ICD-10: O86.03
Infection of obstetric surgical wound, organ and space site
Clinical Information
Inclusion Terms
- Intraabdominal abscess following an obstetrical procedure
- Subphrenic abscess following an obstetrical procedure
Additional Information
Clinical Information
Infection of obstetric surgical wounds, particularly those classified under ICD-10 code O86.03, is a significant concern in obstetric care. This code specifically refers to infections that occur in the organ and space site following obstetric surgical procedures. Understanding the clinical presentation, signs, symptoms, and patient characteristics associated with this condition is crucial for effective diagnosis and management.
Clinical Presentation
Infections of obstetric surgical wounds can manifest in various ways, depending on the severity and the specific site of infection. The clinical presentation typically includes:
- Postoperative Onset: Symptoms often arise within days to weeks following the surgical procedure, such as cesarean delivery or other obstetric surgeries.
- Localized Symptoms: Patients may present with localized pain, swelling, and redness at the surgical site. The area may feel warm to the touch, indicating inflammation.
- Systemic Symptoms: In more severe cases, systemic symptoms such as fever, chills, and malaise may occur, suggesting a more widespread infection.
Signs and Symptoms
The signs and symptoms of an infection of an obstetric surgical wound can be categorized into local and systemic manifestations:
Local Signs and Symptoms
- Erythema: Redness around the incision site.
- Edema: Swelling in the area surrounding the wound.
- Purulent Discharge: Presence of pus or other discharge from the wound, which may have a foul odor.
- Increased Pain: Worsening pain at the surgical site, especially with movement or palpation.
- Dehiscence: Partial or complete separation of the wound edges, which may indicate a more severe infection.
Systemic Signs and Symptoms
- Fever: Elevated body temperature, often above 100.4°F (38°C).
- Chills: Episodes of shivering or feeling cold, often accompanying fever.
- Tachycardia: Increased heart rate, which may occur as a response to infection.
- Fatigue: Generalized weakness and tiredness, which can be profound in cases of severe infection.
Patient Characteristics
Certain patient characteristics may predispose individuals to infections of obstetric surgical wounds:
- Obesity: Higher body mass index (BMI) can increase the risk of wound infections due to impaired healing and increased tissue tension.
- Diabetes Mellitus: Patients with diabetes may have compromised immune responses and poor wound healing, making them more susceptible to infections.
- Immunocompromised States: Conditions that weaken the immune system, such as HIV/AIDS or cancer treatments, can elevate the risk of infections.
- Prolonged Labor or Rupture of Membranes: Extended labor or premature rupture of membranes can increase the likelihood of infection during delivery.
- Previous Surgical History: A history of previous surgeries, particularly abdominal or pelvic surgeries, may increase the risk of complications, including infections.
Conclusion
Infection of obstetric surgical wounds, particularly those classified under ICD-10 code O86.03, presents with a range of clinical signs and symptoms that can significantly impact patient recovery. Recognizing the local and systemic manifestations of this condition, along with understanding the patient characteristics that may predispose individuals to such infections, is essential for healthcare providers. Early identification and appropriate management are crucial to prevent complications and ensure optimal outcomes for patients following obstetric surgeries.
Approximate Synonyms
The ICD-10 code O86.03 specifically refers to "Infection of obstetric surgical wound, organ and space site." This code is part of a broader classification system used for diagnosing and coding various medical conditions, particularly in obstetrics. Below are alternative names and related terms associated with this code.
Alternative Names for O86.03
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Obstetric Surgical Site Infection (SSI): This term is commonly used to describe infections that occur at the site of surgical procedures related to childbirth.
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Postoperative Infection: This is a general term that can apply to infections following any surgical procedure, including those in obstetric cases.
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Infection of Surgical Wound: A broader term that encompasses infections that can occur in any surgical wound, not limited to obstetric cases.
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Organ and Space Surgical Site Infection: This term highlights the specific nature of the infection affecting organs or spaces within the body post-surgery.
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Wound Infection Following Cesarean Section: A specific type of obstetric surgical wound infection that can occur after a cesarean delivery.
Related Terms
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ICD-10-CM Codes: Other related codes in the ICD-10-CM system that pertain to surgical site infections, such as:
- O86.0: Infection of obstetric surgical wound
- O86.1: Infection of obstetric surgical wound, superficial
- O86.2: Infection of obstetric surgical wound, deep -
Surgical Site Infection (SSI): A term used in clinical settings to describe infections that occur at the site of a surgical incision.
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Sepsis: While not directly synonymous, sepsis can arise from infections like those coded under O86.03, particularly if the infection spreads systemically.
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Postpartum Infection: This term refers to infections that occur after childbirth, which may include surgical site infections.
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Healthcare-Associated Infection (HAI): A broader category that includes infections acquired during medical care, which can encompass surgical site infections.
Conclusion
Understanding the alternative names and related terms for ICD-10 code O86.03 is crucial for healthcare professionals involved in coding, billing, and clinical documentation. These terms help in accurately identifying and categorizing infections that arise from obstetric surgical procedures, ensuring proper treatment and management of affected patients. If you need further details or specific coding guidelines, feel free to ask!
Diagnostic Criteria
The ICD-10 code O86.03 refers specifically to "Infection of obstetric surgical wound, organ and space site." This code is part of a broader classification system used for coding diagnoses and procedures in healthcare settings. Understanding the criteria for diagnosing this condition is essential for accurate coding and effective patient management.
Diagnostic Criteria for O86.03
1. Clinical Presentation
- Signs and Symptoms: Patients may present with localized signs of infection at the surgical site, including redness, swelling, warmth, and pain. Systemic symptoms such as fever, chills, and malaise may also be present, indicating a more severe infection.
- Wound Assessment: A thorough examination of the surgical wound is crucial. The presence of purulent drainage, necrotic tissue, or delayed healing can suggest an infection.
2. Timing of Infection
- Postoperative Timeline: Infections typically manifest within 30 days post-surgery. The timing of symptom onset is critical; infections occurring after this period may be classified differently.
- Types of Infections: The infection can be classified as superficial (involving only the skin and subcutaneous tissue) or deep (involving muscle and fascia), with O86.03 specifically addressing deep infections that may involve organs or spaces.
3. Microbiological Evidence
- Cultures and Sensitivity Testing: Laboratory tests, including wound cultures, can help identify the causative organism. Positive cultures from the surgical site support the diagnosis of an infection.
- Antibiotic Response: The patient's response to antibiotic therapy may also provide insight into the presence of an infection.
4. Imaging Studies
- Radiological Evaluation: Imaging studies such as ultrasound or CT scans may be utilized to assess for abscess formation or other complications associated with the infection. These studies can help confirm the diagnosis and guide treatment.
5. Exclusion of Other Conditions
- Differential Diagnosis: It is essential to rule out other potential causes of the symptoms, such as hematomas, seromas, or other non-infectious complications related to the surgical procedure.
Conclusion
Accurate diagnosis of an infection of an obstetric surgical wound, organ, and space site (ICD-10 code O86.03) relies on a combination of clinical evaluation, timing of symptoms, microbiological evidence, imaging studies, and exclusion of other conditions. Proper documentation of these criteria is vital for effective coding and ensuring appropriate patient care. Understanding these elements can help healthcare providers manage infections more effectively and improve patient outcomes.
Treatment Guidelines
Infection of obstetric surgical wounds, classified under ICD-10 code O86.03, is a significant concern in obstetric care, particularly following cesarean sections or other surgical interventions during pregnancy. This condition can lead to complications that may affect both maternal and neonatal health. Here, we will explore standard treatment approaches for managing this type of infection.
Understanding O86.03: Infection of Obstetric Surgical Wound
Infections of obstetric surgical wounds can arise from various factors, including surgical technique, patient health status, and postoperative care. The infection can occur at the site of the incision or deeper within the tissues, potentially involving organs and spaces. Symptoms may include redness, swelling, increased pain, fever, and purulent discharge from the wound site.
Standard Treatment Approaches
1. Antibiotic Therapy
The cornerstone of treatment for surgical wound infections is the use of antibiotics. The choice of antibiotic should be guided by:
- Culture and Sensitivity Testing: If possible, obtaining a culture from the wound can help identify the specific pathogens involved and their antibiotic sensitivities. This allows for targeted therapy.
- Empirical Therapy: In cases where immediate treatment is necessary, broad-spectrum antibiotics may be initiated. Common choices include:
- Cephalosporins (e.g., cefazolin) for skin flora coverage.
- Clindamycin or Vancomycin for suspected MRSA (Methicillin-resistant Staphylococcus aureus) infections.
- Piperacillin-tazobactam for polymicrobial infections, especially if there is a risk of anaerobic bacteria.
2. Wound Care Management
Proper wound care is essential in managing infections:
- Debridement: If necrotic tissue is present, surgical debridement may be necessary to remove infected and dead tissue, promoting healing and reducing the bacterial load.
- Dressing Changes: Regular dressing changes with sterile techniques help maintain a clean environment and allow for monitoring of the wound's healing progress.
3. Supportive Care
Supportive measures are crucial for recovery:
- Fluid Management: Ensuring adequate hydration and electrolyte balance is important, especially if the patient is febrile or has increased fluid losses.
- Nutritional Support: Adequate nutrition supports the immune system and wound healing. Patients may require dietary adjustments or supplements.
4. Monitoring and Follow-Up
Close monitoring of the patient's clinical status is vital:
- Vital Signs: Regular assessment of temperature, heart rate, and blood pressure can help detect worsening infection or sepsis.
- Wound Assessment: Frequent evaluation of the wound for signs of improvement or deterioration is necessary to adjust treatment as needed.
5. Surgical Intervention
In some cases, further surgical intervention may be required:
- Abscess Drainage: If an abscess forms, it may need to be drained surgically to facilitate healing.
- Reoperation: In severe cases, reoperation may be necessary to address complications such as deep tissue infections or to revise the surgical site.
Conclusion
The management of infection of obstetric surgical wounds (ICD-10 code O86.03) involves a multifaceted approach that includes antibiotic therapy, meticulous wound care, supportive measures, and careful monitoring. Early identification and treatment of infections are crucial to prevent complications and ensure optimal recovery for the patient. Collaboration among healthcare providers, including obstetricians, surgeons, and infectious disease specialists, can enhance patient outcomes in these cases.
Description
ICD-10 code O86.03 refers to an "Infection of obstetric surgical wound, organ and space site." This code is part of the broader category of obstetric complications and is specifically used to classify infections that occur in surgical wounds related to obstetric procedures. Below is a detailed clinical description and relevant information regarding this code.
Clinical Description
Definition
O86.03 is used to denote infections that arise in surgical wounds following obstetric surgeries, such as cesarean sections or other surgical interventions during pregnancy or childbirth. These infections can involve various anatomical sites, including the uterus, peritoneal cavity, or other organs and spaces that may be affected during the surgical procedure.
Etiology
The infections classified under this code can be caused by a variety of pathogens, including:
- Bacteria: Commonly, infections may be due to skin flora such as Staphylococcus aureus or Streptococcus species, as well as other organisms like Escherichia coli and Enterobacter species.
- Fungi: In some cases, fungal infections may also occur, particularly in immunocompromised patients.
Risk Factors
Several factors can increase the risk of developing an infection in obstetric surgical wounds:
- Prolonged labor: Extended labor can increase the risk of infection due to prolonged exposure to bacteria.
- Obesity: Higher body mass index (BMI) can complicate surgical procedures and healing.
- Diabetes: Patients with diabetes may have impaired wound healing and increased susceptibility to infections.
- Inadequate surgical technique: Poor surgical practices can lead to contamination and subsequent infections.
Symptoms
Patients with an infection of an obstetric surgical wound may present with:
- Fever: A common systemic sign of infection.
- Localized pain: Pain at the surgical site that may be more intense than expected.
- Redness and swelling: Inflammation around the incision site.
- Discharge: Purulent or foul-smelling drainage from the wound.
Diagnosis and Management
Diagnosis
Diagnosis typically involves:
- Clinical evaluation: Assessment of symptoms and physical examination of the surgical site.
- Laboratory tests: Blood tests may show elevated white blood cell counts, and cultures may be taken from the wound to identify the causative organism.
Management
Management of infections classified under O86.03 may include:
- Antibiotic therapy: Empirical antibiotics may be initiated, followed by targeted therapy based on culture results.
- Surgical intervention: In some cases, drainage of abscesses or debridement of necrotic tissue may be necessary.
- Supportive care: Ensuring adequate hydration and nutrition to support recovery.
Coding Guidelines
When coding for O86.03, it is essential to follow the ICD-10-CM guidelines, which emphasize the importance of specificity in coding. This includes documenting the type of infection, the specific surgical procedure performed, and any relevant patient history that may impact the treatment and management of the infection.
Conclusion
ICD-10 code O86.03 is crucial for accurately documenting infections of obstetric surgical wounds, which can significantly impact patient outcomes. Understanding the clinical implications, risk factors, and management strategies associated with this code is essential for healthcare providers involved in obstetric care. Proper coding not only aids in patient management but also ensures appropriate reimbursement and data collection for healthcare services.
Related Information
Clinical Information
- Postoperative Onset within days to weeks
- Localized pain swelling redness at surgical site
- Systemic symptoms fever chills malaise in severe cases
- Erythema redness around incision site
- Edema swelling surrounding the wound
- Purulent Discharge foul odor from wound
- Increased Pain worsening pain at surgical site
- Dehiscence partial or complete separation of wound edges
- Fever elevated body temperature above 100.4°F (38°C)
- Chills episodes of shivering or feeling cold
- Tachycardia increased heart rate in response to infection
- Fatigue generalized weakness and tiredness
- Obesity increases risk of wound infections due to impaired healing
- Diabetes Mellitus compromised immune responses poor wound healing
- Immunocompromised States weaken the immune system increasing infection risk
- Prolonged Labor or Rupture of Membranes increased likelihood of infection during delivery
Approximate Synonyms
- Obstetric Surgical Site Infection (SSI)
- Postoperative Infection
- Infection of Surgical Wound
- Organ and Space Surgical Site Infection
- Wound Infection Following Cesarean Section
Diagnostic Criteria
- Localized signs of infection at surgical site
- Systemic symptoms such as fever, chills, malaise
- Purulent drainage, necrotic tissue, delayed healing
- Infection within 30 days post-surgery
- Superficial or deep infections (deep involving organs)
- Positive wound cultures from surgical site
- Patient's response to antibiotic therapy
- Radiological evaluation for abscess formation
Treatment Guidelines
- Antibiotic therapy with culture and sensitivity testing
- Empirical therapy with cephalosporins or clindamycin/vancomycin
- Debridement of necrotic tissue for wound care management
- Regular dressing changes with sterile techniques
- Fluid management to ensure adequate hydration and electrolyte balance
- Nutritional support through dietary adjustments or supplements
- Monitoring vital signs and wound assessment regularly
- Surgical intervention for abscess drainage or reoperation as needed
Description
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