Intervention to Improve Timing of Preoperative Antibiotic Prophylaxis in Major Elective Surgery

Aims: Timely administration of antibiotic before incision ensures effective concentration in blood and tissues. Compliance with established guidelines is problematic due to logistics. Aim of this study was to improve timing of antibiotic prophylaxis (AP) with appropriate intervention in existing practices. Methods: Cross sectional study was conducted from May-June 2011 with target of enrolling at least 100 elective major cases (excluding obstetrics) who received AP before surgery. Anesthetists took responsibility of AP administration (Cefazoline 1 g as per our protocol unless indicated otherwise) instead of floor nurse as our earlier practice. Institutional ethical committee approved the study. Data collected in a pre-designed proforma was analyzed using Microsoft Excel. Results: Out of 120 patients, 64% were female. Average age was 43 years (4 to 87). General surgery cases were 51%, urosurgery 20%, gynecology and orthopaedic each 13% and others 6%. One hundred nineteen (99%) received AP before incision, 58(48%) within 60 to 30 minutes before incision and 1 (1%) after the incision. Conclusions: Anesthetist taking charge of the team for AP administration is a feasible option to improve compliance. Nepal Journal of Obstetrics and Gynaecology / Vol 7 / No. 1 / Issue 13 / Jan- June, 2012 / 15-18 DOI: http://dx.doi.org/10.3126/njog.v7i1.8827

Need of improvement in timing of prophylactic antibiotic in elective surgery

INTRODUCTION

Infections in surgery are major concern of morbidity, mortality, and costs. Timely antibiotic prophylaxis before incision ensures optimum concentration of AP in blood and tissues to prevent surgical site infections . However, proper timing of AP remains problematic as reported by various studies, though none so far from Nepal. Aim of this prospective observational study was to assess and address the issues for improvements in timing of AP.

METHODS

The pattern of antibiotic prophylaxis were prospectively collected in respect to time of induction, and incision time were recorded on predesigned 'AP form'. The study included all the elective major cases who received AP of intravenous Cefazoline 1 g as per our existing protocol. The emergency surgeries and obstetric cases were excluded from the study.

RESULTS

There were 125 cases of which 89% received AP before incision (63% within 5 minutes before incision), while 11% had AP after the incision and 1% within the recommended time period of 2 hour to 30 minutes before incision.

CONCLUSIONS

Current practice of antibiotic prophylaxis (AP) needs improvement as per standard guidelines of AP within 2 hour to 30 before incision.

Congenital heart disease in Nepalese children

The present status of congenital heart disease (CHD) from the persepective of the children's health in Nepal is not yeat available. Cross-sectional analysis of all children with heart disease attending Kanti Children Hospital was performed. VSD, ASD, obstructive valvular lesions and cyanotic heart diseases were the most common CHDs. Present data indicate the need for increased levels of cardiac care in children, correctional surgeries, monitoring of the patients and awareness among caregivers of CHD patients.

Pulmonary arterial compliance in children with atrial and ventricular septal defect

Previous studies have documented the normal values of pulmonary arterial compliance (Cp) in animals and adult humans. In the past, variations in Cp and its measurement in children with septal defects has been unknown. In the present study, we found the Windkessel model, which uses compliance and resistance as parameters, to be a useful tool in understanding Cp in pediatric patients. Calculations of Cp were based on the pulmonary arterial diastolic pressure waveform as an exponential function of time. First, Cp was estimated by studying pressure tracings of the main pulmonary artery (MPA) obtained from both routine cardiac catheterization and pressure measured by a catheter-tip manometer, which was performed during a catheterization study of seven children with various congenital heart diseases. Second, 124 children with atrial and ventricular septal defects aged between 45 days and 12 years were studied using the data obtained from routine catheterization. Hemodynamic data were used to calculate pulmonary vascular resistance (Rp), pulmonary arterial time constant (Tp) and Cp. A strong correlation (r = 0.954) was found in the Cp value estimated by data obtained from routine catheterization and from the catheter-tip manometer study. The present study shows an estimated mean (SEM) Cp in normal children of 1.53 (0.17) ml/mmHg per m2. The estimated mean (SEM) Cp was 1.91 (0.10) and 1.70 (0.11) ml/mmHg per m2 in children with atrial septal defect (ASD) and ventricular septal defect (VSD), respectively. It was found that Cp was significantly (P = 0.04) higher in female patients with a VSD. Also, a significantly low Cp (0.95 +/- 0.06 ml/mmHg per m2) was observed in patients with a VSD and pulmonary hypertension (VSDPH). In conclusion, Cp was calculated by the exponential decay portion of the MPA diastolic pressure waveform. A normal Cp value was observed in ASD and VSD patients and a significantly low Cp was observed in children with a VSDPH. Cp was higher in female VSD patients than in male VSD patients.

Tinea capitis infection in school children of Nepal

From among 428 Nepalese schoolchildren hair samples of 102 children with clinical features of tinea capitis, obtained by the sterile hairbrush method, were examined by mycological techniques. Age varied between 4-16 years. Itching was experienced by 96.1% sample subjects and hair loss by 32.4%. Of the 102, 11 (10.8%) were positive for Trichophyton violaceum (TV), 6 being from urban areas, the rest from rural areas. Amongst the 11 patients, 7 (63.6%) were girls and rest boys. Statistical associations were observed between the place of haircut and isolation of the organism (chi2 = 15.2, p <0.01). Statistical association was also present between frequency of bathing and isolation of organism. Sharing of combs was associated with the culture-positive subjects. The prevalence of tinea capitis in the urban and rural children was 2.3% and 3.0%, respectively. The only isolated organism was TV. An association of the isolation of TV was found with risk factors such as family members, sharing of combs, frequency of bathing with the organism. Hair loss was more common in the urban children. Discouragement of sharing combs, increased frequency of hair washing, and use of uncontaminated hair cutting instruments are recommended.

Mycological examination of the hair samples of 11 school-going Nepalese children suspected of tinea capitis

Among 150 students from a semi-urban school in Kathmandu (Nepal), 30 from various age groups and both sexes with symptoms suggestive of scalp ringworm, were examined clinically. Hair samples were collected for mycological examination, using the hair brush method, from 11 of the 30 children (36.7%), aged between 5 and 14 years, who were clinically diagnosed. Four of the cultured samples were positive for isolates of Trichophyton violaceum. This minor study provides evidence that tinea capitis might constitute a substantial infectious dermatological problem in Nepal. The study also indicated T. violaceum as the causative organism of tinea capitis.