Preoperative Preparation to Avoid Surgical Site Infections
This round table discussion focuses on Pre-operative factors that affect Surgical Site Infections (SSIs) in multiple patient examples. The risk of infection ranges widely depending on the patient, clinical features and the type of operation being undertaken. Factors relating to SSIs are delineated, discussed and weighed resulting in a treatment plan for several very complicated patients
This round table discussion involves 4 leaders of Surgical Infection Society;
Donald Fry, Kamal Itani, William Cheadle and Philip Barie.
View Preoperative Preparation to Avoid Surgical Site Infections Roundtable
1. Preparation of a Morbidly Obese, Diabetic Patient with a recurrent Abdominal Wall Hernia: Considerations - nfection rates clearly are affected by whether this is an elective versus emergent operation.
2. Is Preoperative Weight Loss a Realistic Hope? What about Panniculectomy with Hernia Repair?
3. Importance of Diabetes Control – the panelists agree that the peri-operative glucose control is the probably the strongest contributor to the risk of SSI.
4.Technical considerations are critical as a hematoma contributes significantly to the risk of SSI. Given this, is it safer to undertake laparoscopic versus open repairs of herniae (primary or recurrent) in the obese patient. Laparoscopic repairs are associated with lower rates of hematoma but higher rates of enterotomies. How to treat an enterotomy during a hernia repair – leave wound open? Does it change the type of mesh used – debate persists regarding the need to use bioprosthetic rather than synthetic mesh.
5. The Underweight Patient – correctable factors, especially nutrition are stressed. A low pre-albumin is a very strong risk for infectious complications. It is noted that as little as five days of enteral nutrition may reduce SSI risks.
6. Skin Flora and Disinfection – it remains important to have effective drug concentration at the time of skin incision. The role of Vancomycin pre-operatively remain controversial with evidence suggesting that even in the ear of MRSA, vancomycin does not decrease the rate of SSI, but rather changes the flora of the SSI. For skin preparation, chlorhexidine-alcohol remains superior to povidone-iodine.
7. Increasing Antimicrobial Resistance – it is concerning that current practices may be creating the next generation of complications, as has been theorized with widespread use of nasal mupirocin for nasal MRSA eradication.
8. Do Patients Perform the Assigned Preparation? And can we improve patient compliance? – The panelists suggest that the use of messaging to mobile phone may increase patient compliance with pre-operative care.
9. Economic Aspects of SSIs. The cost of SSI is rising and re-imbursements may be directly linked to the rates of SSIs. Given the fact that many of the patient factors are beyond the control of the surgeon, there is increasing incentive not to operate on patients who display poor pre-operative compliance, smoking, obesity with no attempt at weight loss, poorly controlled diabetes.
This highly entertaining manuscript has a wealth of information which is included in the patient discussions and reports. This manuscript is targeted to all care providers involved with surgical infections and includes evidence based literature and studies.
This is a must read for the surgical infection community.