Classification of Operative Wounds
1.
2.
3.
4.
Clean (class I) (1.5 –5.1%) –5.1%) Nontraumatic No inflammation encountered No break in technique Respiratory, alimentary, or genitourinary tract not Entered Clean-contaminated (class II) (7.7 –10.8%) –10.8%) Gastrointestinal or respiratory tract entered without significant spillage Appendectomy Oropharynx entered Vagina entered Genitourinary tract entered in absence of infected urine Biliary tract entered in absence of infected bile Minor break in technique Contaminated (class III) Major break in technique(15.2 –16.3%) –16.3%) Major break in technique Gross spillage from gastrointestinal tract Traumatic wound, fresh Entrance of genitourinary or biliary tracts in presence of infected urine or bile Dirty and infected (class IV) (28.0 – (28.0 –40.0%) 40.0%) Acute bacterial inflammation encountered, without pus Transection of “clean” tissue for the purpose of surgical access to a collection of pus Traumatic wound with retained devitalized tissue, foreign bodies, fecal contamination, or delayed treatment, or all of these; or from dirty source Adapted from Cruse PJE: Wound infections: infections: Epidemiology Epidemiology and clinical characteristics. In Howard RJ, Simmons RL (eds): Surgical Infectious Disease 2nd ed. Norwalk, CT, Appleton & Lange, 1988.
Criteria for Defining a Surgical Site Infection (SSI)71 Superficial incisional SSI Infection occurs within 30 days after the operation, and infection involves only skin or subcutaneous subcutaneous tissue of the incisions, and at least one of the following: 1. Purulent drainage, with or without laboratory confirmation, from the superficial incision 2. Organisms isolated from an aseptically obtained culture of fluid or tissue from the superficial incision 3. At least one of the following signs or symptoms of infection: pain or tenderness, localized swelling, redness, or heat; and superficial incision is is deliberately opened by surgeon, unless incision is culture negative 4. Diagnosis of superficial incisional SSI by the surgeon or attending physician Table 5
Do not report the following conditions as SSI: 1. Stitch abscess (minimal inflammation and discharge confined to the points of suture penetration) 2. Infection of an episiotomy or ne wborn circumcision site 3. Infected burn wound 4. Incisional SSI that extends into the f ascial and muscle layers (see deep incisional SSI) Note: Specific criteria are used for identifying infected episiotomy and circumcision sites and burn wounds
Deep incisional SSI Infection occurs within 30 days after the operation if no implant* is left in place or within 1 yr if implant is i n place and the infection appears to be related to the operation, and infection involves deep soft tissues (e.g., fa scial and muscle layers) on the incision, and at least one of the following: 1. Purulent drainage from the deep incision but no t from the organ/space component of the surgical site 2. A deep incision spontaneously dehisces or is deliberately opened by a surgeon when the patient has at least one of the following signs or symptoms: fever (> 38º C [100.4º F]), localized pain, or tenderness, unless site is culture negative 3. An abscess or other evidence of infection involving the deep incision is found on direct examination, during reoperation, or by histopathologic or radiologic examination 4. Diagnosis of a deep incisional SSI by a surgeon or attending physician Notes: 1. Report infection that involves both superficial and deep incision sites as deep incisional SSI 2. Report an organ/space SSI that drains through the incision as a deep incisional SSI
Organ/space SSI Infection occurs within 30 days after the operation if no implant* is left in place or within 1 yr if implant is in place and the infec tion appears to be related to the operation, and infection involves any part of the anatomy (e.g., organs or spaces), other than the incision, which was opened or manipulated during an operation, and at least one of the following: 1. Purulent drainage from a drain that is placed through a stab wound† into the organ/space 2. Organisms isolated from an aseptically obtained culture of fluid or tissue in the organ/space 3. An abscess or other evidence of infection involving the organ/space that is found on direct exam ination, during reoperation, or by histopathologic or radiologic examination 4. Diagnosis of an organ/space SSI b y a surgeon or attending physician
*National Nosocomial Infection Surveillance definition: a nonhuman-derived implantable foreign body (e.g., prosthetic heart valve, nonhuman vascular graft, mechanical heart, or hip prosthesis) that is permanantly placed in a pa tient during surgery. †If the area around a stab wound becomes infected, it is not an SSI. It is considered a skin or soft tissue infection, depending on its depth. th
Principles of Anitbiotic Prophylaxis : Schwartz’s 7 ed (pp 133, table 5.6) 1. Choose an antibiotic effective against the pathogens most likely to be encountered 2. Choose an antibiotic with SAFE, NON-TOXIC, low toxicity 3. The half-life of the antibiotic selected must be long enough to maintain adequate tissue levels throughout the operation. 4. A single preoperative dose that is of the same strength as a full therapeutic dose is adequate in most instances. Administer a single, fully therapeutic dose intravenously 30-60 min preoperatively 5. administer a second dose of antibiotic if the operation lasts longer than 4 hrs or twice the half-life of the antibiotic 6. Give 2-3 doses post-Op. There is no need to extend administration beyond 24 hrs 7. Use of antibiotics is appropriate when infection is frequent or when consequences of infection would be unusually severe CLEAN CASES Prophylactic antibiotics are not indicated in clean operations if the patient has no host risk factors or if the operation does not involve placement of prosthetic materials.
Respiratory infections: occurs between 4-7 POD Fever with in 24 hrs: 1. Atelectasis High fever ( T > 38.9°C) within 48 hrs Post-Op: 1. Atelectasis 2. peritonitis 2 to leaking viscus 3. Invasive wound infection ( Necrotizing fasciitis, clostridial myositis, cellultitis) Fever at 24-48 hrs: 1. Respiratory complications 2. Catheter –related problems Fever after 48-72 hrs: 1. thrombophlebitis th th 2. wound infection – usually between 5 to 8 POD 3. UTI 4. pneumonitis 5. acute acalculus cholecystitis 6. idiopathic post-op pancreatitis 7. drug allergy
8.
candidiasis
Fever after 1 week post-op: 1. drug allergy 2. leaking anastomosis 3. intraabdominal abscess 4. Deep SSI Wound Classification : ACS 2005, Vol I, pp 100 Clincal Features Tetanus-Prone
Non TetanusProne ≤ 6 hrs
Age of wound
> 6hrs
Configuration
Linear
Depth
Stellate, avulsion, abrasion > 1 cm
Mechanism of injury Signs of infection
Missile, crush, burn, frostbite Present
Sharp surface ( glass, knife) Absent
Devitalized Tissue
Present
Absent
Contaminants ( dirt, feces, soil, saliva) History of Immunization (doses) Unknown or < 3
Present
Absent
3 or more
TT
Yes +
No
HTIG
Yes No
≤ 1cm
TT
Yes ++
No
HTIG
No No
+
Yes, if > than 5 years since last dose Yes, if more than 10 years since last dose
++
Sutures: in the face – removed at day 4 or 5 other areas where skin tension is limited – 7 days
Maximum safe dose of lidocaine: ACS 2005 vol I, pp 106 4mg/kg without epinephrine 7mg/kg with epinephrine ASA Classification Class I (0 to 5 points) has a 0.9% risk of serious cardiac event or death Class II (6 to 12 points) has a 7.1% risk Class III (13 to 25 points) has a 16.0% risk Class IV (>26 points) has a 63.6% risk COMPUTATION OF PULMONARY RESERVE:
Child-Pugh Classification : Points 1 Encephalopathy Ascites Bilirubin mg/dl Albumin g/dl Nutritional Status
2
3
None
Stage I or II
Stage III or IV
Absent
Controlled
Uncontrolled
<2
2-3
>3
> 3.5
2.8 – 3.5
< 2.8
Excellent
Good
Poor
Selected Surgical Procedures Stratified by Degree of Cardiac Risk Degree of Cardiac Risk Low (< 1%)
Type of Procedure
Intermediate (1% –5%)
Child-Turcotte-Pugh Classification Protime prolongation INR
Operative Mortality
< 4 sec < 1.7
4-6 sec 1.7 – 2.3
2%
10%
6 sec > 2.3
High (> 5%)
Endoscopic procedures Ambulatory procedures Ophthalmic procedures Aesthetic procedur Minor vascular procedures (e.g., carotid endarterectomy) Abdominal procedures Thoracic procedures Neurosurgical procedures Otolaryngologic procedures Orthopedic procedures Urologic procedures Emergency procedures (intermediate or high risk) Major vascular procedures (e.g., peripheral vascular surgery, AAA repair) Extensive surgical procedures with profound estimated blood loss, large fluid shifts, or both Unstable hemodynamic situations
50%
Relative Contraindications to Outpatient Surgery Operative Mortality (One point for each): Bilirubin > 2.0 mg/dl Albumin < 3.0 g/dl Protime > 16s Encepahlopathy total points Mortality 1 43% 2 85% 3 100% Grading of Hepatic Encephalopathy : Stage Neurologic Changes
Procedures with an anticipated significant blood loss
Procedures associated with significant postoperative pain
Procedures necessitating extended postoperative I.V. therapy
ASA class IV (or III if the systemic disease is not under control, as with
unstable angina, asthma, diabetes mellitus, and morbid obesity)
Known coagulation problems, including the use of anticoagulants
Inadequate abillity or understanding on the part of caretakers with
Stage I
Mild confusion, euphoria or depression, decreased attention span, slowing of ability to perform men tal tasks, irritability, disorder of sleep pattern
respect to requirements for postoperative care
Stage II
Drowsiness, lethargy, gross deficit in ability to perform mental tasks, obvious personality changes, inappropriate behaviour, intermittent and shortlived disorientation
Stage III
Somnolent but arousable, unable to pe rform mental tasks, disorientation with respect to time, palce and person, amnesia, occasional fits of rage, speech present but incomprehensible
Stage V
Coma
Surgical Categories Category 1 Generally noninvasive procedures with minimal blood loss and with minimal risk to the patient independent of anesthesia Anticipated blood loss less than 250 ml Limited procedure involving skin, subcutaneous, eye, or superficial lymphoid tissue Entry into body without surgical incision Excludes the following:
Fasting Recommendations* to Reduce Risk of Pulmonary Aspiration
Open exposure of internal body organs, repair of vascular or neurologic structures, or placement of prosthetic devices Entry into abdomen, thorax, neck, cranium, or extremities other than wrist, hand, or digits Placement of prosthetic devices Postoperative monitored care setting (ICU, ACU)
Ingested Material Clear liquids‡ Breast milk Infant formula Nonhuman milk§ Light meal¶
Category 2 Procedures limited in their invasive nature, usually with minimal to mild blood loss and only mild associated risk to the patient independent of anesthesia Anticipated blood loss less than 500 ml Limited entry into abdomen, thorax, neck, or extremities for diagnostic or minor therapy without removal or major alteration of major organs Extensive superficial procedure
Excludes the following: Open exposure of internal body organs or repair of vascular or neurologic structures Placement of prosthetic devices Postoperative monitored care setting (ICU, ACU), with no open exposure of abdomen, thorax, neck, cranium, or extremities other than wrist, hand, or digits
Category 3 More invasive procedures and those involving moderate blood loss with moderate risk to the patient independent of anesthesia Anticipated blood loss 500 –1,500 ml Open exposure of the abdomen Reconstructive work on hip, shoulder, knees
Excludes the following: Open thoracic or intracranial procedure Major vascular repair (e.g., aortofemoral bypass) Major orthopedic reconstruction (e.g., spinal fusion) Planned postoperative monitored care setting (ICU, ACU)
Category 4
Procedures posing significant risk to the patient independent of anesthesia or in one or more of the following categories: Procedure for which postoperative intensive care is planned Procedure with anticipated blood loss greater than 1,500 ml Cardiothoracic procedure Intracranial procedure Major procedure on the oropharynx Major vascular, skeletal, or neurologic repair
Minimum Fasting Period† (hr) 2 4 6 6 8
Disposition of Current Medications before Outpatient Surgery97
Continue Antihypertensives Beta blockers Calcium channel blockers ACE inhibitors
Discontinue or withhold Diuretics Insulin Digitalis
Vasodilators
to short-acting agent such as heparin
Anticoagulants (may change
Bronchodilators Antiseizure meds Tricyclic antidepressants MAO inhibitors (controversial) Corticosteroids Thyroid preparations Anxiolytics Modified Aldrete Phase I Postanesthetic Recovery Score42,43 Patient Sign Criterion Score Activity Able to move 4 extremities* 2 Able to move 2 extemities* 1 Able to move 0 extremities* 0 Respiration Able to breathe deeply and cough 2 Dyspnea or limited breathing 1 Apneic, obstructed airway 0 Circulation BP ± 20% of preanesthetic value 2 BP ± 20% –49% of preanesthetic value 1 BP ± 50% of preanesthetic value 0 Consciousness Fully awake 2 Arousable (by name) 1 Nonresponsive 0 Oxygen SpO2 > 92% on room air 2 saturation Requires supplemental O2 to 1 maintain SpO2 > 90% SpO2 < 90% even with O2 supplement 0 *Either spontaneously or on command. SpO2—pulse oximetry
POST-OP MANAGEMENT Issues to Address in Postoperative Instructions Activity Medication Diet Wound care Pain relief Possible complications or side effects (of procedure, anesthesia, or medications) Follow-up testing or treatments Emergency contacts, including surgeon and acute care facility
Assessment of the patient's airway patency (openness of the airway), vital signs, and level of consciousness are the first priorities upon admission to the PACU. The following is a list of other assessment categories: surgical site (intact dressings with no signs of overt bleeding) patency (proper opening) of drainage tubes/drains body temperature (hypothermia/hyperthermia) patency/rate of intravenous (IV) fluids circulation/sensation in extremities after vascular or orthopedic surgery level of sensation after regional anesthesia pain status nausea/vomiting Reasons for Notification of Surgeon37 Unstable Vitals signs Persistent nausea and vomiting Bleeding Fever (usually > 101° F [38.3° C]) Persistent uncontrolled pain Excessive redness or drainage from incision Urinary retention/ decreased urine output
Indications for Nutritional Intervention: The patient has been without nutrition for 10 days Nutritional deficits occur after 7-10 days of partial starvation The duration of illness is anticipated to be longer than 10 days E.g. peritonitis, pancreatitis, injury severity score > 15, burns > 20% TBSA The patient is malnourished ( loss of > 10% of usual body weight over 3 months) Give nutritional support when weight loss approaches or exceeds 15% of usual body weight: %weight loss = Usual weight – present weight X 100 Usual weight
Guidelines for Red Blood Cell Transfusion for Acute Blood Loss * Evaluate risk of ischemia. Estimate/anticipate degree of blood loss. Less than 30% rapid volume loss probably does not require transfusion in a previously healthy individual.
Measure hemoglobin concentration: < 6 g/dL, transfusion usually required; 6 –10 g/dL, transfusion dictated by clinical circumstance; >10 g/dL, transfusion rarely required. Measure vital signs/tissue oxygenation when hemoglobin is 6 to 10 g/dL and extent of blood loss is unknown. Tachycardia and hypotension refractory to volume suggest the need for transfusion; O2 extraction ratio > 50%, VO2 decreased, sugges t that transfusion usually is needed.
Alterations In Metabolic Rate: No post-op complications, fistula without infection = normal Elective major surgery : 24% Mild peritonitis, long bone fracture or mild to moderate injury = add 25% of BEE Skeletal trauma : 34% Blunt Trauma: 37% Head trauma/Steroids: 61% Sepsis: 79% Severe injury or infection in ICU patient, MOF = add 50% of BEE Burn of 40% - 100% TBSA = add 100-132% of BEE BMI: M: BEE( Kcal/day) = 66 + ( 13.7 x wt. in kg) + (5 x ht. in cm) – (6.8 x age in yrs) F: BEE ( Kcal/day) = 665 + ( 9.6 x wt. in kg) + ( 1.7 x ht. in cm) – (4.7 x age in yrs) For most non-trauma, ICU patients: give 35kcal/kg body weight/day CHON = 0.8 g/kg/day or 1.5 -2.0 g/kg/day for cri tically ill patients 1 gram Nitrogen: 150 Kcal - contraindications to high protein diet: Renal failure before dialysis ( BUN > 40mg/dl) Hepatic encephalopathy
DEFINITION OF TERMS: SIRS: ( 2 or more of the ff. are required) 1. Temp > 38° C ( 100.4 °F) or , 36° C ( 96.8°F) 2. HR > 90 bpm 3. RR > 20 cpm 4. WBC > 12, 000/cumm3, < 4, 000/cumm or > 10% bands
SEPSIS: SIRS + Clinically likely source of infection SEVERE SEPSIS SEPSIS + hemodynamic instability necessitating fluid resuscitation (hypoperfusion, hypotension, lactic acidosis, oliguria, mental status changes) SEPTIC SHOCK SEVERE SEPSIS + Hemodynamic instability necessitating inotropic support
Phases of wound healing: ACS 2005 pp 110-115 1. hemostasis – vasoconstriction 2. inflammation – 24 hrs -5-7 days 3. migratory phase nd rd a. angiogenesis – begins at 2 -3 day b. epithelialization – begins approx 24 hrs after wounding th 4. proliferative phase – begins on 5 day a. wound contraction – most active for 12-15 days until wound edges meet 5. late phase ( Remodelling) – begins 3weeks after wounding, continues for 6-12 months; tensile strength plateaus at 6 weeks post injury Wound Dehiscence: separation within the fascial layer serosanguinous discharge on days 5-8 Causes: increasing age technical factors malnutrition hypoproteinemia uremia diabetes increased abdominal pressure ( coughing, ascites) jaundice cancer local factors: hemorrhage Infection excessive suture material poor surgical technique Ranson’s Criteria ( objective sign’s of severity of acute pancreatitis) On Admission: Age > 55 y.o Glucose > 200mg/dl WBC > 16,000/cumm LDH > 350 IU/L AST > 250 U/L
After Initial 48 hrs Serum Ca++ < 8mg/dl Arterial PO2 < 60mmHg
Base Deficit > 4meq/L BUN Increase > 5mg/dl Hematocrit fall > 10% Fluid Sequestration > 6,000ml
Total Body Water : 75-80% in newborns 65% at 1 yr of age 60% lean body weight in young men ±15% 50% in young women and older men ±15% 45% in older women 2/3 intracellular or 30-40% - largest proportion in skeletal muscle mass ECF = 20% body weight Plasma = 5% Interstitial = 15% Average Insensible water loss/day ( pure-water, electrolyte-free)= 500-600cc Skin, lungs ( increased by fever, hyperventilation) Increased renal excretion: diabetic insipidus Water of oxidation = 125 – 800cc/day Avearge Sensible Water losses: Urine = 800- 1500cc, minimum of 300cc Intestinal = 0-250cc
Composition of GI Secretions: Type of Volume Tonicity Major Secretion ( ml/24hrs) electrolytes Salivary 500-2000 cc, Hypotonic HCO3, K Ave = 1500 Gastric 100- 4000cc; Hypotonic Cl, Na Ave = 1500 Duodenum 100-2000cc; Isotonic Na, Cl Ileum 100-9000cc Isotonic Na, Cl Ave = 3000 Colon Hypotonic Na, Cl Pancreas 100-800cc Isotonic Na, HCO3, Cl Bile 50-800cc Isotonic Na, Cl Hypotonic losses: Sweat Vomiting, NGT suction Osmotic cathartics: lactulose, sorbitol Osmotic diuretics: mannitol, glycosuria WaterDeficit = Normal body water ( 1 – serum Sodium/140) IV Fluid challenge: present weight x 0.07 L/kg x 0.10 = IV bolus to be given give 10% of estimated circulating volume blood is 7% of body weight 65%-75% of infused fluids leaves the vascular compartment within 30 min
