Contaminated interventions
Contaminated operations represent a special group of surgical interventions in which the surgical wound has overt signs of non-purulent inflammation. Such tissue status requires heightened attention from the surgeon, as the risk of postoperative complications in these cases reaches 20%.
This category of surgical manipulations traditionally includes:
- Any interventions accompanied by the opening of the gastrointestinal tract lumen.
- Operations on the urogenital organs or biliary tract, if the presence of infected urine or bile is confirmed, respectively.
- Situations where granulating wounds prepared for secondary suturing are present.
- Interventions for open trauma and penetrating wounds if they were treated within the first 24 hours (so-called early primary surgical debridement).
Competent assessment of the degree of wound contamination allows for timely correction of tactics and prevents the transition of non-purulent inflammation into a generalized infectious process.
Surgical and general treatment tactics
General conservative therapy for severe surgical lesions is largely similar to the treatment regimens for thermal burns. The most important feature in managing such patients is monitoring renal function: if anuria develops, indicating acute renal failure (ARF), emergency hemodialysis is indicated.
Surgical treatment is strictly differentiated and depends on the nature of the injuries:
- Necroectomy. The removal of dead tissues has its own characteristics. Unlike thermal burns, the sloughing of necrotic masses occurs much slower here. Due to deep tissue involvement, necroectomy almost always has to be performed in several successive stages.
- Osteonecroectomy. If bone tissue is involved in the pathological process, the removal of affected bone areas must be performed as early as possible.
- Amputation. An absolute indication for radical limb removal is charring. The operation is performed on an urgent basis—this is necessary to prevent life-threatening complications such as profuse hemorrhage, acute renal failure, and sepsis.
- Plastic surgery. Any reconstructive interventions for defect closure are postponed and performed exclusively at a late stage, when the wound is completely clean and ready for plasty.
Primary surgical debridement (PSD)
Primary surgical debridement is the main and most effective method of treating infected wounds. The main goal of this intervention is the complete removal of non-viable, contaminated tissues along with the pathogenic microflora residing within them. PSD serves as the foundation for the prevention of severe wound infection.
Depending on the time elapsed since the injury, PSD is classified into three types:
- Early PSD: performed within the first 24 hours after the incident.
- Delayed PSD: performed during the second day (in the interval between 24 and 48 hours).
- Late PSD: performed more than 48 hours after the injury.
The key rule of purulent surgery states: the earlier adequate surgical debridement is performed, the higher the patient's chances of avoiding infectious complications. The only valid reason for delaying the intervention is a state of shock—in this case, the operation is postponed until the patient is successfully resuscitated from the critical condition.
Prevention of respiratory complications
Patients undergoing surgical treatment are at high risk for developing respiratory complications. To prevent them, a set of measures with a high level of evidence (LE C, GR 5) has been developed.
The standard prevention protocol includes the following measures:
- Regular use of incentive spirometry.
- Mandatory elevation of the head of the functional bed to an angle of 30° or more.
- Early initiation of breathing exercises.
- Early mobilization of the patient.
It is important to adhere to strict timeframes. Training in proper breathing exercise technique should be conducted with the patient before surgery, while they are conscious and able to comprehend the information. The exercises themselves should begin immediately after consciousness normalizes in the postoperative period.
Class and exam questions
An absolute indication is limb charring. The operation is performed early to prevent sepsis, hemorrhage, and acute renal failure.
An absolute indication is limb charring. The operation is performed early to prevent sepsis, hemorrhage, and acute renal failure.
In such wounds, the sloughing of necrotic tissue occurs much slower, and the lesion itself is deep, requiring necroectomy to be performed in several stages.
In such wounds, the sloughing of necrotic tissue occurs much slower, and the lesion itself is deep, requiring necroectomy to be performed in several stages.
The only justified reason for delaying PSD is a state of shock in the patient. The operation is performed only after vital signs have stabilized.
The only justified reason for delaying PSD is a state of shock in the patient. The operation is performed only after vital signs have stabilized.
What else to study on this topic
- Pathogenesis of acute renal failure in severe trauma
- Principles and technique of incentive spirometry
- Criteria for the readiness of a granulating wound for secondary suturing
- Mechanisms of non-purulent inflammation formation in a surgical wound
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