Transcript Webinar 4: Checklist Modification/Customization

Surgical Site Infections:
The Foundation
What Are We Doing Together
Over the Next Two Months
• Talk about ways to prevent surgical site
infections and venous thromboembolism in
surgical patients.
• Webinars every two-weeks where we will
discuss methods that appear in the literature
and that are “low-hanging fruit”.
• The topics that we discuss are things that:
– will make the most difference to your patients
– have clear evidence
– are things that you can put into place in your ORs
We Will Not Go Into Step-By
Step Instructions On How To
Put These Methods Into Place
Today’s Topics
•
•
•
•
•
Brief History of Infection Prevention Techniques
Prophylactic Antibiotic Administration
Weight Based Dosing
Re-dosing
Discontinuing Antibiotics
Common Sense Science
• Bacteria cause infection
• Bacteria are everywhere
• It is a battle against the bacteria
Brief History of Infection
Prevention
Ignaz Semmelweiss
Louis Pasteur
Joseph Lister
Surgery – 1969
Postoperative Wound Infection:
A Prospective Study of Determinant
Factors and Prevention
Polk HC Jr, Lopez-Mayor JF
Surgical Technique, Prophylactic
Antibiotics and SSI
Polk. Surgery 1969;66:97-103
Different Ways of Preventing
SSI’s
•
•
•
•
•
•
•
•
•
Pre-operative screenings
Proper Hair Removal
Skin Prep
Hair Prep
Hand Hygiene
Prophylactic Antibiotics
Surgical Technique
Glucose Control
Hyperoxia
•
•
•
•
•
OR Traffic
Bowel Prep
Temperature Control
Transfusion
Maintenance of
hemostasis and perfusion
• Wound Protectors
• Communication
• Teamwork
Preventing SSI’s
Pre-Incision
•
Patient
•
•
Glucose Control
Hyperoxia
•
•
Basics of Skin
Prep
• Showers
• Skin Wipes
Hair Removal
Weight Based
Dosing
MRSA Screening
Glucose Control
•
•
Antibiotic
Bowel Prep
•
•
•
•
•
Re-dosing
Operating Time
Use of Tourniquet
Surgical Technique
Wound protectors
•
•
•
•
Basics of Sterility
Instrument Sterility
Hand Hygiene
Temperature
Control
Teamwork
Culture
•
•
•
•
•
•
•
Basics of Sterility
Instrument Sterility
Hand Hygiene
OR Traffic
Temperature Control
Teamwork
Culture
•
•
Operation
Environment
Incision/Surgery
•
•
Post Op
•
•
Wound care
Dressings
•
Discontinue
antibiotics
Teamwork
Culture
•
•
Rates of Surgical Site Infection and
Benefit From Prophylactic Antibiotics
Operation
Antibiotic
Yes
Antibiotic
No
Colon
4-12%
24-48%
Number Needed
to Treat
3-5
4-9
Other (mixed) GI
4-6%
15-29%
Vascular
1- 4%
7-17%
Cardiac
3-9%
44-49%
2-3
Hysterectomy
1-16%
18-38%
3-6
Craniotomy
0.5-3%
4-12%
9-29
Spinal Operation
2.2%
5.9%
27
Total Joint
Replacement
0.5-1%
2-9%
Breast & Hernia
Operation
3.5%
5.2%
10-17
12-100
58
Dellinger, Patchen 2013. Hospital Engagement Network
Common Sense Science:
Timing of Antibiotics
• In order for antibiotics to be effective they
need to be in the tissue at the time that the
incision is made.
• It can take more time to reach some
tissues than others.
• Antibiotics can’t get to tissue that has no
blood flow.
Perioperative Prophylactic
Antibiotics
14/369
Timing of Administration
Infections (%)
15/441
1/41
1/47
1/81
2/180
5/699
5/1009
Hours From Incision
Classen. NEJM. 1992;328:281.
Common Sense Science:
Weight Based Dosing
• Larger patients have more tissue and
larger blood volumes.
• Standard antibiotics doses given to larger
patients will result in lower blood and
tissue levels of antibiotics.
• The dose of prophylactic antibiotic should
be adjusted for larger patients.
Obesity Map
Prophylactic Antibiotics:
Size of Patient and Size of Dose
• Morbidly obese patients having bariatric surgery
have higher infection rates.
• Cefazolin levels are lower in obese patients than
in non-obese patients at same dose.
• Cefazolin dose changed from 1 g to 2 g:
– Infection rate at 1g: 16.5%
– Infection rate at 2g: 5.6%
Forse RA. Surgery 1989;106:750
Ancef
• Pediatric Dosing:
– 25 – 50 mg/kg/day divided into three doses
•
•
•
•
70kg x 50 = 3500
3500/3 = ~1000 or 1 gram
100kg x 50 = 5000
5000/3 = ~ 1700 or 2 grams
Recommended Adult Dosing
• < 80 kg -------- 1 gram
• > 80 kg -------- 2 grams
Common Sense Science:
Antibiotic Re-dosing
• The blood level of all antibiotics decreases
with time.
• When the level falls enough, the infections
“fighting power” of the antibiotic is no
longer effective.
• A second [or third] dose of antibiotics
should be given to prevent surgical site
infection.
Results When You Re-Dose
Antibiotics
How Long Between Re-Dosing?
• It turns out that if antibiotics are re-dosed
they can remain clinically effective.
• There is probably some variability in this
[different surgical procedures can change
drug metabolism].
• Other factors can decrease this interval.
Common Sense Science:
Discontinuing Prophylactic
Antibiotics
• The primary effect of giving antibiotics during
surgery comes from the initial dose given
before the incision and additional doses given
while the incision is open.
• That is when most of the bacteria
contamination occurs.
• Additional doses of antibiotics given after the
wound is closed have minimal or no effect on
the development of surgical site infections.
Antibiotic Resistance is a Big
Problem
NEJM: Pallares et al. Vol. 333:474-480.
Staphylococcus Aureus
Emerging Infectious Diseases: Vol.7 No. 2. Chambers, H.F.
Vancomycin
Take Home Messages
• This is hard.
• The GREATER GOOD.
• My patient.
Questions
Upcoming Calls
• Thursday, May 16th 2:00-2:45: The Impact
of Communication, Teamwork, and
Culture on SSI’s.
• Thursday, May 30th 2:00-2:45: Preventing
SSI’s When Preparing Our Patients for
Surgery
Office Hours:
Wednesday 2:00-3:00
Resources
Website:
www.safesurgery2015.org
Email:
[email protected]