The anesthesiologists role in the prevention of surgical site infections

1
The anesthesiologists role in the prevention of
surgical site infections

• William J. Mauermann,M.D., Edward C. Nemergut,
  M.D.
• Anesthesiology 2006 105413-21
• R4 ???

2

• Surgical site infections (SSIs)
• Source of morbidity and mortality
• 17 of all hospital-acquired infections
• Longer hospital stay
• Increased mortality
• Increased healthcare cost

3

• Prevention of SSI
• Sterile surgical technique
• Euthermia
• Hyperoxia
• Euvolemia
• Normoglycemia
• No transfusion
• Antimicrobial prophylaxia

4

• Hypothermia
• Mild perioperative hypothermia 34-36C
• increased duration of hospitalization
• increased intraoperative blood loss and
  transfusion requirements
• Increased adverse cardiac events
• An increase in patient thermal discomfort in the
  recovery
• SSI

5

• Kurz A
• Hypothermic group
• Incidence of SSI 18.8
• Longer hospital stay
• Vasoconstriction
• Increased blood requirments

6

• Flores-Maldonado et
• The average temperature in their hypothermic
  group was 35.4 -0.4C versus 36.2 -0.2C in
  the normothermic group
• The incidence of SSI was 11.5 in the hypothermic
  group and 2 in the normothermic

7

• The major relation between hypothermia and
  increased SSI is thought to be a decrease in
  subcutaneous tissue perfusion mediated by
  vasoconstriction

8

• Hypothermia
• decrease wound perfusion and oxygen supply
• reduces the production of superoxide radicals for
  any given oxygen tension
• reduced bacterial killing by neutrophils
• induces an antiinflammatory T-cell cytokine
  profile with increased levels in interleukin 10
  and decreased levels of interleukin 2
• increases nitrogen losses and decreases collagen
  production

9

• Hyperoxia
• oxygen delivery depends on the amount of oxygen
  bound to hemoglobin than the amount of oxygen
  dissolved in the blood
• the mean extracellular partial pressure of oxygen
  in the subcutaneous tissue is around 60 mmHg
• wound oxygen tension
• oxygen radical production by neutrophils
• development of collagen and epithelium

10

• Belda FJ
• Supplemental perioperative oxygen and the risk of
  surgical wound infection A randomized controlled
  trial. Greif R
• Significant reductions in the rates of SSIs in
  the 0.8 fraction of inspired oxygen (FIO2) group
  versus the 0.3 FIO2 group

11

• Pryor et al.
• 160 patients undergoing major abdominal surgery ?
  35 inspired oxygen or 80 inspired oxygen
• high-inspired oxygen levels in the perioperative
  period ? reducing the incidence of SSIs

12

• Perioperative Fluid Management
• euvolemia
• replace fasting deficits, third space losses, and
  blood loss
• Maintain adequate cardiac output, blood pressure,
  and urine output
• adequate perfusion
• wound healing
• prevention of infection

13

• Lang et al.
• using hydroxyethyl starch intraoperatively and
  postoperatively
• increase in tissue oxygen tension of 54

14
(No Transcript)
15

• Hyperglycemia
• Serum sugar lt 110 mg/dl decreased mortality rate
  from 8.0 to 4.6
• Reduce the incidence of multi-organ system
  failure with sepsis
• A continuous insulin infusion in diabetic
  patients undergoing cardiac surgery
• 66 reduction in deep sternal wound infection

16

• Functional deficits in neutrophils of diabetic
  patients
• Impaired chemotaxis
• Decreased phagocytic ability
• Lower bactericidal capacity
• aggressive treatment of hyperglycemia becomes an
  established standard approximately 200 mg/dl

17

• Blood Transfusion and the Risk of
• Infection
• Transfusion of blood products induce the risk of
  postoperative infection
• allogenic gt autologous no transfusion

18

• Antimicrobial Prophylaxis
• The goal of perioperative antibiotic
  administration
• obtain blood and tissue drug levels
• The National Surgical Infection Prevention
  Project
• Timing
• Choice of antibiotic
• beta-lactam-allergic patients

19

• Timing
• The first clinical trial in 1969
• the most effective time period for administration
  was 1 h before incision
• Current recommendations
• begin within 60 min of incision

20

• Choice of Antibiotic
• Prophylaxis should not be administered with the
  goal of covering all possible pathogens
• the most common pathogens will be skin flora
  microbes
• Streptococcus and Staphylococcus species
• first-generation cephalosporin, ex cefazolin

21

• the bowel ? gram-negative ?anaerobic coverage
• cefoxitin and cefotetan
• vancomycin
• the cluster of MRSA

22

• beta-LactamAllergic Patients
• beta-lactam allergies
• 5 to 20
• early trials of cephalosporins revealed
  cross-reactivity
• Rate of anaphyaxis 8

23

• The end !