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SSI Evidence
–
a Surgeon’s Perspective
E. Patchen Dellinger, MD
University of Washington
Caring for the
Critically Ill Patient
ABC = airway, breathing, circulation
Preventing Surgical Site
Infections (SSI)
ABC = airway, breathing, circulation
= temperature, oxygen, fluids
ABCD - Add drugs (antibiotics)
Add - glucose control
proper hair removal
surgical technique
teamwork
other ??
Prophylactic Antibiotics
Questions
• Which cases benefit?
• Which drug should you use?
• When should you start?
• How much should you give?
• How long should antibiotics be
continued?
Relative Benefit from Antibiotic
Surgical Prophylaxis
Operation
Prophylaxis (%)
Colon
4-12
Other (mixed) GI
4-6
Vascular
1- 4
Cardiac
3-9
Hysterectomy
1-16
Craniotomy
0.5-3
Spinal operation
2.2
Total joint repl
0.5-1
Brst & hernia ops
3.5
Placebo (%)
24-48
15-29
7-17
44-49
18-38
4-12
5.9
2-9
5.2
NNT*
3-5
4-9
10-17
2-3
3-6
9-29
27
12-100
58
Antibiotic Prophylaxis
Demonstrated 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
Prophylactic Antibiotics
Questions
• Which cases benefit?
• Which drug should you use?
• When should you start?
• How much should you give?
• How long should antibiotics be
continued?
Surgical Antibiotic Prophylaxis
My Choices
Bacteroides expected
Cefazolin 2 g + Metronidazole 1g, IV
in OR
Repeat cefazolin q 3 h during
procedure
Bacteroides not expected
Cefazolin 2 g, IV in OR
Repeat q 3 h during procedure
Alternatives
Cefazolin
Other first generation cephalosporin
Cefuroxime, cefamandole, cefonicid
Oxacillin, etc
Cefazolin plus metronidazole
Ertapenem
Aminoglycoside or quinolone plus
clindamycin or metronidazole
Prophylactic Antibiotics
Questions
Which cases benefit?
Which drug should you use?
When should you start?
How much should you give?
How long should antibiotics
be continued?
Lesion Size, (mm)
Decisive Period For Development
Of Wound Infection
Lesion Age (hrs)
Burke. In: Hunt, ed. Wound Healing and Wound Infection, New York: Appleton, 1980:242.
Efficacy Of Prophylaxis Is Independent Of
The Specific Antibiotic
Penicillin, 40,000 U
10
Erythromycin, 0.1 mg/Kg
10
Lesion Size, mm (24 Hours)
Control
5
Staph + Penicillin
0
5
Staph + Erythromycin
0
Chloramphenicol, 0.1 mg/Kg
10
5
Control
Tetracycline, 0.1 mg/Kg
10
Control
0
Staph + Chloramphenicol 5
Control
Staph + Tetracycline
0
-2
0
2
4
6
-2
0
2
Age of Lesion at Antibiotic Injection (Hours)
4
Burke JF. Surgery. 1961;50:161.
6
Perioperative Prophylactic
Antibiotics
4
14/369
Timing of Administration
15/441
Infections (%)
3
1/41
2
1/47
1/81
2/180
1
5/699
5/1009
0
≤-3
-2
-1
0
1
2
3
4
≥5
Hours From Incision
Classen. NEJM. 1992;328:281.
Prophylactic Antibiotics
Timing - 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
Prophylactic Antibiotics
Timing – Cefazolin
Muscle Levels
On Call
Incision
Wound closure
No Drug
Dectectable
Anesth
9
7
17
11
38%
14%
DiPiro JT et al. Arch Surg. 1985;120:829-832.
Prophylactic Antibiotics
Administration in the O.R.
Drugs Given I.V. Push over 5-10 Min
Cefazolin
Drug to incision
Muscle levels
Cefoxitin
Drug to incision
Muscle levels
17 (7-29)
min
76 (9-245) mg/kg
22 (14-27) min
24 (13-45) mg/kg
DiPiro. Arch Surg 1985;120:829
DiPiro. Personal Communication
Timing of Prophylactic Antibiotic
Administration – Cardiac, Arthroplasty,
Hysterectomy
Steinberg. TRAPE. Ann Surg 2009; 250:10
Repeat Antibiotic Prophylaxis Doses
in Gastrointestinal Procedures
Percent
Surgical Site Infections
7
6
5
4
3
2
1
0
< 3 hr
> 3 hr
Cefaz x 1
Cefaz x 2
Cefotetan
Scher. Am Surg 1997;63:59
Prophylactic Antibiotics
Questions
• Which cases benefit?
• Which drug should you use?
• When should you start?
• How much should you give?
• How long should antibiotics be
continued?
Cardiac Surgery Prophylaxis
Effect of Serum Levels
Serum Level
at Wound Closure Infection
None
Present
3/11
2/175
P = .002
Goldmann. J Thorac Cardiovasc Surg. 1977;73:470-479.
Cardiac Surgery Prophylaxis
Effect of Atrial Appendage Levels
Infected
Yes
No
Cephalothin
(mg/l)
6
13
P = .02
Platt. Ann Intern Med. 1984;101:770-774.
Prophylactic Antibiotics
Size 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
Gentamicin Levels and
SSI 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
0.02
0.02
0.04
p
0.05
Gent level < 0.5 at close had 80% SSI rate (p=0.003).
Zelenitsky. Antimicrob Ag Chemother 2002;46:3026-30
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.
New ASHP / IDSA / SHEA / SIS
Antibiotic Prophylaxis
Guidelines
Cefazolin
< 80 kg
> 120 kg
2g
3g
Vancomycin
15 mg/kg
Gentamicin
5 mg/kg
dosing wgt = ideal wgt + 40% of excess wgt
Bratzler. Surgical Infections2013;14:73-156
Prophylactic Antibiotics
Questions
• Which cases benefit?
• Which drug should you use?
• When should you start?
• How much should you give?
• How long should antibiotics be
continued?
Antibiotic Prophylaxis
Duration
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.
Duration of Prophylaxis
Colorectal
Author
Törnqvist 1981
Juul 1987
Drug
Duration Infection
doxycycline
1 dose
3 days
10%
19%
amp/metronid
1 dose
3 days
6%
6%
Duration of Prophylaxis
Joint Replacement
Author
Pollard 1979
(hips)
Heydemann 1986
(hips and knees)
Drug
Duration Infection
cephaloridine
flucloxacillin
12 hours
14 days
1.4%
1.3%
cefazolin
1 dose
24 hours
48 hours
7 days
0
1%
0
1.5%
Duration of Prophylaxis:
Infection and Antibiotic Resistance
Risk in Cardiac Surgery
< 48 hr
>48 hr
Odds
Short
Long
Ratio
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
Favors multiple dose
Single vs Multiple Dose Surgical
Prophylaxis: Systematic Review
100
10
0.1
0.01
All studies, fixed
All studies, random
Multi > 24h
Multi < 24h
Favors single dose
1
McDonald. Aust NZ J Surg 1998;68:388
Relative Benefit from Antibiotic
Surgical Prophylaxis
Operation
Prophylaxis (%)
Placebo (%)
NNT*
Colon
4-12
24-48
3-5
4-6
1-4
3-9
1-16
0.5-3
2.2
0.5-1
3.5
15-29
7-17
44-49
18-38
4-12
5.9
2-9
5.2
4-9
10-17
2-3
3-6
9-29
27
12-100
58
Other (mixed) GI
Vascular
Cardiac
Hysterectomy
Craniotomy
Spinal operation
Total joint repl
Brst & hernia ops
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.
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
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
Antibiotic and Mechanical
Bowel Prep for Colectomy (18
hrs)
Placebo (56)
Neo + Erythro (56)
Any SSI
26 (43%)
5 (9%)
p=0.0001
Clarke. Ann Surg 1977; 186:251-9
Antibiotic and Mechanical Bowel
Prep for Colectomy (48 hrs)
Placebo (59)
Any SSI
25 (42%)
Neo + Metronidazole (51)
9 (18%)
p<0.01
Matheson. Br J Surg 1978; 65:597-600
Antibiotic and Mechanical Bowel
Prep for Colectomy (48 hrs)
Any SSI
16 (41%)
Placebo (39)
Kanamycin + Erythro (38)
3 (8%)
p<0.001
Wapnick. Surgery 1979; 85:317-21
Antibiotic and Mechanical Bowel
Prep for Colectomy (18 - 48 hrs)
Bowel Prep +
1974
1977
1978
1979
Placebo
43%
43%
42%
41%
Oral Ab
5%
9%
18%
8%
Sometime in the 1980’s most
American and Canadian
surgeons adopted oral antibiotic
regimens while most European
surgeons abandoned oral
antibiotics.
Parenteral Alone vs Parenteral and
Oral Antibiotics – All with Bowel
Prep for Colectomy
Parenteral only
Parenteral + Oral
p < 0.002
Lewis. Can J Surg 2002; 45: 173-80
Parenteral Alone vs Parenteral and
Oral Antibiotics – All with Bowel Prep
for Colectomy – Meta-Analysis
Parenteral only
Parenteral + Oral
Lewis. Can J Surg 2002; 45: 173-80
SSI Rate
MBP – yes / no?
Antibiotics – oral / I.V. / both?
N
G
Guenaga. Cochrane Database Syst Rev,2009(1):p.C001544
Nelson. Cochrane Database Syst Rev, 2009,(1): p.CD001181
Bowel Preparation Prior to Elective Colectomy in
Michigan (n=1648)
Overall SSI Rate in Michigan is 8.0%
All patients
Get I.V.
antibiotics
Englesbe. Ann Surg 2010;252: 514–520
Surgical Site Infection Rates following Elective
Colectomy
The Michigan Surgical Quality Collaborative
n=195
All patients
Get I.V.
antibiotics
Propensity Matched
Analysis
(n=740)
Englesbe. Ann Surg 2010;252: 514–520
Oral Antibiotics with a Bowel Preparation
A Propensity Matched Analysis (n=740)
15%
No Oral Antibiotics
Percent of patients
Oral Antibiotics
10%
* P < 0.05
All patients
Get I.V.
antibiotics
5%
0%
C.difficile colitis
Prolonged Ileus
Englesbe. Ann Surg 2010;252: 514–520
“Evidence Based” Bundle to
Prevent SSI in Colorectal Surgery
Process Measure
Study
Control
Mechanical Bowel Prep
Oral Antibiotics
PreOp Warming
No
No
Yes
Yes
Yes
No
IntraOp Warming
FiO2
Wound Protector
SCIP Parenteral Antibiotics
Yes
80%
Yes
Yes
Yes
30%
No
Any SSI*
45%
Yes
24%
Anthony. Arch Surg 2010; 146: 263-9
“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
“Evidence Based” Bundle to
Prevent SSI in Colorectal
Surgery
Waits (MSQC). Surgery 2014;epub
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
Oral Antibiotics for Colorectal
Operations
Cannon. Dis Col Rectum 2012; 55: 1160-6
Differential Parenteral Efficacy
and Addition of Oral
Antibiotics
Agent
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
*P < 0.0001
Deierhoi. JACS 2013; 217:763-9
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
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!
Oxygen and SSI
Diameter Infectious
Necrosis (mm)
Influence of Oxygen on the
Development of Wound Infection
Hours After Innoculation
Hunt. Am J Med. 1981;70:712.
14
19
15
80-89
90-129
24
70-79
33
60-69
25
50-59
25%
20%
15%
10%
5%
0%
-5%
-10%
-15%
40-49
Observed-Expected SSI Rate
Wound Oxygen Tension & SSI
Maximum wound pO2
Hopf. Arch Surg 1997;132:997
Near InfraRed O2 Saturation in
the Surgical Incision at 12 hrs
Abdominal Operations
p < 0.04
Ives. Br J Surg 2007;94:87-91
Oxygen and SSI
• Oxygen tension in the wound
is important.
• How to translate that into
clinical practice that lowers
SSI is less obvious.
Temperature and SSI
(Oxygen)
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
Temperature and SSI Following
Colectomy
SSI
Normo (104)
Hypo (96)
P
6
18
.009
Kurz. NEJM 1996;334:1209
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%)
* p < 0.01
Melling. Lancet 2001;358:876
Perioperative Warming, Intraoperative
Temperature and Complications
----
Open Abdominal Bowel Resections
Periop
N=47
Standard
N=56
P value
200 ml
400 ml
0.011
Any complication
32%
54%
0.027
SSI
13%
33%
0.09
Blood loss
Wong. Br J Surgery 2007; 94: 423-6
Redistribution Hypothermia
Core
37°C
Core
36°C
Periphery Periphery
31-35°C
33-35°C
Vasoconstricted
Anesthesia
Vasodilated
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
o
o
o
20 to 27 , you still have an 10 gradient
between the patient’s temperature and
the room temperature and everyone in
the room is miserable.
Prewarming at UWMC &
First Postoperative Temperature
Post Anesthesia Care Unit (PACU) 2006
o
> 36
o
o
> 36 & < 36.5
o
> 36.5
7836/8132
(96.4%)
1047/2647
(40%)
1491/2647
(56%)
Oxygen (FiO2)
and SSI
Spinal Surgery, FiO2, & SSI
Maragakis. Anesthesiol 2009; 110:556-62
Meta-Analysis: FiO2 & SSI
Mayzler
Pryor
Greif
Belda
Myles
Qadan. O2 & SSI.Review. Arch Surg 2009; 144:359-66
FiO2, SSI, Atelectasis, &
Respiratory Failure
PROXI Trial
80% FiO2
N=685
30% FiO2
N=701
Adjusted
Odds Ratio
131 (19.1%)
141 (20.1%)
0.91
0.69 – 1.20
0.51
Atelectasis
54 (7.9%)
50 (7.1%)
1.13
0.75 – 1.72
0.56
Resp Failure
38 (5.5%)
31 (4.4%)
1.22
0.74 – 2.03
0.44
Outcome
SSI
P
Meyhoff. JAMA 2009; ;302:1543-50
FiO2, SSI, Atelectasis, &
Respiratory Failure
PROXI Trial
80% FiO2
N=685
30% FiO2
N=701
Adjusted
Odds Ratio
131 (19.1%)
141 (20.1%)
0.91
0.69 – 1.20
0.51
Atelectasis
54 (7.9%)
50 (7.1%)
1.13
0.75 – 1.72
0.56
Resp Failure
38 (5.5%)
31 (4.4%)
1.22
0.74 – 2.03
0.44
Outcome
SSI
P
Meyhoff. JAMA 2009; ;302:1543-50
Simply Increasing FiO2 is
Not Enough
Oxygen has to get to the incision to make
a difference
* FiO2
* Regional anesth
* Temperature
* Fluid replacement
* Cardiac output
* Vasopressors
* Vasoconstriction * etc.
Glucose and SSI
Diabetes, Glucose Control, and
SSIs
After Median Sternotomy
% Infections
20
15
10
5
0
<200
200-249
250-299
>300
Latham. ICHE 2001; 22: 607-12
Hyperglycemia and Risk of SSI
after Cardiac Operations
• Hyperglycemia - doubled risk of SSI
• Hyperglycemic:
48% of diabetics
12% of nondiabetics
30% of all patients
• 47% of hyperglycemic episodes were
in nondiabetics
Latham. Inf Contr Hosp Epidemiol. 2001;22:607
Dellinger. Inf Contr Hosp Epidemiol. 2001;22:604
% Deep Sternal Infection
Deep Sternal SSI and
Glucose
8
7
6
5
4
3
2
1
0
100-150
150-200
200-250
250-300
Day 1 Glucose (mg%)
Zerr. Ann Thorac Surg 1997;63:356
Glucose Control and Deep
Sternal Wound Infections
Furnary et al. Ann Thorac Surg 1999:67:352
Early (48h) Postoperative Glucose
Levels and SSI after Vascular Surgery
>151 mg%
117-151 mg%
103-117 mg%
<103 mg%
Vriesendorp. Eur J Vasc Endovasc Surg 2004; 28:520-5
Postop Glucose (within 48h)
and SSI – General Surgery
Glucose
Ata. Arch Surg 2010: 145: 858-864
Risk Adjusted Odds Ratios for Infection
and Operative Intervention
Colectomy and Bariatric Operations
Kwon. Ann Surg. 2013; 257: 8-14
Composite Infection in
Hyperglycemic Patients With
and Without Use of Insulin
Kwon. Ann Surg. 2013; 257: 8-14
Glucose in NonDiabetics having
Colectomy at Cleveland Clinic
Highest Gluc
< 125 mg%
126-200 mg%
200 mg%
All patients
N (%)
816 (33%)
1289 (53%)
342 (14%)
67%
2447 (100%)
Kiran, Ann Surg 2013;258:599–605
Glucose in NonDiabetics having
Colectomy at Cleveland Clinic
8
*p<0.03, ¤ p<0.01, + p<0.05
Per Cent incidence
7
6
5
Mort+
Sepsis¤
SSI*
Reop¤
4
3
2
1
0
<125
126-200
>200
Kiran, Ann Surg 2013;258:599–605
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
70-99
100-139
140-179
>180
384
4251
1801
187
60
pts
pts
pts
pts
pts
31%
Wang. J Surg Res. 2014; 186: 371-8
Preoperative Glucose as a
Screening Tool for Patients
Without Diabetes
25
20
15
Infection
Complication
10
5
0
<70
70-99
100-139 140-179
>180
Wang. J Surg Res. 2014; 186: 371-8
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.
Some Things New
Teamwork,
Communication,
and Discipline
BMRI = Behavioral Marker Risk Index
Briefing, Information sharing, Inquiry, Vigilance and Awareness
Prior to Skin Incision:
All Team Members
Briefing
(Attending Surgeon Leads):
Each person introduces self by name
and role
Surgeon, 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
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
Prior to Skin Incision:
Process Control
Surgeon reviews (as
applicable):
If case expected to be ≥ 1 hour,
add:
Surgeon reviews:

Glucose checked for diabetics

Essential imaging displayed;
right and left confirmed

Insulin protocol initiated if
needed

Antibiotic prophylaxis given
in last 60 minutes


Active warming in place
DVT/PE chemoprophylaxis
and/or mechanical prophylaxis
plan in place

Special instruments and/or
implants

If patient on beta blocker, postop plan formulated

Re-dosing plan for antibiotics

Specialty-specific checklist
After Skin Closure Complete:
No Retained Objects, Debriefing, Care Transition
All Team Members
(Attending Surgeon Leads):
Surgeon and Anesthesia:
 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)
 Key concerns for patient
recovery
 What 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, postop continuation plan formulated
Checklist and Complications
SSI
Unplan Return-O.R.
Any Complic
Death
Before
After
n=3773
n=3955
6.2%
2.4%
11.0%
1.5%
3.4%
1.8%
7.0%
0.8%
Haynes. NEJM 2009; 360: 491-9
Checklist and Complications
SSI
Complic/100 pts
Pts with Complic
Death
Before
After
n=3760
n=3820
3.8%
27.3
15.4%
1.5%
2.7%
16.7
10.6%
0.8%
de Vries. NEJM 2010; 363: 1928-37
Checklist Completion and
Complications
Checklist Completion
Complic
Above median
7.1%
Below median
11.7%
de Vries. NEJM 2010; 363: 1928-37
Checklist Completion and
Mortality
Adjusted Odds Ratio
Mortality
All patients
0.85 (0.73-0.98)
van Klei. Ann Surg 2012; 255: 44-9
Checklist Completion and
Mortality
Adjusted Odds Ratio
Mortality
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
JAMA 2010; 304:1693-1700
Team Training and Mortality
Neily. JAMA 2010; 304:1693-1700
Not Discussed Due to Time
but 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?
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
Slide Set and
References available
by request
Send request to [email protected]