Wound healing, surgical infections, gas gangrene, tetanus Csaba Kósa, M.D. Department of Surgery.
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Transcript of Wound healing, surgical infections, gas gangrene, tetanus Csaba Kósa, M.D. Department of Surgery.
Wound healing, surgical infections, Wound healing, surgical infections, gas gangrene, tetanusgas gangrene, tetanus
Csaba Kósa, M.D.
Department of Surgery
Wound healingWound healing Cover the wound, substitute damaged
tissues Conditions: clear wound, good oxigene
supply, adequate macrophag function First intention or primary
Repair without complication Second intention or secondary
Formation of granulation tissueEventual migration of epithelial cellsInfected (bacterial or abacterial) wounds
and burns
Phases of wound healingPhases of wound healing
Inflammation : 2-3 days, macrophags, gel formation, thrombocyte aggregation, capillarisation
Prolifaration: 4-7 days, fibroblasts, ganulation, collagen and elastin reticulation
Reparation and scar: 8. day, wound contraction, epithelisation
Healing failureHealing failure
Impaired perfusion and oxygenation are the most common causes
Oxygen! Profoundly influenced by local blood
supply, vasoconstriction and factors that govern perfusion
Impaired healingImpaired healing
Disorders of inflammation – excessive and inadequate inflammatory responses can cause problems
Anti-inflammatory corticosteroids, immune suppressants, cancer chemotherapeutic agents
Malnutrition – weight loss, protein depletion
Surgical techniquesSurgical techniques
Technical errors! Tissues should be protected from
drying, contamination Clean, sharp dissection Gentle handling of tissue
Postoperative care!
Surgical infectionsSurgical infections
Definition
Occupies an unvascularized space in tissue or an operated site
Appendicitis, empyema, abscess ect.
Unlikely to respond to conservative treatmentIt can be a vicious circle
PathogenesisPathogenesis
Elements
1. An infectious agent
2. Susceptible host
3. A closed, unperfused space
Surgical infections’ originSurgical infections’ origin
Contact Aerial Hematogen
Endogen
Exogen
1. Infectious agents1. Infectious agents
Staphylococcus aureus Klebsiella
Enteric organismsAnaerobs
Bacteroides, peptosterptococci
Clostridiums
Smear and culture is important! if there is any suspicion
2. Susceptible host2. Susceptible host
Risk factors
Immunosuppression bodyAIDS, burn, diabetes, anergy, ect.
3. Closed space3. Closed space
Denominators are:
Poorly perfused tissue
Local hypoxia, Hypercapnia
Acidosis
Spaces with narrow outlets:
Gallbladder, appendix, intestines
Spread of infectionsSpread of infections
1. Necrotizing infections
2. Abscesses
3. Phlegmons and superficial inf.
4. Spread via lymphatic system
5. Spread via bloodstream
Necrotizing infectionsNecrotizing infections
Spread along anatomically
defined path
1. Clostridial myonecrosis
2. Necrotizing fasciitis
AbscessesAbscesses
Abscesses enlarge, killing more
tissue
Leukocytes contribute to necrosis
by lysosomal enzymes
Phlegmons and superficial Phlegmons and superficial infectionsinfections
Contain little pus, but much
edema
Spread along fat planes with the
features of necrosis and
abscesses
Spread via lymphatic Spread via lymphatic systemsystem
infective agents are streptococcus and staphylococcus
1. Lymphangitis
2. Lymphadenitis
Spread via bloodstreamSpread via bloodstream
Causes metastatic abscesses
1. Empyema
2. Endocarditis
3. Liver abscess
4. Brain abscess
5. Pylephlebitis (septic thrombosis of the portal vein)
ComplicationsComplications
1. Fistulas (abdominal infections)
2. Suppressed wound healing
3. Immunosuppression (consumptional immunopathy)
4. Superinfection – antibiotic resistency
Bacteriaemia and Bacteriaemia and septicaemiasepticaemia
-Bacteria are in the blood
-Infections, manipulations
- Bacteria and endotoxins in
the blood
-clinical features: chill, fever,
hypotension, shock
Sepsis I.Sepsis I.
Diagnosis
Physical examination (locally):
Erythema Induration
Warmth Tenderness
Sepsis II.Sepsis II.
Diagnosis
Laboratory findings:
Leukocytosis CRP, PCT Acidosis
Blood cultures
Sepsis III.Sepsis III.Diagnosis
Imaging studies:
X-ray (chest, abdominal) Ultrasound
CT scan Ga 67 labeling leukocytes
(scintigraphy)
Sepsis IV.Sepsis IV.
TreatmentLocally:
Incision, drainage, excision
Circulatory enhancement:
Antibiotics: First Second
Nutritinal support:
Clostridial infections I.Clostridial infections I.
Anaerobic, sporulating, Gram+ bacteria
Cl. welchii seu perfringens 80% Cl. hystolyticum40% Cl. septicum 20% Mixed infections
Clostridial infections II.Clostridial infections II.
Predisposing factorsPredisposing factors
War injury Dirty wound Necrotic wound Poor tissue perfusion Arterial stenosis
Clostridial infections III.Clostridial infections III.
Pathomechanism
Poorly vascularized tissues Toxins Proteolytic ensymes
(capillary damage)
Local symptoms
Genereal symptoms
Clostridial infections III.Clostridial infections III.
Clinical classification
Simple contamination Gas abscess (Welch’s abscess) Crepitant clostridial cellulitis Localized clostridial myositis Diffuse clostridial myositis (gas
gangrene) Edematous gangrene
Clostridial infections IV.Clostridial infections IV.symptoms, diagnosissymptoms, diagnosis
Latent period of hours to 3 days Local:
Pain, oedemaBrownish colourGravy-like secretionCrepitation, sweet smellMyonecrosis
General:Fever, tachycardia, deliriumHypotension, fluster, ShockMOF
Clostridial infections V.Clostridial infections V.
Treatment
Wide surgical exploration Necrectomy H2O2 locally Antibiotics (Penicillin,
Metronidazole) ICU
Tetanus I.Tetanus I.
Cause:Cause:
Clostridium tetani: spores survive for years, getting into wounds in anaerobic circumstances propagate and produce toxins: tetanospasmin tetanolysin neurotoxin
Tetanus II.Tetanus II.
Predisposing factors Predisposing factors
War injury Dirty wound Necrotic wound Poor tissue perfusion Arterial stenosis
Tetanus III.Tetanus III.
Diagnosis2-21 days latent period
Limitation of movements of jaws Painful muscle spasm-trismus Laryngospasm Stiffnes of the neck Tonic spasms and convulsions Presence of non treated wound
Tetanus IV.Tetanus IV.
Therapy ICU Absorbed Tetanus Toxoid (active
immunization) TIG (3-6000 U im., passive
immunization) Surgery Drugs (Barbiturates, cardiacs, ect.) Penicillin 10-40 MU/day
Tetanus V.Tetanus V.
Prevention
Active immunisation TIG Absorbed Tetanus Toxoid
(booster vaccination every 10 years)
Correct surgical treatment