Eduovisual
Perioperative & Surgical Care
Postoperative wound dehiscence and infection
— Surgical site infection (SSI): infection within 30 days of surgery (or 90 days if implant placed), per CDC/NHSN criteria
— Superficial SSI: skin and subcutaneous tissue only
— Deep SSI: fascia and muscle
— Organ/space SSI: any anatomic structure manipulated during surgery (e.g., intra-abdominal abscess after colectomy)
— Wound dehiscence: partial or complete separation of fascial closure, typically postoperative days 4–14, peak around day 7–10
— Evisceration: dehiscence with visceral protrusion — a surgical emergency
— Fever beyond postop day 3–4 (early fevers more often atelectasis/drug; later fevers think wound, UTI, line, DVT, abscess)
— Wound erythema, induration, tenderness, fluctuance, or new drainage
— Sudden gush of serosanguinous "salmon-pink" fluid from a closed abdominal incision → classic herald of impending fascial dehiscence
— Increasing pain after expected postop decline, or pain disproportionate to exam (worry necrotizing infection)
— Wound failing to seal by postop day 5–7, persistent drainage
— Patient: diabetes with HbA1c >7%, obesity (BMI >30), smoking, malnutrition (albumin <3.5), immunosuppression, chronic steroids, prior radiation, age
— Operative: emergency surgery, contaminated/dirty wound class, duration >2 hr, hypothermia, hyperglycemia (>180 intraop), poor hemostasis, hematoma
— Postop: cough, vomiting, ileus, ascites, abdominal distention raising wall tension
Board pearl: The single most predictive sign of impending fascial dehiscence is a sudden discharge of serosanguinous "pink" fluid from the incision — examine the wound and prepare for OR even if the patient looks well.
Step 3 management: Suspect SSI → inspect wound, mark erythema, check vitals/glucose, send CBC + lactate if systemic signs, and decide drainage vs antibiotics vs OR.
— Days 0–2: Wind (atelectasis, pneumonia) — wound rarely infected this early unless Clostridium perfringens or group A Strep (necrotizing) — both present within 24–72 hours with severe pain, crepitus, "dishwater" drainage
— Days 3–5: Water (UTI) — but also early cellulitis at incision
— Days 5–7: Wound — classic SSI window; staph/strep skin flora, or polymicrobial enteric flora after GI surgery
— Days 7–10: Walking (DVT/PE) — and peak window for fascial dehiscence
— Days >7: Wonder drugs, deep abscess, anastomotic leak presenting as organ/space SSI
— Type and date of surgery, wound classification (clean, clean-contaminated, contaminated, dirty)
— Perioperative antibiotic prophylaxis given? Redosed if case >3–4 hr or >1500 mL blood loss?
— Glycemic control intra- and postop; HbA1c
— Smoking status, nutrition, weight loss, steroid/biologic use
— Bowel function (ileus, distention), cough, vomiting — all raise intra-abdominal pressure and predispose to dehiscence
— Drain output character and volume; sudden change in color (feculent, bilious, purulent) → organ/space infection or leak
— Pain out of proportion + tachycardia + bronze skin/bullae → necrotizing soft tissue infection (NSTI) — call surgery immediately, do not wait for imaging
— Wound pain + low-grade fever + erythema spreading >2 cm from incision → cellulitis vs early SSI
— "Something popped" or "I felt a pull" while coughing → fascial dehiscence until proven otherwise
— Persistent ileus + fever + leukocytosis after bowel surgery → think anastomotic leak as organ/space SSI
Key distinction: Day 1–3 wound infection with systemic toxicity, crepitus, or rapid spread = NSTI or clostridial myonecrosis, not routine SSI — surgical emergency requiring emergent debridement, not just antibiotics.
CCS pearl: Advance the clock cautiously after surgery; re-examine the wound at every visit and document changes — Step 3 CCS rewards serial reassessment.
— Inspect: erythema (mark borders with pen and date), induration, swelling, dehiscence edges, drainage character (serous, serosanguinous, purulent, feculent), staple/suture integrity
— Palpate: warmth, fluctuance (abscess), crepitus (gas-forming organism — emergency), tenderness extending beyond visible erythema
— Probe (sterile): gentle cotton-tip probing for sinus tracts, undermining, or fascial gap; a probe that passes to fascia suggests deep involvement
— Cough test: ask supine patient to cough — bulging or fluid expression confirms fascial disruption
— Skin changes suggesting NSTI: dusky/violaceous skin, bullae (especially hemorrhagic), anesthesia over the wound (cutaneous nerve necrosis), woody induration
— Tachycardia often precedes fever in deep SSI and anastomotic leak — persistent HR >100 postop is never normal
— Fever curve: spiking fevers with rigors suggest abscess or bacteremia
— Hypotension, oliguria, altered mentation → sepsis; consider organ/space SSI or NSTI
— Tachypnea may be the earliest sign of sepsis or PE
— Abdominal exam: peritonitis (rebound, guarding) after GI surgery → anastomotic leak
— Lung exam: rule out pneumonia as alternate fever source
— Calves/legs: DVT
— Lines and catheters: every line is a fever source until cleared
— Score ≥6 suspicious, ≥8 high risk — but do NOT delay surgery for a score if exam is concerning
Board pearl: Pain out of proportion to exam findings in a postop wound is the single most sensitive early sign of necrotizing infection — before bullae, before crepitus, before hemodynamic collapse.
Step 3 management: Mark erythema borders with a date-stamped pen at every encounter — objective progression vs regression drives the decision to escalate antibiotics or return to OR.
— CBC with differential: leukocytosis with left shift; leukopenia in severe sepsis is ominous
— BMP: sodium <135 supports LRINEC; AKI suggests sepsis or hypovolemia
— Glucose/HbA1c: hyperglycemia both cause and consequence; target perioperative glucose 140–180 mg/dL
— Lactate: >2 suggests tissue hypoperfusion; >4 high mortality
— CRP: rises postop normally, but a secondary rise after POD 3 or failure to fall by POD 5–7 suggests infection
— Procalcitonin: can support bacterial etiology but not required
— Blood cultures × 2: if febrile, rigors, or systemic toxicity — before antibiotics if possible
— Coags, type & screen: if dehiscence or return to OR likely
— Superficial swab is low yield (contaminated with skin flora)
— Preferred: deep tissue or aspirate of purulent fluid sent for Gram stain, aerobic, anaerobic, and fungal cultures (fungal in immunocompromised, prolonged antibiotics, or sternal wounds)
— Send tissue for histopathology if NSTI suspected
— Plain film: subcutaneous gas (NSTI, clostridial) — but absence does NOT rule it out
— CT with IV contrast: test of choice for deep/organ-space SSI, abscess, anastomotic leak (look for extraluminal gas, fluid collection, contrast extravasation)
— Ultrasound: quick bedside tool to identify drainable superficial collections
— MRI: problem-solving for spinal/sternal/orthopedic hardware infections
— Sternal wound: CT chest for mediastinitis
— Spinal/ortho hardware: MRI ± tagged WBC scan
— Suspected NSTI: do not delay surgery for imaging if exam is diagnostic
Key distinction: Cellulitis = clinical diagnosis, no imaging needed; abscess = needs drainage and imaging if deep; NSTI = OR, not CT scanner.
Step 3 management: Febrile postop patient → wound exam + CBC, BMP, lactate, blood cultures, UA, CXR; image the wound only when deep infection or collection suspected.
— Largely a clinical diagnosis: gaping wound, palpable fascial gap, or evisceration
— CT abdomen/pelvis confirms occult dehiscence (fascial separation, herniated bowel) when exam is equivocal
— Bedside ultrasound can show fascial defect under intact skin
— CT with IV + oral/rectal contrast: identifies extraluminal contrast, abscess, free gas/fluid beyond expected postop window (free intraperitoneal air usually resolves by POD 7)
— Water-soluble contrast enema for low colorectal anastomoses
— Drain fluid amylase/bilirubin/creatinine to distinguish pancreatic, biliary, or urinary leak
— "Finger test" in OR: easy blunt dissection along fascia, lack of bleeding, "dishwater" pus → NSTI confirmed
— Frozen-section biopsy may support but should not delay debridement
— Type I NSTI: polymicrobial (aerobic + anaerobic, often after GI/GU surgery, in diabetics)
— Type II NSTI: monomicrobial group A Strep ± Staph aureus, including MRSA
— Type III: marine Vibrio vulnificus (saltwater/oyster exposure) or Aeromonas (freshwater)
— Type IV: fungal (immunocompromised, trauma)
— Clostridial myonecrosis (gas gangrene): C. perfringens, dirty traumatic wound or bowel surgery
— Serial CRP, WBC, lactate, and procalcitonin downtrends support adequate source control
— Persistent or rising values after 48–72 hr of therapy → inadequate drainage or wrong antibiotic
— Sonication of removed hardware increases biofilm culture yield
— Repeat imaging at 48–72 hr if not improving — undrained collections are the most common cause of treatment failure
Board pearl: CRP that fails to decline by postop day 4–5 or rises again after initial fall is a sensitive early indicator of evolving SSI or anastomotic leak — order CT before the patient becomes septic.
CCS pearl: When ordering CT for suspected anastomotic leak, specify IV plus enteric contrast — Step 3 CCS scores recognize the appropriate contrast choice.
— Step 1: Is the patient septic or toxic? → resuscitate, broad-spectrum antibiotics, urgent surgical consult
— Step 2: Is this NSTI? (pain out of proportion, crepitus, bullae, rapid spread, hemodynamic instability) → emergent OR debridement, do not wait for imaging
— Step 3: Is there evisceration? → cover bowel with sterile saline-moistened gauze, NPO, IV fluids, antibiotics, emergent OR
— Step 4: Is there fascial dehiscence without evisceration? → abdominal binder, NPO, urgent OR for fascial reclosure
— Step 5: Is there a drainable collection or abscess? → open wound at bedside (superficial) or IR/OR drainage (deep)
— Step 6: Cellulitis without collection? → mark borders, oral or IV antibiotics, daily reassessment
— Superficial SSI: open the wound, evacuate pus, irrigate, pack with moist-to-dry or NPWT, antibiotics only if surrounding cellulitis, systemic signs, or immunocompromised
— Deep SSI: open fascia in OR, debride, often leave open with NPWT (vacuum-assisted closure)
— Organ/space SSI: percutaneous drainage by IR if drainable; OR if not, or if peritonitis/leak
— NNIS / ASA risk index for SSI prediction preop
— LRINEC for NSTI suspicion (adjunct only)
— qSOFA / SIRS for sepsis screening
— Antibiotics never substitute for drainage or debridement
— "The solution to pollution is dilution and removal"
Step 3 management: For any deep or organ-space SSI, call surgery before starting antibiotics when feasible, since cultures from source-control intervention guide narrowing; but never delay antibiotics in septic patients to obtain cultures.
Board pearl: Evisceration management on Step 3 CCS: moist sterile saline gauze + NPO + IVF + IV antibiotics + emergent OR — all five actions, in that order.
— Often no antibiotics needed — incision, drainage, and local care suffice
— If cellulitis present: cephalexin or dicloxacillin PO; if MRSA risk (prior MRSA, healthcare exposure, IVDU): TMP-SMX, doxycycline, or clindamycin PO
— Skin flora coverage: cefazolin IV or vancomycin IV if MRSA risk or β-lactam allergy
— Add anti-pseudomonal coverage if neutropenic or hospital-acquired
— Polymicrobial (gram-negatives + anaerobes + enterococci)
— Piperacillin-tazobactam OR ceftriaxone + metronidazole OR ertapenem
— Severe/critical: meropenem ± vancomycin
— Add vancomycin if MRSA colonized or septic
— Vancomycin (or linezolid) + piperacillin-tazobactam (or carbapenem) + clindamycin (antitoxin/anti-exotoxin effect, suppresses streptococcal/clostridial toxin production)
— Narrow once cultures return; for group A Strep: penicillin G + clindamycin; add IVIG for streptococcal toxic shock
— For clostridial myonecrosis: penicillin G + clindamycin
— Vancomycin trough 15–20 (or AUC 400–600); alternatives: daptomycin (not for pneumonia), linezolid, ceftaroline
— Decolonization with mupirocin nasal + chlorhexidine baths for recurrent SSI or preop in cardiac/orthopedic implants
— Driven by source control adequacy, not arbitrary days
— Uncomplicated SSI after I&D: 5–7 days if antibiotics needed
— Complicated intra-abdominal infection with adequate source control: 4 days post-source control (STOP-IT trial)
— NSTI: until clinically stable + 48–72 hr after last debridement
— De-escalate within 48–72 hr based on cultures and clinical response
— Document indication, duration, and reassessment date in chart
Step 3 management: Empirically cover MRSA + gram-negatives + anaerobes + add clindamycin for any suspected NSTI — clindamycin is the antitoxin pearl Step 3 loves to test.
Board pearl: STOP-IT trial → 4 days of antibiotics for complicated intra-abdominal infection with adequate source control is non-inferior to longer courses.
— Remove staples/sutures over fluctuant area, express pus, irrigate copiously with saline
— Probe for undermining and fascial integrity
— Pack loosely with moist gauze or place NPWT (wound vac) to promote granulation
— Daily dressing changes; healing by secondary intention or delayed primary closure
— NSTI: wide excision of all necrotic tissue to bleeding viable margins; planned re-exploration every 12–24 hr until no further necrosis; multiple debridements are the rule
— Fasciotomy if compartment syndrome
— Diverting stoma may be needed for perineal/perianal NSTI (Fournier gangrene)
— OR closure with interrupted heavy monofilament (e.g., #1 PDS) using small-bite or far-near-near-far technique
— Mesh (biologic or synthetic) for tissue loss or repeat dehiscence
— Postoperative abdominal binder, cough/sneeze precautions, aggressive antiemetic/ileus management
— IR-guided CT or US drainage preferred for accessible abscesses (intra-abdominal, pelvic)
— Leave drain until output <20–30 mL/day and clinical resolution; consider sinogram before removal
— OR drainage if multiloculated, inaccessible, or associated with anastomotic leak requiring revision
— Promotes granulation, reduces edema, removes exudate
— Indicated for large open wounds, dehiscence after debridement, NSTI wounds awaiting closure
— Avoid over exposed bowel, vessels, or untreated osteomyelitis
— Stable + contained leak: percutaneous drainage + antibiotics + bowel rest
— Unstable or free leak: OR for washout, diversion (ostomy), or anastomotic revision
— Hyperbaric oxygen: considered for clostridial myonecrosis and refractory NSTI (controversial; never delays debridement)
— IVIG for streptococcal toxic shock
CCS pearl: On the CCS interface for suspected NSTI: order surgical consult STAT, then antibiotics, IVF, labs — debridement timing within 6 hours is the strongest mortality predictor.
Board pearl: Repeat debridement at 12–24 hours is mandatory in NSTI — a single OR trip is rarely sufficient.
— Blunted febrile response — may present with delirium, anorexia, falls, or functional decline instead of fever
— Lower threshold to image and culture; tachycardia and tachypnea may be the only vital sign abnormalities
— Polypharmacy increases interaction risk (warfarin + TMP-SMX/metronidazole → INR spike; statins + clarithromycin → myopathy)
— Higher risk for C. difficile with broad-spectrum antibiotics — use narrowest effective agent
— Frailty assessment guides aggressive vs comfort-focused approach; involve geriatrics and palliative care for repeated debridements with poor prognosis
— Nutritional optimization: prealbumin, protein supplementation, swallow eval
— Dose-adjust vancomycin, β-lactams (pip-tazo, cefepime), aminoglycosides, daptomycin, TMP-SMX, fluconazole
— Avoid nitrofurantoin if CrCl <30
— Avoid nephrotoxic combinations: vancomycin + pip-tazo has been associated with increased AKI risk — consider cefepime + vancomycin or meropenem alternatives
— Avoid contrast in CT if AKI; use non-contrast or MRI when feasible
— Monitor vancomycin troughs/AUC closely; consider linezolid or daptomycin in unstable renal function
— Dialysis patients: dose vancomycin post-HD, often weekly
— Dose-adjust or avoid: clindamycin, metronidazole (encephalopathy risk), tigecycline, linezolid (lactic acidosis)
— Coagulopathy increases dehiscence and bleeding risk; correct INR with vitamin K/FFP before reoperation
— Ascites independently increases dehiscence risk — drain large-volume ascites preop, treat SBP
— Albumin <3.0 → poor wound healing; consider enteral nutrition supplementation
— Strict glycemic control (140–180 mg/dL inpatient); HbA1c >8% delays elective surgery when possible
— Insulin sliding scale + basal-bolus; hold metformin around contrast
Step 3 management: In an elderly postop patient with delirium and no clear source, examine the wound, check a UA, and image the surgical site — atypical presentation is the rule, not the exception.
Key distinction: AKI from sepsis vs from vancomycin trough — trend creatinine, drug levels, and urine output; switch agents if vancomycin-attributable.
— C-section SSI rate 3–15%; risk factors include obesity, prolonged labor, chorioamnionitis, emergent C-section
— Prophylaxis: cefazolin within 60 min of incision (1–3 g weight-based); add azithromycin for non-elective cesarean (CSOAP trial)
— Safe antibiotics in pregnancy/lactation: β-lactams, cephalosporins, clindamycin, azithromycin, vancomycin
— Avoid: tetracyclines (teeth/bone), fluoroquinolones (cartilage concern), TMP-SMX in first trimester (folate antagonism) and near term (kernicterus)
— Metronidazole acceptable in 2nd/3rd trimester
— Endometritis post-C-section: clindamycin + gentamicin is classic regimen
— Weight-based dosing; pediatric surgery consult for fascial issues
— Pediatric appendectomy SSI: cefoxitin or ceftriaxone + metronidazole
— Avoid fluoroquinolones and tetracyclines when alternatives exist
— Consider non-accidental trauma for unusual wound infections or delayed presentations in children — Step 3 testable
— Broader empiric coverage including anti-pseudomonal and antifungal (especially neutropenic or on prolonged broad-spectrum antibiotics)
— Atypical organisms: Candida, Aspergillus, Nocardia, mycobacteria in delayed/indolent wounds
— Hold biologics (anti-TNF, JAK inhibitors) perioperatively when feasible; coordinate with rheum/GI
— Stress-dose steroids for chronic steroid users to prevent adrenal crisis
— Lower threshold for tissue biopsy and fungal cultures
— Higher SSI rate; double-dose cefazolin (2–3 g) for prophylaxis
— Subcutaneous wound drains and prophylactic NPWT (closed-incision NPWT) reduce SSI in select high-risk closures
Board pearl: Add azithromycin to cefazolin for non-elective cesarean delivery — reduces endometritis and SSI per CSOAP trial.
Step 3 management: Pregnant patient with suspected SSI → β-lactam first-line, clindamycin if allergic; avoid fluoroquinolones and tetracyclines.
— Incisional hernia: late consequence of fascial dehiscence or chronic wound; up to 20% incidence after midline laparotomy SSI
— Chronic non-healing wound / sinus tract: consider retained foreign body (suture, mesh), osteomyelitis, malignancy (Marjolin ulcer in chronic wounds)
— Wound contracture and disfiguring scar: functional and cosmetic impact; refer plastics
— Loss of domain after extensive abdominal wall debridement
— Sepsis and septic shock with organ failure (AKI, ARDS, DIC)
— Bacteremia and metastatic infection: endocarditis (especially Staph aureus), septic arthritis, vertebral osteomyelitis
— Toxic shock syndrome: group A Strep or Staph — rash, hypotension, multi-organ failure
— Disseminated intravascular coagulation
— C. difficile colitis from broad-spectrum antibiotics
— Catheter-associated infections (CLABSI, CAUTI) from prolonged stay
— VTE from immobility — continue prophylaxis
— Pressure injuries from limited mobility
— Delirium, deconditioning, ICU-acquired weakness
— Prolonged hospitalization (mean +7–10 days for SSI)
— Readmission rate up to 30% for complicated SSI
— Increased mortality: NSTI 20–30%; sternal mediastinitis up to 25%
— Chronic pain, opioid dependence, loss of work, mental health impact
— Significant cost burden — average SSI adds $20,000–$30,000 per case
— Mesh infection often requires removal; biologic mesh tolerates contamination better than synthetic
— Orthopedic hardware infection may require staged exchange or removal
Board pearl: Postoperative Staph aureus bacteremia mandates TTE (and TEE if persistent) to rule out endocarditis — never just treat the wound and stop.
Step 3 management: Any new diarrhea on broad-spectrum antibiotics → send C. difficile PCR/toxin, isolate, start oral vancomycin or fidaxomicin; do not give anti-motility agents.
— Septic shock requiring vasopressors
— Respiratory failure / need for mechanical ventilation
— Lactate >4, persistent after resuscitation
— NSTI requiring repeated debridement and resuscitation
— Multi-organ dysfunction (AKI, hepatic dysfunction, coagulopathy)
— Massive evisceration or hemorrhage
— Suspected NSTI
— Evisceration or fascial dehiscence
— Suspected anastomotic leak or peritonitis
— Hemodynamically unstable with abdominal source
— Hardware infection or prosthetic involvement
— Infectious diseases: complicated SSI, MDR organisms, prosthetic infection, immunocompromised, prolonged antibiotic course
— Plastic surgery: complex closure, flap coverage, sternal wounds, large soft tissue defects
— Wound care/ostomy nursing: chronic wounds, NPWT management, ostomy care
— Nutrition: albumin <3, prolonged NPO, NSTI patients
— Endocrinology: poorly controlled diabetes, steroid-dependent
— Palliative care: repeated debridements with poor prognosis, frail patients
— Outpatient candidates: small, well-drained superficial SSI, no systemic signs, reliable patient, oral antibiotics tolerated, close follow-up arranged within 48–72 hr
— Admit if: systemic signs (fever, tachycardia), failure of outpatient therapy, IV antibiotics needed, drainage required beyond bedside, comorbidities (DM, immunosuppression), poor social support
— Transfer to higher level of care if NSTI confirmed and facility lacks 24/7 OR or ICU
— Return precautions: fever, increasing pain, spreading redness, drainage change, wound opening
— Direct phone line to surgical team
— Follow-up appointment scheduled before discharge
CCS pearl: On Step 3 CCS, escalate care early and explicitly: order "transfer to ICU," "consult surgery STAT," and "consult infectious disease" as discrete actions — the simulator credits each.
Step 3 management: Persistent tachycardia or rising lactate after 2–3 hours of resuscitation = inadequate source control until proven otherwise — re-image, re-explore, escalate.
— Postop swelling, tense fluctuance, ecchymosis without classic infection signs (initially)
— May become secondarily infected; drain if expanding, compressive, or symptomatic
— Check coagulation status, reverse anticoagulants if needed
— Painless fluid collection, especially after mastectomy, hernia repair, abdominoplasty
— Usually self-limited; aspirate if symptomatic or persistent; sterile technique to avoid superinfection
— Focal inflammation around suture material; resolves with suture removal
— Distinguish from true SSI by limited extent and lack of systemic signs
— Fascial failure from technical (suture too tight, wrong material), mechanical (increased intra-abdominal pressure), or biological (poor healing) factors
— Often presents with serosanguinous drainage and absence of infection signs
— Still requires OR repair
— Erythema confined to area of tape/dressing/iodine, often pruritic, with sharp borders matching adhesive
— No drainage, no induration; resolves with removal of irritant
— Don't mistake for cellulitis — sparing under areas not exposed to adhesive is the clue
— Marjolin ulcer: SCC in chronic non-healing wound or burn scar — biopsy any wound not healing by 3 months
— Pyoderma gangrenosum: rapidly expanding ulcer with violaceous undermined borders, pathergy (worsens with debridement) — treat with steroids/immunosuppression, NOT surgery
— Necrobiosis lipoidica in diabetics
— DRESS, SJS/TEN from antibiotics started postop
— Vancomycin "red man syndrome" — infusion reaction, not allergy
Key distinction: Pyoderma gangrenosum mimics NSTI but worsens with debridement (pathergy) — biopsy edge, treat with immunosuppression. Mistaking it for NSTI causes catastrophic harm.
Board pearl: Any postoperative wound failing to heal at 3 months warrants biopsy to exclude malignancy (Marjolin), atypical infection, or pyoderma gangrenosum.
— Atelectasis (POD 1–2): low-grade fever, decreased breath sounds; treat with incentive spirometry, ambulation
— Pneumonia (POD 3–5): productive cough, infiltrate on CXR, hypoxia; HCAP coverage
— PE (POD 5–7+): tachycardia, hypoxia, pleuritic pain; CT-PA
— UTI / CAUTI (POD 3–5): catheter-associated, especially in elderly, women, prolonged catheterization
— Remove catheter as soon as feasible; treat per culture
— DVT (POD 5+): unilateral leg swelling, calf tenderness; duplex US
— Septic thrombophlebitis at IV sites; remove line, culture tip
— Drug fever (especially β-lactams, sulfa, phenytoin, anesthetics)
— Malignant hyperthermia (intraop or immediately postop): rigidity, hyperthermia, hypercarbia — dantrolene
— Serotonin syndrome from perioperative medications
— Febrile non-hemolytic, TRALI, acute hemolytic — within hours of transfusion
— Thyroid storm in undiagnosed Graves
— Adrenal insufficiency in chronic steroid users without stress dosing — hypotension, hyponatremia, hyperkalemia
— C. difficile colitis — diarrhea after antibiotics
— Acalculous cholecystitis in critically ill
— Sinusitis from prolonged NGT or intubation
— Line infection / CLABSI — every central line is a fever source
— Endocarditis from bacteremia
— Aspiration pneumonia in post-anesthesia
— Postop meningitis after neurosurgery
— Stroke can rarely cause central fever
Step 3 management: Workup of postop fever = examine wound, lines, lungs, urine, calves, abdomen, drugs; order CBC, BMP, UA, CXR, blood cultures, lactate — broad initial sweep, narrow based on findings.
Key distinction: Fever within 24 hours of cesarean or major surgery is often inflammatory (atelectasis, tissue trauma) and self-limited; fever after POD 3 demands an active source search.
— Confirm IV-to-PO conversion criteria met: afebrile 24 hr, declining WBC, tolerating diet, source controlled
— Choose narrowest oral agent matching culture sensitivities
— Specify exact duration with end date in discharge summary
— OPAT (outpatient parenteral antibiotic therapy) for complicated cases — PICC line, weekly labs, ID follow-up
— Daily dressing change technique demonstrated and teach-back confirmed
— NPWT supplies and home health if wound vac in place
— Showering vs bathing guidance (usually shower OK after POD 2–3; no submersion until closed)
— Signs of worsening: spreading redness, increasing pain, new drainage, fever, wound opening
— HbA1c at discharge and 3-month follow-up; target <7% for most
— Resume or initiate basal-bolus insulin, taper as inflammation resolves
— Diabetes educator referral
— Brief counseling, nicotine replacement, varenicline or bupropion
— Critical for future surgical outcomes — wound healing improves within 4 weeks of cessation
— Protein 1.5–2 g/kg/day for healing
— Vitamin C, zinc supplementation in deficient patients
— Referral to dietitian for chronic wounds or malnutrition
— Extended prophylaxis (28 days) after major abdominal/pelvic cancer surgery with enoxaparin
— Continue mechanical prophylaxis until mobile
— Update tetanus, influenza, pneumococcal, COVID per CDC
— MRSA decolonization if recurrent SSI: mupirocin + chlorhexidine baths × 5 days
— Exam at 1, 6, 12 months; CT if symptomatic
— Elective repair when ready and risk factors optimized
Step 3 management: At discharge after SSI: specific antibiotic end date, wound care teach-back, follow-up in 7–14 days, return precautions written and verbal, diabetes/smoking optimization, VTE prophylaxis — Step 3 rewards comprehensive transition-of-care orders.
Board pearl: Smoking cessation ≥4 weeks preoperatively significantly reduces SSI and wound healing complications — a high-yield secondary prevention pearl.
— 48–72 hours post-discharge: phone call or in-person check by nurse or APP for symptom screen
— 7–14 days: clinic visit with surgeon for wound inspection, suture/staple removal if not done at discharge
— 4–6 weeks: assess healing, return to work/activity clearance, hernia screen
— 3 months and 6 months: for complicated cases — incisional hernia surveillance, chronic wound reassessment
— OPAT patients: weekly CBC, BMP, drug levels, CRP; ID follow-up at end of therapy
— Wound measurements (length × width × depth) documented weekly for chronic wounds
— Photographic documentation when possible
— CRP/WBC trend during antibiotic course
— Drug levels: vancomycin trough, aminoglycoside peak/trough
— HbA1c at 3 months
— Nutritional markers (prealbumin, albumin) if malnourished
— Lifting restriction: typically no >10 lb for 4–6 weeks after laparotomy
— Avoid Valsalva, straining, vigorous coughing without splinting
— Resume sexual activity when comfortable, generally 4–6 weeks for abdominal/pelvic surgery
— Driving: when off opioids and can perform emergency stop
— Sedentary work: 1–2 weeks
— Manual labor: 6–8 weeks
— Document for FMLA/disability paperwork
— Acknowledge body image concerns, especially with large scars or stomas
— Screen for postoperative depression and PTSD (especially after ICU stay)
— Connect to support groups (e.g., ostomy associations)
— Physical therapy for deconditioning, especially post-NSTI or prolonged ICU
— Occupational therapy for ADLs
— Pulmonary rehab if respiratory failure occurred
Step 3 management: First follow-up visit should occur within 7–14 days post-discharge; for high-risk patients (NSTI, organ-space SSI, OPAT), arrange a 48–72 hour transitional contact to catch early failures.
Board pearl: Document return precautions and wound care teach-back in the chart — a transition-of-care safety pearl Step 3 frequently tests in patient safety stems.
— Discuss SSI/dehiscence risk during preoperative consent, especially in high-risk patients (DM, obesity, smoking, immunosuppression)
— Document specific risks discussed; "general risks" alone is legally insufficient
— In urgent cases without capacity, two-physician emergency consent doctrine applies; pursue surrogate decision-maker as time permits
— Ethical and legal duty to disclose adverse events (SSI, dehiscence, retained surgical item) to patient and family
— Apology and transparent disclosure programs reduce litigation; many states have apology laws protecting expressions of sympathy
— Never alter medical records — document the event factually, including time, intervention, and notification
— Retained sponge/instrument is a CMS "never event" — non-reimbursable, mandatory disclosure, internal RCA
— Implement count protocols, radiopaque markers, and time-outs
— Wrong-site surgery: prevented by Universal Protocol (mark site, time-out, verification)
— SSIs reported to NHSN (National Healthcare Safety Network) for benchmarking
— Reportable conditions: certain infections (TB, MDR organisms in some states)
— Sentinel events to The Joint Commission
— Medication reconciliation at every transition (admit, transfer, discharge) — missed home meds and duplicated antibiotics are common errors
— Clear handoff using SBAR or I-PASS
— Discharge summary completed within 24–48 hr and sent to PCP
— Pending culture results: assign explicit follow-up responsibility before discharge
— Patient understanding confirmed via teach-back, language-appropriate materials, interpreter services
— Avoid unnecessary broad-spectrum agents to prevent C. diff, MDR colonization, allergies
— Document indication, duration, and reassessment
— Repeated debridements with poor prognosis (e.g., NSTI in frail elderly): involve palliative care early, discuss goals, document advance directives, consider DNR/DNI when appropriate
Step 3 management: Pending blood culture at discharge → explicitly assign follow-up clinician, document in summary, and provide patient instructions; orphaned results are a leading source of malpractice and patient harm.
Board pearl: Retained surgical sponge = never event → mandatory disclosure, no patient charge, RCA, and quality reporting.
— Class I (clean): 1–3% (e.g., hernia, thyroid)
— Class II (clean-contaminated): 3–10% (e.g., elective colectomy with bowel prep)
— Class III (contaminated): 10–17% (e.g., open fracture <4 hr, gross spillage)
— Class IV (dirty): >27% (e.g., perforated viscus, abscess)
— Give within 60 min before incision (120 min for vancomycin and fluoroquinolones)
— Redose intraoperatively if surgery >2 half-lives or blood loss >1500 mL
— Discontinue within 24 hr postop (48 hr for cardiothoracic, per some guidelines, but trending shorter)
— Clean skin surgery: Staph aureus, CoNS, Strep
— GI surgery: E. coli, Bacteroides, Enterococcus
— Biliary: gram-negatives, enterococci
— GYN: polymicrobial including anaerobes
— Sternal/cardiac: Staph aureus, CoNS
— Prosthetic joint: Staph aureus, CoNS, Cutibacterium acnes (shoulder)
— "Salmon-pink serosanguinous drainage" → impending fascial dehiscence
— "Pain out of proportion + crepitus + bullae" → NSTI
— "Dishwater pus" → NSTI in OR
— "Bronze edema, sweet odor" → clostridial myonecrosis
— "Saltwater/oysters + cirrhosis + sepsis" → Vibrio vulnificus
— "Hot tub or freshwater exposure" → Aeromonas, Pseudomonas
— "Cat or dog bite" → Pasteurella multocida
— "Human bite, fist injury" → Eikenella corrodens
— SSI prevention bundle: chlorhexidine-alcohol skin prep, normothermia, normoglycemia, hair clipping (not shaving), appropriate prophylaxis, supplemental oxygen, double gloving
— Colorectal bundle: oral antibiotic + mechanical bowel prep reduces SSI
— NSTI mortality: 20–30%; reduced by debridement within 6 hr
— Sternal mediastinitis: 10–25% mortality
— Anastomotic leak mortality: up to 20%
Board pearl: Chlorhexidine-alcohol is superior to povidone-iodine for preoperative skin antisepsis in most surgeries — a frequently tested SSI prevention fact.
— POD 7 after midline laparotomy, patient coughs vigorously, "felt a pop," nurse reports salmon-colored drainage from incision
— Best next step: abdominal binder + NPO + IV fluids + IV antibiotics + emergent OR for fascial reclosure
— Distractors: bedside repair (wrong), antibiotics alone (wrong), wait and watch (wrong)
— POD 2 diabetic patient with perineal surgery, severe pain out of proportion, hypotension, crepitus, hemorrhagic bullae
— Best next step: broad-spectrum antibiotics including clindamycin + immediate surgical debridement
— Trap: ordering CT first (wastes time)
— POD 5 colectomy patient with fever 39, tachycardia, abdominal pain, ileus
— Best next step: CT abdomen/pelvis with IV and oral contrast to evaluate for anastomotic leak / organ-space SSI
— Manage with antibiotics + IR drainage or OR
— Patient in labor undergoing non-elective C-section
— Best regimen: cefazolin + azithromycin within 60 min of incision
— Postop SSI in MRSA-colonized patient: vancomycin (or linezolid/daptomycin)
— Penicillin-allergic (severe): clindamycin or vancomycin for skin coverage
— Discharged patient with pending blood culture later grows MRSA
— Best practice: explicit follow-up responsibility documented at discharge, patient contacted immediately to return
— Postop wound rapidly expanding with violaceous undermined edges; worsens after debridement
— Diagnosis: pyoderma gangrenosum; treat: systemic steroids/cyclosporine, NOT more debridement
— Complicated intra-abdominal infection with adequate source control: 4 days of antibiotics is sufficient
— Best timing for cefazolin: within 60 min before incision
— Retained sponge: disclose, no charge, RCA, NHSN/Joint Commission reporting
Step 3 management: When the stem describes "pain out of proportion," your answer should never include "obtain CT before consulting surgery" — surgical consultation always precedes imaging in NSTI.
Board pearl: Step 3 loves transition-of-care stems — pending labs at discharge, medication reconciliation errors, and missed follow-up are recurrent themes layered onto SSI scenarios.
Postoperative wound dehiscence and infection are time-defined, exam-driven diagnoses requiring rapid recognition (salmon-pink drainage = dehiscence; pain out of proportion = NSTI), source control before or alongside antibiotics, and disciplined transition-of-care planning to prevent the avoidable readmissions and never events that Step 3 systematically tests.
— POD 4–7 → think SSI; POD 7–10 → think dehiscence; POD <3 with toxicity → think NSTI or clostridial
— Serosanguinous "salmon" drainage = fascial dehiscence until proven otherwise
— Pain out of proportion + crepitus + bullae + hypotension = NSTI → OR, not CT
— Postop fever workup: wound + wind + water + walking + wonder drugs + lines
— CBC, BMP, lactate, blood cultures, lactate, targeted imaging (CT for deep/organ-space SSI)
— LRINEC supports but never replaces clinical judgment for NSTI
— Superficial SSI: open, drain, pack; antibiotics only if cellulitis/systemic signs
— Deep/organ-space SSI: IR drainage or OR + tailored antibiotics
— NSTI: emergent debridement + vancomycin + pip-tazo (or carbapenem) + clindamycin for antitoxin effect
— STOP-IT trial: 4 days of antibiotics after adequate source control in complicated intra-abdominal infection
— SCIP bundle: chlorhexidine-alcohol prep, cefazolin within 60 min, normothermia, glucose 140–180, hair clipping not shaving
— Discharge: clear antibiotic end date, wound care teach-back, follow-up 7–14 days, return precautions, smoking cessation, glycemic optimization
— Document pending results and assign explicit follow-up — a Step 3 patient-safety mainstay
CCS pearl: On simulated cases, sequence actions as examine wound → resuscitate → consult surgery → empiric antibiotics → imaging only if exam unclear → ICU if unstable — the highest-yield order for postoperative wound emergencies.