Surgical Site Infection

Sunnybrook experience

Claude Laflamme MD, FRCPC Director Cardio-vascular anesthesia

Assistant Professor U of Toronto

Patient and operation

characteristics that may influence

the SSI rates

Age

Nutritional status

Diabetes

Smoking

Obesity

Steroid use

Prolonged pre-op LOS

Patient Operation Post-op care

Antiseptic technique

Surgical technique

Wound classification

Length of surgery

Hair removal, BG,

Antimicrobial prophylaxis

Normothermia,

Blood transfusion

Wound care

Discharge

The Anesthesiologist’s Role

Anesthesiology 2006; 105:413-21

• Hypothermia

• Hyperoxia

• Fluid Management

• Hyperglycemia

• Blood transfusion

• Antimicrobial Prophylaxis

Cardiac Surgery

Quarterly Incidence of Infections

Among Isolated ACB’s 2004-2005

0

5

10

15

20

1st

Quarter

2004

2nd

Quarter

3004

3rd

Quarted

2004

4th

Quarter

2004

1st

Quarter

2005

2nd

Quarter

2005

3rd

Quarter

2005

4th

Quarter

2005

SS

I R

ate

(%

)

Antibiotic Administration in

Cardiac Surgery – June 2005 (N=88)

79

81

0

10

20

30

40

50

60

70

80

88 Patients

Ancef

Vancomycin

Unknown

78

72 1

0

10

20

30

40

50

60

70

80

88 Patients

<60 Minutes Pre-Incision

After Incision

>60 Minutes Pre-Incision

Unknown

GROUP MEAN

0

2

4

6

8

10

12

14

Pre

T15

T30

T45

T60

T75

T90

T12

0Pos

tC

VIC

U

2004

2005

2006 Jan-May

2006 Jun-Aug

[(BG mmol/L) X 18 – 60] X 0.02=units of insulin/hr

2 variables

BG

Multiplier

GOALReduce cardiac surgical site infections (SSI) by 50% by implementing evidence based best practices

PROPHYLACTIC ANTIBIOTIC THERAPYImprovement Strategies (August 2004)

1. Ancef dosage ↑ from 1 gram IV to 2 gram q4h intraop2. Vancomycin 1 gram IV q8h when allergic to penicillin

Results

Reducing Cardiac Surgical Site InfectionsClaude Laflamme MD FRCPC* and Jennifer Williams RN-NP**

Sunnybrook and Women’s College Health Sciences Centre, Department of Anesthesiology*, Department of Cardiovascular Surgery**University of Toronto, Canada

OPTIMIZING SKIN PREPARATIONImprovement Strategies• All patients clipped the morning of operation day• Evidence from other sites indicate that having same day

clipping decreases perioperative SSI by 30%

Results

Data are still being collected

BACKGROUND

• The rate of SSI post-CABG at SWCHSC was 11.29% in 2004

• National Nosocomial Infections Surveillance System (NNIS) benchmark is 5.43%

PRIMARY OBJECTIVES

Antibiotics

• 95% of patients receive prophylactic antibiotics on time

Skin Preparation

• 95% of patients have hair clipping done on the day of surgery or no hair removal

• Skin preparation with Alcohol 70%/Chlorhexidine 2%

Glucose Control

• 95% have glucose < 11.1 mmol/L intraop, and on postop Day 1 and 2

Quarterly Incidence of InfectionsAmong Isolated ACB’s 2004-2005

0

5

10

15

20

1st

Quarter

2004

2nd

Quarter

3004

3rd

Quarted

2004

4th

Quarter

2004

1st

Quarter

2005

2nd

Quarter

2005

3rd

Quarter

2005

4th

Quarter

2005

Antibiotic Administration in

Cardiac Surgery – June 2005 (N=88)

79

81

0

10

20

30

40

50

60

70

80

88 Patients

Ancef

Vancomycin

Unknown

78

72 1

0

10

20

30

40

50

60

70

80

88 Patients

<60 Minutes Pre-Incision

After Incision

>60 Minutes Pre-Incision

Unknown

BLOOD GLUCOSE CONTROL

Improvement Strategies• Adding Hemoglobin A1C to preoperative blood work to

target non-diabetic patients with A1C ≥ 0.07• Tighten perioperative BG control

Results• 9.1% of non-diabetic patients undergoing CABG surgery

had A1C ≥ 0.07

REVIEWING STERILE TECHNIQUE

Improvement Strategies• Staff education sessions by Infection Control Team• 3M module (Mandatory attendance for all OR staff) to

review sterile techniques

• Dental assessment and dental hygiene for all patients prior to valve surgery

• Revise wound care policy

OTHER RECOMMENDATIONSImprovement Strategies

• Purchase whole blood separation system to use concentrated platelet rich plasma spray over incision site to promote healing

• Install a door at the OR nursing station to prevent unauthorized personnel from entering sterile corridor

• Publish the revised Patient Education Booklet• Institute tighter perioperative glucose control• Target BG 6.0-8.0 mmol/L using Point of Care testing –

available for a 6-month trial in 2 CVOR rooms to facilitate

BG control

CHALLENGES• To improve the timing of prophylactic antibiotic

administration to 95% within 60 minutes of skin incision• To decrease postoperative length of stay to 4 days• Change the skin preparation solution to Alcohol 70% and

Chlorhexidine 2%• Resources

Members Of The Team

Sandra Callery, Director IP&C

Dr.Gideon Cohen, CVS, Committee Chair

Dr. Edward Etchells, Director Patient Safety Services

Dr.Stephen Fremes, Head CV Surgery

Laurie Fowler D3, D6 Educator

Elihu Henry RT (OR)

Margaret Gadke, NCC, CV OR

Angie Jeffs, CVICU PCM

Alexandra Leeksma, mgr OR

Jennifer Menezes RN (CVICU)

Jeri Server, Data Manager CV Surgery

Dr. Mary Vearncombe, Medical Director, IP&C

Jennifer Williams, D6 Nurse Practitioner

Dr. Claude Laflamme, Medical Director, Cardiac Anaesthesia

Dr. Jay Silverberg, Head, Endocrinology

Kathleen Browne, Cardiac Coordinator

Kathy Deemar (Manager, Cardiovascular perfusion)

Jane de Lacy, Director Operations, Schulich Heart Program)

Leasa Knechtel, PPL (Cardiology, Cardiac Surgery)

Shirley Lingard, OR Educator/PPL

Charles Smith, D6 PCM

6

7

8

9

10

11

12

13

14

PRE T15 T45 T60 T75 T90 T120 POST CVICU

2004

2005

Intr

aop B

G (

mm

ol/L)

SS

I R

ate

(%

)

Mean Perioperative BG Levels 2004 vs 2005

Time (minutes)

Colorectal Surgery

Infection rates in colorectal

N=44N=29N=15Total

N=16N=14

87.5%

N=2

12.5%

Normothermic

N=28N=15

53.6%

N=13

46.4%

Hypothermic

TotalNo InfectionInfection

P=0.022

Infection rates in colorectalProper antibiotherapy

N=34N=25N=9Total

N=12N=12

100%

N=0

0%

Normothermic

N=22N=13

59.1%

N=9

40.9%

Hypothermic

TotalNo InfectionInfection

P=0.009

Counting only proper Antimicrobial Prophylaxis

Hypo-Infected = 40.9%

Normo-Infected = 0%

P=0.009

2-Tail P=0.013

Bowel Only

Our Tool

C6 PCMSmitha Casper-DeSousa

OR -APNShirley Lingard

OR - RNSherry Porter

APN C6Shari Moura

IPCSandra Callery

Amb - TSRCCMichelle Davis

Wound ExpertiseLouanne Rich-Vanderbij

C6 Team LeaderJessica Simpson

Pre AdmissionGail Sleeman

IPCFatema Jinnah

Anesthesia Ewen Chen

Surgical OncologyDr. Smith

Surgical OncologyDr. Ross

Surgical OncologyDr. Law

Surgical OncologyDr. Hanna

AnesthesiaDr. C Laflamme

Wound ExpertiseDebbie Miller

PACUCarol Deriot

Amb - TSRCCBarbara Anne Maier

OR-PCMAlexa Leeksma

AreaName

Subgroups

• Normothermia Anesthesiology

• Antibiotics Anesthesiology

• Surgical Practice Surgery

• Assessing/tracking wound Infections Infection control

• Wound care Nursing team

• Pre printed oreders Nursing team

Complications of mild hypothermia

• Increases duration of hospitalization

• Increases intra-operative blood loss

• Increases adverse cardiac event

• Increases patient shivering in PACU

• Increases SSI rates

Perioperative hypothermia

• GA alters central thermoregulation

• Thermoregulatory responses are triggered after 2-3ºC of hypothermia (±34ºC)

• Core temperature decreases by 1ºC within 30 minutes of induction

• Heat production decreases by 5%/ºC in the absence of shivering

• Enhanced heat loss

Normothermia for colorectal

surgery

• A Kurz, NEJM 1996; 334:1209-15

• 200 patients, double-blind study

• Followed for 2 weeks

• 34.7±0.6 Celsius VS 36.6±0.5 Celsius

• SSI 18.8% VS 5.8% (p=0.009)

• Sutures were removed one day later (p=0.002)

• Hospital LOS prolonged by 2.6 days (p=0.01)

Hypothermia and cholecystectomy

• Flores-Maldonado et al. 2001

• 290 consecutive patients

• 30-day follow-up

• Patients that received blood transfusion were excluded

• 35.4º±0.4ºC vs 36.2º±0.2ºC

• 11.5% vs 2% SSI

Complications and treatment of

mild hypothermia

Anesthesiology 2001; 95:531-43

• Myocardial Ischemia Frank et al. JAMA 1997;277:1127-34 High risk patients assigned to 1.3ºC core hypothermia were three times as likely to experienced adverse cardiac outcome

• Cold-induced hypertension is associated with a threefold increase in plasma norepinephrine concentrations

Complications and treatment of

mild hypothermia

• Coagulopathy

• Platelet dysfunction (reduction in the release of thromboxane A2

• Clotting factor enzyme

• Fibrinolytic activity-TEG

Complications and treatment of

mild hypothermia

Hypothermia

Impairs neutrophilsfunction

Vasoconstriction

Tissue hypoxia

Hopf et al, Arch Surg 1997

• Subcutaneous oxygen tension at surrogate wound inversely correlated with the risk of SSI

• S/C O2 40-50mmHg had a SSI of 43%

• S/C O2 above 90 mmHg had no SSI

Complications and treatment of

mild hypothermia

• Pharmacokinetics and Pharmacodynamics Reduces clearance during hypothermia

• Prolongs PACU stay

Minimizing hypothermia

• Anesthetics profoundly inhibits central

thermoregulation decreasing the

vasoconstriction threshold by 2-4ºC

• The second major factor is the magnitude of the

core-to-peripheral temperature gradient

• Minimizing the core-to-peripheral temperature

gradient and preoperative vasodilatation, is the

basis to reduce heat redistribution

• Degree of adiposity, concurrent medication

Minimizing hypothermia

• Prewarming: Decreases core-to-peripheral temperature gradient Eventually provokes vasodilatation

• Pharmacologic vasodilatation

Cutaneous warming

• Passive insulation reduces heat loss by approximately 30%

• Active cutaneous heating: efficacy will be proportional to the skin surface warmed Circulating water, Forced air, Radiant warmers

Active cutaneous warming systems

• Forced-air systems

• Circulating-water mattresses

• Resistive heating systems (ICU,trauma) Carbon-fiber patient cover

• Circulating-water garments Water has a conductivity of heat 26 times higher than air

• Infrared radiation(neonats, pediatric Sx)

Core temperature monitoring

• Pulmonary artery

• Nasopharynx

• Tympanic membrane Aural thermocouples probe Infrared thermometer

• Distal Oesophagus

• Rectal temperature during neuraxial anesthesia

Fluid warming

• If more than 2 liters/hr

• One liter of crystalloid or 1 unit of refrigerated blood decreases core temperature by 0.25ºC