Acute post traumatic & postoperative infection_present management.ppt

7/24/2019 Acute post traumatic & postoperative infection_present management.ppt

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Toru Sato, M.D.Toru Sato, M.D.

cute posttraumat cpostoperative infection

present management


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Debridement of necrotic tissue and flapand

antibiotics Debridement of necrotic tissue and flap and

implant removal and antibiotics

Antibiotics only


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Closed fracture .!"

Open fracture #.$" %ustilo type &&&

'.$"

AO documentation

!(') !((

AO documentation

!(') !((

&nfection rate

Closed fracture *$" Open fracture

%ustilo type ) &&&A +*(" %ustilo type &&&B ~ &&&C '*+ "


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-ound contamination

acteria

umber

0irulence

Circulation ecrosis

Alien bodies 1eamatoma &nstability 2esistance

&nfection

Organism


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Contamination Coloni3ation

&nfection

4e can e5plain these definition, but it6s difficult tograsp in clinical situation, because 4e can6t seebacteria and situations change every moment.


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iofilm of Staphy.aureus

Once bacteria adhere a foreign body, they produceglyycocaly5 and a biofilm is built. acteria in thebiofilm are protected from antibiotics ormacrophages or immunoglobulin.

iofilm


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iofilm

- Minimal inhibitory concentration 7M&C8 iniofilm is several ) several hundred times higher

than floating situation.- So, in these situations, Surgical debridement must

be done as soon as possible.
http://ja.wikipedia.org/wiki/%E3%83%95%E3%82%A1%E3%82%A4%E3%83%AB:Staphylococcus_aureus_biofilm_01.jpg


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Discipline in patient management is essential : - wearing face masks - repeated hand disinfection - type and time of hair removal

- correct skin disinfection - no small talk during surgery - sterile gloves for dressing changes

1o4 to reduce the ris9 of contamination

Strict isolation if M S! is suspected

Staphylococcus aureus are everywhere in our hospitalStandard precaution "#$


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Medium :Medium : hematomahematoma seromaseroma fluid collection around implantfluid collection around implant

DeadDead softsoft tissues:tissues: skin necrosisskin necrosis

muscle%periosteummuscle%periosteum thermal damagethermal damage

Dead hard tissue:Dead hard tissue: devasculari&ed 'onedevasculari&ed 'one

foreign 'odiesforeign 'odies

Circumstances favorable for bacteria


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:iving tissue is best protectionagainst infection

one is a plant 4ith its rootin the soft tissue


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1ost related

AgeDisease

DM. 2A. Obesity. Malnutrition.Malignancy.

Dialysis. etc8Drugs Steroid. &mmunosuppressant. etc:ong hospitali3ation&nfection at another region

2is9 factors for surgical site infection


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2is9 factors for surgical site infection

* emergency operation* duration of surgery

* surgical techni;ue


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!( * !(>one defect

Deep soft tissue in=uryacteria contamination

S9in defectCompartment syn.?5. patternS9in condition&schemia

!(+* !(!&schemia Comp. syn.

Soft tissue infectionacteria contamination

S9in condition

S9in defect

Deep soft tissue in=ury

Open fracture

2is9 factors for surgical 7fracture8 site infection

?actors influenced in=. site


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+@( closed fracture!!>/@* !!+/#

/@* !!+/#


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Closed fracture

!!>* !!+

Soft tissue infection @.!" vs '.$"Compartment syn. '. " vs '.!"

Op. time > 1rs '. " vs '.!"

erve in=ury @.@ " vs . "?5. . " vs '.#"

Soft tissue in=ury +. " vs '.@"

2is9 factors for surgical 7fracture8 site infection


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Analysis of accurate in=ury

no4ledge of ris9 factor


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?actors contributing to acute infection

* Contamination 4ith pathogenic organisms

Staphylococcus aureus #+"

*


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Dead tissue debridementEnstable fracture fi5ation1ematoma /seroma drainage

1igh tissue pressure tension free s9in

Management to protect infection


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( :ab. data F Clinical findings

( Surgeons tend to ma9e optimistic =udgments

a bout their o4n operations .(Clear diagnosis : disturbance of wound healing,

necrosis of wound edge, Hematoma in the wound.

Garly diagnosis of acute infection

&f the infection is doubtful, re*opening of the 4oundshould be done as soon as possible.


22/45)mergent op

*+y male*+y male

,all from height .m/

AO+>*C>


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0.days after in1ury2#3-clover4 ", articular surface/ 5 M"34


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6ound edge necrosis

3ost op 0w 3ost op 7w 3ost op +w


25/453ost op +m


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CDC Center for Disease Control and


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- 6ash-out with lots of fluid- 6ash-out with lots of fluid

- De'ridement repeated/ of all dead tissue8- De'ridement repeated/ of all dead tissue8

fi'rin or pusfi'rin or pus

- #hecking sta'ility of fi9ation and implants:- #hecking sta'ility of fi9ation and implants:

- #ement 'eads with anti'iotic - #ement 'eads with anti'iotic

- 6ound closure depending on local situation- 6ound closure depending on local situation- !nti'iotics for + weeks according to culture test/- !nti'iotics for + weeks according to culture test/

Wound revision in acute Wound revision in acute

infectioninfection


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-ith infection in the presence of a fracturefi5ation implant, the goal of treatment is

fracture healing and the prevention ofchronic osteomyelitis


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+0y male+0y male

$rafficaccident

DM

AO+>*C>%ustilo


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)mergent op days after in1ury Skin graft

07 days after in1ury 4 ", articular surface/5 M"34 locking plate/


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3ost op 7m

Distur'ed wound healing

coloni&ation


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Antibiotic prophyla5is reduces a ris9 of infection * efore op. 7before tourni;uet II -ithin$hours8

* Single dose 7 st/$nd generat. Cefalosporin8 ma5. $+hours

ur9e J?!# , SurgeryAntibiotic prophyla5is is not a substitute for careful

surgical techni;ue.odo9i et al l!!>,

o5ma et al !!#

2ole of antibiotics in fracture surgery


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Conclusions

* &ncidence of infection after operative fi5ation ofclosed fractures should be K *$"

* &n case of acute infection immediate action ismandatory

* Thorough debridement of all dead tissue* &mplants providing stability may remain Lin situ

* Mechanical stability and vital tissues are essential to obtain bony union

*


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Than9 you for your attentionThan9 you for your attention

Acute post traumatic & postoperative infection_present management.ppt

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