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