If a patient's wound discharges pus, the aseptic routines described earlier in this chapter have broken down. Although this is not the only cause of a wound infection, it is the most unnecessary one.
Keep a record of your wound infections. They are most likely to occur if: (1) You are operating for some infective condition, such as an acute appendix. (2) The operation is long and difficult. (3) You leave dead tissues, foreign bodies, dirt, or clot, or an excessive number of sutures in the wound. (4) You create dead tissue by operating clumsily. (5) You close a wound by immediate primary closure, when delayed primary closure would been have been wiser (54.4).
If more than about 5% of your clean cases become infected, something has gone wrong. Prophylactic antibiotics are not the answer! The chances are that the aseptic disciplines in Section 2.2 are not being followed, or you are making the errors 3, 4, and 5 above.
SURGICAL SEPSIS. Here are some of the errors that can be made and the lessons to be learnt from them, mostly from the pre- antibiotic days.
(1) A theatre had extractor fans installed, but the only inlets for fresh air were under the doors, so that dust from the corridor was drawn into the theatre continually. Only when three patients had died of tetanus was the flow of the fans reversed. LESSON Keep dust out of the theatre.
(2) In the days before antibiotics a London teaching hospital had two minor theatres in which many septic operations were done. On two mornings a week the same equipment was used for a list of circumcisions. One circumcised child acquired erysipelas which spread from his umbilicus to his toes and killed him. LESSON Where possible don't do clean cases in a theatre which normally does septic ones.
(3) An eminent professor resected a carcinoma of the pelvic colon and did an end-to-end anastomosis, without doing a preliminary colostomy. The patient's gut obstructed, and when his abdomen was explored there was a huge abscess round a leaking anastomosis. Peritonitis killed him. LESSON If there are surgical procedures which will minimise the risk of infection, use them.
(4) Hamilton Bailey, subsequently a distinguished surgeon, but then a registrar, was deputizing for his chief. Having done a ''cold list' which began at 1.30 p.m. he insisted on continuing with a non-stop flood of emergencies which continued rolling in all the evening. At 3 a.m. the following morning, ''dead on his feet', he pricked himself when operating on a patient with streptococcal peritonitis. Bailey insisted that his finger be amputated, and survived. The patient died. LESSON Accidents, including those which increase the risk of sepsis, are particularly likely if you are overtired. Amputation for this reason should never be necessary, now that antibiotics are available. Stirling HL, ''The aetiology, prevention, and treatment of surgical sepsis', Tropical Doctor 1979;2:131[nd]134.
WOUND INFECTIONS For the care of particular wounds, see the appropriate sections, for example, laparotomy wounds (9.12), rectal wounds (66.12), joint wounds (69.8).
THE PREVENTION [s7]OF WOUND INFECTIONS AUTOCLAVING. (1) Check that your autoclave does reach 1 kg/cm['2] (2.4), that the air is being discharged, and that the holding time is being maintained. (2) Check that the drums are not being overpacked, that they are labelled after autoclaving, and that the label includes the date.
THEATRE DISCIPLINE. Check that you and ALL your staff are following all the aseptic disciplines in Section 2.3 carefully. If you set the example, your staff will follow them.
Check that: (1) the theatre table and especially the macintosh cover on its mattress, are being properly cleaned, (2) there is no infected member of staff.
SURGICAL TECHNIQUE. Examine yourself. Are you committing errors 3, 4, or 5 above?
THE TREATMENT [s7]OF WOUND INFECTIONS Sedate the patient with morphine (or pethidine) and diazepam. In infected sutured wounds the pus usually tracks the whole length of the subcutaneous tissues. So remove all sutures and convert the wound into a gutter. Either alllow it to granulate or close it by secondary suture. If possible, send a swab for culture.
Establish free drainage, especially in the depths of the wound, keep it open so that it can heal from the bottom, and let it drain into dressings.
If a wound fails to heal, think of HIV (Chapter 28a).
Fig. 2-11 CONSIDER THE TRAFFIC. Wounds are less likely to become infected, if the theatre is not used as a storeroom, and if there is the minimum of traffic in and out of it. So remove the teacups and cartons, the umbrella, and that coat! Drawn by Nette de Glanville, and reproduced with the permission of the editor of the Transactions of the East African Association of Surgeons. ;$ 3 The control of bleeding