Patients with postoperative haematoma with ot without persistent wound drainage, elevated markers for inflammation, increased body temperatures (< 38 degrees), etc. are subjected to surgical irrigation and debridement after 4, 7, 14 or 30 postoperative days according to different authors. What is your approach to prevent an eventual early deep infection in similar cases ?
Dear Panayot
This is another of the interesting and tricky questions of yours.
Personally I would prefer to wait and open again after the surgical wound is healed, so I would have less chances to introduce infection, as the wound itself is considered contaminated till is healed. So I would operate after the 14th day.
Despite this statement the decision for opening depends on the clinical picture of each and everyone patient and the condition of his/her wound.
So if there is fear that by leaving it un-operated there will be risk of deep infection due to continuing discharge from the wound or having the surgical wound at risk of break open, then the decision to operate earlier will be made even if is the 3rd or 4th day. Following the revision of the surgical wound and the drainage of the haematoma, the closure of the wound will be in the same manner as I would use for an infected joint and I will treat it as such.
Dear George,
Thank you for appreciating my questions. I must say that my approach in similar cases coincides with yours. I would only add that in my experience a persistent wound drainage after the 7th postoperative day rarely heals well. So in these cases I would go ahead with return to OR (within 7 days post op.).
Once more a very good and difficult question. You've already underlined the different options available; my preference would probably be an "early revision"... Despite the literature on this subject it's hard to find out any issue with standard rules. If I do agree
(sorry) with "the sooner, the better", it's still hard to define what "soon" means or should be.
I would use the followings:
Clinical statement: abnormal fever, tiredness, appetite, unusual pain, wound swelling, abnormal drainage after 2-3 days, local inflammation, ...
Blood sample results and inflammation markers (Leucocytes, CRP, ESR, PCT, ...) but their analysis is not so easy. It's rather the absence of regular decrease that would suggest an early wound revision for extended washing, debridement and possible spacer exchange.
So, with exception for specific early and evident septic cases, I wouldn't go back to surgery before the 7th post-operative day (as Prof. TANCHEV already said a persisting drainage after this date is rather of bad prognosis). But I would certainly go back before the 14th day.
Let's be reminded that I would probably decide this revision earlier for a TKR, the implants of which are nor protected by sufficient surrounding muscles...
All the bast to U all
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