ssi evidence – a surgeon’s perspective
DESCRIPTION
SSI Evidence – a Surgeon’s Perspective. E. Patchen Dellinger, MD University of Washington. Caring for the Critically Ill Patient. ABC= airway, breathing, circulation. Preventing Surgical Site Infections (SSI). ABC= airway, breathing, circulation = temperature, oxygen, fluids - PowerPoint PPT PresentationTRANSCRIPT
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SSI Evidence–
a Surgeon’s Perspective
E. Patchen Dellinger, MDUniversity of Washington
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Caring for theCritically Ill Patient
ABC = airway, breathing, circulation
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Preventing Surgical Site Infections (SSI)
ABC = airway, breathing, circulation
= temperature, oxygen, fluidsABCD - Add drugs (antibiotics)
Add - glucose controlproper hair removalsurgical techniqueteamworkother ??
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Prophylactic AntibioticsQuestions
• Which cases benefit?• Which drug should you use?• When should you start?• How much should you give?• How long should antibiotics be
continued?
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Relative Benefit from Antibiotic Surgical Prophylaxis
Operation Prophylaxis (%) Placebo (%) NNT*Colon 4-12 24-48 3-5Other (mixed) GI 4-6 15-29 4-9Vascular 1- 4 7-17 10-17Cardiac 3-9 44-49 2-3Hysterectomy 1-16 18-38 3-6Craniotomy 0.5-3 4-12 9-29Spinal operation 2.2 5.9 27Total joint repl 0.5-1 2-9 12-100Brst & hernia ops 3.5 5.2 58
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Antibiotic ProphylaxisDemonstrated Benefit: All Procedures??
• Review of prophylaxis meta-analyses suggests that there is a consistent relative risk of wound infection less than one associated with antibiotic prophylaxis.
• This is independent of the type of operation or the baseline (placebo) rate of infection.
Bowater. Ann Surg 2009;249: 551–556
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Prophylactic AntibioticsQuestions
• Which cases benefit?• Which drug should you use?• When should you start?• How much should you give?• How long should antibiotics be
continued?
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Surgical Antibiotic ProphylaxisMy Choices
Bacteroides expectedCefazolin 2 g + Metronidazole 1g, IV
in ORRepeat cefazolin q 3 h during
procedureBacteroides not expected
Cefazolin 2 g, IV in ORRepeat q 3 h during procedure
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AlternativesCefazolin
Other first generation cephalosporinCefuroxime, cefamandole, cefonicidOxacillin, etc
Cefazolin plus metronidazoleErtapenemAminoglycoside or quinolone plus
clindamycin or metronidazole
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Prophylactic AntibioticsQuestions
Which cases benefit?Which drug should you use?When should you start?How much should you give?How long should antibiotics
be continued?
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Burke. In: Hunt, ed. Wound Healing and Wound Infection, New York: Appleton, 1980:242.
Decisive Period For Development Of Wound Infection
Lesion Age (hrs)
Lesio
n Si
ze, (
mm
)
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Efficacy Of Prophylaxis Is Independent Of The Specific Antibiotic
Age of Lesion at Antibiotic Injection (Hours)
Lesi
on S
ize,
mm
(24
Hou
rs)
0
5
10
Penicillin, 40,000 U
Staph + PenicillinControl
Chloramphenicol, 0.1 mg/Kg
Erythromycin, 0.1 mg/Kg
Tetracycline, 0.1 mg/Kg
0 2 4 6-2 0 2 4 6-2
0
5
10
0
5
10
0
5
10
Control Control
ControlStaph + Erythromycin
Staph + TetracyclineStaph + Chloramphenicol
Burke JF. Surgery. 1961;50:161.
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0
1
2
3
4
≤-3 -2 -1 0 1 2 3 4 ≥5
Classen. NEJM. 1992;328:281.
Perioperative Prophylactic Antibiotics
Timing of AdministrationIn
fect
ions
(%)
Hours From Incision
14/369
5/6995/10092/180
1/81
1/411/47
15/441
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Prophylactic AntibioticsTiming - Cefazolin
Serum Levels (mg/L)On Call Anesth
Incision 87 1481 hour 37 572 hours 25 39
DiPiro. Arch Surg 1985;120:829
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Prophylactic AntibioticsTiming – Cefazolin
IncisionWound closureNo Drug Dectectable
97
38%
1711
14%
On Call Anesth
Muscle Levels
DiPiro JT et al. Arch Surg. 1985;120:829-832.
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Prophylactic AntibioticsAdministration in the O.R.
Drugs Given I.V. Push over 5-10 Min
CefazolinDrug to incision 17 (7-29) minMuscle levels 76 (9-245) mg/kg
CefoxitinDrug to incision 22 (14-27) minMuscle levels 24 (13-45) mg/kg
DiPiro. Arch Surg 1985;120:829DiPiro. Personal Communication
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Timing of Prophylactic Antibiotic Administration – Cardiac, Arthroplasty,
Hysterectomy
Steinberg. TRAPE. Ann Surg 2009; 250:10
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Repeat Antibiotic Prophylaxis Doses in Gastrointestinal Procedures
01234567
Cefaz x 1 Cefaz x 2 Cefotetan
< 3 hr> 3 hr
Surgical Site Infections
Per
cent
Scher. Am Surg 1997;63:59
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Prophylactic AntibioticsQuestions
• Which cases benefit?• Which drug should you use?• When should you start?• How much should you give?• How long should antibiotics be
continued?
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Cardiac Surgery ProphylaxisEffect of Serum Levels
None
Present
3/11
2/175
Serum Levelat Wound Closure Infection
Goldmann. J Thorac Cardiovasc Surg. 1977;73:470-479.
P = .002
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Cardiac Surgery ProphylaxisEffect of Atrial Appendage Levels
YesNo
613
InfectedCephalothin (mg/l)
Platt. Ann Intern Med. 1984;101:770-774.
P = .02
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Prophylactic AntibioticsSize of Patient and Size of Dose
• Morbidly obese patients having bariatric operation with a high infection rate
• Cefazolin levels lower than in non-obese patients at same dose
• Cefazolin dose changed from 1 g to 2 gInfection rate at 1g: 16.5%Infection rate at 2g: 5.6%
Forse RA. Surgery 1989;106:750
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Gentamicin Levels andSSI Risk for Colectomy
Closing Gent level (mg/L) D.M. (%) Stoma (%) Age
SSI 1.3+1.0 29 50 59+14
No SSI 2.1+0.9 2 24 55+19
p 0.02 0.02 0.04 0.05
Gent level < 0.5 at close had 80% SSI rate (p=0.003).
Zelenitsky. Antimicrob Ag Chemother 2002;46:3026-30
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Dose of Antibiotic for Prophylaxis
• Always give at least a full therapeutic dose of antibiotic.
• Consider the upper range of doses for large patients and/or long operations.
• Repeat doses for long operations.
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New ASHP / IDSA / SHEA / SIS Antibiotic Prophylaxis
Guidelines
Cefazolin< 80 kg 2 g> 120 kg 3 g
Vancomycin 15 mg/kg
Gentamicin 5 mg/kgdosing wgt = ideal wgt + 40% of excess wgt
Bratzler. Surgical Infections2013;14:73-156
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Prophylactic AntibioticsQuestions
• Which cases benefit?• Which drug should you use?• When should you start?• How much should you give?• How long should antibiotics
be continued?
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Antibiotic ProphylaxisDuration
Most studies have confirmed efficacy of
12 hrs.Many studies have shown efficacy of a
single dose.Whenever compared, the shorter
course has been as effective as the longer course.
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Duration of ProphylaxisColorectal
Author Drug Duration InfectionTörnqvist 1981doxycycline 1 dose 10%
3 days 19%Juul 1987 amp/metronid 1 dose 6%
3 days 6%
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Duration of ProphylaxisJoint Replacement
Author Drug Duration InfectionPollard 1979 cephaloridine 12 hours 1.4%
(hips) flucloxacillin 14 days 1.3%
Heydemann 1986 cefazolin 1 dose 0(hips and knees) 24 hours 1%
48 hours 0 7 days 1.5%
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Duration of Prophylaxis:Infection and Antibiotic Resistance
Risk in Cardiac Surgery< 48 hr >48 hr OddsShort LongRatio
Number 1502 1139SSI 131 (8.7%) 100(8.8%) 1.0 (0.8-1.3)Acq Ab Res 6% 1.6 (1.1-2.6)
Harbarth. Circulation 2000;101:2916
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Single vs Multiple Dose Surgical Prophylaxis: Systematic Review
0.01
0.1
1
10
100
McDonald. Aust NZ J Surg 1998;68:388
All
stud
ies,
fixe
dA
ll st
udie
s, ra
ndom
Mul
ti >
24h
Mul
ti <
24h
Favo
rs s
ingl
e do
seFa
vors
mul
tiple
dos
e
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Relative Benefit from Antibiotic Surgical Prophylaxis
Operation Prophylaxis (%) Placebo (%) NNT*
Colon 4-12 24-48 3-5Other (mixed) GI 4-6 15-29 4-9Vascular 1-4 7-17 10-17Cardiac 3-9 44-49 2-3Hysterectomy 1-16 18-38 3-6Craniotomy 0.5-3 4-12 9-29Spinal operation 2.2 5.9 27Total joint repl 0.5-1 2-9 12-100Brst & hernia ops 3.5 5.2 58
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When I started my residency in 1970 all
patients having colectomy got a bowel prep
as inpatients before their operation, and we
had just seen the first widely believed paper
that demonstrated a beneficial effect of
parenteral prophylactic antibiotics for
patients having GI operations. Oral
antibiotics were not used.
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Effect of Mechanical Bowel Prep on Colon Flora (log 10)
Coliforms Bacteroides Clostridia
No Prep 4.5 – 7.5 7.9 – 9.5 1.8 – 3.6
Prep 3.0 – 4.3 7.8 – 9.0 0.7 – 2.5
Nichols. Dis Col & Rect 1971; 14: 123-7
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Antibiotic and Mechanical Bowel Prep for Colectomy (48 hrs)
Any SSI
Placebo (63) 27 (43%)
Neomycin (68) 28 (41%)
Neo + Tetracycline (65) 3 (5%)
p<0.01
Washington. Ann Surg 1974;180:567-71
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Antibiotic and Mechanical Bowel Prep for Colectomy (18
hrs)Any SSI
Placebo (56) 26 (43%)
Neo + Erythro (56) 5 (9%)p=0.0001
Clarke. Ann Surg 1977; 186:251-9
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Antibiotic and Mechanical Bowel Prep for Colectomy (48 hrs)
Any SSIPlacebo (59) 25 (42%)
Neo + Metronidazole (51) 9 (18%)p<0.01
Matheson. Br J Surg 1978; 65:597-600
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Antibiotic and Mechanical Bowel Prep for Colectomy (48 hrs)
Any SSIPlacebo (39) 16 (41%)
Kanamycin + Erythro (38) 3 (8%)p<0.001
Wapnick. Surgery 1979; 85:317-21
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Antibiotic and Mechanical Bowel Prep for Colectomy (18 - 48 hrs)
Bowel Prep + Placebo Oral Ab197443% 5%197743% 9%197842% 18%197941% 8%
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Sometime in the 1980’s most American and Canadian surgeons adopted oral antibiotic regimens while most European surgeons abandoned oral antibiotics.
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Parenteral Alone vs Parenteral and Oral Antibiotics – All with Bowel
Prep for Colectomy
Lewis. Can J Surg 2002; 45: 173-80
Parenteral only
Parenteral + Oral
p < 0.002
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Parenteral Alone vs Parenteral and Oral Antibiotics – All with Bowel Prep
for Colectomy – Meta-Analysis
Lewis. Can J Surg 2002; 45: 173-80
Parenteral only
Parenteral + Oral
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MBP – yes / no?Antibiotics – oral / I.V. / both?
Guenaga. Cochrane Database Syst Rev,2009(1):p.C001544Nelson. Cochrane Database Syst Rev, 2009,(1): p.CD001181
SS
I Rat
e
N G
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Bowel Preparation Prior to Elective Colectomy in Michigan (n=1648)
Overall SSI Rate in Michigan is 8.0%
Englesbe. Ann Surg 2010;252: 514–520
All patientsGet I.V. antibiotics
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Surgical Site Infection Rates following Elective Colectomy
The Michigan Surgical Quality Collaborative
Propensity Matched Analysis(n=740)
Englesbe. Ann Surg 2010;252: 514–520
n=195
All patientsGet I.V. antibiotics
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0%
5%
10%
15%
C.difficile colitis Prolonged Ileus
No Oral Antibiotics
Oral Antibiotics
Per
cent
of p
atie
nts
* P < 0.05
Oral Antibiotics with a Bowel Preparation A Propensity Matched Analysis (n=740)
Englesbe. Ann Surg 2010;252: 514–520
All patientsGet I.V. antibiotics
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“Evidence Based” Bundle to Prevent SSI in Colorectal Surgery
Process Measure Study ControlMechanical Bowel Prep No Yes
Oral Antibiotics No YesPreOp Warming Yes No
IntraOp Warming Yes YesFiO2 80% 30%
Wound Protector Yes NoSCIP Parenteral Antibiotics Yes Yes
Any SSI* 45% 24%
Anthony. Arch Surg 2010; 146: 263-9
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“Evidence Based” Bundle to Prevent SSI in Colorectal
Surgery1. Appropriate SCIP IV prophylactic
antibiotics2. Postop normothermia (T>98.6/37)3. Oral antibiotics and bowel prep4. Minimally invasive surgery5. Short operative duration (<100 min)
Waits (MSQC). Surgery 2014;epub
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“Evidence Based” Bundle to Prevent SSI in Colorectal
Surgery
Waits (MSQC). Surgery 2014;epub
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Oral Antibiotics Without Bowel Prep?
VASQIP, 9940 patients, 112 hospitalsIncidence SSI
Bowel prep, no oral Ab 39% 20%No prep at all, no oral Ab 20% 18%Bowel prep + oral Ab 34% 9%No prep + oral Ab (n=723) 7% 8%
Cannon. Dis Col Rectum 2012; 55: 1160-6
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Oral Antibiotics for Colorectal Operations
Cannon. Dis Col Rectum 2012; 55: 1160-6
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Differential Parenteral Efficacyand Addition of Oral
AntibioticsAgent Odds Ratio RangeCefaz/Metron 1.0 ReferenceAmp/Sulbactam 2.16 1.35 - 3.58Cefotetan 2.53 1.51 - 4.22Cefoxitin 2.56 1.73 - 3.81Add Oral Ab* 0.37 0.29 - 0.46
Deierhoi. JACS 2013; 217:763-9*P < 0.0001
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Most Recent Cochrane Review
Comparison Odds Ratio Range
Ab Proph vs none 0.34 0.28 – 0.41
Oral + I.V. vs I.V. 0.56 0.43 – 0.74
Oral + I.V. vs Oral 0.56 0.40 – 0.76Greater than 2300 pts in each comparison
GRADE evidence quality HIGHNelson RL, Cochrane Rev 2014; #5: CD001181
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Conclusions - ?• If you are not going to give any oral
antibiotics then the MBP is not necessary and there is a suggestion of harm along with more GI symptoms.
• However, if you are going to take my colon out I will suffer through the bowel prep and take oral antibiotics in advance of the operation for the lowest SSI rate!
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Oxygen and SSI
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Hunt. Am J Med. 1981;70:712.
Influence of Oxygen on the Development of Wound Infection
Hours After Innoculation
Diam
eter
Infe
ctio
us
Necr
osis
(mm
)
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Wound Oxygen Tension & SSI
-15%-10%-5%0%5%
10%15%20%25%
40-4
9
50-5
9
60-6
9
70-7
9
80-8
9
90-1
29
Obs
erve
d-Ex
pect
ed S
SI R
ate
Maximum wound pO2
Hopf. Arch Surg 1997;132:997
3324
19 15
25
14
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Near InfraRed O2 Saturation inthe Surgical Incision at 12 hrs
Ives. Br J Surg 2007;94:87-91
p < 0.04
Abdominal Operations
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Oxygen and SSI• Oxygen tension in the wound
is important.
• How to translate that into clinical practice that lowers SSI is less obvious.
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Temperature and SSI
(Oxygen)
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Temperature and Tissue O2 tension
• Subcut temp increase 4° C• Subcut O2 tension increase 40 torr• Linear correlation between
temperature and O2 tension• Threefold increase in local perfusion
Rabkin. Arch Surg 1987;122:221
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Temperature and SSI Following Colectomy
Normo (104) Hypo (96) PSSI 6 18 .009
Kurz. NEJM 1996;334:1209
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Local Warming and SSI after Clean Operations
Local Systemic ControlSSI* 5 (4%)8 (6%)19 (14%)Post-op antibiotics* 9 (7%)9 (7%)22 (16%)
Melling. Lancet 2001;358:876* p < 0.01
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Perioperative Warming, Intraoperative Temperature and Complications
----
Open Abdominal Bowel Resections
Wong. Br J Surgery 2007; 94: 423-6
PeriopN=47
StandardN=56 P value
Blood loss 200 ml 400 ml 0.011
Any complication 32% 54% 0.027
SSI 13% 33% 0.09
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Redistribution Hypothermia
Core37°C
Vasoconstricted
Periphery31-35°C
Anesthesia
Periphery33-35°C
Core36°C
Vasodilated
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Keeping Your Patient Warm in the O.R.
• Prewarming and active warming in the O.R. is much more important than the O.R. room temperature.
• If you raise O.R. room temperature from 20o to 27o, you still have an 10o gradient between the patient’s temperature and the room temperature and everyone in the room is miserable.
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Prewarming at UWMC &First Postoperative TemperaturePost Anesthesia Care Unit (PACU) 2006
> 36o 7836/8132 (96.4%)
> 36o & < 36.5o 1047/2647 (40%)
> 36.5o1491/2647 (56%)
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Oxygen (FiO2)
and SSI
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Spinal Surgery, FiO2, & SSI
Maragakis. Anesthesiol 2009; 110:556-62
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Meta-Analysis: FiO2 & SSI
Qadan. O2 & SSI.Review. Arch Surg 2009; 144:359-66
Mayzler
Pryor
Greif
Belda
Myles
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FiO2, SSI, Atelectasis, & Respiratory Failure
PROXI Trial
Outcome80% FiO2
N=68530% FiO2
N=701Adjusted
Odds Ratio P
SSI 131 (19.1%) 141 (20.1%) 0.910.69 – 1.20
0.51
Atelectasis 54 (7.9%) 50 (7.1%) 1.130.75 – 1.72
0.56
Resp Failure 38 (5.5%) 31 (4.4%) 1.220.74 – 2.03
0.44
Meyhoff. JAMA 2009; ;302:1543-50
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FiO2, SSI, Atelectasis, & Respiratory Failure
PROXI Trial
Outcome80% FiO2
N=68530% FiO2
N=701Adjusted
Odds Ratio P
SSI 131 (19.1%) 141 (20.1%) 0.910.69 – 1.20
0.51
Atelectasis 54 (7.9%) 50 (7.1%) 1.130.75 – 1.72
0.56
Resp Failure 38 (5.5%) 31 (4.4%) 1.220.74 – 2.03
0.44
Meyhoff. JAMA 2009; ;302:1543-50
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Simply Increasing FiO2 isNot Enough
Oxygen has to get to the incision to make a difference* FiO2 * Regional anesth* Temperature * Fluid replacement* Cardiac output * Vasopressors* Vasoconstriction * etc.
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Glucose and SSI
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Diabetes, Glucose Control, and SSIs
After Median Sternotomy
0
5
10
15
20
<200 200-249 250-299 >300
% In
fect
ions
Latham. ICHE 2001; 22: 607-12
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Hyperglycemia and Risk of SSI after Cardiac Operations
• Hyperglycemia - doubled risk of SSI• Hyperglycemic:
48% of diabetics12% of nondiabetics30% of all patients
• 47% of hyperglycemic episodes were in nondiabetics
Latham. Inf Contr Hosp Epidemiol. 2001;22:607Dellinger. Inf Contr Hosp Epidemiol. 2001;22:604
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Deep Sternal SSI and Glucose
012345678
100-150 150-200 200-250 250-300
Day 1 Glucose (mg%)
% D
eep
Ster
nal I
nfec
tion
Zerr. Ann Thorac Surg 1997;63:356
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Furnary et al. Ann Thorac Surg 1999:67:352
Glucose Control and Deep Sternal Wound Infections
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Early (48h) Postoperative Glucose Levels and SSI after Vascular Surgery
Vriesendorp. Eur J Vasc Endovasc Surg 2004; 28:520-5
<103 mg%
103-117 mg%
117-151 mg%
>151 mg%
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Postop Glucose (within 48h) and SSI – General Surgery
Ata. Arch Surg 2010: 145: 858-864
Glucose
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Risk Adjusted Odds Ratios for Infection and Operative Intervention
Colectomy and Bariatric Operations
Kwon. Ann Surg. 2013; 257: 8-14
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Composite Infection in Hyperglycemic Patients With
and Without Use of Insulin
Kwon. Ann Surg. 2013; 257: 8-14
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Glucose in NonDiabetics having Colectomy at Cleveland Clinic
Highest Gluc N (%)< 125 mg% 816 (33%)126-200 mg% 1289 (53%)200 mg% 342 (14%)
All patients 2447 (100%)
Kiran, Ann Surg 2013;258:599–605
67%
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Glucose in NonDiabetics having Colectomy at Cleveland Clinic
Kiran, Ann Surg 2013;258:599–605
Per C
ent i
ncid
ence
<125 126-200 >2000
1
2
3
4
5
6
7
8
Mort+Sepsis¤SSI*Reop¤
*p<0.03, ¤ p<0.01, + p<0.05
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Preoperative Glucose as a Screening Tool for Patients
Without Diabetes• Random glucose within 30 days of operation• Average 8 days before operation• 16% within one day and 29% within 3 days• 6683 patients
• <70 384 pts• 70-99 4251 pts• 100-139 1801 pts• 140-179 187 pts• >180 60 pts
Wang. J Surg Res. 2014; 186: 371-8
31%
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Preoperative Glucose as a Screening Tool for Patients
Without Diabetes
<70 70-99 100-139 140-179 >1800
5
10
15
20
25
InfectionComplication
Wang. J Surg Res. 2014; 186: 371-8
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Glucose Levels & SSI• The exact “best” level of glucose control in
the perioperative period is not known.• High glucose levels unequivocally increase
the risk of SSI and other perioperative infections.
• Tight glucose control in the perioperative period is tricky.
• Hypoglycemia increases the risk of morbidity and mortality.
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Some Things New
Teamwork,Communication,and Discipline
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BMRI = Behavioral Marker Risk IndexBriefing, Information sharing, Inquiry, Vigilance and Awareness
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Prior to Skin Incision: Briefing
Nursing/Tech reviews:Equipment issues
(instruments ready, trained on, requested implants available, gas tanks full)
Sharps management plan
Other patient concerns
Anesthesia reviews:Airway or other
concerns Special meds (beta
blockers, etc.) Allergies Conditions affecting
recovery
All Team Members (Attending Surgeon Leads):Each person introduces self by
name and roleSurgeon, Anesthesia team and
Nurse confirm patient (at least 2 identifiers), site, procedure
Personnel exchanges: timing, plan for announcing changes
Description of procedure and anticipated difficulties
Expected duration of procedure
Expected blood loss & blood availability
Need for instruments/supplies/IV access beyond those normally used for the procedure
Questions/issues from any team member and invitation to speak up at any time in the procedure
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Prior to Skin Incision:Process Control
If case expected to be ≥ 1 hour, add:
Surgeon reviews: Glucose checked for
diabetics Insulin protocol initiated
if needed DVT/PE
chemoprophylaxis and/or mechanical prophylaxis plan in place
If patient on beta blocker, post-op plan formulated
Re-dosing plan for antibiotics
Specialty-specific checklist
Surgeon reviews (as applicable): Essential imaging
displayed; right and left confirmed
Antibiotic prophylaxis given in last 60 minutes
Active warming in place Special instruments
and/or implants
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After Skin Closure Complete: No Retained Objects, Debriefing, Care Transition
Surgeon and Anesthesia:Key concerns for patient
recoveryWhat is the plan for pain
mgmt?What is the plan for
prevention of PONV?Does patient need special
monitoring (time in RR, ICU, tele?)
If patient has elevated blood glucose, plan for insulin drip formulated
If patient on beta blocker, post-op continuation plan formulated
All Team Members (Attending Surgeon Leads):Confirm final
needles/sponges/ instruments count correct
Nursing/Tech show Surgeon and Anesthesia all sponges and laps in holders (“Show Me Ten”)
Confirm name of procedure If specimen, confirm label
and instructions (e.g., orientation of specimen, 12 lymph nodes for colon CA)
Equipment issues to be addressed?
Response planned (who/when)
What could have been better?
Improvement planned (who/when)
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Checklist and Complications
Before Aftern=3773 n=3955
SSI 6.2% 3.4%Unplan Return-O.R. 2.4% 1.8%Any Complic 11.0% 7.0%Death 1.5% 0.8%
Haynes. NEJM 2009; 360: 491-9
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Checklist and Complications
Before Aftern=3760 n=3820
SSI 3.8% 2.7%Complic/100 pts 27.3 16.7Pts with Complic 15.4% 10.6%Death 1.5% 0.8%
de Vries. NEJM 2010; 363: 1928-37
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Checklist Completion and Complications
Checklist Completion Complic
Above median 7.1%Below median11.7%
de Vries. NEJM 2010; 363: 1928-37
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Checklist Completion and Mortality
Adjusted Odds RatioMortality
All patients 0.85 (0.73-0.98)
van Klei. Ann Surg 2012; 255: 44-9
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Checklist Completion and Mortality
Adjusted Odds RatioMortality
All patients 0.85 (0.73-0.98)
Completed 0.44 (0.28-0.70)
Partial 1.09 (0.78-1.52)
Not done 1.16 (0.86-1.56
van Klei. Ann Surg 2012; 255: 44-9
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JAMA 2010; 304:1693-1700
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Neily. JAMA 2010; 304:1693-1700
Team Training and Mortality
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Not Discussed Due to Timebut probably or possibly(?) important
• Screening and decolonizing S. aureus• Skin prep• Sterile technique• “Wound protectors?”• Impregnated sutures?• Prevention of “nonsurgical” infections• Management of the incision after
operation?
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Preventing SSI• Have good teamwork at all times• Prewarm the patient• Enough of the right antibiotic at the
right time and repeat if necessary• Don’t shave• Thorough skin prep• Warm the patient in the O.R.• High FiO2
• Control glucose• Good teamwork