require Admission
Most Of The Hospitalized Infections Require Surgical Drainage
Preoperative Preparation And Postoperative Nursing Care Is Critical To Successful Outcome

3. Acute Purulent Aerobic Infections
The Cause Of The Most Frequently Purulent Surgical Infections:
Staphylococcal Infections.
Streptococcal Infections.
Gram - Negative Infections.
Mixed Bacterial Infections.

4. Five Classical Local Signs Of Inflammation Are:
Heat-the Inflamed Area Feels Warmer Than The Surrounding Tissues.
Redness Of The Skin Over The Inflamed Area.
Tenderness, Due To The Pressure Of Exudate On The Surrounding Nerves.
Swelling.
Loss Of Function

5. Boil (Furuncles)
Boil Constitute One Of The Very Widespread Purulent Diseases Of The Hair Follicle And Sebaceous

6. Boil (Furuncles)

7. Boil (Furuncles)

8. Complications
Boils May Lead To Cellulitis, Particularly In Those Whose Power Of Immunity Is Less.
Boils May Also Lead To Infection Of The Neighboring Hair Follicles Where Numbers Of Hair Follicles Are Too Many (E.G. Axilla) Leading To Hidradenitis.
Boils Usually Secondarily Infect The Regional Lymph Nodes.

9. Hidradenitis

10. Carbuncle

11. Carbuncles
After Penetration Of Pyogenic Bacteria Under The Skin Through Hair Follicles And Sebaceous Glands The Process Spreads In Depth, If The Conditions Are Unfavorable To The Body, And Affects Considerable Sections Of Subcutaneous Tissue. It Is An Infective Gangrene Of The Subcutaneous Tissue Due To Staphylococcal (Staphylococcus Aureus) Infection. Gram-negative Bacilli And Streptococci May Be Found Coincidently.

12. Carbuncle

13. Treatment Treat Medical Conditions Culture Antibiotic.
Operation May Be Required:
Unresponsive To Antibiotic
Carbuncle Is More Than 2 Inches In Diameter With Fluctuance
Ultrasound Can Be Used To Detect Abscess Cavity

14. Abscess
An Abscess Is A Cavity Filled With Pus And Lined By A Pyogenic Membrane. This Pyogenic Membrane Consists Of Dead Tissue Cells And A Wall Of Granulation Tissue Consisting For The Most Part Of Phagocytic Histiocytes.

15. Abscess

16. Abscess

17. Treatment The Basic Principle Of Treatment Of An Abscess Are:
To Drain The Pus;
To Send A Sample Of Pus For Culture And Sensitivity Test;
To Give Proper Antibiotic.

18. Erysipelas
It Is An Acute Inflammation Of The Lymphatics Of The Skin Or Mucous Membrane. The Causative Organism Is Usually Streptococcus Haemolyticus.

19. Erysipelas

20. Erysipelas

21. Erysipelas

22. Erysipelas

23. Lymphangitis
A Spread Of Infection Along The Lymphatic System Is Manifested In A Disease Of The Lymphatic Vessels And Lymph Nodes. Inflammation Of The Lymphatic Vessels (Lymphangitis) Is One Of The Frequent Complications Of Infected Wounds, Especially During The First Weeks Following Injury, And Of Local Purulent Diseases.

24. Lymphangitis

25. Treatment
The Treatment Of Lymphangitis Consists Primarily In Elimination Of Its Cause (Incision Of The Abscess, Pockets Of The Wound, Etc.) And In Giving The Affected Organ Complete Rest.

26. Paraproctitis

27. Paraproctitis
Is The Purulent Inflammation Of Around-rectal Cellular Tissue.
Can Progress To Fournier’s Gangrene

28. Skin Abscess Require Incision And Drainage
Make Large Enough Incision To Drain Purulent Collection
Greater Then 6 Cm Or Complex/Deep Infection May Require General Anesthesia
Take Cultures Before Starting Antibiotics
Pack Wound Tightly To Prevent Bleeding In First 6 Hours

29. Post Operative Care Leave Packing For 6-12 Hours
Pre And Postoperative Antibiotics
Monitor Fever, WBC, Associated Cellulitis
Return To The OR If Have Fasciitis Or Advancing Infection
Start Wet To Dry Packing To Debride Surface Of SQ Tissues And Create Granulation Tissue

30. Preoperative Care Antibiotics
Start As Soon As Diagnosis Made But
Try To Get Cultures If Possible First
Want To Cover Gram Positives In Routine Skin Infections
Gram Positives, Gram Negatives/Anerobes If Fasciitis Or Life/Limb Threatening Infection

31. Preoperative Care Antibiotics Skin Infections-mssa Po Iv Dicloxicillin
Cephalexin Iv
Nafcillin/Oxacillin
Cefazolin

32. Preoperative Care Antibiotics Skin Infections-mrsa Po Iv Bactrim DS
Clindamycin
Doxycyline
Linezolid Iv
Vancomycin

33. Preoperative Care Antibiotics Life Or Limb Threatening Infections
Diabetic Foot Infections
Faciitis
Cover Gram Negatives And Anerobes As Well As Gram Positives
Vancomycin And
Unasyn
Timentin
Zosyn
Ertapenem/Imipenem/Meropenem

34. Post Operative Care
Once Purulence Is Controlled, Consider Wound Vacuum Assisted Closure (VAC)
Drains Wound
Lessens Need For Dressing Changes
Often Less Painful For Patients
Quickens Wound Closure

35. Clinical Benefits Of V.A.C. Therapy
Maintenance Of Moist, Protected Environment
Removal Of Excess Interstitial Fluid From The Wound Periphery
Increased Local Vascularity
Decreased Bacterial Colonization
Quantification/Qualification Of Wound Drainage
Increased Rate Of Granulation Tissue Formation
Increased Rate Of Contraction
Increased Rate Of Epithelialization

36. V.A.C. Therapy Indications
Acute Wounds
Full-thickness Surgical Wounds
Chronic Wounds
Stage 3 Pressure Ulcers
Stage 4 Pressure Ulcers
Diabetic Ulcers
Venous Stasis Ulcers
Traumatic Wounds
Dehisced Wounds

37. V.A.C. Therapy Contraindications
Active Infections
Nearby Blood Vessels
Malignancy In Wound
Untreated Osteomyelitis
Nearby Bowel

38. Perioperative Care Broad Spectrum Antibiotics Control Blood Glucose
Start Empiric (Best Guess) Coverage Then Use Culture/Gram Stain Results
Cover MRSA
Control Blood Glucose
Patient/Wound Isolation
Pain Control
KT/Physical Therapy-prevent Contractures

39. Perioperative Care Dressing Changes More Frequent If Trying To Debride
Packing Should Be Loose But Want To Cover The Surface Of The Cavity
Start With Saline Soaked Gauze-avoid Betadine For Repeated Wound Dressings
Can Add Dakin’s Solution If Concerned For Superficial Pseudomonas
Best If Can Remove Dry, To Help Debride Surface Of Cavity

40. Perioperative Care Consider For Discharge Adequate Pain Control
Afebrile
Decreasing WBC
Resolving Cellulitis
No Evidence For Sepsis/SIRS
Normal BP
No Orthostatic Changes
Adequate Pain Control
Appropriate Home Care

41. Necrotizing Fasciitis
Life-threatening, Progressive, Rapidly Spreading, Inflammatory Infection Located In The Deep Fascia.
Infection Rapidly Destroy The Skin And Soft Tissue Beneath It
Also Known As: “Flesh-eating” Bacteria.
Other Names: Β-hemolytic Streptococcal Gangrene, Meleney Ulcer, Acute Dermal Gangrene, Hospital Gangrene, And Necrotizing Cellulitis.
3 Types Of NF.
Type I : A Polymicrobial Flora.
Type II Group A Β-streptococcus Bacteria (Most Common Case)
Type III : Marine Vibrio Gram-negative Rods.

42. Cofactors That Increase Risks
Diabetes
Alcoholism
Immuno-suppression
Severe Illnesses: Heart, Lung, Or Liver Disease
Obesity

43. Pathophysiology Bacteria Destroy Tissue Between Skin And Muscle
Increase In Sensitivity Or Anesthetic Feel To The Skin Itself
Inflammatory Response By Immune System
Bacterial Toxins Released
Cytokines Impede Function Of Phagocytic Cells
Anaerobes Thrive Speeding Up Necrotic Process
Endothelial Cells Become Damaged;
Increased Permeability Of The Lining Of Vessels In The Body

44. Pathophysiology Poor Blood Supply Inhibit:
Inflammatory Response Process
Ability For The Immune System To Properly Work
Ability To Transfer Antibiotics To The Affected Fascial Layer
Vasoconstriction And Thrombosis  Edema  Hypoxia  Necrosis Of The Fascia, Skin, Soft Tissue, And Muscles.
Additional Necrosis Involving The Subcutaneous Nerves.

45. Early Symptoms And Signs Of NF?
Flu like symptoms that include fever, chills, nausea, weakness, dizziness, aches and a heat rate of more than 100 beats per minute.
Skin becomes tender, warm, red in color, and will start to swell.
Patients may experience pain greater than expected from the appearance of the wound.
Subcutaneous tissue may also have a hard feel on palpation that goes past the visibly infected area.
Clinically indistinguishable from other possible soft tissue infections with only the presentation of pain, tenderness, and warm skin.

46. Advanced Symptoms…
The advanced symptoms appear as the disease progresses
The area of the body experiencing pain begins to swell excessively.
Multiple discolored patches develop to produce a large area of gangrenous skin.
Initial necrosis appears as a massive destruction of the skin and subcutaneous layer.
The normal skin and subcutaneous tissue are loosened.
Large, dark marks that become blisters filled with a yellow-green necrotic fluid appear.

47. Critical Symptoms…
The Critical Symptoms Form In The Last Stages Of NF.
30% Of Patient’s Develop Hemorrhagic Bullae Which May Cause Them To Become Anemic.
Vasculature Of The Skin Becomes Inflamed And Thrombosed. Resulting In Necrotic Eschars That Look Like Deep Thermal Burns.
Without Treatment, Secondary Involvement Of Deeper Muscle Layers May Occur.

48. Critical Symptoms…
Patients May Become Numb Because Of Nerve Damage And Progressing Gangrene In The Infected Area.
Unconsciousness Will Occur As The Body Becomes Too Weak To Fight Off The Infection Along With A Severe Decrease In The Patient’s Blood Pressure.
As Toxins Are Being Released, The Body’s Organ May Go Into Septic Shock While Contracting A High Fever, High White Blood Count, And Becoming Disoriented. This May Result Into Respiratory Failure, Heart Failure And Renal Failure.

49. Treating NF Early Diagnosis And Treatment Is Vital
Emergency Debridement
IV Antibiotic Treatment
Hyperbaric Oxygen Therapy Is Recommended For Anaerobic Organisms
Morphine Drip And A Patient-controlled Analgesia Pump To Control Pain
Soft Tissue Reconstruction
Monitor Nutrition
If Sepsis Has Set In, Vasoconstricting Medications Should Be Given.
Education And Counseling

50. Other Soft Tissue Infections
Fournier’s Gangrene
Diabetic Foot Ulcers
Vascular Leg Ischemia
Post Operative Wound/Graft Infections
Primary Cellulitis

51. Conclusion
Early Recognition And Treatment Is Critical To The Prevention Of Complications Of Skin And Soft Tissue Infections
Surgical I&D And Debridement With Perioperative Directed Antibiotics Coverage Is The Hallmark Of Treatment Of Progressive Infections
Perioperative Nursing Care Is Critical To A Successful Outcome