Operative Wound Classification and Management Table
Wound Type | Description | Examples | Management |
Clean Wounds | No infection or inflammation. | Elective hernia repair, mastectomy | Standard surgical technique, sterile dressing. |
Clean-Contaminated | Controlled entry into respiratory, alimentary, genital, or urinary tracts. | Cholecystectomy, gastric surgery | Prophylactic antibiotics may be used, sterile dressing. |
Contaminated | Open, fresh accidental wounds; major breaks in sterile technique; gross spillage | Trauma with debris, acute inflammation | Debridement, irrigation, prophylactic and therapeutic antibiotics as needed. |
Dirty or Infected | Old traumatic wounds with necrotic tissue; existing clinical infection. | Perforated bowel, abscess | Debridement, culture-specific antibiotics, possibly secondary closure or delayed primary closure. |
Grading Severity of Infected Wound
Grade | Description | Symptoms | Management |
Mild (I) | Localized redness, slight pain, minimal swelling. | No systemic symptoms. | Topical antibiotics (e.g., mupirocin), local wound care, oral antibiotics if needed. |
Moderate (II) | Increased redness, swelling, pain, warmth, and possibly purulent discharge. | Mild systemic symptoms (low-grade fever). | Oral antibiotics (e.g., amoxicillin-clavulanate), wound irrigation, possible minor debridement. |
Severe (III) | Severe infection with systemic signs (fever >38°C, chills, elevated WBC >12,000/µL). | Extensive local tissue involvement, abscess formation, or necrosis. | Hospitalization, intravenous antibiotics (e.g., ceftriaxone + metronidazole), surgical debridement, and possible drainage. |
Differentiating Infected Wound from Cellulitis
Condition | Symptoms | Physical Exam | Lab Investigations |
Infected Wound | Localized erythema, warmth, swelling, pain, purulent discharge, bad odor. | Check for signs of wound dehiscence, necrosis, localized tenderness. | Wound culture, CBC (WBC >12,000/µL), CRP (>10 mg/L), ESR (>30 mm/hr). |
Cellulitis | Diffuse erythema, swelling, warmth, tenderness beyond wound margins. | Assess for spreading erythema, induration, systemic signs like fever. | Blood cultures (if febrile), CBC (WBC >12,000/µL), CRP (>10 mg/L), ESR (>30 mm/hr). |
Important Drug Dosage and Administration
Drug | Indication | Dosage | Administration | Monitoring |
Vancomycin | MRSA infections, severe skin infections | 15-20 mg/kg IV every 8-12 hours | Infuse over at least 60 minutes to prevent "red man syndrome." | Trough levels 10-20 mcg/mL, adjust based on renal function. |
Piperacillin/Tazobactam | Broad-spectrum for polymicrobial infections | 3.375-4.5 g IV every 6-8 hours | Infuse over 30 minutes | Renal function, liver function tests. |
Cephalexin | Mild to moderate skin infections | 500 mg PO every 6 hours | Oral; can be taken with or without food | Watch for signs of allergic reactions. |
Cefazolin | Moderate to severe skin infections | 1 g IV every 8 hours | Infuse over 30 minutes | Renal function, signs of allergic reactions. |
Clindamycin | Skin infections, anaerobic bacteria | 600 mg IV every 8 hours | Infuse over at least 30 minutes | Watch for signs of Clostridium difficile infection. |
Operative Wound Type Classification:
Clean Wounds:
No infection or inflammation.
Examples: Elective hernia repair, mastectomy.
Management: Standard surgical technique, sterile dressing.
Clean-Contaminated Wounds:
Controlled entry into respiratory, alimentary, genital, or urinary tracts.
Examples: Cholecystectomy, gastric surgery.
Management: Prophylactic antibiotics may be used, sterile dressing.
Contaminated Wounds:
Open, fresh accidental wounds; major breaks in sterile technique; gross spillage from GI tract.
Examples: Acute inflammation encountered during surgery, trauma with debris.
Management: Debridement, irrigation, prophylactic and sometimes therapeutic antibiotics.
Dirty or Infected Wounds:
Old traumatic wounds with necrotic tissue; existing clinical infection.
Examples: Perforated bowel, abscess.
Management: Debridement, culture-specific antibiotics, possibly secondary closure or delayed primary closure.
Grading Severity of Infected Wound:
Grade I (Mild):
Localized redness, slight pain, minimal swelling.
No systemic symptoms (no fever, no elevated WBC).
Management: Topical antibiotics (e.g., mupirocin), local wound care, oral antibiotics if needed.
Grade II (Moderate):
Increased redness, swelling, pain, warmth, and possibly purulent discharge.
Mild systemic symptoms might be present (low-grade fever).
Management: Oral antibiotics (e.g., amoxicillin-clavulanate), wound irrigation, possible minor debridement.
Grade III (Severe):
Severe infection with systemic signs (fever >38°C, chills, elevated WBC >12,000/µL).
Extensive local tissue involvement, abscess formation, or necrosis.
Management: Hospitalization, intravenous antibiotics (e.g., ceftriaxone + metronidazole), surgical debridement, and possible drainage.
Differentiating Infected Wound from Cellulitis:
Infected Wound:
Symptoms: Localized erythema, warmth, swelling, pain, purulent discharge, bad odor.
Physical Exam: Check for signs of wound dehiscence, necrosis, and localized tenderness.
Lab Investigations:
Wound culture.
CBC: Look for WBC >12,000/µL (infection).
CRP: >10 mg/L indicates significant inflammation.
ESR: >30 mm/hr suggests infection.
Cellulitis:
Symptoms: Diffuse erythema, swelling, warmth, tenderness beyond wound margins.
Physical Exam: Assess for spreading erythema, induration, and systemic signs like fever.
Lab Investigations:
Blood cultures (if febrile).
CBC: WBC >12,000/µL.
CRP: >10 mg/L.
ESR: >30 mm/hr.
Management Approach for Surgical Residents:
Infected Wound:
Definitive Treatment:
Surgical Debridement: Remove necrotic tissue.
Antibiotics:
IV Vancomycin:
Dose: 15-20 mg/kg IV every 8-12 hours.
Monitoring: Trough levels should be 10-20 mcg/mL, adjust dose based on renal function and serum levels.
IV Piperacillin/Tazobactam:
Dose: 3.375-4.5 g IV every 6-8 hours.
Monitoring: No specific serum levels required, but renal function should be monitored.
Supportive Treatment:
Wound Care: Daily dressing changes, keep the wound clean and dry.
Pain Management:
NSAIDs (e.g., Ibuprofen 400 mg PO every 6-8 hours).
Acetaminophen (500 mg PO every 6 hours, max 3 g/day).
Hydration and Nutrition: Ensure adequate fluid intake and nutrition to promote healing.
Cellulitis:
Definitive Treatment:
Antibiotics:
Oral Cephalexin:
Dose: 500 mg PO every 6 hours.
Duration: 7-14 days.
IV Cefazolin:
Dose: 1 g IV every 8 hours.
Monitoring: No specific serum levels, but renal function should be monitored.
IV Clindamycin:
Dose: 600 mg IV every 8 hours.
Monitoring: Watch for signs of Clostridium difficile infection.
Supportive Treatment:
Elevation: Keep the affected limb elevated to reduce swelling.
Pain Management:
NSAIDs (e.g., Ibuprofen 400 mg PO every 6-8 hours).
Acetaminophen (500 mg PO every 6 hours, max 3 g/day).
Hydration: Ensure adequate fluid intake.
Important Drug Dosage and Administration:
Vancomycin:
Indication: MRSA infections, severe skin and soft tissue infections.
Dosage: 15-20 mg/kg IV every 8-12 hours.
Administration: Infuse over at least 60 minutes to prevent "red man syndrome."
Monitoring: Trough levels should be 10-20 mcg/mL, adjust based on renal function.
Piperacillin/Tazobactam (Zosyn):
Indication: Broad-spectrum coverage for polymicrobial infections, including Pseudomonas.
Dosage: 3.375-4.5 g IV every 6-8 hours.
Administration: Infuse over 30 minutes.
Monitoring: Renal function, liver function tests.
Cephalexin (Keflex):
Indication: Mild to moderate skin infections.
Dosage: 500 mg PO every 6 hours.
Administration: Oral; can be taken with or without food.
Monitoring: Watch for signs of allergic reactions.
Cefazolin (Ancef):
Indication: Moderate to severe skin infections.
Dosage: 1 g IV every 8 hours.
Administration: Infuse over 30 minutes.
Monitoring: Renal function, signs of allergic reactions.
Clindamycin:
Indication: Skin infections, particularly those caused by anaerobic bacteria.
Dosage: 600 mg IV every 8 hours.
Administration: Infuse over at least 30 minutes.
Monitoring: Watch for signs of Clostridium difficile infection.
By understanding these classifications, grading systems, and specific drug dosages, surgical residents can effectively manage operative and infected wounds, ensuring optimal patient care.
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