SSI Evidence – a Surgeon’s Perspective E. Patchen Dellinger, MD University of Washington.
-
Upload
katelin-laycock -
Category
Documents
-
view
217 -
download
0
Transcript of SSI Evidence – a Surgeon’s Perspective E. Patchen Dellinger, MD University of Washington.
![Page 1: SSI Evidence – a Surgeon’s Perspective E. Patchen Dellinger, MD University of Washington.](https://reader030.fdocuments.in/reader030/viewer/2022012922/56649cbf5503460f949855e4/html5/thumbnails/1.jpg)
SSI Evidence–
a Surgeon’s Perspective
E. Patchen Dellinger, MDUniversity of Washington
![Page 2: SSI Evidence – a Surgeon’s Perspective E. Patchen Dellinger, MD University of Washington.](https://reader030.fdocuments.in/reader030/viewer/2022012922/56649cbf5503460f949855e4/html5/thumbnails/2.jpg)
Caring for theCritically Ill Patient
ABC = airway, breathing, circulation
![Page 3: SSI Evidence – a Surgeon’s Perspective E. Patchen Dellinger, MD University of Washington.](https://reader030.fdocuments.in/reader030/viewer/2022012922/56649cbf5503460f949855e4/html5/thumbnails/3.jpg)
Preventing Surgical Site Infections (SSI)
ABC = airway, breathing, circulation
= temperature, oxygen, fluidsABCD - Add drugs (antibiotics)
Add - glucose controlproper hair removalsurgical techniqueteamworkother ??
![Page 4: SSI Evidence – a Surgeon’s Perspective E. Patchen Dellinger, MD University of Washington.](https://reader030.fdocuments.in/reader030/viewer/2022012922/56649cbf5503460f949855e4/html5/thumbnails/4.jpg)
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?
![Page 5: SSI Evidence – a Surgeon’s Perspective E. Patchen Dellinger, MD University of Washington.](https://reader030.fdocuments.in/reader030/viewer/2022012922/56649cbf5503460f949855e4/html5/thumbnails/5.jpg)
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
![Page 6: SSI Evidence – a Surgeon’s Perspective E. Patchen Dellinger, MD University of Washington.](https://reader030.fdocuments.in/reader030/viewer/2022012922/56649cbf5503460f949855e4/html5/thumbnails/6.jpg)
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
![Page 7: SSI Evidence – a Surgeon’s Perspective E. Patchen Dellinger, MD University of Washington.](https://reader030.fdocuments.in/reader030/viewer/2022012922/56649cbf5503460f949855e4/html5/thumbnails/7.jpg)
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?
![Page 8: SSI Evidence – a Surgeon’s Perspective E. Patchen Dellinger, MD University of Washington.](https://reader030.fdocuments.in/reader030/viewer/2022012922/56649cbf5503460f949855e4/html5/thumbnails/8.jpg)
![Page 9: SSI Evidence – a Surgeon’s Perspective E. Patchen Dellinger, MD University of Washington.](https://reader030.fdocuments.in/reader030/viewer/2022012922/56649cbf5503460f949855e4/html5/thumbnails/9.jpg)
Surgical Antibiotic ProphylaxisMy Choices
Bacteroides expectedCefazolin 2 g + Metronidazole 1g, IV
in OR
Repeat cefazolin q 3 h during procedure
Bacteroides not expectedCefazolin 2 g, IV in OR
Repeat q 3 h during procedure
![Page 10: SSI Evidence – a Surgeon’s Perspective E. Patchen Dellinger, MD University of Washington.](https://reader030.fdocuments.in/reader030/viewer/2022012922/56649cbf5503460f949855e4/html5/thumbnails/10.jpg)
Alternatives
Cefazolin
Other first generation cephalosporin
Cefuroxime, cefamandole, cefonicid
Oxacillin, etc
Cefazolin plus metronidazole
Ertapenem
Aminoglycoside or quinolone plus clindamycin or metronidazole
![Page 11: SSI Evidence – a Surgeon’s Perspective E. Patchen Dellinger, MD University of Washington.](https://reader030.fdocuments.in/reader030/viewer/2022012922/56649cbf5503460f949855e4/html5/thumbnails/11.jpg)
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?
![Page 12: SSI Evidence – a Surgeon’s Perspective E. Patchen Dellinger, MD University of Washington.](https://reader030.fdocuments.in/reader030/viewer/2022012922/56649cbf5503460f949855e4/html5/thumbnails/12.jpg)
Burke. In: Hunt, ed. Wound Healing and Wound Infection, New York: Appleton, 1980:242.
Decisive Period For Development Of Wound Infection
Lesion Age (hrs)
Lesi
on
Siz
e,
(mm
)
![Page 13: SSI Evidence – a Surgeon’s Perspective E. Patchen Dellinger, MD University of Washington.](https://reader030.fdocuments.in/reader030/viewer/2022012922/56649cbf5503460f949855e4/html5/thumbnails/13.jpg)
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 + Penicillin
Control
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
Control
Staph + Erythromycin
Staph + TetracyclineStaph + Chloramphenicol
Burke JF. Surgery. 1961;50:161.
![Page 14: SSI Evidence – a Surgeon’s Perspective E. Patchen Dellinger, MD University of Washington.](https://reader030.fdocuments.in/reader030/viewer/2022012922/56649cbf5503460f949855e4/html5/thumbnails/14.jpg)
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
ion
s (%
)
Hours From Incision
14/369
5/6995/1009
2/180
1/81
1/411/47
15/441
![Page 15: SSI Evidence – a Surgeon’s Perspective E. Patchen Dellinger, MD University of Washington.](https://reader030.fdocuments.in/reader030/viewer/2022012922/56649cbf5503460f949855e4/html5/thumbnails/15.jpg)
Prophylactic AntibioticsTiming - Cefazolin
Serum Levels (mg/L)
On Call Anesth
Incision 87 148
1 hour 37 57
2 hours 25 39
DiPiro. Arch Surg 1985;120:829
![Page 16: SSI Evidence – a Surgeon’s Perspective E. Patchen Dellinger, MD University of Washington.](https://reader030.fdocuments.in/reader030/viewer/2022012922/56649cbf5503460f949855e4/html5/thumbnails/16.jpg)
Prophylactic AntibioticsTiming – Cefazolin
Incision
Wound closure
No Drug Dectectable
9
7
38%
17
11
14%
On Call Anesth
Muscle Levels
DiPiro JT et al. Arch Surg. 1985;120:829-832.
![Page 17: SSI Evidence – a Surgeon’s Perspective E. Patchen Dellinger, MD University of Washington.](https://reader030.fdocuments.in/reader030/viewer/2022012922/56649cbf5503460f949855e4/html5/thumbnails/17.jpg)
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
![Page 18: SSI Evidence – a Surgeon’s Perspective E. Patchen Dellinger, MD University of Washington.](https://reader030.fdocuments.in/reader030/viewer/2022012922/56649cbf5503460f949855e4/html5/thumbnails/18.jpg)
Timing of Prophylactic Antibiotic Administration – Cardiac, Arthroplasty,
Hysterectomy
Steinberg. TRAPE. Ann Surg 2009; 250:10
![Page 19: SSI Evidence – a Surgeon’s Perspective E. Patchen Dellinger, MD University of Washington.](https://reader030.fdocuments.in/reader030/viewer/2022012922/56649cbf5503460f949855e4/html5/thumbnails/19.jpg)
Repeat Antibiotic Prophylaxis Doses in Gastrointestinal Procedures
0
1
2
3
4
5
6
7
Cefaz x 1 Cefaz x 2 Cefotetan
< 3 hr
> 3 hr
Surgical Site Infections
Pe
rce
nt
Scher. Am Surg 1997;63:59
![Page 20: SSI Evidence – a Surgeon’s Perspective E. Patchen Dellinger, MD University of Washington.](https://reader030.fdocuments.in/reader030/viewer/2022012922/56649cbf5503460f949855e4/html5/thumbnails/20.jpg)
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?
![Page 21: SSI Evidence – a Surgeon’s Perspective E. Patchen Dellinger, MD University of Washington.](https://reader030.fdocuments.in/reader030/viewer/2022012922/56649cbf5503460f949855e4/html5/thumbnails/21.jpg)
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
![Page 22: SSI Evidence – a Surgeon’s Perspective E. Patchen Dellinger, MD University of Washington.](https://reader030.fdocuments.in/reader030/viewer/2022012922/56649cbf5503460f949855e4/html5/thumbnails/22.jpg)
Cardiac Surgery ProphylaxisEffect of Atrial Appendage Levels
Yes
No
6
13
InfectedCephalothin (mg/l)
Platt. Ann Intern Med. 1984;101:770-774.
P = .02
![Page 23: SSI Evidence – a Surgeon’s Perspective E. Patchen Dellinger, MD University of Washington.](https://reader030.fdocuments.in/reader030/viewer/2022012922/56649cbf5503460f949855e4/html5/thumbnails/23.jpg)
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 g
Infection rate at 1g: 16.5%
Infection rate at 2g: 5.6%
Forse RA. Surgery 1989;106:750
![Page 24: SSI Evidence – a Surgeon’s Perspective E. Patchen Dellinger, MD University of Washington.](https://reader030.fdocuments.in/reader030/viewer/2022012922/56649cbf5503460f949855e4/html5/thumbnails/24.jpg)
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
![Page 25: SSI Evidence – a Surgeon’s Perspective E. Patchen Dellinger, MD University of Washington.](https://reader030.fdocuments.in/reader030/viewer/2022012922/56649cbf5503460f949855e4/html5/thumbnails/25.jpg)
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.
![Page 26: SSI Evidence – a Surgeon’s Perspective E. Patchen Dellinger, MD University of Washington.](https://reader030.fdocuments.in/reader030/viewer/2022012922/56649cbf5503460f949855e4/html5/thumbnails/26.jpg)
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
![Page 27: SSI Evidence – a Surgeon’s Perspective E. Patchen Dellinger, MD University of Washington.](https://reader030.fdocuments.in/reader030/viewer/2022012922/56649cbf5503460f949855e4/html5/thumbnails/27.jpg)
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?
![Page 28: SSI Evidence – a Surgeon’s Perspective E. Patchen Dellinger, MD University of Washington.](https://reader030.fdocuments.in/reader030/viewer/2022012922/56649cbf5503460f949855e4/html5/thumbnails/28.jpg)
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.
![Page 29: SSI Evidence – a Surgeon’s Perspective E. Patchen Dellinger, MD University of Washington.](https://reader030.fdocuments.in/reader030/viewer/2022012922/56649cbf5503460f949855e4/html5/thumbnails/29.jpg)
Duration of ProphylaxisColorectal
Author Drug Duration Infection
Törnqvist 1981doxycycline 1 dose 10%3 days 19%
Juul 1987 amp/metronid 1 dose 6%3 days 6%
![Page 30: SSI Evidence – a Surgeon’s Perspective E. Patchen Dellinger, MD University of Washington.](https://reader030.fdocuments.in/reader030/viewer/2022012922/56649cbf5503460f949855e4/html5/thumbnails/30.jpg)
Duration of ProphylaxisJoint Replacement
Author Drug Duration Infection
Pollard 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%
![Page 31: SSI Evidence – a Surgeon’s Perspective E. Patchen Dellinger, MD University of Washington.](https://reader030.fdocuments.in/reader030/viewer/2022012922/56649cbf5503460f949855e4/html5/thumbnails/31.jpg)
Duration of Prophylaxis:Infection and Antibiotic Resistance
Risk in Cardiac Surgery
< 48 hr >48 hr OddsShort LongRatio
Number 1502 1139
SSI 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
![Page 32: SSI Evidence – a Surgeon’s Perspective E. Patchen Dellinger, MD University of Washington.](https://reader030.fdocuments.in/reader030/viewer/2022012922/56649cbf5503460f949855e4/html5/thumbnails/32.jpg)
Single vs Multiple Dose Surgical Prophylaxis: Systematic Review
0.01
0.1
1
10
100
McDonald. Aust NZ J Surg 1998;68:388
All
stu
die
s, f
ixe
dA
ll st
ud
ies,
ra
nd
om
Mu
lti >
24
hM
ulti
<
24
h
Fav
ors
sing
le d
ose
Fav
ors
mul
tiple
dos
e
![Page 33: SSI Evidence – a Surgeon’s Perspective E. Patchen Dellinger, MD University of Washington.](https://reader030.fdocuments.in/reader030/viewer/2022012922/56649cbf5503460f949855e4/html5/thumbnails/33.jpg)
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
![Page 34: SSI Evidence – a Surgeon’s Perspective E. Patchen Dellinger, MD University of Washington.](https://reader030.fdocuments.in/reader030/viewer/2022012922/56649cbf5503460f949855e4/html5/thumbnails/34.jpg)
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.
![Page 35: SSI Evidence – a Surgeon’s Perspective E. Patchen Dellinger, MD University of Washington.](https://reader030.fdocuments.in/reader030/viewer/2022012922/56649cbf5503460f949855e4/html5/thumbnails/35.jpg)
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
![Page 36: SSI Evidence – a Surgeon’s Perspective E. Patchen Dellinger, MD University of Washington.](https://reader030.fdocuments.in/reader030/viewer/2022012922/56649cbf5503460f949855e4/html5/thumbnails/36.jpg)
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
![Page 37: SSI Evidence – a Surgeon’s Perspective E. Patchen Dellinger, MD University of Washington.](https://reader030.fdocuments.in/reader030/viewer/2022012922/56649cbf5503460f949855e4/html5/thumbnails/37.jpg)
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
![Page 38: SSI Evidence – a Surgeon’s Perspective E. Patchen Dellinger, MD University of Washington.](https://reader030.fdocuments.in/reader030/viewer/2022012922/56649cbf5503460f949855e4/html5/thumbnails/38.jpg)
Antibiotic and Mechanical Bowel Prep for Colectomy (48 hrs)
Any SSI
Placebo (59) 25 (42%)
Neo + Metronidazole (51) 9 (18%)
p<0.01
Matheson. Br J Surg 1978; 65:597-600
![Page 39: SSI Evidence – a Surgeon’s Perspective E. Patchen Dellinger, MD University of Washington.](https://reader030.fdocuments.in/reader030/viewer/2022012922/56649cbf5503460f949855e4/html5/thumbnails/39.jpg)
Antibiotic and Mechanical Bowel Prep for Colectomy (48 hrs)
Any SSI
Placebo (39) 16 (41%)
Kanamycin + Erythro (38) 3 (8%)
p<0.001
Wapnick. Surgery 1979; 85:317-21
![Page 40: SSI Evidence – a Surgeon’s Perspective E. Patchen Dellinger, MD University of Washington.](https://reader030.fdocuments.in/reader030/viewer/2022012922/56649cbf5503460f949855e4/html5/thumbnails/40.jpg)
Antibiotic and Mechanical Bowel Prep for Colectomy (18 - 48 hrs)
Bowel Prep + Placebo Oral Ab
197443% 5%
197743% 9%
197842% 18%
197941% 8%
![Page 41: SSI Evidence – a Surgeon’s Perspective E. Patchen Dellinger, MD University of Washington.](https://reader030.fdocuments.in/reader030/viewer/2022012922/56649cbf5503460f949855e4/html5/thumbnails/41.jpg)
Sometime in the 1980’s most American and Canadian surgeons adopted oral antibiotic regimens while most European surgeons abandoned oral antibiotics.
![Page 42: SSI Evidence – a Surgeon’s Perspective E. Patchen Dellinger, MD University of Washington.](https://reader030.fdocuments.in/reader030/viewer/2022012922/56649cbf5503460f949855e4/html5/thumbnails/42.jpg)
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
![Page 43: SSI Evidence – a Surgeon’s Perspective E. Patchen Dellinger, MD University of Washington.](https://reader030.fdocuments.in/reader030/viewer/2022012922/56649cbf5503460f949855e4/html5/thumbnails/43.jpg)
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
![Page 44: SSI Evidence – a Surgeon’s Perspective E. Patchen Dellinger, MD University of Washington.](https://reader030.fdocuments.in/reader030/viewer/2022012922/56649cbf5503460f949855e4/html5/thumbnails/44.jpg)
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
![Page 45: SSI Evidence – a Surgeon’s Perspective E. Patchen Dellinger, MD University of Washington.](https://reader030.fdocuments.in/reader030/viewer/2022012922/56649cbf5503460f949855e4/html5/thumbnails/45.jpg)
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
![Page 46: SSI Evidence – a Surgeon’s Perspective E. Patchen Dellinger, MD University of Washington.](https://reader030.fdocuments.in/reader030/viewer/2022012922/56649cbf5503460f949855e4/html5/thumbnails/46.jpg)
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
![Page 47: SSI Evidence – a Surgeon’s Perspective E. Patchen Dellinger, MD University of Washington.](https://reader030.fdocuments.in/reader030/viewer/2022012922/56649cbf5503460f949855e4/html5/thumbnails/47.jpg)
0%
5%
10%
15%
C.difficile colitis Prolonged Ileus
No Oral Antibiotics
Oral Antibiotics
Pe
rce
nt o
f pa
tient
s
* 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
![Page 48: SSI Evidence – a Surgeon’s Perspective E. Patchen Dellinger, MD University of Washington.](https://reader030.fdocuments.in/reader030/viewer/2022012922/56649cbf5503460f949855e4/html5/thumbnails/48.jpg)
“Evidence Based” Bundle to Prevent SSI in Colorectal Surgery
Process Measure Study Control
Mechanical Bowel Prep No YesOral Antibiotics No Yes
PreOp Warming Yes No
IntraOp Warming Yes YesFiO2 80% 30%
Wound Protector Yes No
SCIP Parenteral Antibiotics Yes Yes
Any SSI* 45% 24%
Anthony. Arch Surg 2010; 146: 263-9
![Page 49: SSI Evidence – a Surgeon’s Perspective E. Patchen Dellinger, MD University of Washington.](https://reader030.fdocuments.in/reader030/viewer/2022012922/56649cbf5503460f949855e4/html5/thumbnails/49.jpg)
“Evidence Based” Bundle to Prevent SSI in Colorectal
Surgery
1. Appropriate SCIP IV prophylactic antibiotics
2. Postop normothermia (T>98.6/37)
3. Oral antibiotics and bowel prep
4. Minimally invasive surgery
5. Short operative duration (<100 min)
Waits (MSQC). Surgery 2014;epub
![Page 50: SSI Evidence – a Surgeon’s Perspective E. Patchen Dellinger, MD University of Washington.](https://reader030.fdocuments.in/reader030/viewer/2022012922/56649cbf5503460f949855e4/html5/thumbnails/50.jpg)
“Evidence Based” Bundle to Prevent SSI in Colorectal
Surgery
Waits (MSQC). Surgery 2014;epub
![Page 51: SSI Evidence – a Surgeon’s Perspective E. Patchen Dellinger, MD University of Washington.](https://reader030.fdocuments.in/reader030/viewer/2022012922/56649cbf5503460f949855e4/html5/thumbnails/51.jpg)
Oral Antibiotics Without Bowel Prep?
VASQIP, 9940 patients, 112 hospitals
Incidence 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
![Page 52: SSI Evidence – a Surgeon’s Perspective E. Patchen Dellinger, MD University of Washington.](https://reader030.fdocuments.in/reader030/viewer/2022012922/56649cbf5503460f949855e4/html5/thumbnails/52.jpg)
Oral Antibiotics for Colorectal Operations
Cannon. Dis Col Rectum 2012; 55: 1160-6
![Page 53: SSI Evidence – a Surgeon’s Perspective E. Patchen Dellinger, MD University of Washington.](https://reader030.fdocuments.in/reader030/viewer/2022012922/56649cbf5503460f949855e4/html5/thumbnails/53.jpg)
Differential Parenteral Efficacyand Addition of Oral
AntibioticsAgent Odds Ratio Range
Cefaz/Metron 1.0 Reference
Amp/Sulbactam 2.16 1.35 - 3.58
Cefotetan 2.53 1.51 - 4.22
Cefoxitin 2.56 1.73 - 3.81
Add Oral Ab* 0.37 0.29 - 0.46
Deierhoi. JACS 2013; 217:763-9*P < 0.0001
![Page 54: SSI Evidence – a Surgeon’s Perspective E. Patchen Dellinger, MD University of Washington.](https://reader030.fdocuments.in/reader030/viewer/2022012922/56649cbf5503460f949855e4/html5/thumbnails/54.jpg)
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 – 0.76
Greater than 2300 pts in each comparison
GRADE evidence quality HIGH
Nelson RL, Cochrane Rev 2014; #5: CD001181
![Page 55: SSI Evidence – a Surgeon’s Perspective E. Patchen Dellinger, MD University of Washington.](https://reader030.fdocuments.in/reader030/viewer/2022012922/56649cbf5503460f949855e4/html5/thumbnails/55.jpg)
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!
![Page 56: SSI Evidence – a Surgeon’s Perspective E. Patchen Dellinger, MD University of Washington.](https://reader030.fdocuments.in/reader030/viewer/2022012922/56649cbf5503460f949855e4/html5/thumbnails/56.jpg)
![Page 57: SSI Evidence – a Surgeon’s Perspective E. Patchen Dellinger, MD University of Washington.](https://reader030.fdocuments.in/reader030/viewer/2022012922/56649cbf5503460f949855e4/html5/thumbnails/57.jpg)
![Page 58: SSI Evidence – a Surgeon’s Perspective E. Patchen Dellinger, MD University of Washington.](https://reader030.fdocuments.in/reader030/viewer/2022012922/56649cbf5503460f949855e4/html5/thumbnails/58.jpg)
![Page 59: SSI Evidence – a Surgeon’s Perspective E. Patchen Dellinger, MD University of Washington.](https://reader030.fdocuments.in/reader030/viewer/2022012922/56649cbf5503460f949855e4/html5/thumbnails/59.jpg)
![Page 60: SSI Evidence – a Surgeon’s Perspective E. Patchen Dellinger, MD University of Washington.](https://reader030.fdocuments.in/reader030/viewer/2022012922/56649cbf5503460f949855e4/html5/thumbnails/60.jpg)
![Page 61: SSI Evidence – a Surgeon’s Perspective E. Patchen Dellinger, MD University of Washington.](https://reader030.fdocuments.in/reader030/viewer/2022012922/56649cbf5503460f949855e4/html5/thumbnails/61.jpg)
![Page 62: SSI Evidence – a Surgeon’s Perspective E. Patchen Dellinger, MD University of Washington.](https://reader030.fdocuments.in/reader030/viewer/2022012922/56649cbf5503460f949855e4/html5/thumbnails/62.jpg)
Oxygen and SSI
![Page 63: SSI Evidence – a Surgeon’s Perspective E. Patchen Dellinger, MD University of Washington.](https://reader030.fdocuments.in/reader030/viewer/2022012922/56649cbf5503460f949855e4/html5/thumbnails/63.jpg)
Hunt. Am J Med. 1981;70:712.
Influence of Oxygen on the Development of Wound Infection
Hours After Innoculation
Dia
mete
r In
fect
iou
s N
ecr
osi
s (m
m)
![Page 64: SSI Evidence – a Surgeon’s Perspective E. Patchen Dellinger, MD University of Washington.](https://reader030.fdocuments.in/reader030/viewer/2022012922/56649cbf5503460f949855e4/html5/thumbnails/64.jpg)
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
Ob
serv
ed-E
xpec
ted
SS
I R
ate
Maximum wound pO2
Hopf. Arch Surg 1997;132:997
3324
19 15
25
14
![Page 65: SSI Evidence – a Surgeon’s Perspective E. Patchen Dellinger, MD University of Washington.](https://reader030.fdocuments.in/reader030/viewer/2022012922/56649cbf5503460f949855e4/html5/thumbnails/65.jpg)
Near InfraRed O2 Saturation inthe Surgical Incision at 12 hrs
Ives. Br J Surg 2007;94:87-91
p < 0.04
Abdominal Operations
![Page 66: SSI Evidence – a Surgeon’s Perspective E. Patchen Dellinger, MD University of Washington.](https://reader030.fdocuments.in/reader030/viewer/2022012922/56649cbf5503460f949855e4/html5/thumbnails/66.jpg)
Oxygen and SSI• Oxygen tension in the wound
is important.
• How to translate that into clinical practice that lowers SSI is less obvious.
![Page 67: SSI Evidence – a Surgeon’s Perspective E. Patchen Dellinger, MD University of Washington.](https://reader030.fdocuments.in/reader030/viewer/2022012922/56649cbf5503460f949855e4/html5/thumbnails/67.jpg)
Temperature and SSI
(Oxygen)
![Page 68: SSI Evidence – a Surgeon’s Perspective E. Patchen Dellinger, MD University of Washington.](https://reader030.fdocuments.in/reader030/viewer/2022012922/56649cbf5503460f949855e4/html5/thumbnails/68.jpg)
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
![Page 69: SSI Evidence – a Surgeon’s Perspective E. Patchen Dellinger, MD University of Washington.](https://reader030.fdocuments.in/reader030/viewer/2022012922/56649cbf5503460f949855e4/html5/thumbnails/69.jpg)
Temperature and SSI Following Colectomy
Normo (104) Hypo (96) P
SSI 6 18 .009
Kurz. NEJM 1996;334:1209
![Page 70: SSI Evidence – a Surgeon’s Perspective E. Patchen Dellinger, MD University of Washington.](https://reader030.fdocuments.in/reader030/viewer/2022012922/56649cbf5503460f949855e4/html5/thumbnails/70.jpg)
Local Warming and SSI after Clean Operations
Local Systemic Control
SSI* 5 (4%)8 (6%)19 (14%)
Post-op antibiotics* 9 (7%)9 (7%)22 (16%)
Melling. Lancet 2001;358:876
* p < 0.01
![Page 71: SSI Evidence – a Surgeon’s Perspective E. Patchen Dellinger, MD University of Washington.](https://reader030.fdocuments.in/reader030/viewer/2022012922/56649cbf5503460f949855e4/html5/thumbnails/71.jpg)
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
![Page 72: SSI Evidence – a Surgeon’s Perspective E. Patchen Dellinger, MD University of Washington.](https://reader030.fdocuments.in/reader030/viewer/2022012922/56649cbf5503460f949855e4/html5/thumbnails/72.jpg)
Redistribution Hypothermia
Core37°C
Vasoconstricted
Periphery31-35°C
Anesthesia
Periphery33-35°C
Core36°C
Vasodilated
![Page 73: SSI Evidence – a Surgeon’s Perspective E. Patchen Dellinger, MD University of Washington.](https://reader030.fdocuments.in/reader030/viewer/2022012922/56649cbf5503460f949855e4/html5/thumbnails/73.jpg)
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.
![Page 74: SSI Evidence – a Surgeon’s Perspective E. Patchen Dellinger, MD University of Washington.](https://reader030.fdocuments.in/reader030/viewer/2022012922/56649cbf5503460f949855e4/html5/thumbnails/74.jpg)
Prewarming at UWMC &First Postoperative TemperaturePost Anesthesia Care Unit (PACU) 2006
> 36o
7836/8132 (96.4%)
> 36o
& < 36.5o
1047/2647 (40%)
> 36.5o
1491/2647 (56%)
![Page 75: SSI Evidence – a Surgeon’s Perspective E. Patchen Dellinger, MD University of Washington.](https://reader030.fdocuments.in/reader030/viewer/2022012922/56649cbf5503460f949855e4/html5/thumbnails/75.jpg)
Oxygen (FiO2)
and SSI
![Page 76: SSI Evidence – a Surgeon’s Perspective E. Patchen Dellinger, MD University of Washington.](https://reader030.fdocuments.in/reader030/viewer/2022012922/56649cbf5503460f949855e4/html5/thumbnails/76.jpg)
Spinal Surgery, FiO2, & SSI
Maragakis. Anesthesiol 2009; 110:556-62
![Page 77: SSI Evidence – a Surgeon’s Perspective E. Patchen Dellinger, MD University of Washington.](https://reader030.fdocuments.in/reader030/viewer/2022012922/56649cbf5503460f949855e4/html5/thumbnails/77.jpg)
Meta-Analysis: FiO2 & SSI
Qadan. O2 & SSI.Review. Arch Surg 2009; 144:359-66
Mayzler
Pryor
Greif
Belda
Myles
![Page 78: SSI Evidence – a Surgeon’s Perspective E. Patchen Dellinger, MD University of Washington.](https://reader030.fdocuments.in/reader030/viewer/2022012922/56649cbf5503460f949855e4/html5/thumbnails/78.jpg)
![Page 79: SSI Evidence – a Surgeon’s Perspective E. Patchen Dellinger, MD University of Washington.](https://reader030.fdocuments.in/reader030/viewer/2022012922/56649cbf5503460f949855e4/html5/thumbnails/79.jpg)
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
![Page 80: SSI Evidence – a Surgeon’s Perspective E. Patchen Dellinger, MD University of Washington.](https://reader030.fdocuments.in/reader030/viewer/2022012922/56649cbf5503460f949855e4/html5/thumbnails/80.jpg)
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
![Page 81: SSI Evidence – a Surgeon’s Perspective E. Patchen Dellinger, MD University of Washington.](https://reader030.fdocuments.in/reader030/viewer/2022012922/56649cbf5503460f949855e4/html5/thumbnails/81.jpg)
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.
![Page 82: SSI Evidence – a Surgeon’s Perspective E. Patchen Dellinger, MD University of Washington.](https://reader030.fdocuments.in/reader030/viewer/2022012922/56649cbf5503460f949855e4/html5/thumbnails/82.jpg)
Glucose and SSI
![Page 83: SSI Evidence – a Surgeon’s Perspective E. Patchen Dellinger, MD University of Washington.](https://reader030.fdocuments.in/reader030/viewer/2022012922/56649cbf5503460f949855e4/html5/thumbnails/83.jpg)
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
![Page 84: SSI Evidence – a Surgeon’s Perspective E. Patchen Dellinger, MD University of Washington.](https://reader030.fdocuments.in/reader030/viewer/2022012922/56649cbf5503460f949855e4/html5/thumbnails/84.jpg)
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
![Page 85: SSI Evidence – a Surgeon’s Perspective E. Patchen Dellinger, MD University of Washington.](https://reader030.fdocuments.in/reader030/viewer/2022012922/56649cbf5503460f949855e4/html5/thumbnails/85.jpg)
Deep Sternal SSI and Glucose
0
1
2
3
4
5
6
7
8
100-150 150-200 200-250 250-300
Day 1 Glucose (mg%)
% D
eep
Ste
rnal
Infe
ctio
n
Zerr. Ann Thorac Surg 1997;63:356
![Page 86: SSI Evidence – a Surgeon’s Perspective E. Patchen Dellinger, MD University of Washington.](https://reader030.fdocuments.in/reader030/viewer/2022012922/56649cbf5503460f949855e4/html5/thumbnails/86.jpg)
Furnary et al. Ann Thorac Surg 1999:67:352
Glucose Control and Deep Sternal Wound Infections
![Page 87: SSI Evidence – a Surgeon’s Perspective E. Patchen Dellinger, MD University of Washington.](https://reader030.fdocuments.in/reader030/viewer/2022012922/56649cbf5503460f949855e4/html5/thumbnails/87.jpg)
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%
![Page 88: SSI Evidence – a Surgeon’s Perspective E. Patchen Dellinger, MD University of Washington.](https://reader030.fdocuments.in/reader030/viewer/2022012922/56649cbf5503460f949855e4/html5/thumbnails/88.jpg)
Postop Glucose (within 48h) and SSI – General Surgery
Ata. Arch Surg 2010: 145: 858-864
Glucose
![Page 89: SSI Evidence – a Surgeon’s Perspective E. Patchen Dellinger, MD University of Washington.](https://reader030.fdocuments.in/reader030/viewer/2022012922/56649cbf5503460f949855e4/html5/thumbnails/89.jpg)
Risk Adjusted Odds Ratios for Infection and Operative Intervention
Colectomy and Bariatric Operations
Kwon. Ann Surg. 2013; 257: 8-14
![Page 90: SSI Evidence – a Surgeon’s Perspective E. Patchen Dellinger, MD University of Washington.](https://reader030.fdocuments.in/reader030/viewer/2022012922/56649cbf5503460f949855e4/html5/thumbnails/90.jpg)
Composite Infection in Hyperglycemic Patients With
and Without Use of Insulin
Kwon. Ann Surg. 2013; 257: 8-14
![Page 91: SSI Evidence – a Surgeon’s Perspective E. Patchen Dellinger, MD University of Washington.](https://reader030.fdocuments.in/reader030/viewer/2022012922/56649cbf5503460f949855e4/html5/thumbnails/91.jpg)
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%
![Page 92: SSI Evidence – a Surgeon’s Perspective E. Patchen Dellinger, MD University of Washington.](https://reader030.fdocuments.in/reader030/viewer/2022012922/56649cbf5503460f949855e4/html5/thumbnails/92.jpg)
Glucose in NonDiabetics having Colectomy at Cleveland Clinic
Kiran, Ann Surg 2013;258:599–605
Per
Cen
t in
cid
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
![Page 93: SSI Evidence – a Surgeon’s Perspective E. Patchen Dellinger, MD University of Washington.](https://reader030.fdocuments.in/reader030/viewer/2022012922/56649cbf5503460f949855e4/html5/thumbnails/93.jpg)
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%
![Page 94: SSI Evidence – a Surgeon’s Perspective E. Patchen Dellinger, MD University of Washington.](https://reader030.fdocuments.in/reader030/viewer/2022012922/56649cbf5503460f949855e4/html5/thumbnails/94.jpg)
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
![Page 95: SSI Evidence – a Surgeon’s Perspective E. Patchen Dellinger, MD University of Washington.](https://reader030.fdocuments.in/reader030/viewer/2022012922/56649cbf5503460f949855e4/html5/thumbnails/95.jpg)
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.
![Page 96: SSI Evidence – a Surgeon’s Perspective E. Patchen Dellinger, MD University of Washington.](https://reader030.fdocuments.in/reader030/viewer/2022012922/56649cbf5503460f949855e4/html5/thumbnails/96.jpg)
Some Things New
Teamwork,
Communication,
and Discipline
![Page 97: SSI Evidence – a Surgeon’s Perspective E. Patchen Dellinger, MD University of Washington.](https://reader030.fdocuments.in/reader030/viewer/2022012922/56649cbf5503460f949855e4/html5/thumbnails/97.jpg)
BMRI = Behavioral Marker Risk IndexBriefing, Information sharing, Inquiry, Vigilance and Awareness
![Page 98: SSI Evidence – a Surgeon’s Perspective E. Patchen Dellinger, MD University of Washington.](https://reader030.fdocuments.in/reader030/viewer/2022012922/56649cbf5503460f949855e4/html5/thumbnails/98.jpg)
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
![Page 99: SSI Evidence – a Surgeon’s Perspective E. Patchen Dellinger, MD University of Washington.](https://reader030.fdocuments.in/reader030/viewer/2022012922/56649cbf5503460f949855e4/html5/thumbnails/99.jpg)
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
![Page 100: SSI Evidence – a Surgeon’s Perspective E. Patchen Dellinger, MD University of Washington.](https://reader030.fdocuments.in/reader030/viewer/2022012922/56649cbf5503460f949855e4/html5/thumbnails/100.jpg)
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)
![Page 101: SSI Evidence – a Surgeon’s Perspective E. Patchen Dellinger, MD University of Washington.](https://reader030.fdocuments.in/reader030/viewer/2022012922/56649cbf5503460f949855e4/html5/thumbnails/101.jpg)
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
![Page 102: SSI Evidence – a Surgeon’s Perspective E. Patchen Dellinger, MD University of Washington.](https://reader030.fdocuments.in/reader030/viewer/2022012922/56649cbf5503460f949855e4/html5/thumbnails/102.jpg)
Checklist and Complications
Before Aftern=3760 n=3820
SSI 3.8% 2.7%
Complic/100 pts 27.3 16.7
Pts with Complic 15.4% 10.6%
Death 1.5% 0.8%
de Vries. NEJM 2010; 363: 1928-37
![Page 103: SSI Evidence – a Surgeon’s Perspective E. Patchen Dellinger, MD University of Washington.](https://reader030.fdocuments.in/reader030/viewer/2022012922/56649cbf5503460f949855e4/html5/thumbnails/103.jpg)
Checklist Completion and Complications
Checklist Completion Complic
Above median 7.1%
Below median11.7%
de Vries. NEJM 2010; 363: 1928-37
![Page 104: SSI Evidence – a Surgeon’s Perspective E. Patchen Dellinger, MD University of Washington.](https://reader030.fdocuments.in/reader030/viewer/2022012922/56649cbf5503460f949855e4/html5/thumbnails/104.jpg)
Checklist Completion and Mortality
Adjusted Odds RatioMortality
All patients 0.85 (0.73-0.98)
van Klei. Ann Surg 2012; 255: 44-9
![Page 105: SSI Evidence – a Surgeon’s Perspective E. Patchen Dellinger, MD University of Washington.](https://reader030.fdocuments.in/reader030/viewer/2022012922/56649cbf5503460f949855e4/html5/thumbnails/105.jpg)
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
![Page 106: SSI Evidence – a Surgeon’s Perspective E. Patchen Dellinger, MD University of Washington.](https://reader030.fdocuments.in/reader030/viewer/2022012922/56649cbf5503460f949855e4/html5/thumbnails/106.jpg)
JAMA 2010; 304:1693-1700
![Page 107: SSI Evidence – a Surgeon’s Perspective E. Patchen Dellinger, MD University of Washington.](https://reader030.fdocuments.in/reader030/viewer/2022012922/56649cbf5503460f949855e4/html5/thumbnails/107.jpg)
Neily. JAMA 2010; 304:1693-1700
Team Training and Mortality
![Page 108: SSI Evidence – a Surgeon’s Perspective E. Patchen Dellinger, MD University of Washington.](https://reader030.fdocuments.in/reader030/viewer/2022012922/56649cbf5503460f949855e4/html5/thumbnails/108.jpg)
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?
![Page 109: SSI Evidence – a Surgeon’s Perspective E. Patchen Dellinger, MD University of Washington.](https://reader030.fdocuments.in/reader030/viewer/2022012922/56649cbf5503460f949855e4/html5/thumbnails/109.jpg)
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