Transcript SSIs Risk Factors

1
FASCIAL DEHISCENCE
FASCIAL DEHISCENCE
Fascial disruption is due to abdominal wall
tension overcoming tissue or suture strength,
or knot security. It can occur early or late in
the postoperative period, and involve a
portion of the incision (ie, partial dehiscence)
or the entire incision (ie, complete fascial
dehiscence).
FASCIAL DEHISCENCE
• With early fascial dehiscence, the skin
closure may be intact depending upon the
method of closure (ie, staples, sutures); the
patient, nevertheless, is at risk for
evisceration. Early postoperative fascial
dehiscence is a surgical emergency.
• The late complication of fascial disruption is
incisional hernia.
Risk Factors
Risk Factors
• Technical factors — Fascial dehiscence
may also be related to technique.
• Incisional factors — Tension on an incision
is proportional to its length . Herniation is
more common when the incision length
exceeds 18 cm . It was thought that
longitudinal incisions were at greater risk of
dehiscence than transverse incisions
but..........
Risk Factors
• Suture — The main causes of wound
separation are failure of suture to remain
anchored in the fascia, suture breakage, knot
failure, and excessive stitch interval which
allows protrusion of viscera.
Risk Factors
• In up to 95 percent of abdominal wound
dehiscences, the sutures and knots are
intact, but the suture has pulled through the
fascia. This is usually the result of fascial
necrosis from sutures being placed too close
to the edge or under too much tension.
Risk Factors
• Sutures should be about 1 cm from the
wound edge and about 1 cm from the
adjacent suture to ensure that the tissue is
strong enough to hold the suture.
• For continuous closure, the total length of
the suture should be approximately four
times the length of the incision.
Clinical manifestations and diagnosis
Clinical manifestations and diagnosis
• Signs and symptoms of a complete
dehiscence include profuse serosanguinous
drainage, often preceded by a popping
sensation and an incisional bulge
exacerbated by Valsalva maneuvers.
• Most dehiscences occur 4 to 14 days after
surgery, with a mean of 8 days.
Treatment
Treatment
• When fascial disruption is suspected, wound
exploration should be performed in the
operating room. Complete fascial dehiscence
is associated with a mortality rate of 10
percent, and is a surgical emergency.
Treatment
• At the bedside, a moist dressing is placed
over the wound and a binder can be placed
around the patient's abdomen to prevent
overt evisceration on the way to the
operating room. A binder should not be used
in cases of complete dehiscence and
evisceration due to the potential for bowel
injury.
Treatment
• Once the wound is opened, the edges are
thoroughly debrided.
• A mass closure with continuous, slowly
absorbable suture should be performed .
Depending upon the circumstance, the skin
may or may not be left open.
Prevention
Prevention
●Use of a simple running technique
●Use of #1 or #2 delayed absorbable suture
●Use of mass closure to incorporate all layers of the
abdominal wall (except skin)
●Taking wide tissue bites (about 1 cm)
●Use of a short stitch interval (about 1 cm)
●Use of a suture length to wound length ratio of 4 to 1
●Use of non-strangulating tension on the suture
Prevention
• Continuous mass closure or interrupted
Smead-Jones closure (vertical mattress) with
permanent or delayed absorbable suture are
both safe and effective.
• Most midline closures should be performed
with continuous mass closure supported by
several recent metaanalyses.
SSIs
SSIs
• Surgical wound infections are a common
cause of nosocomial infection. The United
States Centers for Disease Control and
Prevention (CDC) has developed criteria that
define surgical site infection (SSI) as
infection related to an operative procedure
that occurs at or near the surgical incision
within 30 days of the procedure, or within 90
days if prosthetic material is implanted at
surgery.
SSIs Risk Factors
SSIs Risk Factors
Factors that may impact the rate of SSIs (apart from
antimicrobial prophylaxis) include :
●Attention to basic infection control strategies
●Surgical technique
●Prolonged duration of surgery
●Hospital and operating room environments
●Instrument sterilization
●Preoperative preparation (surgical scrub, skin antisepsis)
●Perioperative management (thermoregulation, glycemic
control)
●Underlying medical condition of the patient
SSIs Risk Factors
Several factors related to the surgical environment and
operative practices have been identified as risk factors for
SSI. These include:
●Preoperative hair removal (particularly shaving)
●Inordinate personnel traffic during an operation
●Excessive use of electrosurgical cautery units
●Presence of a prosthesis or other foreign body
●Degree of tissue trauma
●Need for blood transfusion
SSIs Risk Factors
Several other patient characteristics have been identified as risk factors for
SSI, including :
●Age
●Diabetes
●Obesity
●Cigarette smoking
●Immunosuppression
●Malnutrition
●Preoperative colonization with potentially pathogenic microorganisms
●Presence of infection at a nonsurgical site
●Recent surgery
●Duration of preoperative hospitalization
●Severity of underlying illness(es)
Prophylaxis
Prophylaxis
•
Antibiotic prophylaxis should be administered in doses
sufficient to achieve adequate serum and tissue drug levels
for the interval during which the surgical site is open. For
most adults, it is acceptable to dose antimicrobials based on
standardized doses for safety, efficacy, and convenience.
However, the serum and tissue concentrations of some
drugs administered to obese patients may differ from those
in nonobese patients for a number of reasons, including
pharmacokinetic variability related to the lipophilicity of the
administered drug.
Prophylaxis
• Timing — Antimicrobial therapy should be
completely infused 60 minutes prior to
surgical incision, if possible, to optimize
adequate drug tissue levels at the time of
initial incision.
Prophylaxis
•
Administration of vancomycin or a fluoroquinolone should
begin 120 minutes before surgical incision because of the
prolonged infusion times required for these drugs. Some
studies suggest lower infection risk with initiation of
antimicrobial administration within 30 minutes before
surgical incision, although thus far data are insufficient to
support this approach as a routine practice.
•
If the 60-minute window for prophylaxis has passed,
antimicrobial administration 30 to 60 minutes prior to
incision appears to be more effective than administration
immediately before surgical incision.
Prophylaxis
• Repeat dosing — To ensure adequate
antimicrobial serum and tissue
concentrations, repeat intraoperative dosing
is warranted for procedures that exceed two
half-lives of the drug and for procedures in
which there is excessive blood loss (>1500
mL).
Prophylaxis
• Duration — In general, repeat antimicrobial
dosing following wound closure is not
necessary and may increase the risk for
development of antimicrobial resistance .
• For cases in which prophylaxis beyond the
period of surgery is warranted, in general,
the duration should be less than 24 hours .