Transcript What is the wound class?

General & Vascular Surgery
Wound Class Review & Quiz
Bruce Ryon, RN, MS, PhD
KPSF NSQIP SCNR
[email protected]
415-833-0987
Wound Class Review
Defined by the CDC
- Largely related to bacteria presence & activity
Bruce Ryon, RN, MS, PhD
Wound Class Review
Defined by the CDC
- Largely related to bacteria presence & activity
#1 - Clean
- Any incision thru non-infected material NOT in major tracts
Bruce Ryon, RN, MS, PhD
Wound Class Review
Defined by the CDC
- Largely related to bacteria presence & activity
#1 - Clean
- Any incision thru non-infected material NOT in major tracts
#2 - Clean, Contaminated
- Baseline in GI, respiratory, reproductive, urinary tracts
Bruce Ryon, RN, MS, PhD
Wound Class Review
Defined by the CDC
- Largely related to bacteria presence & activity
#1 - Clean
- Any incision thru non-infected material NOT in major tracts
#2 - Clean, Contaminated
- Baseline in GI, respiratory, reproductive, urinary tracts
#3 - Contaminated
- Presence of contained acute inflammation (not chronic)
- Dry, but not wet and active gangrene
- Example: inflamed, non-perforated appendix
Bruce Ryon, RN, MS, PhD
Wound Class Review
Defined by the CDC
- Largely related to bacteria presence & activity
#1 - Clean
- Any incision thru non-infected material NOT in major tracts
#2 - Clean, Contaminated
- Baseline in GI, respiratory, reproductive, urinary tracts
#3 - Contaminated
- Presence of contained inflammation
- Dry, but not wet and active gangrene
- Example: inflamed, non-perforated appendix
#4 – Dirty/Infected
- Incision into infected material
- Spilled purulence or fecal material, wet gangrene
- Example: perforated and inflamed appendix with presence
of purulence outside of appendix
Bruce Ryon, RN, MS, PhD
Wound Class Review
Defined by the CDC
- Largely related to bacteria presence & activity
#1 - Clean
- Any incision thru non-infected material NOT in major tracts
#2 - Clean, Contaminated
- Baseline in GI, respiratory, reproductive, urinary tracts
#3 - Contaminated
- Presence of contained inflammation
- Dry, but not wet and active gangrene
- Example: inflamed, non-perforated appendix
#4 – Dirty/Infected
- Incision into infected material
- Spilled purulence or fecal material, wet gangrene
- Example: perforated and inflamed appendix with presence
of purulence outside of appendix
Bruce Ryon, RN, MS, PhD
Baseline Procedures
& Wound Class
Non-tracts
Tracts
• Orthopedics – 1
• Head & Neck – 2
• Breast – 1
• Thoracic (lung) - 2
• Vascular – 1
• OB/GYN – 2
• Cardiovascular – 1
• Colorectal – 2
• Plastics – 1
• Hepatobiliary – 2
• Hernia - 1
• Urology – 2
Bruce Ryon, RN, MS, PhD
Wound Class Quiz
• 1st Slide – actual KPSF cases
– Scenario explained with choices
– Circulator recording marked by *asterisk
– Think about the baseline of the procedure
– Then think about anything that would
change that baseline
• 2nd Slide
– Shows the answer in multiple asterisks
– Note on key or important criteria
Bruce
Bruce Ryon,
Ryon, RN,
RN, MS,
MS, PhD
PhD
What is the wound class?
A patient under went a Whipple for cancer.
Surgery included a cholecystectomy. Gallbladder
was documented as having changes consistent
with chronic cholecystitis.
1.Clean
2.Clean/contaminated
*3.Contaminated
4.Dirty/Infected
Bruce Ryon, RN, MS, PhD
What is the wound class?
A patient under went a Whipple for cancer.
Surgery included a cholecystectomy. Gallbladder
was documented as having changes consistent
with chronic cholecystitis.
1.Clean
******* 2.Clean/contaminated *******
3.Contaminated
4.Dirty/Infected
Note: Chronic inflammation would not bump it to a 3
Bruce Ryon, RN, MS, PhD
What is the wound class?
An 18 year old patient with extensive Crohns
disease underwent a total colectomy with a
colostomy.
1.Clean
2.Clean/contaminated
*3.Contaminated
4.Dirty/Infected
Bruce Ryon, RN, MS, PhD
What is the wound class?
An 18 year old patient with extensive Crohns
disease underwent a total colectomy with a
colostomy.
1.Clean
******* 2.Clean/contaminated *******
3.Contaminated
4.Dirty/Infected
Note: Chronic inflammation would keep it at a 2 and not bump it to a 3
Bruce Ryon, RN, MS, PhD
What is the wound class?
Patient underwent a breast biopsy. The operative
report noted multiple areas of fatty necrosis on
the large mass. There was also necrotic tissue
around the mass.
1.Clean
2.Clean/contaminated
3.Contaminated
*4.Dirty/Infected
Bruce Ryon, RN, MS, PhD
What is the wound class?
Patient underwent a breast biopsy. The operative
report noted multiple areas of fatty necrosis on
the large mass. There was also necrotic tissue
around the mass.
1.Clean
2.Clean/contaminated
******* 3.Contaminated *******
4.Dirty/Infected
Note: Necrotic, ischemic dead tissue, without infection is a 3
Bruce Ryon, RN, MS, PhD
What is the wound class?
Patient underwent laparoscopic appendectomy.
The pre op CT scan reported the appendix
contained a fecalith. There was no mention of
infection, rupture or inflammation on the operative
report.
1.Clean
2.Clean/contaminated
*3.Contaminated
4.Dirty/Infected
Bruce Ryon, RN, MS, PhD
What is the wound class?
Patient underwent laparoscopic appendectomy.
The preop CT scan reported the appendix
contained a fecalith. There was no mention of
infection, rupture or inflammation on the operative
report.
1.Clean
******* 2.Clean/contaminated *******
3.Contaminated
4.Dirty/Infected
Note: Fecalith contained within GI tract w/o infection, inflammation is a 2
Bruce Ryon, RN, MS, PhD
What is the wound class?
Patient underwent a laparoscopic appendectomy.
The operative report states “inflamed appendix
without perforation”.
*1.Clean
2.Clean/contaminated
3.Contaminated
4.Dirty/Infected
Bruce Ryon, RN, MS, PhD
What is the wound class?
Patient underwent a laparoscopic appendectomy.
The operative report states “inflamed appendix
without perforation”.
1.Clean
2.Clean/contaminated
******* 3.Contaminated ********
4.Dirty/Infected
Note: Acute inflammation is a 3
Bruce Ryon, RN, MS, PhD
What is the wound class?
Patient underwent a laparoscopic appendectomy.
The operative report states “inflamed appendix
without perforation with exudates”.
1.Clean
2.Clean/contaminated
3.Contaminated
*4.Dirty/Infected
Bruce Ryon, RN, MS, PhD
What is the wound class?
Patient underwent a laparoscopic appendectomy.
The operative report states “injected appendix
without perforation with exudates”.
1.Clean
2.Clean/contaminated
******* 3.Contaminated *******
4.Dirty/Infected
Note: Exudates outside of non-perforated injected appendix is a 3
Bruce Ryon, RN, MS, PhD
What is the wound class?
Patient underwent a laparoscopic appendectomy.
The operative report states “acute appendix with
perforation”.
1.Clean
*2.Clean/contaminated
3.Contaminated
4.Dirty/Infected
Bruce Ryon, RN, MS, PhD
What is the wound class?
Patient underwent a laparoscopic appendectomy.
The operative report states “acute appendix with
perforation”.
1.Clean
2.Clean/contaminated
3.Contaminated
******* 4.Dirty/Infected *******
Note: Perforated appendix assumes contents have spilled into abdominal cavity
Bruce Ryon, RN, MS, PhD
What is the wound class?
Patient underwent an exploratory laparoscopic for
possible small bowel obstruction. The procedure
performed was terminal ileum resection. The
operative report states “necrotic cecum and
appendix”.
1.Clean
2.Clean/contaminated
3.Contaminated
* 4.Dirty/Infected
Bruce Ryon, RN, MS, PhD
What is the wound class?
Patient underwent an exploratory laparoscopic for
possible small bowel obstruction. The procedure
performed was a terminal ileum resection. The
operative report states surgeon found a “necrotic
cecum and appendix”.
1.Clean
2.Clean/contaminated
******* 3.Contaminated *******
4.Dirty/Infected
Note: Necrosis, ischemic dead tissue, is generally not infected
Bruce Ryon, RN, MS, PhD
What is the wound class?
With a patient in significant abdominal pain, a
preop CT scan indicated patient had SBO (small
bowl obstruction). An ex-lap was performed and
adhesion lysis freed up a SBO.
1.Clean
*2.Clean/contaminated
3.Contaminated
4.Dirty/Infected
Bruce Ryon, RN, MS, PhD
What is the wound class?
With a patient in significant abdominal pain, a
preop CT scan indicated patient had SBO (small
bowl obstruction). An ex-lap was performed and
adhesion lysis freed up a SBO.
******* 1.Clean *******
2.Clean/contaminated
3.Contaminated
4.Dirty/Infected
Note: Bowel was never incised, therefore surgery is on par with hernia repair
Bruce Ryon, RN, MS, PhD
What is the wound class?
Patient had necrotic foot d/t complications from
peripheral ischemia r/t 150 pack years of smoking.
Surgeon performed below knee amputation where
the incision was clean without infection.
1.Clean
2.Clean/contaminated
3.Contaminated
*4.Dirty/Infected
Bruce Ryon, RN, MS, PhD
What is the wound class?
Patient had necrotic foot d/t complications from
peripheral ischemia r/t 150 pack years of smoking.
Surgeon performed below knee amputation where
the incision was clean without infection.
******* 1.Clean ********
2.Clean/contaminated
3.Contaminated
4.Dirty/Infected
Note: Incision was in a clean area, therefore on par with ortho baseline surgery
Bruce Ryon, RN, MS, PhD
What is the wound class?
Long term diabetic patient had infected
gangrenous below-the-knee-amputation stump
after vascular grafts failed to improve leg
perfusion. Surgeon performed above the knee
amputation where the initial incision expressed
lymphatic pus. AKA surgery successful.
1.Clean
2.Clean/contaminated
*3.Contaminated
4.Dirty/Infected
Bruce Ryon, RN, MS, PhD
What is the wound class?
Long term diabetic patient had infected
gangrenous below-the-knee-amputation stump
after vascular grafts failed to improve leg
perfusion. Surgeon performed above the knee
amputation where the initial incision expressed
lymphatic pus. AKA surgery successful.
1.Clean
2.Clean/contaminated
3.Contaminated
******* 4.Dirty/Infected *******
Note: Incision cut into infected material
Bruce Ryon, RN, MS, PhD
What is the wound class?
Patient underwent a rectopexy procedure (rectal
prolapse) where a portion of the rectum was
resected. The anastamosis was checked for
patency/leaks by rigid sigimoidoscopy.
1.Clean
2.Clean/contaminated
3.Contaminated
*4.Dirty/Infected
Bruce Ryon, RN, MS, PhD
What is the wound class?
Patient underwent a rectopexy procedure (rectal
prolapse) where a portion of the rectum was
resected. The anastamosis was checked for
patency/leaks by rigid sigimoidoscopy.
1.Clean
******* 2.Clean/contaminated *******
3.Contaminated
4.Dirty/Infected
Note: Anal & rectum procedures are 2, unless infection present, e.g. abscess/fistula
Bruce Ryon, RN, MS, PhD