Author(s): *Richard P. Evans, MD and Terry A Clyburn, MD; University of Arkansas for Medical Sciences, Little Rock, AR
Title: The Infected Orthopedic Surgery: Current Concepts in Surgical Wound Infection Prevention
Purpose: Developed in conjunction with the AAOS Patient Safety Committee and the Center for Disease Control, this presentation provides a method of surgical site infection prevention that is organized into a straightforward method of implementation.
Methods: This information is designed to educate the Fellowship and is conceptually organized from the outside-to-in as it relates to operating room environment, personnel and patient preparation and wound management. Emphasis is placed on the proper environmental controls and the selection, timing and mode of delivery of antibiotics in the changing environment of emerging resistance of infectious agents. Evidence based standards and recommendations of infection prevention were identified, reviewed and ranked. This allowed development of a method of surgical site infection prevention that is organized into an outside-toin system of implementation.
This presentation originally began as an AAOS Infection Committee Scientific Exhibit and has been presented annually at the annual AAOS meeting. It has evolved and this updated presentation has been submitted by the Patient Safety Committee to The AAOS for a third exhibit presentation.
Results: Evidence based standards and recommendations can be categorized into an outside-to-in system of implementation that includes the following:
Operating Room ¡V
Maintaining positive pressure in the conventional operating room > than 15 operating room volumes exchanges per hour.
Consider performing joint replacement in ultra clean air.
Personnel -
Provide personnel with efficacious hand antisepsis/skin care.
Prevent exposed hair/street clothes.
Use body isolation hoods/gowns in laminar flow rooms.
Patient Systemic Environment -
Monitor and maintain normal glycemia and normothermia (above 36 degrees).
Perform proper skin preparation, clipping only if required.
Use appropriate antiseptic and incise drape application.
Use the appropriate antimicrobial and dosing.
Give the initial dose within one hour preceding incision.
Repeat the dose during surgery as needed to maintain blood levels.
Stop prophylactic antimicrobials within 24 hours even with catheters or drains still in place.
Vancomycin should be used to treat known infections, not for routine prophylaxis.
Wound Environment -
Minimize operative time.
Maintain hemostasis.
Gentle handling of tissue.
Eradicate dead space, dead tissue and foreign bodies.
Discussion: Currently in the United States more than 500,000 Surgical Site Infections occur annually at a cost of over five billion dollars. Each of these evidence based practices has been shown to decrease the risk of surgical site infection. Standardizing these techniques and organizing the implementation of each of them into routine outside-to-in practice will decrease the incidence of surgical site infection.
