post surgery infections - diagnosis/treatment?

[rob_zzz]

Controversy aside I'd be interested in a discussion on post surgery infections and anyone's experience with them.

How is a post surgery infection diagnosed, what are the possible symptoms and risks of a post surgery infection, and how are they typically addressed/treated? Does the patient usually have a temperature if there is an infection in the wound or can an infection exist without a temperature?

thanks
Rob

[Alastair]

From medscape -- - - there is a LARGE article there of which this is page 3

http://www.medscape.com/viewarticle/462185


Patients typically present initially with signs and symptoms of an infection after a mean of 15 days from the index procedure, and 93% present with wound drainage.[24] In most, however, no fever is present. Wound inflammation is common, and rarely is the wound benign in appearance. Because there are no pathogno-monic symptoms or signs, laboratory studies are useful in helping the clinician to establish the correct diagnosis. The mean sedimentation rate in patients in one study was 71.5 mm/hour.[24] When faced with abnormal values, one should have knowledge of the normal postoperative course of recovery of these indices. In a study of patients who underwent uncomplicated spinal surgery, none of whom developed a postprocedural infection, the postoperative values for CRP and erythrocyte sedimentation rate were quantified.[23] The CRP level peaked at 2 to 3 days postoperatively and normalized between Days 5 and 14. The erythrocyte sedimentation rate peaked on Day 5 but declined at a much more variable rate than CRP, often staying elevated at 21 to 42 days postoperatively. These indices are considered sensitive but not specific. They can be elevated by an infection at any site, but when combined with an inflamed or draining lumbar wound within the appropriate time frame, elevation in the CRP or erythrocyte sedimentation rate can aid in the diagnosis by indicating the presence of a postoperative wound infection.

Diagnostic Imaging Modalities
Plain radiography, CT scanning, and MR imaging are often of limited value in the diagnosis of a postoperative wound infection in the setting of internal fixation. Plain radiography can assist in determining the presence of indirect indicators of a spinal infection such as early implant loosening, rapid loss of adjacent-level disc space height, or abnormal soft-tissue swelling. Plain radiography will also detect the presence of a retained foreign body in the spinal wound. Both CT and MR imaging can demonstrate whether a fluid collection exists. Some authors have strongly supported the immediate use of contrast-enhanced MR imaging when an epidural abscess is suspected.[15] It is not usually possible, however, to differentiate between a postoperative fluid collection in the form of a sterile seroma and a postoperative abscess. Some authors, however, have reported success with CT and MR imaging in distinguishing between blood, purulent material, and granulation tissue.[21] Unfortunately, the presence of instrumention-related metal artifact often makes these advanced modalities of little value.

Gadolinium-enhanced MR imaging is of value in detecting an early-onset postoperative discitis even in cases in which posterior hardware has been placed. One should note, however, that following operative manipulation of the disc space, an increase in postcontrast MR imaging signal intensity or edema may not be indicative of a infection but in fact may be a normal postoperative finding. Because there is no optimal imaging modality for detecting a postoperative wound infection, these studies should be used to provide additional information when formulating a diagnosis of a postoperative spinal infection.

[mmglobal]

I've known people with discitis... that is very rare, but very severe. I've not seen it in disc replacement patients... the people I've known with serious infection problems were

discitis --> osteomyelitis (infection of adjacent vertebral bodies) from endoscopic discectomy... not from any of the docs I work with.

MRSA - severe deep wound infection associated with lumbar fusion / revisions. I've also seen deep wound infections associated with other abdominal surgery. I've seen people hospitalized for this... they get PICC lines for IV antibiotics... I've seen people who spend weeks in the hospital with the big abdominal wound open for healing... very nasty stuff.

I hope some of the nurses will come along and address some of Rob's questions. I do believe that running a substantial temp for a length of time can be an indicator and such a symptom should be presented to your doc. I have also seen many people who run low-grade temps after surgery without concern on the docs part. I think that staying on top of the situation and running the appropriate labs keeps things in check.

I've seen some people who's wounds don't heal as fast as others. Some are sealed up right away... some ooze for many days or longer. Again, you should check with your doc to know when to be concerned. I believe that the subcutaneous fat tissue necrosis is not uncommon and usually resolves itself without the patient even knowing that it occurred. (These may be the folks with more slowly healing wounds.) Also, many will have a seroma, or an accumulation of clear fluid after surgery, especially abdominal surgery. Many will have seroma and never know it. Seroma in conjunction with a small topical infection or the fat tissue necrosis may create a confluence of problems that my generate more weeping of a wound.

Infection rates may vary greatly from one facility to another, or from one surgeon to another. Fortunately, patients of good surgeons working in good facilities enjoy very, very low infection rates. I believe that a post-op infection can be serious and therefore should be worked up and treated quickly. People with infections that aren't taken seriously can wind up in much worse shape than if they had gotten early, appropriate treatment.

Small infections of incision sites are not uncommon and are easily treated, but the big 'deep wound' infection is a very serious complication. I wish we had easy access to numbers for infection rates in US hospitals. I believe that we'd find that most are excellent, but some facilities should be avoided.

As aways... the "I'm not a doctor" disclaimer applies here. I'm just sharing my impressions from my experience. I hope that someone with much more knowledge than me will come along and post. Maybe some internet miner can dig up some study data. (Although I take study data with a grain of salt.)

All the best,

Mark

[KL Aguilar]

When I had minimally invasive spinal surgery, the surgeon told me that they always put antibiotics in the IV. I asked due to the experience I'll describe below. I will always ask prior to any surgery.

I had an emergency C-section in 1978 at Cedar Sinai in Los Angeles. Within a few hours, I developed a very high fever. I have a vague memory of my rolling hospital bed being rushed down a hallway and I was put in isolation. It took them a day or two to determine that I had a blood infection called klebsiela. For forty-eight hours they took blood every hour, first to identify the problem and then to monitor how I was doing. They ran out of veins and had to go between my toes. I was in ICU for seven days and in the hospital for ten days, with two IVs the entire time. Eventually, the veins in my arms did not cooperate and they put the IVs in the backs of my hands. I have scars on my hands to this day. I had to take antibiotics for six weeks after leaving the hospital.

Not surprisingly, I am still needle phobic. And of course, I have terrible veins which only make it worse.

[mmglobal]

They named a sausage after an infection?

[Maria]

www.NetCe.com
Nosocomial Infections

This is for Continuing Education units for Nurses. The Nosocomial Infection CEU has a good amount of information that may be of interest to those reading here. I'm not sure if it's Ok or not to do this however, if one would like to read the content of this CEU course which is quite informative, just go to the website, click on Courses on the left hand side, put in Nurse Practitioner (or whatever ~ my license is for RN,FNP) for job title and California is the jurisdiction I entered.

It's a pretty good read~ check it out. If I've directed anyone to do something that's not kosher please let me know Mark! I don't know how to get the content on here otherwise~

[mmglobal]

Maria... as kosher as kielbasa!

This is a great find... I was pleasantly surprised to discover that you can get to the content without buying anything... This is a great resource.

Thanks,

Mark

[ans]

I agree. What a great info. source.

Thx - ans

[sahuaro]

Yes, thanks, Maria! I am just about to schedule a routine colonoscopy and never thought about the possibility of infection--something else to get anxious about! But now I know why the nurses wrapped me in those cozy, warm blankets after my shoulder surgeries!

K L Aguilar: Your experience sounds really frightening--and such an awful way to enter the postpartum period with your new baby. Do you think that your surgeons are more watchful now with any other procedures/surgeries, given your history, or that their care provided for you is just their standard?

[KL Aguilar]

Sahuaro,

My experience was made even worse by the fact that I used to wear contacts (have since had laser surgery) and was not permitted to in the hospital. I had glasses, but the prescription was very old and the glasses were basically useless. They would bring my baby to the doorway of the ICU unit every day, but not bring her in. I could see there was a baby, but nothing to identify her in any way. She went home after a few days and I stayed in the hospital. I did not meet my daughter until I went home ten days after her birth.

As I said, my standard procedure is to ask about post-op infections. It is not that I am in more danger of a post-op infection, but that I am paranoid about one. Every time I have done so, I have been told that the surgeon always has antibiotics administered thru the IV. I am not sure if all surgeons do this, but every surgeon I have talked to since 1978 for any family member having surgery has told me the same thing.