Atlas surgical site infection

Surgery, Infections, Surgical Site infections, OR, OT, Operation Theatre

1. Surgical Site Infection
PPT MADE BY:
DR RAJESH T EAPEN
ATLAS HOSPITAL
MUSCAT

2. What is a Surgical Site Infection (SSI)?
A surgical site infection is an infection
that occurs after surgery in the part of
the body where the surgery took place.

SSIs are one of the most important causes of
healthcare-associated infections (HCAIs).

3. Outcomes
Increase morbidity
Increase mortality
Increase length of stay
Increase cost

5. Three levels of SSI:
• superficial incisional, affecting the skin
and subcutaneous tissue- may be
indicated by localized signs such as
redness, pain, heat or swelling at the site of
the incision or by the drainage of pus.

• deep incisional, affecting the fascial and
muscle layers- indicated by the presence
of pus or an abscess, fever with tenderness
of the wound, or a separation of the edges
of the incision exposing the deeper tissues.

6. Levels of SSI…contd….

•organ or space infection- which involves any
part of the anatomy other than the incision that
is opened or manipulated during the surgical
procedure, for example joint or peritoneum.

7. Cross Section of Abdominal Wall
Depicting SSI Classification

8. Symptoms of a surgical site
infection include:

A delay in healing of the surgical site
The tissue around the surgical site may be
discolored
A foul odor coming from the incision site
Pain or sever tenderness in the area of the
incision
Severe swelling of the incision
Incision is hot to the touch
Doctor should be notified at the earliest sign
of symptoms.

9. Wound discharge with no other complications



Life-threatening condition


Other clinical outcomes of SSIs
•poor scars that are cosmetically unacceptable, (spreading,
hypertrophic or keloid, persistent pain and itching, restriction
of movement, particularly when over joints)

10. Pathogenesis of surgical site infection


The development of an SSI depends on
contamination of the wound site at the end
of a surgical procedure and specifically
relates to the pathogenicity and inoculum
of microorganisms present, balanced
against the host’s immune response.

11. Microorganisms that cause SSIs are usually
derived from the patient (endogenous
infection), being present on their skin or from
an opened viscus.

Exogenous infection occurs when
microorganisms from instruments or the
theatre environment contaminate the site at
operation, when microorganisms from the
environment contaminate a traumatic wound,
or when microorganisms gain access to the
wound after surgery, before the skin has
sealed.

13. SSI Risk Factors
•Age
•Obesity
•Diabetes
•Malnutrition
•Prolonged preoperative
stay
•Infection at remote site
•Systemic steroid use
•Nicotine use
•Hair removal/Shaving
•Duration of surgery
•Surgical technique
•Presence of drains
•Inappropriate use of
antimicrobial
prophylaxis

15. Surgical Technique
•Removing devitalized tissue
•Maintaining effective hemostasis
•Gently handling tissues
•Eradicating dead space
•Avoiding inadvertent entries into a
viscus
•Using drains and suture material
appropriately

16. Parameters for Operating
Room Ventilation*
•Temperature: 68
o
-73
o
F, depending on
normal ambient temp
•Relative humidity: 30%-60%
•Air movement: from “clean to less clean”
areas
•Air changes: >15 total per hour
>3 outdoor air per hour
*American Institute of Architects, 1996

17. Practices to prevent SSI are therefore aimed
at :
•minimising the number of microorganisms introduced
into the operative site
• removing microorganisms that normally colonise the skin
• preventing the multiplication of microorganisms at the
operative site, for example by using prophylactic
antimicrobial therapy
• enhancing the patient’s defenses against infection, for
example by minimising tissue damage and maintaining
normothermia
• preventing access of microorganisms into the incision
postoperatively by use of wound dressings.

18. Staphylococcus aureus is the
microorganism most commonly cultured
from SSIs.
Operations on sites that are normally sterile (‘clean’) thus have
relatively low rates of SSI (generally less than 2%), whereas
after operations in ‘contaminated’ or ‘dirty’ sites, rates may
exceed 10%.

19. Obesity :Adipose tissue is poorly vascularized
and is thought to increase the risk of SSI.
Smoking: The wound healing process may be
affected by the vaso-constrictive effects and
reduced oxygen-carrying capacity of blood
associated with smoking cigarettes. Smoking,
duration of smoking and number of cigarettes
smoked are associated with an increased risk of
SSI
Other factors for risk of infection :

20. Most SSIs respond to the removal of sutures with drainage of
pus if present and, occasionally, there is a need for debridement
and open wound care.
Many complications of postoperative wounds do not represent
infection but exudation of tissue fluid or an early failure to heal,
which is common in patients with a high body mass index (BMI).
Incomplete sealing of the wound edges can often be managed
by using a delayed primary or secondary suture or closure with
adhesive tape, but in larger open wounds the granulation tissue
must be healthy with a low bio-burden of colonizing or
contaminating organisms if healing is to occur.
Management of surgical site infection

21. Preoperative showering
Advise patients to shower or have a bath (or help
patients to shower, bath or bed bath) using soap,
either the day before, or on the day of, surgery.
Hair removal
•Do not use hair removal routinely to reduce the
risk of surgical site infection.
•If hair has to be removed, use electric clippers
with a single-use head on the day of surgery. Do
not use razors for hair removal, because they
increase the risk of surgical site infection.


Preoperative phase

22. Preoperative phase…contd.
Patient theatre wear
•Give patients specific theatre wear that is
appropriate for the procedure and clinical
setting and that provides easy access to the
operative site and areas for placing devices,
such as intravenous cannulas.

•Consider also the patient’s comfort and
dignity.

23. Staff theatre wear
•All staff should wear specific non-sterile
theatre wear in all areas where
operations are undertaken.
Staff leaving the operating area
•Staff wearing non-sterile theatre wear
should keep their movements in and out
of the operating area to a minimum.
Hand jewellery, artificial nails and nail
polish
•The operating team should remove hand
jewellery before operations.
•The operating team should remove
artificial nails and nail polish before
operations.
Preoperative phase…contd.

24. Antibiotic prophylaxis
Give antibiotic prophylaxis to patients before:
• clean surgery involving the placement of a prosthesis
or implant
• clean-contaminated surgery
• contaminated surgery.

Do not use antibiotic prophylaxis routinely for clean
non-prosthetic uncomplicated surgery.
•Use the local antibiotic formulary and always
consider potential adverse effects when choosing
specific antibiotics for prophylaxis.
•Consider giving a single dose of antibiotic prophylaxis
intravenously on starting anaesthesia.

25. Antibiotic prophylaxis

Give prophylaxis earlier for operations in which a
tourniquet is used.
Before giving antibiotic prophylaxis, consider the timing
and pharmacokinetics (for example, the serum half-life)
and necessary infusion time of the antibiotic. Give a
repeat dose of antibiotic prophylaxis when the operation
is longer than the half-life of the antibiotic given.
Give antibiotic treatment (in addition to prophylaxis) to
patients having surgery on a dirty or infected wound.
Inform patients before the operation if they will need
antibiotic prophylaxis, and afterwards if they have been
given antibiotics during their operation

26. Intraoperative phase
Hand decontamination
•The operating team should wash their hands prior to
the first operation on the list using an aqueous
antiseptic surgical solution, with a single-use brush or
pick for the nails, and ensure that hands and nails are
visibly clean.
•Before subsequent operations, hands should be
washed using either an alcoholic hand rub or an
antiseptic surgical solution. If hands are soiled then
they should be washed again with an antiseptic
surgical solution.

29. Use of sterile gowns
The operating team should wear sterile gowns in the
operating theatre during the operation.
Gloves
Consider wearing two pairs of sterile gloves when there is
a high risk of glove perforation and the consequences of
contamination may be serious.
Incise drapes
•Do not use non-iodophor-impregnated incise drapes
routinely for surgery as they may increase the risk of
surgical site infection.
•If an incise drape is required, use an iodophor-
impregnated drape unless the patient has an iodine
allergy.

30. Antiseptic skin preparation
Prepare the skin at the surgical site immediately before
incision using an antiseptic (aqueous or alcohol-based)
preparation: povidone-iodine or chlorhexidine are most
suitable.
Diathermy
•If diathermy is to be used, ensure that antiseptic skin
preparations are dried by evaporation and pooling of
alcohol-based preparations is avoided.
•Do not use diathermy for surgical incision to reduce
the risk of surgical site infection.

31. Maintaining patient homeostasis
•Maintain patient temperature
•Maintain optimal oxygenation during surgery. In
particular, give patients sufficient oxygen during major
surgery and in the recovery period to ensure that a
haemoglobin saturation of more than 95% is
maintained.
•Maintain adequate perfusion during surgery

Blood Glucose control
Do not give insulin routinely to patients who do not have
diabetes to optimise blood glucose postoperatively as a
means of reducing the risk of surgical site infection.

32. Wound irrigation and intracavity lavage
•Do not use wound irrigation to reduce the risk of
surgical site infection.
•Do not use intra-cavity lavage to reduce the risk of
surgical site infection.
•Antiseptic and antimicrobial agents before wound
closure
•Do not use intraoperative skin re-disinfection or
topical cefotaxime in abdominal surgery to reduce
the risk of surgical site infection.
Wound dressings
•Cover surgical incisions with an appropriate
interactive dressing at the end of the operation.

33. Postoperative phase
Changing dressings
Use an aseptic non-touch technique for changing or
removing surgical wound dressings.
Postoperative cleansing
•Use sterile saline for wound cleansing up to 48 hours
after surgery.
•Advise patients that they may shower safely 48 hours
after surgery.
•Use tap water for wound cleansing after 48 hours if the
surgical wound has separated or has been surgically
opened to drain pus.
•Topical antimicrobial agents for wound healing by
primary intention

34. Postoperative cleansing

•Do not use topical antimicrobial agents for
surgical wounds that are healing by primary
intention to reduce the risk of surgical site
infection.
•Dressings for wound healing by secondary
intention
•Do not use Eusol and gauze, or moist cotton
gauze or mercuric antiseptic solutions to
manage surgical wounds that are healing by
secondary intention.

35. Use an appropriate interactive dressing to manage
surgical wounds that are healing by secondary
intention.

Antibiotic treatment of surgical site infection
and treatment failure
•When surgical site infection is suspected (i.e.
cellulitis), give the patient an antibiotic that covers
the likely causative organisms.
•Consider local resistance patterns and the results of
microbiological tests in choosing an antibiotic.
Debridement
Do not use Eusol and gauze for debridement in the
management of surgical site infection.

36. PREVENTION
IS PRIMARY!
Protect patients…protect healthcare personnel…
promote quality healthcare!

39. YES WE CAN !!