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Humez M, Fröschen FS, Wirtz DC, Kühn KD. [The third-generation modern cementing technique in hip and knee arthroplasty]. ORTHOPADIE (HEIDELBERG, GERMANY) 2023; 52:968-980. [PMID: 37828239 DOI: 10.1007/s00132-023-04446-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 09/01/2023] [Indexed: 10/14/2023]
Abstract
BACKGROUND Implant loosening is the most common reason for revision surgery. OBJECTIVES Contribution of modern cementing technique to the long-term stability of an implant. METHODS Evaluation of the available evidence on modern cementing technique. RESULTS Modern cementing technique in hip arthroplasty is considered established and leads to better cementing results. In knee arthroplasty, there are also specific recommendations, including intensive cleaning of the bone bed, mixing of bone cement under vacuum and application of bone cement to the implant and the bone. CONCLUSIONS The use of modern cementing technique in hip and knee arthroplasty facilitates cementing, increases safety, and minimizes the risk of mechanical loosening.
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Affiliation(s)
- Martina Humez
- Heraeus Medical GmbH, Philipp-Reis-Str. 8/13, 61273, Wehrheim, Deutschland.
| | | | | | - Klaus-Dieter Kühn
- Heraeus Medical GmbH, Philipp-Reis-Str. 8/13, 61273, Wehrheim, Deutschland
- Department of Orthopaedics and Trauma, Medizinische Universität Graz, Graz, Österreich
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Luck T, Zaki P, Michels R, Slotkin EM. The Cost-Effectiveness of Normal-Saline Pulsed Lavage for Infection Prophylaxis in Total Joint Arthroplasty. Arthroplast Today 2022; 18:107-111. [PMID: 36304695 PMCID: PMC9593269 DOI: 10.1016/j.artd.2022.09.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/25/2022] [Accepted: 09/22/2022] [Indexed: 11/11/2022] Open
Abstract
Background Prosthetic joint infection (PJI) is a well-described complication after total joint arthroplasty which imposes a substantial burden of morbidity and mortality on the individual, as well as cost to the health-care system. This study used a break-even analysis to investigate the cost-effectiveness of pulsed saline lavage (PSL) for PJI prophylaxis after a primary total knee arthroplasty (TKA) and total hip arthroplasty (THA). Methods An established model was used to calculate the minimum cost-effective absolute risk reduction of PSL for infection prophylaxis after a total joint arthroplasty. Baseline infection rates of TKA and THA and the cost of a revision surgery for PJI were derived from the literature while the cost of PSL implementation was obtained from institutional data. Results PSL is cost-effective at an initial infection rate of 1.10%, revision costs of $32,132 for TKA PJI, and a protocol cost of $38.28 if it reduces infection rates by 0.12% or prevents infection in 1 out of 839 patients. PSL is cost-effective at an initial infection rate of 1.63% and a revision cost of $39,713 for THA PJI if it reduces infection rates by 0.10% or prevents infection in 1 out of 1037 patients. The absolute risk reduction needed for economic viability did not change with varying baseline infection rates and did not exceed 0.38% for infection treatment costs as low as $10,000 and remained less than 0.47% even if PSL cost was as high as $150. Conclusions The use of PSL is a cost-effective protocol for PJI prophylaxis after TKAs and THAs.
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Affiliation(s)
- Trevor Luck
- Drexel University College of Medicine, Philadelphia, Pennsylvania,Corresponding author. Drexel University College of Medicine, 613 Sandstone Drive, Wyomissing, PA 19610, USA. Tel.: +1 207 590 8513.
| | - Peter Zaki
- Drexel University College of Medicine, Philadelphia, Pennsylvania
| | - Ryan Michels
- Reading Hospital, Orthopaedic Associates of Reading, Wyomissing, Pennsylvania
| | - Eric M. Slotkin
- Reading Hospital, Orthopaedic Associates of Reading, Wyomissing, Pennsylvania
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Bath MF, Davies J, Suresh R, Machesney MR. Surgical site infections: a scoping review on current intraoperative prevention measures. Ann R Coll Surg Engl 2022; 104:571-576. [PMID: 36044920 PMCID: PMC9433173 DOI: 10.1308/rcsann.2022.0075] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/25/2022] [Indexed: 09/03/2023] Open
Abstract
INTRODUCTION Surgical site infections (SSIs) remain a significant cause of morbidity for surgical patients worldwide and with growing rates of antibiotic resistance, the development of new nonantimicrobial techniques to target SSI reduction is crucial. This review aimed to explore available nonantibiotic intraoperative interventions to reduce the risk of SSI. METHODS A literature search was undertaken using Medline, Web of Science, Embase, and Cochrane Library databases. Any study published from 1 January 1980 to 1 September 2021 that described any nonantibiotic intraoperative physical technique aiming to reduce SSI rates, with a primary or secondary outcome of SSI rates, was included. FINDINGS A total of 45 articles were included in the final scoping review. The current nonantibiotic intraoperative interventions advised for use include chlorhexidine skin preparation with alcohol, pressurised wound irrigation, Triclosan-coated sutures for skin closure, and negative pressure wound therapy. Many other widely used surgical practices do not have the supporting evidence to validate their routine use in clinical practice to reduce SSI rates. CONCLUSIONS We identified several techniques that can be used in the operating theatre to provide additional opportunities to reduce SSI rates. However, strict adherence to current established SSI prevention guidelines remains the mainstay of ensuring SSI rates remain low.
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Affiliation(s)
- MF Bath
- Whipps Cross Hospital, Barts Health NHS Trust, UK
| | - J Davies
- Whipps Cross Hospital, Barts Health NHS Trust, UK
| | - R Suresh
- Whipps Cross Hospital, Barts Health NHS Trust, UK
| | - MR Machesney
- Whipps Cross Hospital, Barts Health NHS Trust, UK
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Marcasciano M, Kaciulyte J, Giuli RD, Marcasciano F, Torto FL, Guerra M, Prà GD, Barellini L, Mazzocchi M, Casella D, Ribuffo D. "Just Pulse it!" Introduction of a conservative implant salvage protocol to manage infection in pre-pectoral breast reconstruction: Case series and literature review. J Plast Reconstr Aesthet Surg 2021; 75:571-578. [PMID: 34794920 DOI: 10.1016/j.bjps.2021.09.060] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2020] [Revised: 04/25/2021] [Accepted: 09/27/2021] [Indexed: 10/20/2022]
Abstract
Post-operative implant infection is generally rare after breast augmentation, but it can occur in up to 35% of cases in post-mastectomy breast reconstruction. Standard treatment consists in the administration of antibiotics, implant removal, and delayed prosthesis replacement leading to multiple operations, with a negative impact on patient's clinical, economical, and psychological outcomes. There is little information published in the literature on the management of periprosthetic infection following pre-pectoral reconstructions. Capsule's removal from a pre-pectoral plane brings the risk of excessive tissue thinning and the compromise of skin flaps viability. In this preliminary multi-center case series, eight patients diagnosed with implant infection following oncological mastectomy and two-stage heterologous pre-pectoral breast reconstruction underwent the same protocol, consisting in tissue expander removal and conservative surgical revision supplemented by an antibiotate pulse lavage of the pocket surface. All patients achieved a successful infection resolution with immediate prosthesis replacement switching the temporary expander to definitive implant. No additional surgical revision was registered during follow-up. The intermittent irrigation is meant to disrupt the biofilm structure and restore antibiotic susceptibility. Moreover, pulse lavage allows the cleansing of the prosthetic capsule, thus avoiding the vascular stress associated with subcutaneous capsulectomy. To the best of our knowledge, this is the first series reporting on the use of Pulsavac in periprosthetic infection following pre-pectoral breast reconstruction, in an attempt to set the basis for an alternative conservative protocol to manage breast implant infection. A thorough literature review on pulse lavage in breast surgery was carried out.
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Affiliation(s)
- Marco Marcasciano
- Unità di Oncologia Chirurgica Ricostruttiva della Mammella, "Spedali Riuniti" di Livorno, "Breast Unit Integrata di Livorno, Cecina, Piombino, Elba, Azienda USL Toscana Nord Ovest", Livorno, Italy.
| | - Juste Kaciulyte
- Sapienza University of Rome, Policlinico Umberto I, Department of Surgery "P. Valdoni", Unit of Plastic and Reconstructive Surgery, Roma, Italy; Unit of Plastic and Reconstructive Surgery, Department of Surgery, Ospedale Santa Maria Della, Misericordia, Perugia, Italy
| | - Riccardo Di Giuli
- Unit of Plastic and Reconstructive Surgery, Department of Surgery, Ospedale Santa Maria Della, Misericordia, Perugia, Italy
| | - Fabio Marcasciano
- UOC Chirurgia Plastica e Ricostruttiva, Azienda Ospedaliera San Camillo - Forlanini, Roma, Italy
| | - Federico Lo Torto
- Sapienza University of Rome, Policlinico Umberto I, Department of Surgery "P. Valdoni", Unit of Plastic and Reconstructive Surgery, Roma, Italy
| | - Maristella Guerra
- Unità di Chirurgia Plastica, Polo Ospedaliero Santo Spirito ASL/RME, Roma, Italy
| | - Giovanni Dal Prà
- Unità di Chirurgia Plastica, Polo Ospedaliero Santo Spirito ASL/RME, Roma, Italy
| | - Leonardo Barellini
- Unità di Oncologia Chirurgica Ricostruttiva della Mammella, "Spedali Riuniti" di Livorno, "Breast Unit Integrata di Livorno, Cecina, Piombino, Elba, Azienda USL Toscana Nord Ovest", Livorno, Italy
| | - Marco Mazzocchi
- Unit of Plastic and Reconstructive Surgery, Department of Surgery, Ospedale Santa Maria Della, Misericordia, Perugia, Italy
| | - Donato Casella
- UOC Chirurgia Oncologica della Mammella, Azienda Ospedaliera Universitaria Senese, Siena, Italy
| | - Diego Ribuffo
- Sapienza University of Rome, Policlinico Umberto I, Department of Surgery "P. Valdoni", Unit of Plastic and Reconstructive Surgery, Roma, Italy
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Sharma D, Spacey K, Sharma V, Vince A. Cessation of Pulsed Lavage During the SARS-CoV-2 Pandemic: The Effect on Hip Hemiarthroplasty Cement Mantles. Cureus 2021; 13:e16809. [PMID: 34513414 PMCID: PMC8407275 DOI: 10.7759/cureus.16809] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/01/2021] [Indexed: 12/15/2022] Open
Abstract
Background With the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) pandemic, we were issued with guidance to minimize aerosol-generating procedures and discontinued the use of pulsed lavage for hip hemiarthroplasty. Instead, we used a bladder syringe to wash the femoral canal. The aim of this study was to assess whether this change in practice had a detrimental effect on the quality of the bone cement mantles in patients undergoing cemented hip hemiarthroplasty. Methodology We performed a retrospective review of all patients treated at a tertiary teaching hospital in the United Kingdom (Addenbrookes, Cambridge University Hospitals) presenting with a neck of femur fracture requiring a hemiarthroplasty between October 2019 and June 2020. We retrospectively assessed 100 post-operative radiographs for patients who had received hip hemiarthroplasty following neck of femur fragility fracture (50 before the service change and 50 after). The Barrack classification was used to assess the quality of the bone cement mantle. Results Pre-SARS-CoV-2, 30% of hemiarthroplasties were deemed as being "at risk" of aseptic loosening. During SARS-CoV-2, 64% of hips were deemed as being "at risk." This represents a statistically significant absolute increase of 34% (P < 0.05, the P value is 0.000645). Both clinicians agreed on the classification of hips "at risk" or "not at risk" (i.e., grades C/D and A/B, respectively) in 85% of the cases. Cohen's kappa coefficient was calculated as 0.68, indicating substantial agreement. Conclusions Following our experience of this forced service change, we would discourage abandoning the use of pulsed lavage in future pandemics. We have demonstrated an association between abandoning pulsed lavage and detrimental effects on the procedural quality for hip hemiarthroplasty. Patients treated over this time period will be closely monitored for operative complications. As this was the only equipment change made for this procedure, we have demonstrated its detrimental effect on the procedural quality. Should pulsed lavage be discontinued, patients may need to be counseled for higher risk of early failure and revision surgery and may require long-term radiographic follow-up. In SARS-CoV-2-positive patients, Surgeons should carefully consider the risks and benefits of using pulsed lavage in accordance with the personal protective equipment they have available and the consequential impact on the bone cement mantle quality.
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Affiliation(s)
- Dhiraj Sharma
- Department of Trauma and Orthopaedics, Addenbrooke's Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge, GBR
| | - Kate Spacey
- Department of Trauma and Orthopaedics, Addenbrooke's Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge, GBR
| | - Vivek Sharma
- Department of Trauma and Orthopaedics, Norfolk and Norwich University Hospitals Foundation Trust, Norwich, GBR
| | - Alastair Vince
- Department of Trauma and Orthopaedics, Addenbrooke's Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge, GBR
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Bath MF, Suresh R, Davies J, Machesney MR. Does pulsed lavage reduce the risk of surgical site infection? A systematic review and meta-analysis. J Hosp Infect 2021; 118:32-39. [PMID: 34454976 DOI: 10.1016/j.jhin.2021.08.021] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2021] [Revised: 08/11/2021] [Accepted: 08/12/2021] [Indexed: 10/20/2022]
Abstract
BACKGROUND Surgical site infections (SSIs) remain a significant and common postoperative complication. Whereas most surgeons use some form of wound irrigation during closure, its impact on SSI rates is debated. Preliminary studies in the use of pressurized irrigation, termed pulsed lavage, may have potential benefit to reduce the risk of SSI. AIM To perform a systematic review to identify studies that reported SSI rates following surgery, comparing the use of pulsed lavage to controls, following PRISMA guidelines. METHODS All study types and those published up to January 1st, 2021 were included. Odds ratios (ORs) were calculated for each included study using a Mantel-Haenszel statistical analysis, via a random effects model. A sub-analysis on abdominal procedures only was also performed. FINDINGS Eleven studies met the inclusion criteria, covering either orthopaedic or general surgery procedures; 1875 patients were included, with 816 patients in the pulsed lavage group and 1059 patients in the control group. Overall study quality was low. There was a significant reduction in the SSI rate with the use of pulsed lavage (odds ratio (OR): 0.39; 95% confidence interval (CI): 0.25-0.62; P < 0.0001). Sub-analysis on abdominal operations only showed further improvement to the SSI rate with pulsed lavage (OR: 0.32; 95% CI: 0.21-0.49; P < 0.0001). CONCLUSION Pulsed lavage significantly reduces the rate of SSIs in surgical procedures, the effect being most pronounced in abdominal operations; however, current study quality is low. Randomized controlled trial data are essential to fully assess the potential clinical and financial benefits pulsed lavage can confer to SSI reduction.
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Affiliation(s)
- M F Bath
- Department of Surgery, Whipps Cross University Hospital, Barts Health NHS Trust, London, UK.
| | - R Suresh
- Department of Surgery, Whipps Cross University Hospital, Barts Health NHS Trust, London, UK
| | - J Davies
- Department of Surgery, Whipps Cross University Hospital, Barts Health NHS Trust, London, UK
| | - M R Machesney
- Department of Surgery, Whipps Cross University Hospital, Barts Health NHS Trust, London, UK
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Use of Pulsed Lavage Reduces the Rate of Surgical Site Infection After Laparotomy. J Surg Res 2021; 266:300-305. [PMID: 34038852 DOI: 10.1016/j.jss.2021.04.019] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2020] [Revised: 03/01/2021] [Accepted: 04/10/2021] [Indexed: 01/24/2023]
Abstract
INTRODUCTION Surgical site infections (SSI) are a preventable and common post-operative complication within general surgery. Intra-operative irrigation of surgical incisions is an inexpensive method to reduce post-operative SSI rates, however its use is predominantly limited to orthopaedic surgery. We aimed to assess the effects of pulsed lavage (PL) irrigation on SSI rates following elective and emergency laparotomies. METHODS Elective and emergency patients who underwent a laparotomy between 2018 and 2019 were included. Relevant demographic and peri-operative risk factors collected retrospectively, following strengthening the reporting of observational studies in epidemiology (STROBE) criteria. The primary outcome was rate of superficial SSI within 30 days of the operation. Independent risk factors were assessed via multivariate logistic regression analysis. RESULTS 176 patients were identified, with an average age of 60.7 ± 19.1 y. 82.4% (145/176) were emergencies and the mean ASA grade was 2.8. Fifty-two patients (29.5%) had PL used during their operation. Thirty-seven patients (29.8%, 37/124) in the control group developed a SSI, compared to seven patients (13.5%, 7/52) in the PL group (P = 0.022). At multi-variate analysis, the use PL conferring an Odds Ratio 0.36 (CI 0.12-0.94, P= 0.047) for developing a SSI. CONCLUSION PL appears to significantly reduced the rate of SSI following laparotomy. There remains scope to reduce the incidence of this common and expensive post-operative complication, and PL could provide a potential cost-effective means to deliver improved outcomes. Future prospective randomised trials are essential to fully assess its benefits and wider use within general surgery.
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8
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Masters J, Metcalfe D, Ha JS, Judge A, Costa ML. Surgical site infection after hip fracture surgery: a systematic review and meta-analysis of studies published in the UK. Bone Joint Res 2020; 9:554-562. [PMID: 32922764 PMCID: PMC7469514 DOI: 10.1302/2046-3758.99.bjr-2020-0023.r1] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
Aims This study explores the reported rate of surgical site infection (SSI) after hip fracture surgery in published studies concerning patients treated in the UK. Methods Studies were included if they reported on SSI after any type of surgical treatment for hip fracture. Each study required a minimum of 30 days follow-up and 100 patients. Meta-analysis was undertaken using a random effects model. Heterogeneity was expressed using the I2 statistic. Risk of bias was assessed using a modified Newcastle-Ottawa Scale (NOS) system. Results There were 20 studies reporting data from 88,615 patients. Most were retrospective cohort studies from single centres. The pooled incidence was 2.1% (95% confidence interval (CI) 1.54% to 2.62%) across ‘all types’ of hip fracture surgery. When analyzed by operation type, the SSI incidences were: hemiarthroplasty 2.87% (95% CI 1.99% to 3.75%) and sliding hip screw 1.35% (95% CI 0.78% to 1.93%). There was considerable variation in definition of infection used, as well as considerable risk of bias, particularly as few studies actively screened participants for SSI. Conclusion Synthesis of published estimates of infection yield a rate higher than that seen in national surveillance procedures. Biases noted in all studies would trend towards an underestimate, largely due to inadequate follow-up.
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Affiliation(s)
- James Masters
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - David Metcalfe
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Joon Soo Ha
- The Royal College of Surgeons of England, London, UK
| | - Andrew Judge
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK.,Musculoskeletal Research Unit, Bristol Medical School, University of Bristol, Bristol, UK
| | - Matthew L Costa
- Oxford Trauma, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
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Thom H, Norman G, Welton NJ, Crosbie EJ, Blazeby J, Dumville JC. Intra-Cavity Lavage and Wound Irrigation for Prevention of Surgical Site Infection: Systematic Review and Network Meta-Analysis. Surg Infect (Larchmt) 2020; 22:144-167. [PMID: 32352895 DOI: 10.1089/sur.2019.318] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023] Open
Abstract
Background: Surgical site infections (SSIs) are costly and associated with poorer patient outcomes. Intra-operative surgical site irrigation and intra-cavity lavage may reduce the risk of SSIs through removal of dead or damaged tissue, metabolic waste, and site exudate. Irrigation with antibiotic or antiseptic solutions may further reduce the risk of SSI because of bacteriocidal properties. Randomized controlled trials (RCTs) have been conducted comparing irrigation solutions, but important comparisons (e.g., antibiotic vs. antiseptic irrigation) are absent. We use systematic review-based network meta-analysis (NMA) of RCTs to compare irrigation solutions for prevention of SSI. Methods: We used Cochrane methodology and included all RCTs of participants undergoing a surgical procedure with primary site closure, in which method of irrigation was the only systematic difference between groups. We used a random effects Bayesian NMA to create a connected network of comparisons. Results are presented as odds ratios (OR) of SSI, where OR <1 indicates a beneficial effect. Results: We identified 42 eligible RCTs with 11,726 participants. Most were at unclear or high risk of bias. The RCTs included groups given no irrigation or non-antibacterial, antiseptic, or antibiotic irrigation. There was substantial heterogeneity, and a random effects model was selected. Relative to non-antibacterial irrigation, mean OR of SSI was 0.439 (95% credible interval: 0.282, 0.667) for antibiotic irrigation and 0.573 (0.321, 0.953) for antiseptic agents. No irrigation was similar to non-antibacterial irrigation (OR 0.959 [0.555, 1.660]). Antibiotic and antiseptic irrigation were ranked as most effective for preventing SSIs; this conclusion was robust to potential bias. Conclusions: Our NMA found that antibiotic and antiseptic irrigation had the lowest odds of SSI. There was high heterogeneity, however, and studies were at high risk of bias. A large RCT directly comparing antibiotic irrigation with both antiseptic and non-antibacterial irrigation is needed to define the standard of care for SSI prevention by site irrigation.
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Affiliation(s)
- Howard Thom
- Population Health Science, Bristol Medical School, University of Bristol, Bristol, United Kingdom
| | - Gill Norman
- Division of Nursing, Midwifery and Social Work, School of Health Sciences, Manchester University NHS Foundation Trust, University of Manchester, Manchester Academic Health Science Centre, Manchester, United Kingdom
| | - Nicky J Welton
- Population Health Science, Bristol Medical School, University of Bristol, Bristol, United Kingdom
| | - Emma J Crosbie
- Division of Cancer Sciences, Faculty of Biology, Medicine and Health, Manchester University NHS Foundation Trust, University of Manchester, Manchester Academic Health Science Centre, Manchester, United Kingdom.,Department of Obstetrics and Gynaecology, Manchester University NHS Foundation Trust, University of Manchester, Manchester Academic Health Science Centre, Manchester, United Kingdom
| | - Jane Blazeby
- Population Health Science, Bristol Medical School, University of Bristol, Bristol, United Kingdom
| | - Jo C Dumville
- Division of Nursing, Midwifery and Social Work, School of Health Sciences, Manchester University NHS Foundation Trust, University of Manchester, Manchester Academic Health Science Centre, Manchester, United Kingdom
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10
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Wood T, Ekhtiari S, Mundi R, Citak M, Sancheti PK, Guerra-Farfan E, Schemitsch E, Bhandari M. The Effect of Irrigation Fluid on Periprosthetic Joint Infection in Total Hip and Knee Arthroplasty: A Systematic Review and Meta-Analysis. Cureus 2020; 12:e7813. [PMID: 32467789 PMCID: PMC7249750 DOI: 10.7759/cureus.7813] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2020] [Accepted: 04/24/2020] [Indexed: 11/05/2022] Open
Abstract
Introduction Rates of osteoarthritis and total joint arthroplasty (TJA) are on the rise globally. Periprosthetic joint infection (PJI) is the most devastating complication of TJA. A number of different intraoperative interventions have been proposed in an effort to reduce infection rates, including antibiotic cements, local antibiotic powder, and various irrigation solutions. The evidence on the importance of irrigation solutions is limited but has gained prominence recently, including the publication of a large randomized controlled trial (RCT). Thus, the purpose of this study was to evaluate the effectiveness of various irrigation solutions and pressures at reducing the rates of PJI. Methods A systematic review was performed using the electronic databases MEDLINE, Embase, and Web of Science. All records were screened in duplicate. Data collected included basic study characteristics, the details of the intervention and comparison solutions, if applicable, and rates of superficial and deep infection. A meta-analysis of comparative studies was performed to assess for consistency and potential direction of effect. Results A total of ten studies were included, of which one was an RCT, eight were retrospective cohorts, and one was a case series. In total, there were 29,630 TJAs in 29,596 patients. The mean age ranged from 61 to 80 years. Six studies compared povidone-iodine (Betadine®) to normal saline, two studies compared chlorhexidine to saline, one study compared "triple prophylaxis" to standard practice, and one study used gentamicin but had no comparison group. The pooled risk ratio for deep infection in studies using Betadine® compared to saline was 0.62 (95% confidence interval [CI]: 0.33-1.19), while for chlorhexidine it was 0.74 (95%CI: 0.33-1.65). Discussion Current evidence on the relative efficacy of irrigating solutions as prophylaxis for infection following TJA remains inconclusive. Imprecision of estimates vindicates the need for a definitive trial to further inform their use in surgical practice. Conclusion Antiseptic irrigation during TJA with solutions (Betadine®, chlorhexidine) may decrease PJI risk in patients undergoing primary and revision total hip and knee arthroplasties. Wide confidence intervals and heterogeneity among studies, however, render conclusions untrustworthy. Well-conducted RCTs are very much needed to help further investigate this issue.
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Affiliation(s)
- Thomas Wood
- Orthopaedic Surgery, McMaster University, Hamilton, CAN
| | | | | | - Mustafa Citak
- Orthopaedic Surgery, Helios Endo-Klinik, Hamburg, DEU
| | - Parag K Sancheti
- Orthopaedics, Sancheti Institute for Orthopaedics and Rehabilitation, Pune, IND
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De Simone B, Sartelli M, Coccolini F, Ball CG, Brambillasca P, Chiarugi M, Campanile FC, Nita G, Corbella D, Leppaniemi A, Boschini E, Moore EE, Biffl W, Peitzmann A, Kluger Y, Sugrue M, Fraga G, Di Saverio S, Weber D, Sakakushev B, Chiara O, Abu-Zidan FM, ten Broek R, Kirkpatrick AW, Wani I, Coimbra R, Baiocchi GL, Kelly MD, Ansaloni L, Catena F. Intraoperative surgical site infection control and prevention: a position paper and future addendum to WSES intra-abdominal infections guidelines. World J Emerg Surg 2020; 15:10. [PMID: 32041636 PMCID: PMC7158095 DOI: 10.1186/s13017-020-0288-4] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2019] [Accepted: 01/01/2020] [Indexed: 01/27/2023] Open
Abstract
BACKGROUND Surgical site infections (SSI) represent a considerable burden for healthcare systems. They are largely preventable and multiple interventions have been proposed over past years in an attempt to prevent SSI. We aim to provide a position paper on Operative Room (OR) prevention of SSI in patients presenting with intra-abdominal infection to be considered a future addendum to the well-known World Society of Emergency Surgery (WSES) Guidelines on the management of intra-abdominal infections. METHODS The literature was searched for focused publications on SSI until March 2019. Critical analysis and grading of the literature has been performed by a working group of experts; the literature review and the statements were evaluated by a Steering Committee of the WSES. RESULTS Wound protectors and antibacterial sutures seem to have effective roles to prevent SSI in intra-abdominal infections. The application of negative-pressure wound therapy in preventing SSI can be useful in reducing postoperative wound complications. It is important to pursue normothermia with the available resources in the intraoperative period to decrease SSI rate. The optimal knowledge of the pharmacokinetic/pharmacodynamic characteristics of antibiotics helps to decide when additional intraoperative antibiotic doses should be administered in patients with intra-abdominal infections undergoing emergency surgery to prevent SSI. CONCLUSIONS The current position paper offers an extensive overview of the available evidence regarding surgical site infection control and prevention in patients having intra-abdominal infections.
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Affiliation(s)
- Belinda De Simone
- Department of General Surgery, Azienda USL-IRCSS di Reggio Emilia, Guastalla Hospital, Via Donatori di sangue 1, 42016 Guastalla, RE Italy
| | - Massimo Sartelli
- Department of General Surgery, Macerata Hospital, 62100 Macerata, Italy
| | - Federico Coccolini
- General, Emergency and Trauma Surgery, Pisa University Hospital, 56124 Pisa, Italy
| | - Chad G. Ball
- Department of Surgery and Oncology, Hepatobiliary and Pancreatic Surgery, Trauma and Acute Care Surgery, University of Calgary Foothills Medical Center, Calgary, Alberta T2N 2T9 Canada
| | - Pietro Brambillasca
- Anesthesia and Critical Care Department, Papa Giovanni XXIII Hospital, P.zza OMS 1, 24128 Bergamo, Italy
| | - Massimo Chiarugi
- Emergency Surgery Unit and Trauma Center, Cisanello Hospital, Pisa, Italy
| | | | - Gabriela Nita
- Unit of General Surgery, Castelnuovo ne’Monti Hospital, AUSL, Reggio Emilia, Italy
| | - Davide Corbella
- Anesthesia and Critical Care Department, Papa Giovanni XXIII Hospital, P.zza OMS 1, 24128 Bergamo, Italy
| | - Ari Leppaniemi
- Abdominal Center, Helsinki University Hospital Meilahti, Helsinki, Finland
| | - Elena Boschini
- Medical Library, Papa Giovanni XXIII Hospital, P.zza OMS 1, 24128 Bergamo, Italy
| | - Ernest E. Moore
- Ernest E Moore Shock Trauma Center at Denver Health and University of Colorado, Denver, USA
| | - Walter Biffl
- Trauma and Acute Care Surgery, Scripps memorial Hospital, La Jolla, CA USA
| | - Andrew Peitzmann
- Department of Surgery, University of Pittsburgh School of Medicine, Pittsburgh, USA
| | - Yoram Kluger
- Division of General Surgery, Rambam Health Care Campus, Haifa, Israel
| | - Michael Sugrue
- Department of Surgery, Letterkenny University Hospital and Donegal Clinical Research Academy, Letterkenny, Ireland
| | - Gustavo Fraga
- Division of Trauma Surgery, School of Medical Sciences, University of Campinas, Campinas, SP Brazil
| | | | - Dieter Weber
- Trauma and General Surgery, Royal Perth Hospital, Perth, Australia
| | - Boris Sakakushev
- University Hospital St George First, Clinic of General Surgery, Plovdiv, Bulgaria
| | - Osvaldo Chiara
- State University of Milan, Acute Care Surgery Niguarda Hospital, Milan, Italy
| | - Fikri M. Abu-Zidan
- Department of Surgery, College of Medicine and Health Sciences, UAE University, Al-Ain, United Arab Emirates
| | | | | | - Imtiaz Wani
- Department of Surgery, Sheri-Kashmir Institute of Medical Sciences, Srinagar, India
| | - Raul Coimbra
- Department of Surgery, UC San Diego Medical Center, San Diego, USA
| | | | - Micheal D. Kelly
- Department of General Surgery, Albury Hospital, Albury, NSW 2640 Australia
| | - Luca Ansaloni
- Department of Emergency and Trauma Surgery, Bufalini Hospital, 47521 Cesena, Italy
| | - Fausto Catena
- Department of Emergency and Trauma Surgery, University Hospital of Parma, 43100 Parma, Italy
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12
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Boyle KK, Duquin TR. Antibiotic Prophylaxis and Prevention of Surgical Site Infection in Shoulder and Elbow Surgery. Orthop Clin North Am 2018; 49:241-256. [PMID: 29499825 DOI: 10.1016/j.ocl.2017.11.011] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
Infection after orthopedic procedures is a devastating and serious complication associated with significant clinical and financial challenges to the health care system and unfortunate patient. The time and resource-intensive nature of treating infection after orthopedic procedures has turned attention toward enhancing prevention and establishing quality improvement measures. Prevention strategies throughout the perioperative period include host optimization, risk mitigation, reducing bacterial burden and proper wound management. Understanding the most common offending organisms of the shoulder, Propionibacterium acnes and coagulase negative Staphylococcus species, and their hypothesized mechanism of infection is crucial to selecting appropriate preventative measures.
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Affiliation(s)
- K Keely Boyle
- Department of Orthopaedics, State University of New York at Buffalo, Erie County Medical Center, 462 Grider Street, Buffalo, NY 14215, USA.
| | - Thomas R Duquin
- Department of Orthopaedics, State University of New York at Buffalo, Erie County Medical Center, 462 Grider Street, Buffalo, NY 14215, USA
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Norman G, Atkinson RA, Smith TA, Rowlands C, Rithalia AD, Crosbie EJ, Dumville JC. Intracavity lavage and wound irrigation for prevention of surgical site infection. Cochrane Database Syst Rev 2017; 10:CD012234. [PMID: 29083473 PMCID: PMC5686649 DOI: 10.1002/14651858.cd012234.pub2] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
BACKGROUND Surgical site infections (SSIs) are wound infections that occur after an operative procedure. A preventable complication, they are costly and associated with poorer patient outcomes, increased mortality, morbidity and reoperation rates. Surgical wound irrigation is an intraoperative technique, which may reduce the rate of SSIs through removal of dead or damaged tissue, metabolic waste, and wound exudate. Irrigation can be undertaken prior to wound closure or postoperatively. Intracavity lavage is a similar technique used in operations that expose a bodily cavity; such as procedures on the abdominal cavity and during joint replacement surgery. OBJECTIVES To assess the effects of wound irrigation and intracavity lavage on the prevention of surgical site infection (SSI). SEARCH METHODS In February 2017 we searched the Cochrane Wounds Specialised Register; the Cochrane Central Register of Controlled Trials (CENTRAL); Ovid MEDLINE; Ovid Embase and EBSCO CINAHL Plus. We also searched three clinical trials registries and references of included studies and relevant systematic reviews. There were no restrictions on language, date of publication or study setting. SELECTION CRITERIA We included all randomised controlled trials (RCTs) of participants undergoing surgical procedures in which the use of a particular type of intraoperative washout (irrigation or lavage) was the only systematic difference between groups, and in which wounds underwent primary closure. The primary outcomes were SSI and wound dehiscence. Secondary outcomes were mortality, use of systemic antibiotics, antibiotic resistance, adverse events, re-intervention, length of hospital stay, and readmissions. DATA COLLECTION AND ANALYSIS Two review authors independently assessed studies for inclusion at each stage. Two review authors also undertook data extraction, assessment of risk of bias and GRADE assessment. We calculated risk ratios or differences in means with 95% confidence intervals where possible. MAIN RESULTS We included 59 RCTs with 14,738 participants. Studies assessed comparisons between irrigation and no irrigation, between antibacterial and non-antibacterial irrigation, between different antibiotics, different antiseptics or different non-antibacterial agents, or between different methods of irrigation delivery. No studies compared antiseptic with antibiotic irrigation. Surgical site infectionIrrigation compared with no irrigation (20 studies; 7192 participants): there is no clear difference in risk of SSI between irrigation and no irrigation (RR 0.87, 95% CI 0.68 to 1.11; I2 = 28%; 14 studies, 6106 participants). This would represent an absolute difference of 13 fewer SSIs per 1000 people treated with irrigation compared with no irrigation; the 95% CI spanned from 31 fewer to 10 more SSIs. This was low-certainty evidence downgraded for risk of bias and imprecision.Antibacterial irrigation compared with non-antibacterial irrigation (36 studies, 6163 participants): there may be a lower incidence of SSI in participants treated with antibacterial irrigation compared with non-antibacterial irrigation (RR 0.57, 95% CI 0.44 to 0.75; I2 = 53%; 30 studies, 5141 participants). This would represent an absolute difference of 60 fewer SSIs per 1000 people treated with antibacterial irrigation than with non-antibacterial (95% CI 35 fewer to 78 fewer). This was low-certainty evidence downgraded for risk of bias and suspected publication bias.Comparison of irrigation of two agents of the same class (10 studies; 2118 participants): there may be a higher incidence of SSI in participants treated with povidone iodine compared with superoxidised water (Dermacyn) (RR 2.80, 95% CI 1.05 to 7.47; low-certainty evidence from one study, 190 participants). This would represent an absolute difference of 95 more SSIs per 1000 people treated with povidone iodine than with superoxidised water (95% CI 3 more to 341 more). All other comparisons found low- or very low-certainty evidence of no clear difference between groups.Comparison of two irrigation techniques: two studies compared standard (non-pulsed) methods with pulsatile methods. There may, on average, be fewer SSIs in participants treated with pulsatile methods compared with standard methods (RR 0.34, 95% CI 0.19 to 0.62; I2 = 0%; two studies, 484 participants). This would represent an absolute difference of 109 fewer SSIs occurring per 1000 with pulsatile irrigation compared with standard (95% CI 62 fewer to 134 fewer). This was low-certainty evidence downgraded twice for risks of bias across multiple domains. Wound dehiscenceFew studies reported wound dehiscence. No comparison had evidence for a difference between intervention groups. This included comparisons between irrigation and no irrigation (one study, low-certainty evidence); antibacterial and non-antibacterial irrigation (three studies, very low-certainty evidence) and pulsatile and standard irrigation (one study, low-certainty evidence). Secondary outcomesFew studies reported outcomes such as use of systemic antibiotics and antibiotic resistance and they were poorly and incompletely reported. There was limited reporting of mortality; this may have been partially due to failure to specify zero events in participants at low risk of death. Adverse event reporting was variable and often limited to individual event types. The evidence for the impact of interventions on length of hospital stay was low or moderate certainty; where differences were seen they were too small to be clinically important. AUTHORS' CONCLUSIONS The evidence base for intracavity lavage and wound irrigation is generally of low certainty. Therefore where we identified a possible difference in the incidence of SSI (in comparisons of antibacterial and non-antibacterial interventions, and pulsatile versus standard methods) these should be considered in the context of uncertainty, particularly given the possibility of publication bias for the comparison of antibacterial and non-antibacterial interventions. Clinicians should also consider whether the evidence is relevant to the surgical populations under consideration, the varying reporting of other prophylactic antibiotics, and concerns about antibiotic resistance.We did not identify any trials that compared an antibiotic with an antiseptic. This gap in the direct evidence base may merit further investigation, potentially using network meta-analysis; to inform the direction of new primary research. Any new trial should be adequately powered to detect a difference in SSIs in eligible participants, should use robust research methodology to reduce the risks of bias and internationally recognised criteria for diagnosis of SSI, and should have adequate duration and follow-up.
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Affiliation(s)
- Gill Norman
- University of Manchester, Manchester Academic Health Science CentreDivision of Nursing, Midwifery & Social Work, School of Health Sciences, Faculty of Biology, Medicine & HealthJean McFarlane BuildingOxford RoadManchesterUKM13 9PL
| | - Ross A Atkinson
- University of Manchester, Manchester Academic Health Science CentreDivision of Nursing, Midwifery & Social Work, School of Health Sciences, Faculty of Biology, Medicine & HealthJean McFarlane BuildingOxford RoadManchesterUKM13 9PL
| | - Tanya A Smith
- Southmead Hospital, North Bristol Foundation TrustTrauma and OrthopaedicsSouthmead WayBristolAvonUKBS10 5NB
| | - Ceri Rowlands
- Severn Deanery, Health Education South West, EnglandGeneral SurgeryFlat 407, 51.02 ApartmentsBristolUKBS1 3LY
| | - Amber D Rithalia
- Independent Researcher7 Victoria Terrace, KirkstallLeedsUKLS5 3HX
| | - Emma J Crosbie
- Faculty of Biology, Medicine and Health, University of ManchesterDivision of Cancer Sciences5th Floor ‐ ResearchSt Mary's HospitalManchesterUKM13 9WL
| | - Jo C Dumville
- University of Manchester, Manchester Academic Health Science CentreDivision of Nursing, Midwifery & Social Work, School of Health Sciences, Faculty of Biology, Medicine & HealthJean McFarlane BuildingOxford RoadManchesterUKM13 9PL
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14
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Fry DE. Pressure Irrigation of Surgical Incisions and Traumatic Wounds. Surg Infect (Larchmt) 2017; 18:424-430. [DOI: 10.1089/sur.2016.252] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Affiliation(s)
- Donald E. Fry
- MPA Healthcare Solutions, Chicago, Illinois; Department of Surgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois; Department of Surgery, University of New Mexico School of Medicine, Albuquerque, New Mexico
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de Jonge SW, Boldingh QJJ, Solomkin JS, Allegranzi B, Egger M, Dellinger EP, Boermeester MA. Systematic Review and Meta-Analysis of Randomized Controlled Trials Evaluating Prophylactic Intra-Operative Wound Irrigation for the Prevention of Surgical Site Infections. Surg Infect (Larchmt) 2017; 18:508-519. [PMID: 28448203 DOI: 10.1089/sur.2016.272] [Citation(s) in RCA: 56] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND Surgical site infections (SSIs) are one of the most common hospital-acquired infections. To reduce SSIs, prophylactic intra-operative wound irrigation (pIOWI) has been advocated, although the results to date are equivocal. To develop recommendations for the new World Health Organization (WHO) SSI prevention guidelines, a systematic literature review and a meta-analysis were conducted on the effectiveness of pIOWI using different agents as a means of reducing SSI. METHODS The PUBMED, Embase, CENTRAL, CINAHL, and WHO databases were searched. Randomized controlled trials (RCTs) comparing either pIOWI with no pIOWI or with pIOWI using different solutions and techniques were retrieved with SSI as the primary outcome. Meta-analyses were performed, and odds ratios (OR) and the mean difference with 95% confidence intervals (CI) were extracted and pooled with a random effects model. RESULTS Twenty-one studies were suitable for analysis, and a distinction was made between intra-peritoneal, mediastinal, and incisional wound irrigation. A low quality of evidence demonstrated a statistically significant benefit for incisional wound irrigation with an aqueous povidone-iodine (PVP-I) solution in clean and clean contaminated wounds (OR 0.31; 95% CI 0.13-0.73; p = 0.007); 50 fewer SSIs per 1,000 procedures (from 19 fewer to 64 fewer)). Antibiotic irrigation had no significant effect in reducing SSIs (OR 1.16; 95% CI 0.64-2.12; p = 0.63). CONCLUSION Low-quality evidence suggests considering the use of prophylactic incisional wound irrigation to prevent SSI with an aqueous povidone-iodine solution. Antibiotic irrigation does not show a benefit and therefore is discouraged.
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Affiliation(s)
- Stijn W de Jonge
- 1 Department of Surgery, Academic Medical Center Amsterdam , The Netherlands
| | | | - Joseph S Solomkin
- 2 Department of Surgery, University of Cincinnati College of Medicine , Cincinnati, Ohio
| | - Benedetta Allegranzi
- 3 Infection Prevention and Control Global Unit, Service Delivery and Safety, World Health Organization , Geneva, Switzerland
| | - Matthias Egger
- 4 Institute of Social and Preventive Medicine, University of Bern , Bern, Switzerland
| | | | - Marja A Boermeester
- 1 Department of Surgery, Academic Medical Center Amsterdam , The Netherlands
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Majumder A, Miller HJ, Patel P, Wu YV, Elliott HL, Novitsky YW. Evaluation of antibiotic pressurized pulse lavage for contaminated retromuscular abdominal wall reconstruction. Surg Endosc 2016; 31:2763-2770. [PMID: 27800587 DOI: 10.1007/s00464-016-5283-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2016] [Accepted: 10/04/2016] [Indexed: 11/30/2022]
Abstract
BACKGROUND Despite patient risk factors such as diabetes and obesity, contamination during surgery remains a significant cause of infections and subsequent wound morbidity. Pressurized pulse lavage (PPL) has been utilized as a method to reduce bacterial bioburden with promising results in many fields. Although existing methods of lavage have been utilized during abdominal operations, no studies have examined the use of PPL during complex hernia repair. METHODS Patients undergoing abdominal wall reconstruction (AWR) in clean-contaminated or contaminated fields with antibiotic PPL, from January 2012 to May 2013, were prospectively evaluated. Primary outcome measures studied were conversion of retrorectus space culture from positive to negative after PPL and 30-day surgical site infection (SSI) rate. RESULTS A total of 56 patients underwent AWR, with 44 patients (78.6 %) having clean-contaminated fields and 12 patients (21.4 %) having contaminated ones. Twenty-two patients (39.3 %) had positive pre-PPL cultures, 18 of which (81.8 %) converted to negative cultures after PPL. Eleven patients (19.6 %) developed SSIs. Those with persistently positive cultures after PPL had the highest rate of SSI, where two out of four patients (50.0 %) developed an SSI. Contrastingly, only 5 of 18 patients (27.8 %) who converted from a positive to negative culture after PPL developed an SSI. CONCLUSION Our findings demonstrate that antibiotic PPL is an effective method to reduce bacterial bioburden during AWR in clean-contaminated and contaminated fields. While complete conversion and eradication of SSI were not achieved, we believe that PPL may be a useful adjunct to standard operative asepsis in preventing prosthetic contamination during contaminated AWR.
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Affiliation(s)
- Arnab Majumder
- Department of Surgery, UH Comprehensive Hernia Center, University Hospitals Cleveland Medical Center, 11100 Euclid Avenue, Cleveland, OH, 44106, USA
| | - Heidi J Miller
- Department of Surgery, UH Comprehensive Hernia Center, University Hospitals Cleveland Medical Center, 11100 Euclid Avenue, Cleveland, OH, 44106, USA
| | - Parita Patel
- Department of Surgery, UH Comprehensive Hernia Center, University Hospitals Cleveland Medical Center, 11100 Euclid Avenue, Cleveland, OH, 44106, USA
| | - Yuhsin V Wu
- Department of Surgery, UH Comprehensive Hernia Center, University Hospitals Cleveland Medical Center, 11100 Euclid Avenue, Cleveland, OH, 44106, USA
| | - Heidi L Elliott
- Department of Surgery, UH Comprehensive Hernia Center, University Hospitals Cleveland Medical Center, 11100 Euclid Avenue, Cleveland, OH, 44106, USA
| | - Yuri W Novitsky
- Department of Surgery, UH Comprehensive Hernia Center, University Hospitals Cleveland Medical Center, 11100 Euclid Avenue, Cleveland, OH, 44106, USA.
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17
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Allegranzi B, Zayed B, Bischoff P, Kubilay NZ, de Jonge S, de Vries F, Gomes SM, Gans S, Wallert ED, Wu X, Abbas M, Boermeester MA, Dellinger EP, Egger M, Gastmeier P, Guirao X, Ren J, Pittet D, Solomkin JS. New WHO recommendations on intraoperative and postoperative measures for surgical site infection prevention: an evidence-based global perspective. THE LANCET. INFECTIOUS DISEASES 2016; 16:e288-e303. [PMID: 27816414 DOI: 10.1016/s1473-3099(16)30402-9] [Citation(s) in RCA: 476] [Impact Index Per Article: 59.5] [Reference Citation Analysis] [Abstract] [Subscribe] [Scholar Register] [Received: 06/17/2016] [Revised: 08/28/2016] [Accepted: 09/13/2016] [Indexed: 12/11/2022]
Abstract
Surgical site infections (SSIs) are the most common health-care-associated infections in developing countries, but they also represent a substantial epidemiological burden in high-income countries. The prevention of these infections is complex and requires the integration of a range of preventive measures before, during, and after surgery. No international guidelines are available and inconsistencies in the interpretation of evidence and recommendations in national guidelines have been identified. Considering the prevention of SSIs as a priority for patient safety, WHO has developed evidence-based and expert consensus-based recommendations on the basis of an extensive list of preventive measures. We present in this Review 16 recommendations specific to the intraoperative and postoperative periods. The WHO recommendations were developed with a global perspective and they take into account the balance between benefits and harms, the evidence quality level, cost and resource use implications, and patient values and preferences.
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Affiliation(s)
- Benedetta Allegranzi
- Infection Prevention and Control Global Unit, Service Delivery and Safety, WHO, Geneva, Switzerland.
| | - Bassim Zayed
- Infection Prevention and Control Global Unit, Service Delivery and Safety, WHO, Geneva, Switzerland
| | - Peter Bischoff
- Institute of Hygiene and Environmental Medicine, Charité-University Medicine, Berlin, Germany
| | - N Zeynep Kubilay
- Infection Prevention and Control Global Unit, Service Delivery and Safety, WHO, Geneva, Switzerland
| | - Stijn de Jonge
- Department of Surgery, Academic Medical Center Amsterdam, Amsterdam, Netherlands
| | - Fleur de Vries
- Department of Surgery, Academic Medical Center Amsterdam, Amsterdam, Netherlands
| | | | - Sarah Gans
- Department of Surgery, Academic Medical Center Amsterdam, Amsterdam, Netherlands
| | - Elon D Wallert
- Department of Surgery, Academic Medical Center Amsterdam, Amsterdam, Netherlands
| | - Xiuwen Wu
- Jinling Hospital, Medical School of Nanjing University, Nanjing, Jiangsu, China
| | - Mohamed Abbas
- Infection Control Programme, University of Geneva Hospitals and Faculty of Medicine, Geneva, Switzerland
| | - Marja A Boermeester
- Department of Surgery, Academic Medical Center Amsterdam, Amsterdam, Netherlands
| | | | - Matthias Egger
- Institute of Social and Preventive Medicine, University of Bern, Bern, Switzerland
| | - Petra Gastmeier
- Institute of Hygiene and Environmental Medicine, Charité-University Medicine, Berlin, Germany
| | | | - Jianan Ren
- Jinling Hospital, Medical School of Nanjing University, Nanjing, Jiangsu, China
| | - Didier Pittet
- Infection Control Programme, University of Geneva Hospitals and Faculty of Medicine, Geneva, Switzerland; WHO Collaborating Centre on Patient Safety (Infection Control and Improving Practices), University of Geneva Hospitals and Faculty of Medicine, Geneva, Switzerland
| | - Joseph S Solomkin
- OASIS Global, Cincinnati, OH, USA; University of Cincinnati College of Medicine, Cincinnati, OH, USA
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18
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Luján S, Rogel R, Broseta E, Boronat F. Local Treatment of Penile Prosthesis Infection as Alternative to Immediate Salvage Surgery. Sex Med 2016; 4:e255-e258. [PMID: 27484916 PMCID: PMC5121535 DOI: 10.1016/j.esxm.2016.06.002] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2016] [Revised: 05/21/2016] [Accepted: 06/05/2016] [Indexed: 11/28/2022] Open
Abstract
INTRODUCTION Penile prosthesis (PP) is the established treatment for patients with erectile dysfunction (ED) who do not respond to phosphodiesterase inhibitors and intracavernosal injections. In general, these devices have been largely successful but there are not free of serious complication such as PP infection (PPI). PPI requires immediate surgical removal or salvage rescue of the PP. AIM In this report, we present two clinical cases with inflatable PP (IPP) treated locally with antibiotic and high pressure irrigation and then avoid the PP removal or salvage rescue. METHODS We present two patients with PPI in our institution and literature review. MAIN OUTCOME MEASURES Resolution of the two cases. RESULTS Patient A (A) was 44 years old and patient B (B) 51 years old presented PPI after three weeks (A) and eight weeks (B). Both patients were diabetic. Physical exploration revealed an open scrotal incision at its margin with a clear discharge. The rest of the incision and scrotum were clean and dry. They had not scrotum pain/tenderness or systemic/septic symptoms. The bacterial culture of the incisional drainage revealed a Staphylococcus aureus (A) and Staphylococcus epidermidis (B). In both cases, we performed an excision of the tissue around the pump with a high pressure pulsed irrigation (Interpulse; Stryker Corp, Kalamazoo, MI, USA). For the irrigation we used three different solutions that included povidone-iodine, antibiotics (gentamicin plus vancomicin), and hydrogen peroxyde. Finally, we performed a multilayered surgical closure with the use of aspirate drainage over 24 hours and intravenous antibiotics. The patients had a total resolution of its symptoms after 20 months (A) and 36 months (B), and the IPP worked properly. CONCLUSION This treatment could be an option for to perform specific patients with local IPP infection without systemic symptoms instead of surgical removal.
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Affiliation(s)
- Saturnino Luján
- Department of Urology, Hospital Universitari i Politècnic La Fe, València, Spain.
| | - Ramón Rogel
- Department of Urology, Hospital Universitari i Politècnic La Fe, València, Spain
| | - Enrique Broseta
- Department of Urology, Hospital Universitari i Politècnic La Fe, València, Spain
| | - Francisco Boronat
- Department of Urology, Hospital Universitari i Politècnic La Fe, València, Spain
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19
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The effect of isotonic saline on the strength of bone cement during the polymerisation period. Hip Int 2016; 21:238-42. [PMID: 21484740 DOI: 10.5301/hip.2011.6517] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/15/2011] [Indexed: 02/04/2023]
Abstract
It is common practice to irrigate the wound in hip and knee replacement surgery during the working and setting phases of cement polymerisation. We sought to establish whether the addition of normal saline during the various stages of polymerisation would affect bone cement strength. Cement specimens were moulded to the dimensions defined in ISO 5833: 2002 and tested in an electro-mechanical test machine with a calibrated 50 kN load cell at a compression rate of 24 mm/min. The results suggest that the compressive strength of bone cement is not affected by the presence of saline following the initiation of polymerisation. However, saline added to the mix prior to the initiation of polymerisation increased its porosity and significantly decreased its strength. This may explain why vacuum mixing is important as it removes water vapour.
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20
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George DA, Gant V, Haddad FS. The management of periprosthetic infections in the future: a review of new forms of treatment. Bone Joint J 2015; 97-B:1162-9. [PMID: 26330580 DOI: 10.1302/0301-620x.97b9.35295] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
The number of arthroplasties being undertaken is expected to grow year on year, and periprosthetic joint infections will be an increasing socioeconomic burden. The challenge to prevent and eradicate these infections has resulted in the emergence of several new strategies, which are discussed in this review. Cite this article: Bone Joint J 2015;97-B:1162-9.
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Affiliation(s)
- D A George
- University College London Hospitals, 235 Euston Road, London, NW1 2BU, UK
| | - V Gant
- University College London Hospitals, 235 Euston Road, London, NW1 2BU, UK
| | - F S Haddad
- University College London Hospitals, 235 Euston Road, London, NW1 2BU, UK
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21
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Dineen SP, Pham TH, Murray BW, Parker BJ, Hartless K, Anthony T, Huerta S. Feasibility of Subcutaneous Gentamicin and Pressurized Irrigation as Adjuvant Strategies to Reduce Surgical Site Infection in Colorectal Surgery: Results of a Pilot Study. Am Surg 2015. [DOI: 10.1177/000313481508100620] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Surgical site infections (SSIs) remain a common and costly morbidity after colorectal surgery. This rate remains high even in the setting of strict adherence to Surgical Care Improvement Project Protocols. The aim of our pilot study was to determine the feasibility and safety of subcutaneous gentamicin injection or pressurized irrigation as adjuncts to reduce SSI. A total of 132 patients who underwent colorectal surgery at the VA North Texas Health Care System were prospectively assigned to a pressurized irrigation group (n = 44), a preincision gentamicin injection group (n = 48), or control (n = 40). The primary objective was to assess safety and feasibility of these strategies. Patient demographics were matched among groups. Univariate and multivariate analyses were performed to identify possible predictions of SSI in this cohort. The rate of SSI in the control group was 25 per cent, 13.5 per cent in the pressurized irrigation group, and 12.5 per cent in the gentamicin group ( P = 0.26). Combined, the intervention groups had a 13 per cent SSI versus 25 per cent control ( P = 0.09). Operative time was not increased by the interventions and no intraoperative complications specifically related to the interventions were noted. Postoperative complications were not different between groups. Both albumin and body mass index were associated with SSI. Body mass index was and independent predictor of SSI ( P = 0.006). In conclusion, this pilot study demonstrates the feasibility of the interventions described. There was no detrimental effect of either intervention. There was trend toward a reduction in SSI in the intervention group, which warrants further investigation.
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Affiliation(s)
- Sean P. Dineen
- Department of Surgery, University of Texas Southwestern and VA North Texas Healthcare System, Dallas, Texas
| | - Thai H. Pham
- Department of Surgery, University of Texas Southwestern and VA North Texas Healthcare System, Dallas, Texas
| | - Bryce W. Murray
- Department of Surgery, University of Texas Southwestern and VA North Texas Healthcare System, Dallas, Texas
| | - Betty J. Parker
- Department of Surgery, University of Texas Southwestern and VA North Texas Healthcare System, Dallas, Texas
| | - Kathleen Hartless
- Department of Surgery, University of Texas Southwestern and VA North Texas Healthcare System, Dallas, Texas
| | - Thomas Anthony
- Department of Surgery, University of Texas Southwestern and VA North Texas Healthcare System, Dallas, Texas
| | - Sergio Huerta
- Department of Surgery, University of Texas Southwestern and VA North Texas Healthcare System, Dallas, Texas
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Nikfarjam M, Weinberg L, Fink MA, Muralidharan V, Starkey G, Jones R, Staveley-O'Carroll K, Christophi C. Pressurized pulse irrigation with saline reduces surgical-site infections following major hepatobiliary and pancreatic surgery: randomized controlled trial. World J Surg 2014; 38:447-55. [PMID: 24170152 DOI: 10.1007/s00268-013-2309-x] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
BACKGROUND Surgical site infections (SSI) are a significant cause of postoperative morbidity. Pressurized pulse irrigation of subcutaneous tissues may lower infection rates by aiding in the debridement of necrotic tissue and reducing bacterial counts compared to simply pouring saline into the wound. METHODS A total of 128 patients undergoing laparotomy extending beyond 2 h were randomized to treatment of wounds by pressurized pulse lavage irrigation (<15 psi) with 2 L normal saline (pulse irrigation group), or to standard irrigation with 2 L normal saline poured into the wound, immediately prior to skin closure (standard group). Only elective cases were included, and all cases were performed within a specialized hepatobiliary and pancreatic surgery unit. RESULTS There were 62 patients managed by standard irrigation and 68 were managed by pulse irrigation. The groups were comparable in most aspects. Overall there were 16 (13 %) SSI. Significantly fewer SSI occurred in the pulse irrigation group [4 (6 %) vs. 12 (19 %); p = 0.032]. On multivariate analysis, the use of pulse irrigation was the only factor associated with a reduction in SSI with an odds ratio (OR) of 0.3 [95 % confidence interval (95 % CI) 0.1-0.8; p = 0.031]. In contrast, hospital length of stay of greater than 14 days was associated with increased infections with an OR of 7.6 (95 % CI 2.4-24.9; p = 0.001). CONCLUSIONS Pulse irrigation of laparotomy wounds in operations exceeding 2 h duration reduced SSI after major hepatobiliary pancreatic surgery. (Australian New Zealand Clinical Trials Registry, ACTRN12612000170820).
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Affiliation(s)
- Mehrdad Nikfarjam
- University of Melbourne Department of Surgery, Austin Health, LTB 8, Studley Rd, Heidelberg, VIC, 3084, Australia,
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Alijanipour P, Karam J, Llinás A, Vince KG, Zalavras C, Austin M, Garrigues G, Heller S, Huddleston J, Klatt B, Krebs V, Lohmann C, McPherson EJ, Molloy R, Oliashirazi A, Schwaber M, Sheehan E, Smith E, Sterling R, Stocks G, Vaidya S. Operative environment. J Orthop Res 2014; 32 Suppl 1:S60-80. [PMID: 24464899 DOI: 10.1002/jor.22550] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
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Muñoz-Mahamud E, García S, Bori G, Martínez-Pastor JC, Zumbado JA, Riba J, Mensa J, Soriano A. Comparison of a low-pressure and a high-pressure pulsatile lavage during débridement for orthopaedic implant infection. Arch Orthop Trauma Surg 2011; 131:1233-8. [PMID: 21387137 DOI: 10.1007/s00402-011-1291-8] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/04/2010] [Indexed: 01/06/2023]
Abstract
INTRODUCTION The aim of our study was to compare the effectiveness of high-pressure pulsatile lavage and low-pressure lavage in patients with an orthopaedic implant infection treated with open débridement followed by antibiotic treatment. PATIENTS AND METHODS Patients with an orthopaedic implant infection requiring open débridement from January 2008 to August 2009 were randomized prospectively to a low-pressure or a high-pressure pulsatile lavage arm. Relevant information about demographics, co-morbidity, type of implant, microbiology data, surgical treatment, and outcome were recorded. Comparison of proportions was made using χ(2) test or Fisher exact test when necessary. The Kaplan-Meier survival method was used to estimate the cumulative probability of treatment failure from open débridement to the last visit. RESULTS Seventy-nine patients were included. There were no differences between the main characteristics between both groups (p > 0.05). Mean (SD) age of the whole cohort was 70.2 (11.9) years. There were 46 infections on knee prosthesis, 17 on hip prosthesis, 7 on hip hemiarthroplasties and 9 on osteosynthesis devices. There were 69 acute post-surgical infections, 8 acute haematogenous infections and 2 chronic infections. The most common microorganisms isolated were coagulase-negative Staphylococci in 34 cases, Staphylococcus aureus in 26 and Escherichia coli in 19 cases. There were 30 polymicrobial infections. A total of 42 and 37 patients were randomized to a high-pressure pulsatile or a low-pressure lavage, respectively. There was no difference in the success rate between both arms (80.9 vs. 86.5%, p = 0.56). CONCLUSION The use of a high-pressure pulsatile lavage during open débridement of implant infections had a similar success rate as a low-pressure lavage.
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Affiliation(s)
- E Muñoz-Mahamud
- Department of Orthopaedic and Trauma Surgery, Bone and Joint Infection Unit, Hospital Clínic of Barcelona, University of Barcelona, Spain.
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Abstract
Infection of a prosthetic joint is a significant adverse event, affecting the patient, the surgical team, and consuming hospital resources. The patient faces multiple operations, a prolonged hospital stay and a more challenging period of rehabilitation. The surgeon must perform longer and more technically demanding revision operations in order to remove the infected prosthesis, increasing the burden on hospital resources. It has been estimated that that the cost of managing an infected total hip replacement (THR) is four times greater than for a primary procedure (Dreghorn & Hamblen 1989). The personal cost to the patient must also be emphasised.
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Affiliation(s)
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- Department of Research and Scientific Affairs, American Academy of Orthopaedic Surgeons, Rosemont, IL 60018, USA
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Wick M, Maul I, Muhr G. [Early-onset infection after hemiarthroplasty of the hip: an algorithm for surgical therapy]. DER ORTHOPADE 2009; 38:600-5. [PMID: 19513691 DOI: 10.1007/s00132-009-1439-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND In a retrospective study, we compared the results of different surgical therapies in 30 patients who had an early-onset infection after implantation of a hip hemiarthroplasty. MATERIAL AND METHODS Patients were divided into two groups: In group 1 (n=16, deep infection), we changed the polyethylene inlay as well as the femoral head. In group 2 (n=14, deep infection), an acetabular component was also implanted. RESULTS In group 1, successful treatment was achieved in 37.5% of patients 6 months after the last operation, compared with 71.4% in group 2 (p=0.019). All patients were supported with antibiotics. In group 1, three patients died from septic multiorgan failure. Two patients in group 1 and one patient in group 2 received a Girdlestone operation. CONCLUSIONS These results suggest that aggressive surgical treatment with soft tissue revision, lavage, and implantation of an acetabular component in combination with antibiotics is a useful technique for treating early-onset infection.
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Affiliation(s)
- M Wick
- Abteilung für Chirurgie, Standort Eggenfelden, Rottal-Inn-Krankenhäuser, Simonsöder Allee 20, 84307 Eggenfelden.
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Nikfarjam M, Kimchi ET, Gusani NJ, Avella DM, Shereef S, Staveley-O'Carroll KF. Reduction of surgical site infections by use of pulsatile lavage irrigation after prolonged intra-abdominal surgical procedures. Am J Surg 2009; 198:381-6. [PMID: 19344885 DOI: 10.1016/j.amjsurg.2008.12.021] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2008] [Revised: 12/05/2008] [Accepted: 12/05/2008] [Indexed: 11/27/2022]
Abstract
BACKGROUND Surgical site infections cause significant postoperative morbidity and may be reduced by pressurized irrigation of high-risk laparotomy wounds before closure. This was a retrospective review (June 2007 to May 2008) from a surgical unit at a tertiary care center. METHODS Patients undergoing laparotomy extending beyond 4 hours, when a standard wound management strategy was instituted by either simple irrigation or pressurized pulsatile lavage (<15 psi) with saline before closure, were included. The outcome measures were the surgical site infections and factors contributing to them. RESULTS The median surgical time for the patients was 8 hours, with 34 wounds managed by simple irrigation and 42 wounds managed by pulse irrigation. Both groups had similar characteristics. Overall there were 15 (20%) surgical site infections. Significantly fewer infections occurred in the pulse irrigation group (10% vs 32%; P = .019). The use of a pulse irrigation device was the only factor associated with a reduction in wound infections (P = .019). CONCLUSIONS Surgical site infections appear to be reduced with pulsatile lavage irrigation of wounds before skin closure in patients undergoing prolonged intra-abdominal surgeries.
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Affiliation(s)
- Mehrdad Nikfarjam
- Section of Surgical Oncology, Department of Surgery, Milton S Hershey Medical Center, Hershey, PA 17033-0850, USA
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Brain monitoring of apnea; antimicrobial surgical mask coating; stress and surgeon performance; pulsatile Lavage. AORN J 2006. [DOI: 10.1016/s0001-2092(06)60155-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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