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Importance of preventive surgical protocols.Importance of preventive surgical protocols.

Deep prosthetic joint infection- most dreadful complication .

Best and the most effective method - prevention.

Awareness , education and participation of entire surgical teamcritical.

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JOINT REPLACEMENT SURGERYJOINT REPLACEMENT SURGERY

ELECTIVE

PROPER PLANNING

CALL 2 WKS PRIOR FOR PRE OP INV

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Pre operative EvaluationPre operative Evaluation

  IDENTIFY PATIENTS WITH

 Impaired host defenses

Operative sites that may provide a poor wound environment

Remote sources of infection 

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BLOOD INVBLOOD INV

HB, PCV, ESR DLC TLC BLOOD GR & CROSS MATCH BLOOD SUGAR HbA1C LFT  RFT  BT, CT, PT, INR HIV, HBSAG

Radiology

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URINE EXAMINATIONURINE EXAMINATION

ROUTINE

MICROSCOPY

CULTURE

 

MID STREAM , CLEAN CATCH

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CARDIAC EVALUATIONCARDIAC EVALUATION

ECG

2 D ECHO

CARDIOLOGIST OPINION IF DEEMED NECESSARY

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FOCI OF INFECTION FOCI OF INFECTION 

DENTAL ( CARIES)

ENT ( OM, CSOM )

LOCAL SKIN ( PSORAISIS, PREVIOUS INCISIONS, ULCERS,FOLLOCULITIS, FUNGAL INFCTIONS)

PULMONARY INFECTION

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P A AssessmentP A Assessment

Essential part of pts prep before surgery

Educates patient about anaesthesia

Communicates actual RISK to patient

Helps in allaying anxiety

 

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Host FactorsHost Factors

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Diabetes and obesityDiabetes and obesity 

 Lethal Combination

Infection rate was lower with drain .

Risk factors for periprosthetic infection after TKA.

Clin Orthop Relat Res. 2009 Jun;467(6):1577-81. Epub 2008 Oct 8.

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Stroke, UTI, ileus, post op hemorrhage, transfusions andwound infections.

Higher mortality 

Increased length of stay .

J Bone Joint Surg Am. 2009 Jul;91(7):1621-9.

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Immunocompromised StatesImmunocompromised States

•   Joint replacement uncommon in HIV+ve.

• Most experience gained in patients with haemophilia.

• Deep sepsis - 18.7% primary and 36.3% for revisions.

• A total of 44% of infections resolved fully after medicaland/or surgical treatment.

Journal of Bone and Joint Surgery - British Volume, Vol 83-B, Issue 7,1050-1054

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HaemophiliaHaemophilia

High risk of failure as a result of infection. 

Most by Staphylococcus epidermidis, hematogenous - coagulation factor.

Life expectancy low.

Improvement in quality of life may outweigh the risk of failure.

Total Knee Arthroplasty in Hemophilic Arthropathy

John M. Norian, BS, Michael D. Ries, MD, Susan Karp, RN andJulie Hambleton, MD

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MalnutritionMalnutrition

Total lymphocyte count of less than 1500 cells per cubic millimeter(1.5 x 109 per liter)

Albumin level 

of less than 35 grams per liter

 increased prevalence of wound complications.

J. Arthroplasty , 6: 321-325, 1991

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SmokingSmoking

Wound healing, cardiopulmonary.

Postoperative intensive care, delay in discharge

Wound complications rate twice that of non-smokers.

J Bone Joint Surg Br, Mar 2003; 85-B: 178 - 181

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METHOTREXATEMETHOTREXATE

Can be continued.

No increase in risk for perioperative infections.

  Discontinuing MTX - disease flare .

Grenan DM, Gray J, Loudon J, Fear S. Ann Rheum Dis. 2001

Perhala RS, Wilke WS, Clough JD, Segal AM.. Arthritis Rheum.1991

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CLOPIDOGREL DISCONTINUED ATLEAST 7 DAYS PRIOR (1) 

INTRA-ARTICULAR STEROIDS – SX TO BE POSTPONED FOR ATLEAST 3 MNTHS (2) 

(1) Anaesthesia & intensive care , June 2005(2) A. V. Papavasiliou, D. L. Isaac,

R. Marimuthu, A. Skyrme ,JBJS British Volume, Vol 88-B, 2006

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Skin careSkin care

Shaving not recommended.

  Remove hair with clippers where necessary in the operating ward.

Clippers- reduction in postoperative infection rates

Alexander JW, Fischer JE, Boyajian M, Palmquist J, Morris MJ. Arch Surg.1983; 118:347 -52.

Balthazar ER, Colt JD, Nichols RL.. South Med J.1982; 75:799 -801.

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The surgical wardThe surgical ward

Avoid preoperative stay in the ward

Clean environment to protect from colonization with bacteria frominfected patients.

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SKIN ANTISEPSISSKIN ANTISEPSIS 

MICROSHIELD : 2.5% CHLORHEXIDINE

+ 75% ETHANOL STERLIUM : PROPANOL

10% BETADINE : Povidone-iodine BACTOSCRUB : 4% CHORHEXIDINE

GLUCONATE

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Povidone-iodine may impair wound-healing

Toxic to fibroblasts and keratinocytes (1) 

Not be used for preparation of open wounds or on postoperative dressings (2) 

 

(1) Cooper ML, Laxer JA, Hansbrough JF.. J Trauma.1991; 31:775 -84.

(2) Kramer SA.. J Vasc Nurs.1999; 17:17 -23.

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Surgeon scrubSurgeon scrub  Chlorhexidine gluconate achieved significantly (p < 0.01) greater

adjusted mean log bacterial count reductions than did povidone-iodineat all sampling times.

 

Aly R, Maibach HI. Am J Infect Control. 1988;16:173 -7.

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Povidone-iodine and chlorhexidine gluconate have equal efficacy in decreasingthe initial bacterial contamination of the skin of a patient or surgeon

Chlorhexidine gluconate longer effect, less toxic in open wounds and causesless skin irritation with prolonged use (1)

(1) Grabsch EA, Mitchell DJ, Hooper J, Turnidge JD.. ANZ J Surg.2004;74:769 72.

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During draping, leg should be held by a scrubbed & gowned memberof the team.

Bacterial air counts have been shown to be 4.4 times higher duringdraping using unscrubbed, ungowned leg holder

Brown AR, Taylor GJ, J bone Joint Surg Br 1996;78:92

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Occlusive DrapesOcclusive Drapes 

Ioban : Prevents penetration & lateral migration of bacteria, reducewound contamination as measured by positive cultures of specimensobtained from the skin

Plastic adhesive drapes can avulse or harm thin, friable skin

  Levy JH, Nagle DM, Curling PE, Waller JL, Kopel M, Tobia V. Crit

Care Med.1988

Geelhoed GW, Sharpe K, Simon GL. Surg Gynecol Obstet. 1983

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DISPOSABLE NON WOVENDISPOSABLE NON WOVEN

CLOTHINGCLOTHING Spun laced fibre

Bacteria tend to get entrapped within the fibres

Open structure so air circulation not impended

Single use & expensive

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Wraparound gowns and synthetic gownsWraparound gowns and synthetic gowns

Decreases the number of colony-forming units compared with thatDecreases the number of colony-forming units compared with thatassociated with the use of cotton gowns or operating room clothingassociated with the use of cotton gowns or operating room clothing

Hubble MJ, Weale AE, Perez JV, Bowker KE, MacGowan AP,Hubble MJ, Weale AE, Perez JV, Bowker KE, MacGowan AP,

Bannister GC.Bannister GC.

.J Hosp Infect. 1996.J Hosp Infect. 1996

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GLOVESGLOVES

Gloves perforation during orthopaedics procedure 40 %. So double gloving.

Gloves exclusively for draping are most likely to be contaminated. So routine changing of outer gloves after draping is advisable

James Howard & Arlen Hanssen. Journal of Arthroplasty 2007; 22 

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Avoid repetitive touching of surgical gown with gloves becausebacteria invariably progress to surface of gown

James Howard & Arlen Hanssen. Journal of Arthroplasty 

2007; 22 

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Surgical site infection decreased bySurgical site infection decreased by

•  Control of perioperative glucose levels especially in patients withdiabetes.

• Maximizing patient oxygenation in the first twenty-four hoursperioperatively

• Normothermia in the perioperative period

• Latham R, Lancaster AD, Covington JF, Pirolo JS, Thomas CS. Infect Control Hosp Epidemiol. 2001

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DRAINSDRAINS•  Clamping drains intermittently intotal knee arthroplasty results in

significantly less external blood loss

• No change in morbidity or mortality.

• This study was a level 1 therapeutic study

ANZ J Surg. 2007 May;77(5):333-5.

Drain clamping in knee arthroplasty a randomized controlled trial