The prophylactic antibiotic puzzle.
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Anti-Bacterial Agents↗
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Results for “Prophylactic Surgical Procedures”
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Safe prophylactic perioperative use of anticoagulants.
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Anticoagulants↗
Prophylactic antibiotics in elective orthopedic surgery: a prospective study of 1,591 cases.
A double-blind prospective study involving 1,591 clean orthopedic surgical procedures was done to test the effectiveness of preoperative and intraoperative antibiotics in reducing the postoperative infection rate. The antibiotic and placebo groups were analyzed carefully for factors known to predispose to infection. Several minor exceptions were noted, but generally the antibiotic and placebo groups were comparable with regard to these factors. A decrease in overall postoperative infection rate from 5.0% in the placebo group to 2.8% in the antibiotic group was found. In specific areas such as the hip and spine a much greater reduction in postoperative wound infections occurred than in the group as a whole.
Adult↗
Prevention of wound sepsis in gastro-intestinal surgery.
After gastro-intestinal operations wound infection is usually caused by the inoculation of bacteria present within the intestinal tract into the incision during the surgical procedure. In theory, wound sepsis may be minimized by the following methods: (a) avoiding intestinal contamination of the incision; (b) altering the normal flora of the intestinal tract by adding oral antimicrobials to bowel preparation; (c) using topical or systemic prophylactic antibiotic administration for certain high-risk patients. The relative importance of these methods of prophylaxis is described.
Anti-Bacterial Agents↗
Natural and synthetic antifibrinolytics in cardiac surgery.
In an effort to reduce morbidity associated with transfusion of blood products, the use of antifibrinolytics to decrease bleeding and transfusions after cardiopulmonary bypass (CPB) is receiving widespread attention. The predominant haemostatic defect induced by CPB and, therefore, the mechanisms by which natural (aprotinin) or synthetic antifibrinolytics (sigma-amino-caproic acid, tranexamic acid) exert their effects have been difficult to define. Nonetheless, all three substances appear to be effective in the treatment or in the prevention of excessive bleeding associated with cardiac surgery. However, the administration of these drugs should not attempt to replace meticulous surgical and anaesthetic care. In particular, the importance of an appropriate transfusion practice cannot be overemphasized. The efficient use of these, sometimes expensive, drugs must take into account not only the initial cost, but also the short- and long-term economic consequences for the health care provider of using, or not using, a given medication. Unfortunately, the comprehensive data on which authoritative conclusions may be reached are not yet available. Pending availability of these data, the present use of antifibrinolytics at the Montreal Heart Institute is the following: (1) patients undergoing elective primary myocardial revascularization or valve surgery do not receive prophylactic antifibrinolytics; (2) patients undergoing repeat myocardial revascularization, repeat valve surgery, or primary or repeat combined procedures, receive prophylactic sigma-aminocaproic acid; (3) sigma-aminocaproic acid may be used to treat excessive chest drainage in the postoperative period; (4) the prophylactic and the therapeutic uses of low doses of aprotinin are currently under investigation.
Aminocaproic Acid↗
New approaches to serious infections in the surgical patient.
The primary treatment of serious surgical infections involves a surgical procedure--debridement, drainage, or diversion--coupled with the adjunctive use of antibiotic therapy. Antibiotics are administered as prophylaxis, as presumptive therapy, or as precise therapy. Prophylactic antibiotics must be nontoxic, inexpensive, and have a broad spectrum of activity. It is also important that they not interfere with the primary treatment or the host defense. Antibiotics for presumptive therapy must be active against a wide range of presumed pathogens, but they are chosen primarily for their efficacy and secondarily for their lack of toxic and immunosuppressive effects. Because surgical infections are polymicrobial, standard therapy has consisted of a combination of antibiotics; monotherapy with an agent that is less toxic but as effective as combination therapy is a promising new approach to treatment.
Anti-Bacterial Agents↗
The effect of hair on infection after cranial surgery.
OBJECTIVE: Reports of large series of patients who had undergone successful cranial neurosurgery without hair removal led part of our team to abandon the practice of shaving patients' heads pre-operatively. The aim of this study was to assess whether this change in routine, which was implemented in 1992, has affected the rate of postoperative infection in our cranial surgery patients. METHODS: A group of patients whose heads were shaved pre-operatively was compared to a group whose hair was not shaved prior to cranial surgery. The latter patients had their hair washed with shampoo and 4% chlorhexidine within 24 hours of their operation. In the operating room, the surgical site was scrubbed for 8-10 minutes with 4% chlorhexidine diluted with water, and then cleansed with 10% povidone-iodine solution. Prophylactic antibiotics were administered for 3 days. RESULTS: We performed 1,038 cranial procedures without hair removal. The procedures included craniotomy for tumour, trauma, aneurysm, other vascular lesions and intracerebral haemorrhage (n = 847), stereotactic biopsy (n = 90), stereotactic craniotomy (n = 34), ventriculoperitoneal shunt placement (n = 27), surgical treatment of infection with aspiration of brain abscess or resection of infected tissue (n = 14), microvascular decompression for trigeminal neuralgia or hemifacial spasm (n = 11), and other miscellaneous procedures (n = 15). We observed 13 postoperative wound infections (1.25%), including 9 deep (0.87%) and 4 superficial infections (0.39%). There was no significant difference between the rate of infection in patients whose heads were shaven (12/980) and the rate in those whose hair was spared (13/1038) (p > 0.05). In addition. there were no other problems related to the surgical preparation technique in the latter group. CONCLUSION: Cranial surgery without hair removal is safe and does not increase the risk of surgical wound infection. Patients naturally prefer to keep their full head of hair. We believe that preoperative hair removal is not necessary in preparation for any type of cranial neurosurgery.
Hair Removal↗
Edgar J. Poth Memorial Lecture. Surgical aspects of the short-bowel syndrome.
BACKGROUND: Surgeons are frequently confronted with patients with the short-bowel syndrome. Important surgical issues are maintaining intestinal continuity, treating complications, and performing procedures to improve intestinal function. METHODS: A comprehensive review of the English language literature and the author's own experience were employed to make recommendations about surgical management of the short-bowel syndrome. CONCLUSION: At the time of initial resection, ostomy formation is often prudent. The decision to restore continuity at a later time should balance anticipated functional outcome against potential complications. Several surgical strategies can be employed at reoperation in these patients to minimize further loss of intestine. Prophylactic cholecystectomy should be considered because of the increased risk of cholelithiasis. Gastric hypersecretion rarely requires operative therapy. Surgical therapy for the short-bowel syndrome includes procedures to slow intestinal transit, optimize intestinal function, and increase intestinal surface area. The choice of operation is influenced by intestinal remnant length and caliber and its function. Only a small proportion of patients are candidates for nontransplant procedures, of which intestinal lengthening is most efficacious. Intestinal transplantation, either alone or combined with the liver, is emerging as the most promising therapy in short-bowel syndrome.
Humans↗
Hemophilic synovitis of the knee and the elbow.
A prospective study from 1974 to 1996 was done to determine optimal treatment for chronic hemophilic synovitis of the knee and synovitis of the elbow. Sixty-five patients with synovitis affecting 65 knee joints and 40 patients who had synovitis of the elbow (44 elbows), despite a 3-month trial of prophylactic substitution therapy, were treated by synovectomy. Radiation synovectomies (Au-198 synoviorthesis) were done on 38 knees, open surgical synovectomy on 18, and nine had an arthroscopic procedure. Radioactive gold synoviorthesis was performed on 29 elbows, and 15 had a resection of the radial head and partial open synovectomy. Synovectomy (by any method) significantly reduced bleeding episodes, but did not halt the radiographic deterioration of the joints. It is thought that radiation synovectomy is the best choice for patients with persistent synovitis of the knee and synovitis of the elbow unresponsive to a 3-month trial of prophylactic factor replacement. If two to three consecutive synoviortheses with 3 to 6 months intervals had been ineffective, or when the radiographic score is more than two points, an open synovectomy is indicated.
Adolescent↗
Abdominal hysterectomy: indications and complications.
This retrospective study was conducted to evaluate the indications and complications for non-radical abdominal hysterectomy. Between 1 July 1990 and 30 June 1991, 176 women underwent abdominal hysterectomy in our Department. The indications for hysterectomy, the conservation of ovaries, type of concurrent procedures, choice of incision, choice of fascial closure in midline incisions, use of prophylactic antibiotics and complications of abdominal hysterectomy were analysed. The most common indication was uterine leiomyomata followed by pelvic endometriosis and premalignant disease. Haemorrhage requiring transfusion was the commonest intra-operative complication. Unintended surgical procedures occurred in almost 3% of patients.
Adolescent↗
[Therapy and prevention of hemorrhage from esophageal varices].
Management of variceal hemorrhage includes emergency treatment of bleeding esophageal varices and prophylactic treatment for the prevention of first bleeding or rebleeding. Endoscopic injection sclerotherapy appears to be the most effective therapeutic option to control acute variceal hemorrhage. When sclerotherapy fails or cannot be performed a Sengstaken-Blakemore tube can be used. Supportive treatment is provided by vasodilator or vasoconstrictor therapy. At present, operative treatment modalities such as portosystemic shunts or esophageal transection are secondary to sclerotherapy or balloon tamponade. The probability of recurrent variceal hemorrhage after a first bleeding is 70%. This necessitates preventive measures such as endoscopic sclerotherapy, beta-blockade, or surgical procedures. Meta-analysis of randomised controlled trials indicates that sclerotherapy appears to reduce the number of episodes of recurrent variceal hemorrhage better than other prophylactic treatments and to improve survival. Chronic sclerotherapy may be the procedure of first choice in patients with good liver function when elective shunt surgery is provided for those who have recurrent bleeding despite sclerotherapy. The role of beta-blockade in the prevention of recurrent bleeding remains to be clearly defined. Prevention of first esophageal bleeding by invasive treatment modalities could reasonably only be performed in patients with high bleeding risk, which, however, cannot be defined accurately at present. The use of beta-blockers in the prevention of first variceal hemorrhage should be restricted to clinical trials.
Combined Modality Therapy↗
[Performance of restoration surgeries in postburn stenosis of the esophagus and stomach].
The thirty-years experience of treatment of 987 patients with postburn stenosis of the gut upper parts was summarized. Of the total amount of restorational operations performed in 431 patients there were: esophagoplasty using colon--in 313 (72.62%), small intestine--in 26 (6.04%), stomach--in 66 (15.32%), segment of colon and ileum on the vascular pedicle--in 10 (2.31%), autotransplantation of jejunal segment--in 2 (0.47%), esophagocardioplasty--in 5 (1.15%), plasty with application of local tissues--in 9 (2.09%). Total mortality had constituted 6.96%, but during last 12 years it had subsided down to 1.91% due to perfection of the operations technique performed, new procedures introduction, the anesthesiological support improvement, wide usage of prophylactic measures for possibly occurring complications.
Anastomosis, Surgical↗
[Systemic mezlocillin prophylaxis in elective colon surgery].
A prospective randomized, controlled study comprising 100 patients was performed to evaluate the effect of mezlocillin given prophylactically in elective colon surgery. Fifty-two patients were treated and 48 served as controls. Both groups were well-matched for age, sex, disease and surgical procedure. 2 g of mezlocillin were given intravenously before surgery and then every eight hours until the fifth postoperative day. The concentrations of mezlocillin in serum and tissues were determined in 20 patients and related to the MICs of the contaminants and the bacteria isolated postoperatively. A significantly lower incidence of intra-abdominal complications, peritonitis, urinary tract infections and wound infections was found in the mezlocillin group (10%) than in the controls (46%). The average number of postoperative hospital days decreased significantly from 23 days in the control group to 19 days in the mezlocillin group. The analysis of the bacteriological results gave no indication of a selection of resistant strains due to the prophylactic use of mezlocillin. No side-effects were found in connection with mezlocillin prophylaxis.
Adult↗
Malignant hyperthermia and the otolaryngologist.
Malignant hyperthermia is a rare disorder that can occur in patients who are sensitive to certain agents used in general anesthesia. The treatment of malignant hyperthermia has not changed over the years, but prevention strategies have evolved. These strategies include an increased emphasis on how patients are managed prior to a surgical procedure, on the selection of the particular anesthetic agent, and on postoperative vigilance. Susceptible patients who undergo simple excisions or a low degree of surgical stress can receive treatment safely in the office or ambulatory surgery center and be discharged the same day, provided that all known triggering agents are avoided. For more extensive procedures that cause a moderate level of surgical stress to susceptible patients, facilities for managing malignant hyperthermia should be readily available. Susceptible patients who undergo high-stress invasive procedures should be hospitalized. Routine preoperative prophylactic drug administration, even with dantrolene, is no longer considered necessary for any susceptible patients. All local anesthetics--including lidocaine, which had been previously contraindicated--are now considered to be safe for use in patients who are susceptible to malignant hyperthermia. In this article, we review the prevention, diagnosis, and management of malignant hyperthermia. We also report our experience in anesthetizing a patient who had a history of malignant hyperthermia--a case that illustrates the uncertainty that can complicate the management of such patients.
Adult↗
[The alcoholic patient in the daily routine].
Chronic alcohol abuse is of significant clinical and economic relevance. A major part of internal medical pathology is associated with chronic alcoholism. 50% of all accidents with subsequent traumatic injuries are related to alcohol intake. Patients who are chronic alcohol abusers have prolonged hospital stays and substantial increases in postoperative morbidity. A sophisticated diagnosis of alcoholism within standard clinical routine is often difficult, and in most cases the treatment of alcohol-related diseases and complications is protracted and requires increased energy expenditure by the treating physicians. In surgical patients, chronic alcohol abuse is associated with a 3- to 4-fold risk of infections, sepsis, cardiac and bleeding complications. Therefore, the patients themselves, along with the general practitioner and an in-hospital interdisciplinary team should cooperate in medical and operative treatment in order to attain better clinical outcome. Each patient history should include a detailed assessment of the quantity of daily alcohol intake. Alcoholic diagnostic regimens including questionnaires (i.e. CAGE, AUDIT) in combination with specific laboratory markers (CDT, GGT, MCV), if implemented, could prove valuable, especially in cases where major surgical procedures are considered. Strict abstinence by alcoholic patients with organ pathology in medical and elective surgical settings as well as the prophylactic treatment of pre-operative alcohol withdrawal appear to be useful strategies to reduce the risk of complications. Short-term interventions are associated with reduced alcohol intake and decreased incidence of re-trauma. Considering the clinical relevance of alcohol abuse, sufficient screening, interventions, and open approaches to address alcohol problems should be important components of the daily clinical routine in outpatient clinics, emergency rooms, in GPs' offices and in general hospitals.
Acute Disease↗
Antimicrobial prophylaxis in the surgical patient.
The primary prophylactic measure against postoperative infection is antiseptic technique in patient preparation, during surgery, and in postoperative patient care. Antimicrobial prophylaxis against postoperative infection is not indicated for procedures with a low infection rate because the expected benefit of antimicrobial treatment is less than the risk of an adverse medication reaction. Antimicrobial prophylaxis has been demonstrated to be of greater benefit than risk in some procedures with higher infection rates; however, because the problem is complex and the data are limited, extra-polating these findings to the practitioner's setting and the individual patient remains a challenge (Table 1). Although antimicrobial prophylaxis for bacterial endocarditis is not effective for most patients, the seriousness of the potential infection has driven the creation of guidelines recommending prophylaxis for at-risk patients undergoing at-risk procedures. Applying these guidelines appropriately could help to reduce unwarranted use of antimicrobials. In the prophylactic use of antimicrobials, as in many medical interventions, the difficulty is balancing the risks of the intervention with the potential benefits. Although we do not have either the randomized, controlled trials or the detailed, patient-specific information to estimate this balance precisely, there are general guidelines to help the clinician choose treatment for most patients.
Anti-Bacterial Agents↗
Ventricular arrhythmia following successful myocardial revascularization: incidence, predictors and prevention.
OBJECTIVES: We estimated the risk of sudden cardiac death (SCD), from a spontaneous episode of ventricular arrhythmia (VT/VF), after a successful surgical myocardial revascularization (coronary artery bypass grafting; CABG) procedure. Predictors of these events were identified, and long term benefits of the prophylactic regimes, that were used to control these events, were evaluated. METHODS: We selected 8642 consecutive patients, who had undergone an isolated and first time CABG procedure, between 1/3/1980 and 1/3/1995. A standard hazard function model (1) was used for statistical analysis. Efficacy of the prophylactic regimes, was examined in a group of 350 high risk patients, with a preoperative left ventricular ejection fraction 30% or less, who were recently operated since 1/1/1988. Electrophysiologic (EP) guided prophylaxis was used in 92 (26%) patients, who had survived a documented episode of SCD, and remaining 258 patients were maintained on antiarrhythmic medication on an empirical basis. A sequential EP evaluation was performed, when indicated. RESULTS: During an early phase of hazard, which mainly lasted for up to 3 months after CABG, incremental risk factors were preoperative LVEF 30% or less (P = 0.0007) and preoperative episodes of VT/VF (P = 0.04). This phase was followed by a constant phase with a low risk of the events, which merged into a slowly rising late phase after 6 years. EP guided prophylaxis, reduced the risk of SCD in high risk patients (P = 0.03). A sequential EP evaluation, helped to detect the problems of drug resistance and a cross over from non-sustained to sustained runs of VT/VF. CONCLUSIONS: Despite a successful CABG surgery, risk of VT/VF persists. A routine EP evaluation before and after a CABG procedure is recommended in all patients with a poor left ventricular function.
Arrhythmias, Cardiac↗
Membranous obstruction of the inferior vena cava and hepatic veins. Budd-Chiari syndrome? A treatable disease.
Three cases of membranous obstruction of the inferior vena cava (IVC) are presented. Two of them underwent transcardiac membranotomy with good results. The third patient was treated symptomatically and died from gastrointestinal hemorrhage and hepatic coma two years after the diagnosis of Budd-Chiari syndrome. At autopsy, membranes were found in the inferior vena cava and hepatic veins. Differentiation of Budd-Chiari syndrome secondary to the presence of such a membrane is essential since these patients are potentially curable by surgical treatment. Cavography visualizes the obstruction and is the procedure of choice for diagnosis of this condition. Surgical treatment with transcardiac membranotomy is effective. Some hepatic abnormalities regress after surgery. Prophylactic postoperative treatment with diuretics seems advisable in these patients to prevent congestive cardiac failure.
Adult↗