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PubMed1978

Prophylactic use of antibiotics in surgery.

"Sound and careful surgery is the sine qua non of wound management; antimicrobials are adjunctive." The key to successful use of prophylactic antibiotics in surgery is careful selection of cases and medication. There are no final rule or formulas that will always give optimal results. Listed below are some guidelines that may assis the clinician in determining the need and form of antimicrobial use. 1. The operation must carry a significant risk of bacterial contamination. Refined-clean and clean procedures should not be given prophylactic antibiotics. 2. Bacterial cultures should be taken when possible, and the medication used for prophylaxis should be effective against the organisms expected to be encountered. 3. Narrow spectrum antibiotics should be used to conserve the body's normal flora. Broad spectrum antibiotics needed to combat resistant infections should not be used for prophylaxis. 4. The antibiotic should be present in the wound in effective concentrations at the time of the incision and be maintained only as long as the risk of new bacterial contamination exists.

Anti-Bacterial Agents↗
PubMed1997

Practice of standards in female sterilisation.

During training of trainers (TOT) courses organised for medical personnel of Haryana Civil Medical Services (HCMS) by COE Medical College, Rohtak, 55 doctors involved in female sterilisations were interrogated regarding practices in counselling, informed decision, asepsis, surgical procedure, operative and postoperative care and follow-up of the clients accepting sterilisation as contraception. Counselling was the responsibility of auxiliary nurse cum midwife (ANM) lady health volunteer (LHV)/other paramedical workers as viewed by 89.1% participants whereas 85.4% thought that the registration clerk should take the informed consent. Eligibility criteria were always adhered to by 10.9% participants. Asepsis and sterilisation of instruments, etc, were maintained by operation theatre (OT) attendant or OT nurse as answered by 90.9% doctors. Skin preparation was done by a solution containing cetrimide and chlorhexidine alone by 70.8% doctors. The ligation and excision was the method practised by all. Catgut suture was used by only 43.6% doctors. Twenty-six maternal deaths were reported by 20 participants during their whole career. There were 7 deaths on the table, all with laparoscopic sterilisation. Peritonitis with septicaemia was the major cause of death in majority of cases. To ensure high quality and safety of voluntary surgical contraception, programmes must establish a system to ensure that standards are maintained.

Adult↗
PubMed1994

Starch powder contamination of surgical wounds.

OBJECTIVES: To determine if (1) lubricating starch glove powder contaminates surgical wounds even after powdered gloves have been washed and/or wiped: (2) starch powder can be eliminated from surgical wounds when the surgical team wears only powderless gloves; and (3) starch powder introduced into surgical wounds may increase scar formation. DESIGN AND OUTCOME MEASURES: Human surgical wounds were irrigated at the end of operations in which various combinations of powdered and powderless gloves were used. Team members who wore powdered gloves washed them in a saline solution and wiped them on surgical towels. The starch particles in the irrigant were counted. In addition, two series of breast biopsies were performed, one in which the surgeon wore powdered gloves and the other, powderless gloves. Pathologic specimens from reexcisions (for carcinoma) were examined for starch granules and inflammation. RESULTS: Starch granules were found in proportion to the number of surgical team members who wore powdered gloves and to the proximity of the wearer(s) to the operative site. Exclusive use of powderless gloves eliminated the presence of starch powder. Starch-containing phagocytes in tissue were surrounded by an inflammatory reaction, and in one patient the inflammation and scarring were severe. CONCLUSIONS: Starch powder is introduced into wounds by the use of powdered gloves despite glove washing and wiping. It can be eliminated by the exclusive use of powderless gloves. The inflammatory reaction to starch is variable and can be severe.

Equipment Contamination↗
PubMed2001

Aortic graft infections: replacement with autogenous vein.

The purpose of this review article is to summarize our published experience with the use of the superficial femoral-popliteal vein (SFPV) to replace infected aortic prostheses. The SFPV has proven to be resistant to infections of all types and has shown no signs of degeneration over the long term. Since SFPV bypass and prosthetic graft excision are performed as a single stage, operative times are extensive. Therefore, it may not be appropriate for the sickest patients with severe medical comorbidities. Nevertheless, the operation has been associated with gratifyingly low mortality and amputation rates that are far better than published rates associated with graft excision and extra-anatomic bypass. It is particularly suited to patients with complex aortofemoral graft reconstructions who cannot undergo extra-anatomic revascularization for technical reasons. The venous sequella of SFPV harvest are minimal. These data and those from three other centers support the conclusion that graft excision and replacement with SFPV is an excellent alternative for treatment of aortic graft infections.

Aorta↗
PubMed1984

Re-operation for intra-abdominal sepsis. Indications and results in modern critical care setting.

In a 2-year period (1981-1983), 87 abdominal re-explorations (1.6% of total laparotomies) were performed on 77 patients for sepsis in five Downstate hospitals. Fifty-one patients were re-explored solely on clinical grounds, 21 on clinical plus radiographic criteria, four solely on radiographic grounds, and 11 for multiple organ failure. The overall mortality rate was 43%. As expected, the most common laparotomy finding was intra-abdominal abscess (47); other findings included anastomotic leak (14), necrotic bowel (10), evidence of technical error (five), and acalculous cholecystitis (two). The most common clinical findings were localized tenderness, fever, and absent bowel sounds (85%). Fifty-four special studies were performed with an overall accuracy rate of 76%. CAT scans and contrast radiographs were most accurate (92% and 81%) while sonography and gallium scans were less useful (59% and 60%). Seven patients had negative laparotomies. While all were distended and six were febrile, only one patient had focal tenderness. In the 11 patients explored solely for multiple organ failure, six patients had drainable pus despite negative radiographic studies, and two survived. The other five patients had negative laparotomies, and all died. Factors correlated with mortality were age over 50, peritonitis at the primary operation, and multiple organ failure. The approach to these seriously ill patients should be governed by a high index of suspicion. Clinical findings are at least as reliable as sophisticated radiographic modalities of which CAT scan appears to be the most accurate. Re-exploration for multiple organ failure alone will yield a significant group of patients with drainable septic foci and some survivors; thus, exploration for this indication appears to be defensible.

Abdomen↗
PubMed1985

[Postoperative T cell suppression in relation to preoperative nutritional status in childhood].

The influence of moderate malnutrition on the cellular immunity was studied in 59 operated infants and children aged 1 day to 14 years. Except during the neonatal period the number of blood T-cells preoperatively and the degree of the postoperative T-cell suppression did not show a significant difference between children suffering from moderate malnutrition (weight for age less than or equal to 10 percent, less than or equal to 90% of the normal median weight) and the control group. However some datas indicate that even borderline malnutrition impairs the cellular immune-status.

Adolescent↗
PubMed1998

[Late postoperative purulent complications].

557 case records of patients with late postoperative purulent complications (LPC), admitted to department of purulent infection during 10 years were studied (4% of total number of operated patients). The mean duration of hospitalization period of rehospitalized patients made up 14.2 bed days. Mortality rate was 0.4%. 70% of patients with LPC were people of working age. 3 groups of patients were singled out regarding the time after the operation until readmission: group 1 (38.5%) 1 month since the discharge of the patients; group 2 (31.5%) up to 12 months; group 3 (30%) more than 1 year after. In group 1 purulent infection of the wounds predominated, in group 2--infiltrates and mattery fistulas, in group 3--ligature-fistulas, infiltrates of abdominal cavity. LPC after appendectomy was observed in 53% of cases. Among complications purulent infection predominated (60%). 75.8% of patients with LPC needed surgery.

Adult↗
PubMed2001

Antibiotic prophylaxis in clean surgery: breast surgery and hernia repair.

Use of prophylactic antibiotics in clean surgery is still controversial. We reviewed the literature of the last 10 years to identify the best way to approach clean surgery. The question is more important for patients undergoing breast surgery. The presence of an infected breast wound delays the beginning of postoperative adjuvant anticancer therapy: there is good evidence to suggest that delayed adjuvant therapy compromises the outcome for patients in terms of both local control and survival. There are several clinical trials that have addressed the efficacy of prophylactic antibiotics for patients undergoing breast surgery and hernia repair. Platt et al assessed the efficacy of preoperative antibiotic prophylaxis in a clinical trial of 1218 patients undergoing clean surgery with an absolute reduction rate of 39% in wound infections. Gupta et al reported no influence on the incidence of infective complications by antibiotic prophylaxis in 357 patients undergoing elective breast surgery. Like breast surgery, use of prophylaxis in hernia repair is not clear: a prospective, randomized, double-blind, multicenter study of 619 patients assessed no benefit of antibiotic prophylaxis. On the other hand Lewis et al reported a 75% reduction of infections in low-risk patients when a single dose of cefotaxime was used in clean operations. A particularly interesting point is the use of prosthetic mesh in hernia repair and primary reconstructive surgery in breast surgery. Amland et al reported a significant reduction of the incidence of wound infections in a group of patients undergoing reconstructive breast surgery, receiving azithromycin vs placebo (5% vs 20%). In hernia repair we stress the need to prevent wound infections: currently Liechtestein's technique is widely performed all over the world. Mesh infection is an unpleasant event that requires prosthesis removal. The lack of conclusive studies about antibiotic prophylaxis in clean surgery suggests that a single-dose of cephalosporin at the induction of anesthesia may be prudent. This procedure is certainly inexpensive and safe and, more importantly, probably does not have an impact on antibiotic resistance.

Anti-Bacterial Agents↗
PubMed1987

Antibiotic usage in surgery in a large teaching hospital.

A prevalence study of the antibiotic usage in the surgical departments at the Karolinska Hospital, Stockholm, showed that 126/517 hospitalized patients (24%) received antibiotics and that 100/306 operated patients (33%) received antibiotics. 44 (44%) of the operated patients were given their antibiotics as prophylaxis and 46 (37%) of all patients receiving antibiotics were given them as prophylaxis. Antibiotics were administered intravenously to 35 (28%) patients, orally to 75 (60%), and topically to 16 patients (13%) (eye department only). The most commonly used drugs in prophylaxis were isoxazolylpenicillins and trimethoprim-sulphonamide while cephalosporins accounted for a minor part. In therapy the most commonly used drug was isoxazolylpenicillin, followed by ampicillin derivatives, metronidazole, tetracyclines, trimethoprim-sulphonamide and cephalosporins. The pattern of antibiotic usage differed markedly between departments.

Age Factors↗
PubMed2004

Outcomes in heart failure patients after major noncardiac surgery.

OBJECTIVES: The purpose of this study was to evaluate mortality and readmission rates of heart failure (HF) patients after major noncardiac surgery. BACKGROUND: There is a lack of generalizable outcome data on HF patients undergoing major noncardiac surgery because previous studies have been limited to a few academic centers or have not focused on this group of patients. METHODS: Using the 1997 to 1998 Standard Analytic File 5% Sample of Medicare beneficiaries, we identified patients with HF who underwent major noncardiac surgery. A multivariable logistic regression model was used to provide adjusted mortality and readmission rates in patients after noncardiac surgery. Patients with coronary artery disease (CAD) and all other remaining patients (Control) who had similar surgery served as reference groups. RESULTS: Of 23,340 HF patients and 28,710 CAD patients, 1,532 (6.56%) HF patients and 1,757 (6.12%) CAD patients underwent major noncardiac surgery. There were 44,512 patients in the Control group with major noncardiac surgery. After accounting for demographic characteristics, type of surgery, and comorbid conditions, the risk-adjusted operative mortality (death before discharge or within 30 days of surgery) was HF 11.7%, CAD 6.6%, and Control 6.2% (HF vs. CAD, p < 0.001; CAD vs. Control, p = 0.518). The risk-adjusted 30-day readmission rate was HF 20.0%, CAD 14.2%, and Control 11.0% (p < 0.001). CONCLUSIONS: In patients 65 years of age and older, HF patients undergoing major noncardiac surgery suffer substantial morbidity and mortality despite advances in perioperative care, whereas patients with CAD without HF have similar mortality compared with a more general population.

Aged↗
PubMed1981

Antibiotic prophylaxis in surgery.

This review examines the principles and practice of antibiotic prophylaxis in surgery. Such prophylaxis is required to decrease the frequency of postoperative infection in most patients with clean-contaminated and contaminated wounds, to prevent infrequent but devastating infection of prostheses in cardiovascular and orthopedic surgery and to prevent endocarditis in noncardiac surgery in patients who have valvular heart disease. Prophylaxis should begin before operation; it is usually unnecessary afterwards. The antibiotic may be given topically or parenterally. The latter is more certain, but oral prophylaxis in bowel surgery may offer additional protection by reducing colonic flora, and topical wound and peritoneal antibiotics may be augment protective antibiotic levels at those sites. Antibiotics, such as the cephalosporin cefazolin (but not cephalothin), which penetrate blood and tissues rapidly and for prolonged periods, afford excellent prophylaxis at most sites. But for prophylaxis in colonic surgery, antibiotics directed against Bacteroides fragilis may be superior, and to prevent endocarditis in noncardiac surgery, vancomycin or a combination of penicillin and an aminoglycoside is best.

Administration, Oral↗
PubMed1990

Surgical wound infection and cancer among the elderly: a case control study.

Surgical wound infection occurs in fewer than 5% of operations. Nevertheless, it represents the second most common type of hospital-acquired infection and results in increased morbidity and mortality. As with all nosocomial infections, the rate of surgical wound infection increases with age. Patients over 65 years of age run an approximately 15% risk of surgical wound infection. Two-thirds of patients with invasive cancer other than non-melanotic skin cancer are aged 65 years and over. Over half of them are treated surgically for their cancer. Cancer and other chronic diseases have been cited as possible causes of the increased risk of nosocomial infection among the elderly. Using the Foothills Hospital Wound Study Data Base as the sampling frame, we conducted a case-control study of surgical wound infection and cancer among the elderly. Cancer was found not to be a risk factor for surgical wound infection. The results are discussed in relation to the role of immunity in both disorders.

Age Factors↗