**General surgery**

Dr Alan Shortt

51 Surgical sieves

VITAMIN C DIP
Vascular
Infective
Trauma
Allergic/immunological
Metabolic/endocrine
Iatrogenic
Neoplastic
Congenital
Degenerative
Idiopathic
Psychogenic

In a surgeons gown a physician can cause inevitable damage to patients

incidence
age
sex
geography
aetiology
pathology
clinical presentation
complications
investigations
differential
treatment
prognosis

INVESTIGATIONS

Iatrogenic
Neoplastic
Vascular
Endocrine
Structural/ Mechanical
Traumatic
Inflammatory Genetic/ Congenital
Autoimmune
Toxic
Infective
Old age/ Degenerative
Nutritional
Spontaneous/ Idiopathic

Pressure area care

NICE pressure sores

NICE CG29 Pressure ulcer management Sep 2005 QRG

European Pressure Ulcer Advisory Panel classification system of pressure ulcer grades
Grade1	non-blanchable erythema of intact skin. Discolouration of the skin, warmth, oedema, induration or hardness may also be used as indicators, particularly on individuals with darker skin
Grade2	partial thickness skin loss involving epidermis or dermis, or both. The ulcer is superficial and presents clinically as an abrasion
Grade3	full thickness skin loss involving damage to or necrosis of subcutaneous tissue that may extend down to, but not through, underlying fascia
Grade4	extensive destruction, tissue necrosis, or damage to muscle, bone or supporting structures with or without full thickness skin loss

@@@ wound care and dressings formulary

Tayside Wound Formulary

Bucks Wound Formulary July 2011 @ NeLM

Types of Dressings
GranuflexMepilex	Dry, granulating pressure sores and other dry wounds.
AquacellIodosorb	Wet wounds including pressure sores.
Kaltostatcarboflex	Fungating, malodorous wounds.
Iodoflex	Necrotic, ‘wet’ areas
INADINmepore	Simple dressing, good for acute wounds.
IntrasiteTegaderm	Dry necrotic wounds.
LyofoamMepore	Overgranulating wounds

wound colours chronic wounds
colour	may mean	action
pink	epithelialisation	protect
red	granulation	protect
yellow	sloughy	clean
green	infected	clean
black	necrotic	debride

Fitness for surgery

Diabetes perioperative management

NHS Diabetes peri-operative guidelines June 11

Diabetes Handbook TAYSIDE DIABETES MCN WEBSITE G Brennan, L Walton, D Voigt Tayside January 2008

Three aspects to the peri-operative management of diabetic patients:

1. General Assessment

Check for the presence of cardiac, renal and neurological sequelae of diabetes as the presence of these may complicate the peri-operative management and increase patient risk.

Please take this opportunity to ensure that patients have had their eyes screened for retinopathy within the last year (either retinal photo or attendance at an Ophthalmology Clinic). If eye screening has not been done, please contact the Retinal Screening team directly Ensure that no other diabetes-related problems need to be attended to.

2. Assessment of Glycaemic Control:

HbA1c is an indicator of recent control i.e. over the 6-8 weeks. If the HbA1c is above 9 %, control is poor and the Diabetes team should be involved. If above 12 %, consideration should be given to improving control before elective surgery is undertaken.

3. Careful Peri-operative Control of Blood Glucose:

Management of patients on diet alone or oral hypoglycaemic agents

Minor Operations (Body surface or endoscopic procedures)

Omit oral hypoglycaemic therapy on the day of operation and avoid glucose infusion

Check finger prick blood glucose on the morning of the operation and regularly thereafter as clinical circumstances dictate

The management of these patients is easier if they are operated on early in the morning. For afternoon cases, patients taking oral hypoglycaemic drugs should omit these in the early am and have clear fluids only thereafter.

There is no need to stop Metformin any sooner than on the day of surgery

Oral medication should be restarted as normally prescribed with the first meal. The only exception to this is for patients taking Metformi

NB Metformin and lactic acidosis. This is more likely if there is renal impairment present and so Metformin should not be restarted post operatively unless the renal function is OK

Metformin should not be used if eGFR <30 and doses not higher than 500mg BD are advised for patients with eGFR 30-45

If Metformin is contraindicated, then additional hypoglycaemic therapy may be required. If in doubt, contact the Diabetes team for advice

Major Operations

Patients undergoing major operations will require intravenous insulin. There is no advantage in starting intravenous insulin therapy until the patient is fasted as otherwise the glucose control will escape during eating

Patients on oral therapy who are inadequately controlled (i.e. random venous blood glucose >15.0 mmol/l or HbA1c >9%) should be stabilized on insulin pre-operatively and managed in the same way as insulin-treated patients

Management of patients on insulin (type 1 and type 2)

Pre operativelyAll patients on insulin should be adequately controlled pre-operatively and they should ideally be stabilised over 48 hours

For patients using twice daily insulin, this may be possible with their usual regime but it may involve switching them to a multiple injection regimen.

For people with type 1 diabetes on multiple daily insulin regimens, it is advisable to continue their ‘usual’ daily long acting analogue insulin (Lantus or Levemir). This will reduce the risk of diabetic ketoacidosis if IV insulin is interrupted, and it will facilitate a smooth transition to subcutaneous insulin at a suitable mealtime post operatively

Remember that some patients with type 2 diabetes may be treated with both insulin and Metformin – see guidance above regarding monitoring of renal function post-operatively before re-starting Metformin

On the day prior to operation, check random venous blood glucose and urea and electrolytes

On the morning of the operation

Check the blood glucose and commence an intravenous infusion of glucose and insulin – use a GKI infusion unless specifically requested to do otherwise by the anaesthetist

Ensure that the patient does not receive any subcutaneous rapid acting or pre-mixed insulin on the day of surgery. The last dose of either type of insulin should have been given on the previous evening

Continue to check the blood glucose hourly, pre ,intra and post-operatively

Post-operatively

Change to subcutaneous insulin post-operatively when eating normally

It is important to continue the IV insulin infusion for 60 minutes after the first subcutaneous insulin injection has been given

If the patient has been previously poorly controlled (HbA1c >9%) please refer to the Diabetes team for further advice before discharge

Management of patients on insulin undergoing day case surgery

Aim for “first on list”

For those on a multiple injection regimen, continue the usual basal (long acting) insulin on the evening prior to procedure

For patients on twice daily insulin, continue the usual evening insulin prior to the procedure

Fast from midnight and omit the morning insulin

Check a finger prick blood glucose before and after the procedure

Resume the usual insulin and diet after the procedure. If a BD insulin regimen is restarted at lunchtime it is recommended that half of the normal ‘breakfast’ insulin dose should be prescribed with lunch after procedure

The above applies if rapid recovery is expected i.e. the patient is expected to be eating within 2 hours of the procedure

If the patient is unable to tolerate diet or the blood glucose is >14 mmol/L, then a GKI infusion or alternative (see below) will be required

Glucose/Potassium/Insulin (GKI) Infusion

Take a 500-ml bag of 10% Glucose and add short acting insulin according to the table below. The insulin should be injected into the bag and mixed thoroughly

Add 10 mmols of Potassium Chloride to each bag. NB Omit potassium if patient has renal failure or pre op potassium > 5 mmols/L

A pre mixed bag of 10% Glucose with 10 mmols of Potassium Chloride may be used if available

Monitor potassium carefully

Run infusion at 100mls/hour, via infusion pump, e.g.-Braun, IVAC

Each change in units of insulin per bag requires a new bag

Target glucose 7-10 mmols /l

It is not acceptable to allow blood glucose levels to be consistently greater than 10mmol/L and hypoglycaemia < 4mmol/L should be avoided

Blood glucose mmol/L Insulin (units) in each 500mL bag

<4 Seek help

4 – 6.9 10

7 – 12.9 15

13 – 17 20

>17 Seek help

If blood glucose levels in the hypoglycaemic range, i.e.<3mmols/l, run in 50 mls of 10% glucose and re-check blood glucose before adding insulin

If the patient is obese or on steroids, add an additional 5 units of insulin to each bag

If the patient has significantly impaired renal function (eGFR < 30), seek advice as they may need a reduced insulin dose or a reduced infusion rate

Check fingerprick blood glucose immediately pre-op, at least hourly intra op and again immediately post-op. Once stable, the post op blood glucose may be checked 2 hourly

Recheck K+ on afternoon of operation, then urea and electrolytes daily if infusion continues

Change to subcutaneous insulin when eating normally. It is important to continue the IV insulin infusion for 60 minutes after the first subcutaneous insulin injection has been given

Patients previously on oral hypoglycaemic agents should usually be changed from insulin to their normal regime prior to discharge

If diabetes previously poorly controlled (HbA1c >9%) please refer to the Diabetes team for advice

Insulin via Pump (sliding scale) with Glucose/Potassium Infusion

This is an alternative to the GKI infusion which is more suitable for very ill patients peri- or post-operatively

Note it involves separate infusions of glucose and insulin and appropriate precautions should be taken to ensure both remain infusing e.g. by using a Protect-A-Line 2 Extension set, with anti-syphon and anti-reflux valves

The blood glucose and urea and electrolytes should be monitored as above

10% Glucose is infused at 100mls/hour (or less if renal or cardiac failure or raised intracranial pressure)

Add 10 mmols of Potassium Chloride to each 500 ml bag of 10% Glucose unless patient has renal failure or pre op potassium >5mmols/l. Monitor potassium carefully

A separate infusion pump with 50units of Actrapid in 50mls 0.9% saline is infused simultaneously. This is infused at the following rate

Blood glucose mmol/L Units of insulin/hour

<4 0.5 (inform doctor)

4 – 6.9 1

7 – 10.9 2

11 – 15.9 4

16 – 20 5 – consider changing glucose to 0.9% saline

>20 6 (inform doctor)

Optimal glycaemic control will aid recovery

Agree individual blood glucose level targets e.g. 7-10mmol/L and ensure IV insulin ratio in sliding scale is altered if this target is not being achieved

Occasionally the regime has to be adapted for a specific patient

It is not acceptable to allow blood glucose levels to be consistently greater than 10mmol/L and hypoglycaemia <4mmol/L should be avoided

Multiple Injection Regimen

A multiple injection regimen should consist of:

short acting soluble insulin (e.g. Humulin S or Actrapid, ) taken 30 min prior to meals with intermediate acting insulin (e.g. Humulin I, Insulatard) administered at 10 p.m.

alternatively a rapid acting insulin analogue e.g. Insulin Lispro (Humalog), Insulin Aspart (Novorapid) or Insulin Glulisine (Apidra) may be injected immediately before main meals and is combined with a long acting insulin analogue e.g. Insulin Glargine (Lantus) or Insulin Detemir (Levemir). The latter is most commonly taken at teatime or bedtime, although less commonly, some patients do so at breakfast time

Contacting the Diabetes Team

Ideally difficult cases and patients undergoing major operations, particularly if insulin treated, should be discussed with the Diabetes team, well in advance if possible

Gowning gloving hand-washing

Drug therapy in relation to surgey and anaesthesia

Post-op complications

post operative complications Archer usmlestep3 blog

The five W’s–post-operative fever

Wind–pneumonia, atelectasis
Water–urinary tract infection
Wound–wound infections
Wonderdrugs–especially anesthesia
Walking–walking can help reduce deep vein thromboses and pulmonary embolus

Time off after surgery

Suture removal

Suture Removal stuartxchange.org

AB prophylaxis in surgery

GASTROINTESTINAL ENDOSCOPY/VARICEAL BLEEDING/SBP

Adapted from BSG guidelines 2009

All procedures:

high risk patients (prosthetic heart valve, previous endocarditis, surgically constructed systemic-pulmonary shunt or conduit synthetic vascular graft less than 1 year old)

No longer recommended – see BNF

ERCP or ultra sound guided drainage pancreatic pseudocyst or unlikely/unable to achieve complete biliary decompression Ciprofloxacin PO 750mg 60-90 minutes prior to procedure.

See Antibiotic Prophylaxis in General Surgery for ERCP guidance.

PEG tube insertion all patients

(if patient is already receiving broad-spectrum antibiotics additional prophylaxis is not required)

Co-trimoxazole 480mg/5mL suspension. 10mL (960mg) to be given through PEG tube just after insertion.

ANTIBIOTIC PROPHYLAXIS FOR SBP (Spontaneous Bacterial Peritonitis) IN PATIENTS WITH ASCITES

Co-trimoxazole 480mg/5mL suspension. 10mL (960mg) to be given through PEG tube just after insertion.

ANTIBIOTIC PROPHYLAXIS FOR SBP (Spontaneous Bacterial Peritonitis) IN PATIENTS WITH ASCITES

Abdominal examination (surgical)

Hepatomegaly Causes (UK)
CCF	malaria
Ca (mets, hepatoma lymphoma)	polycystic liver
Cirrhosis	riedels lobe
Myeloproliferative diseases	Storage disease (glycoge, amyloid, Nieman Pick,)
Viral Hepatitis	Budd Chiari
Fatty Liver	Non Viral infections (TB, hydatid cyst, amoebic abcess, toxoplasmosid, schistosomiasis)
Biliary obstruction	(Aids to Clinical Exam Hayes MacWalter CL 1986)

Anterior edge of normal liver is occasionally palpable just below right costal margin.

Liver enlargement described in cm below the costal margin.

(Upper border – dull to percussion up to 4th ICS)

Describe liver edge (regular or irregular)

Surface (smooth or nodular)

Consistancy (hard or firm)

Tenderness

Bruits or rub.

Assosciated features

Splenomegaly

Ascites

Caput Medusa

Lymphadenopathy

Spider naevi

Leuchonychia

Raised JVP

Jaundice

Gynaecomastica

Testicular atrophy

Oedema

Splenomegaly
Mild	Moderate	Massive
Viral hepatitis Glandular Fever Septicaemia Typhoid Brucellosis SLE	CLL Lymphoma Aculte leukaemia Anaemia (aplastic, pernicious and haemolytic) ITP PBC Infective endocarditis Sarcoid Amyloisd portal hypertension	CML Myelofibrosis PRV Malaria Kala-azar

Spleen is normally impalpbale and has to enlarge 2-3 x normal before becoming palpable behind the left costal margin.

Look for associated

hepatomegaly

ascites

lymphadenopathy

anaemia

jaundice

plethoric facies

sternal tenderness

splinter haemorrhages

rheumatoid hands

Clinical features of an enlarged spleen cf kidney in LUQ

Has palpable notch on the anterior border.
Can’t get your hand above it (unlike kidney)
Not bimanually papable/ballotable
Dull to percussion cg kidney (retroperitoneal) which is resonant due to overlying transverse colon.
Moves with respiration
Enlarges down and medially.

Causes of enlarged kidney

Healthy left kidney is not normally palpbale but lower pole of right kidney can occasionally be felt in thin females.
PCKD
Hydronephrosis
Cancer
Nephrotic Syndrome

Hepatosplenomegaly

Lymphoma
Leukaemia
Cirrhosis
Myeloproliferative disorders

Causes of Ascites( free fluid in peritoneal cavity)
Transudate	Exudate	Chylous
Cirrhosis

CCF

Nephrotic syndromeTB peritonitis

Carcinomatous peritonitisMalignancy

Trauma

Features of ascites

Distended abdomen with fullness in flanks
Fluid thrill and Shifting dullness
Associated hepatosplenomegaly may be difficult to detect

May be dilated abdominal veins – caput medusa – due to portal obstruction and opening up of the round ligament between the portal and parietal veins. Direction of blood flow is away from umbilicus in all directions.

Abdo pain adults

Abdo pain children

Abdo Pain Children Periodic Syndrome Abdominal Migraines

Beware: intussusception, torsion of the testis, strangulated hernia and appendicitis

Children may not have typical symptoms or signs-as always take a careful history, examine and test the urine

Look out for UTI and test and culture

Appendicitis

Mass in RIF

Crohns
Appenix abcess
Tubo-ovarian mass
Carcinoid tumour
TB Omoeba

Meckels Diverticulum

Arises in the ileum from persistant remnant of the foetal vitello-intestinal duct

Rule of 2s

2% of the population
2:1 male to female
2 inches long
2 feet from ileocoecal valve

Usually asymptomatic incidental finding.

Lined with ectopic gastric mucosa which may ulcerate and bleed or perforate

Or may become blocked and inflamed and present like acute appendicitis.

May be diagnosed by technetium 99 radionucleotide scan – HCl producing parietal cells selectively take up the isotope.

Dysphagia (general surgery)

Hiatus hernia

Achalasia

Abdominal mass swelling

abdominal distension

fat
fluid
flatus
foetus
fibroid
faeces

Epigastric Mass

Altered bowel habit

Haemorrhoids

Dilatations of the fibrovascular venous cushions draining into the superior and inferior rectal/haemorrhoidal veins inside the anal canal.

Occur at 3 7 and 11 o’clock.

They may prolapse (‘come down’) on straining, when they may be visible as soft, purple grape-like swellings

protruding from the anus. They may cause bleeding, itching or discomfort.

youtu.be/j0Oqs6q-g4o

AETIOLOGY/PATHOGENESIS

Haemorrhoidal tissue consists of fibrovascular cushions that are suspended in the anal canal by a connective tissue framework derived from the internal anal sphincter and longitudinal muscle.

The venous plexus of each cushion is fed by arteriovenous communications that allow for enlargement of the cushion to help control continence. With age and the passage of hard stools, the connective tissue supporting the cushions becomes weaked so that these cushions may descend. Straining produces an increase in venous pressure and engorgement. The prolapsed cushion has an impaired venous return, which results in dilatation of the plexus and venous stasis. A decreased venous outflow can also result from, for example, spasm of the anal sphincter straining and tumours in the pelvis. Alternatively, arterial inflow can increase via infection or alcohol. Inflammation occurs with erosion of the cushion’s epithelium, resulting in bleeding.

haemorrhoids
Grade 1	haemorrhoids that are only visible on proctoscopy (grade 1)
Grade 2	those that prolapse when straining, but which reduce spontaneously
Grade 3	those that spontaneously prolapse, but which can be reduced digitally
Grade 4	prolapse and cannot be reduced

HISTORY

toilet habits and constipation

about any changes in bowel habit

about the relationship between rectal blood loss and defaecation (the amount, whether it is bright or dark red, the presence of mucus, and whether the blood is only on the toilet paper, or also in, or on the surface of, the faeces)

about pain (pain is not a symptom of uncomplicated haemorrhoids; if pain is present, this suggests an anal fissure (or a perianal haematoma)

about risk factors for colonic carcinoma (positive family history for polyposis coli or colon carcinoma, long-term ulcerative colitis).

When the patient strains, the GP should look for prolapse of haemorrhoids or mucosa.

The swelling of external haemorrhoids should be clearly visible.

During palpation and the digital rectal examination, check for induration, sphincter tension (hypotonia, hypertonia), tumours, and abnormalities of the prostate, the uterus and the pouch of Douglas. Internal haemorrhoids are not usually palpable. They will, however, be visible on proctoscopy.

Further investigation is usually unnecessary for blood loss resulting from haemorrhoids in patients under 50 years old without risk factors for colonic carcinoma. However, it is indicated for rectal blood loss with existing haemorrhoids in patients above this age, to exclude co-pathology.

Local therapy consists of treating the accompanying perianal dermatitis, cooling the area with ice (which reduces swelling, itching and pain), and warm baths, which relax the anal sphincter (thereby improving venous outflow) and protect the skin and mucous membrane.

Sclerotherapy or rubber-band ligation (for grades 1,2 and 3) or surgical therapy (for grades 3 and 4) should only be carried out if there are persistent symptoms.

Thrombosed external pile

Caused by a sudden leakage of blood from a ruptured tributory of one of the inferior rectal veins. small blood vessel near the anus. The blood stretches the sensitive skin and is very painful. It will gradually disperse, but if the patient presents early it is possible to radially incise it and relieve pain by expressing the blood clot.

Prolapsed Strangulated Piles

Presents similarly with painful lump at anal verge. Prolapsed piles become gripped by anal sphincter, venous return is obstructed and thrombosis occurs.

Anal fissure

Midline split in the anal skin and deeper tissues due to passing a large, hard stool. 90%at 6 o’clock 10% 12 oclock – usually females. Causes pain and bleeding on defaecation. There is usually an associated tag of anal epithelium which points to the fissure (sentinel pile)

Sphincter spasm causes local ishaemia increasing pain and fear of defacaetion further hardening of stool pain spasm etc. Most will heal within 6 weeks, provided that the stools remain soft. Untreated this may result in a chronic fissure.

Anal fissures must be differentiated from other disorders of the anal skin including ulcerative colitis and Crohn’s disease. In 7% of patients with ulcerative colitis, fissures are present that are multiple in number, wide, infected and located outside the median line. In Crohn’s disease, the anal lesions are larger and the ulceration more extensive, and they are accompanied by oedema and large skin tags.

Act on the normal defecation reflex and to ensure the proper consistency of the faeces: a cellulose rich diet (fruit, fresh or raw vegetables, brown bread and rye bread), possibly supplemented for a short time with volume-increasing laxatives (e.g. psyllium seed, sterculia gum). Warm baths after a bowel movement can help prevent and relieve the anal spasm.

The pain can be treated locally by short-term, sparing use of a local anaesthetic ointment, such as lidocaine.

Topical glyceryl trinitrate ointment : every 3 hours (not during the night) to the entire anal dermis.

If the fissure has not healed at that point, the patient must be referred for further tests, and possibly, in the most extreme cases, for surgery or for ‘chemical denervation’ of the internal sphincter (with botulinum toxin). An operation must also be considered for a fissure accompanied by an abscess or fistula

Perianal abcess

Perianal Abcess Medscape

Ischiorectal abcess

Ischiorectal Abcess Medscape

Pilonidal sinus

Portsmouth Pilonidal-Centre

Fistula in ano

Anal Pain

Rectal bleeding

rectal bleeding

Rectal discharge

Rectal Prolapse

Faecal incontinence

Inguinal hernia

4 questions
Is there a hernia
Is it reducible
Is it inguinal or femoral
If inguinal is it direct or indirect

Lump in Groin DIH

femoral Aneuysm
Femoral Hernia
Hydrocoelse
Incrcerated Inguinal Hernia
Indirect Inguinal Hernia
Psoas Abcess
Saphena Varix
Other Hernias

Arterial Disease PAD

Abdominal Aortic Aneurism AAA

Venous Leg Ulcers

Venous Ulcer Arterial Ulcer

Varicose /venous/gravitational ulcer

Due to venous incompetence (vvs previous DVT) leading to venous hypertension stasis and oedema, varicose eczema (haemosiderin deposition from damaged red cells squeezed out of the capillaries) , bacterial infection, then ulceration around medial malleolus and lower leg

Rx^[1]

elevation – foot higher than knee and knee higher than hip.

drynonadherent dressing + paste bandage + elastoplast bandage from toes to knee. Change weekly initially then more frequently as heals.

elastic stocking once healed

Arterial / Ischaemic ulcers

Seen in advanced PAD. Confirm by APBI and investigate with femoral arteriogram to assess location and degree of stenosis and collateral run off.

Rx Balloon angiography +/- stent. Surgical reconstruction with saphenous graft.

Rheumatoid ulcers

Deep indolent ulcers over lower legs .

Necrobiosis lipoidica diabeticorum

Red/yellow sclerotic plaques with ulceration seen on shins

Pyoderma gangrenosa

Elevated purulent border with undermining of the skin and zone of erythema beyond the edge. Seen on legs and trunk. Seen in UC, MM and leukaemia.

Sickle cell disease

Punched out sharp edged round or oval lesions in Afro Caribean patient.

Syphilitic ulcers

Sloughing gummatous ulcer with punched out edges below the knee seen in tertiary syphilis.

APBI Measurement

APBI
<0.5	arterial ulcer
0.5-0.7 /0.7-0.8	mixed arterial-venous ulcer
>0.9	venous ulcer
>1.2	possible calcific vessels

Other Leg Ulcers

Varicose Ulcer
Pressure Sores
Ischaemic Ulcers
Trophic Ulcers
Malignant Skin Ulcers
Siphilitic Ulcer
Trophic Ulcers

Varicose Veins

Phlebitis

Sterile inflammation of clotted stagnant blood in varicose vein.

Rx elevation and analgesia.

Raynaud’s disease

WBC

White arteriolar spasm
Blue dilated capillaries skin feels cold numb
Crimson red reactive hyperaemia as vasosasm relaxes

Idiopathic paroxysmal spasm of digital arterioles in response to cold. Characteristic colour change as above. Mainly females.

Use gloves. Avoid smoking and betablockers. Try Ca antagonists eg diltiazem or nifedipine. Sympathectomy may be helpful.

Raynauds phenomenon

Scleroderma
Cryoglobiaemia
cervical rib
arterial trauma
embolism
vibratory white hand

Pernio Chilblains

Pernio Medscape

Pernio in Children Paediatrics 2005

Arterial thrombus

6 Ps – MSK or Arterial Occlusion
Pain
Paraesthesia
Paralysis
Pallor
Pulse
Perishingly cold

Cellulitis

hacking-medschool/bacterial-skin-infections

Cellulitis & Erysipelas

Organisms S. pyogenes. S. aureus.

PVL toxin is produced by 2% of S. aureus and produces recurrent abscesses or cellulitis.

Risk factors include young age, patients in close communities, contact sportsmen and possibly travel abroad (e.g. US, Australia).

Treatment

1st line Flucloxacillin 1g four times daily for 7-14 days. In penicillin allergic patients, doxycycline 100mg twice daily for 7-14 days.

If history or risk of MRSA check sensitivities or start antibiotics as below and adjust in line with sensitivities.

If no improvement seek ID/Microbiology advice.

Always use dual therapy except for doxycycline or co-trimoxazole.

Details on decolonisation programme can be obtained from Infection Control.

1st line Doxycycline 100mg twice daily (7-14 days).

2nd line Trimethoprim 200mg twice daily and rifampicin 300mg twice daily (7-14 days).

The use of antibiotics in the treatment of leg ulcers is only recommended with clear evidence of clinical infection (pain, cellulitis, fever, progressing infection), refer to the SIGN guideline 26 – The Care of Patients with Chronic Leg Ulcer

Patients should be warned that rifampicin therapy may colour body secretions yellow or orange (including soft contact lenses).

Be aware of important drug interactions with rifampicin, e.g. failure of the oral contraceptive due to enzyme induction – consult current BNF for details.