Infection control and surgical wound complications (1) (1)

wound

1. Infection control and surgical wound complications Dr S hambhavi s harma Resident SURGERY PAHS

2. INTRODUCTION Mechanical failure or failure of wound healing at the surgical site can lead to disruption of the closure leading to seroma , hematoma, wound dehiscence, or hernia. Other complications : surgical site infection and nerve injury

3. Surgical wound complications

4. Wound Dehiscence-Burst Abdomen Wound dehiscence is disruption or loss of continuity of a surgically closed layer of skin or fascia. -Evisceration is a frank fascial disruption resulting in exposure of abdominal contents Incidence: 1-3% Mostly develops at 7-10 th post op day

5. Risk factors Wrong suture technique Wound tension ischemia, hematoma, seroma poor nutrition steroids Obesity midline incisions Elevaed IAP Radiation therapy and chemotherapy

6. Clinical diagnosis Salmon-colored serosanguinous fluid in 1st postop week impending dehiscence in 25% cases

7. Prevention Proper Suture technique https://www.slideshare.net/jibranmohsin/european-hernia-society-ehs-2014-guidelines-closure-of-abdominal-wall-incisions-midline-elective?qid=f4cef2b2-9b79-4454-9a66-e2ef0b8f7c8c&v=&b=&from_search=2

8. Treatment Small dehiscence in upper midline 10-12 post op:saline moistened gauze packing of the wound and use of abdominal binder Evisceration: Fluid resuscitation Cover the intestinal contents with sterile gauze

9. Methods of surgical management In operating table:

10. ENTEROCUTANEOUS FISTULA abnormal communication between the bowel lumen and the skin, with drainage of bowel contents to the outside Gastrocutaneous , Enterocutaneous and Colocutaneous fistulas most commonly in patients with Multiple abdominal injuries, multiple surgeries, or a “damage control” abdomen

11. Diagnosis Bowel contents and air bubbles draining into the wound make the clinical diagnosis. may be confirmed by CT scan with oral contrast, a small bowel series with contrast looking for extravasation of contrast into the wound, or sinogram

12. Prevention

13. Treatment Consists of bowel rest, TPN, correction of electrolytes,acid suppression and wound care Octreotide to reduce secretions Low output fistulas heal in weeks to months if no distal obstruction High ouput fistulas > 500ml/day need surgical closure

14. Surgical closure for high output fistula

15. Incisional hernias Risk factors in various incisions

16. Evidence for lap hernia repair

17. Surgical Site Infection CDC defines : A surgical site infection is an infection that occurs after surgery in the part of the body where the surgery took place

18. Make tables Within 30 or 90 days of NHSN procedure Δ Deep soft tissues of the incision such as the fascia and muscle layers Fever (>38°C) Localized pain or tenderness Deep incision that spontaneously dehisces or is opened by the surgeon (or other designated clinician) because of concern for deep SSI  AND  organisms are identified by culture (or non-culture-based microbiologic testing method) performed for clinical diagnosis or treatment ( eg , not surveillance). Presence of at least one clinical feature, in absence of microbiologic testing

19. Classification

20. Superficial Incisional Primary (SIP) – a superficial incisional SSI that is identified in the primary incision in a patient that has had an operation with one or more incisIONS Superficial Incisional Secondary (SIS) – a superficial incisional SSI that is identified in the secondary incision in a patient that has had an operation with more than one incision (for example, donor site incision for CBGB) Date of event occurs within 30 days after any NHSN operative procedure (where day 1 = the procedure date) AND involves only skin and subcutaneous tissue of the incision AND patient has at least one of the following: a. purulent drainage from the superficial incision. b. organism(s) identified from an aseptically-obtained specimen from the superficial incision or subcutaneous tissue by a culture or non-culture based microbiologic testing . c. superficial incision that is deliberately opened by a surgeon, attending physician* or other designee and culture or non-culture based testing of the superficial incision or subcutaneous tissue is not performed AND patient has at least one of the following signs or symptoms: localized pain or tenderness; localized swelling; erythema; or heat.

21. Within 30days or 90 days of NHSN involves deep soft tissues of the incision (for example, fascial and muscle layers) AND patient has at least one of the following: a. purulent drainage from the deep incision b. a deep incision that spontaneously dehisces, or is deliberately opened or aspirated by a surgeon, attending physician* or other designee AND organism(s) identified from the deep soft tissues of the incision by a culture or non-culture AND patient has at least one of the following signs or symptoms: fever (>38°C); localized pain or tenderness. c. an abscess or other evidence of infection involving the deep incision that is detected on gross anatomical or histopathologic or imaging

22. Organ or space SSI Within 30 or 90 days of NHSN procedure Any part of the body deeper than the fascia/muscle layers that was opened or manipulated during the procedure Clinical features for specific organ/space infection Eg : for intra-abdominal infection, at least two of the following Fever (>38°C) Hypotension Nausea, vomiting Abdominal pain or tenderness Elevated transaminases Jaundice Appropriate clinical features specific to the organ/space  AND  at least one of the following: Purulent drainage from a drain placed into the organ/space Organisms identified from culture of fluid or tissue obtained from a superficial incision Abscess or other evidence of infection involving the organ/space detected on gross anatomical exam or histopathologic exam Radiographic imaging findings suggestive of infection

23. SSI burden worldwide About 80 000 hospitalised patients in Europe have at least one HAI on any given day In Europe, SSI are the second most frequent type of HAI (19.6%) – 543 149 (298 167-1 062 673) SSI episodes/year (HAI prevalence survey 2011) In the US, the overall SSI rate was 0.9% in 2014 (data from 3654 hospitals over 2 417 933 surgical procedures) SSI are the most frequent type of HAI on admission (67% in US, 33% in Europe) Surgical sepsis accounts for approximately 30% of all septic patients

24. Risk Factors for SSI: The Patient Age Nutritional status Diabetes Nicotine use Obesity Coexistent infection Colonization Altered immune response Long preoperative stay

25. Pre- and Intraoperative Inappropriate use of antimicrobial prophylaxis Infection at remote site not treated prior to surgery Shaving the site vs. clipping Long duration of surgery Improper skin preparation Improper surgical team hand antisepsis Environment of the room (ventilation, sterilization) Surgical attire and drapes Asepsis 

26. Surgical technique : hemostasis , sterile field Selected Surgical Procedures • Cardiac • Coronary Artery Bypass Graft (CABG) • Colon • Hip & Knee Arthroplasty • Abdominal & Vaginal Hysterectomy • Vascular Surgery: – Aneurysm repair – Thromboendarterectomy – Vein Bypass

27. Early vs late SSI Primary vs secondary SSI

28. Important Definitions: Colonization – Bacteria present in a wound with no signs or symptoms of systemic inflammation – Usually less than 105 cfu / mL Contamination – Transient exposure of a wound to bacteria – Varying concentrations of bacteria possible – Time of exposure suggested to be < 6 hours – SSI prophylaxis best strategy

29. Infection prevention Source control Antibiotic prophylaxis

30. CDC GUIDELINES (2017) Administer preoperative antimicrobial agents only when indicated Timely administration so that a bactericidal concentration is established in serum and tissues when the incision is made (strong recommendation; accepted practice)

31. WHO guidelines (2016) administration of SAP within 120 min before incision, while considering the half-life of the antibiotic Preoperative oral antibiotics should be combined with mechanical bowel preparation to reduce the risk of SSI in adult patients undergoing elective colorectal surgery.

32. In clean and clean-contaminated procedures, do not administer additional prophylactic antimicrobial agent doses after the surgical incision is closed in the operating room (OR), even in the presence of a drain Do not apply antimicrobial agents ( ie , ointments, solutions, or powders) to the surgical incision

33. Advise patients to shower or bathe the full body with either antimicrobial or nonantimicrobial soap or an antiseptic agent on at least the night before the day of the procedure Hair should either not be removed or, if absolutely necessary, should be removed only with a clipper or a depilator Decolonization (WHO guidelines)

34. Alcohol-based antiseptic solutions are recommended based on CHG for surgical site skin preparation in patients undergoing surgical procedures Int J Surg.  2017 Aug;44:176-184. doi : 10.1016/j.ijsu.2017.06.001. Epub 2017 Jun 3. Preoperative chlorhexidine versus povidone -iodine antisepsis for preventing surgical  siteinfection : A meta-analysis and trial sequential analysis of randomized controlled trials. Conclusion: CH should be more preferentially recommended for preoperative skin preparation as compared with PVI in clean and clean-contaminated surgery.

35. Surgical hand preparation should be performed by scrubbing with either a suitable antimicrobial soap and water or using a suitable alcohol-based handrub before using sterile gloves. soap and water are more effective against Cryptosporidium ,  norovirus , and  Clostridium difficile  

36. Operating room Limiting traffic though operating room Laminar flow

37. Surgical technique (WHO Guidelines) Consider the use of triclosan -coated sutures Consider intraoperative irrigation of deep or subcutaneous tissues with aqueous iodophor solution Intraperitoneal lavage with aqueous iodophor solution not necessary in contaminated or dirty abdominal procedures

38. Other techniques: Lessen the use of electrocautery devices ( decrease nidus for bacterial contamination)

39. Surgical attire and barrier devices SCRUBS : ( uptodate ) GLOVES: The use of plastic adhesive drapes with or without antimicrobial properties is not necessary ( WHO)

40. ERAS PROTOCOL in preventing SSI

41. recommendation (add a journal)

42. WHO GUIDELINES Implement perioperative glycemic control, and use blood glucose target levels lower than 200 mg/ dL in patients with and without diabetes Maintain perioperative normothermia For patients with normal PFT undergoing GA , employ an increased ( FiO   2 80% ) during the surgical procedure and after extubation in the immediate postoperative period (2-6hours)

43. Negative pressure therapy in surgical closure Studies by Stannard et al (2006) and Atkins et al (2009) highlighted benefits of the therapy in relation to wound NPWT can help to remove some of the fluid and debris that builds up in the wound. Grauhan eal (2013) hypothesised that people with high BMI scores who are undergoing cardiac surgery experience infections due to the tension on the sutures, allowing some skin flora to travel into the wound, and that NPWT has the potential to keep bacteria on the skin from entering the wound.