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3. Contaminated (class III) Major break in 1. Purulent drainage from the deep incision but not from the
technique(15.216.3%) organ/space component of the surgical site
Major break in technique 2. A deep incision spontaneously dehisces or is deliberately
Gross spillage from gastrointestinal tract opened by a surgeon when the patient has at least one of the
Traumatic wound, fresh following signs or symptoms: fever (> 38 C [100.4 F]),
Entrance of genitourinary or biliary tracts in presence localized pain, or tenderness, unless site is culture negative
of infected urine or bile 3. An abscess or other evidence of infection involving the deep
4. Dirty and infected (class IV) (28.040.0%) incision is found on direct examination, during reoperation, or
Acute bacterial inflammation encountered, without by histopathologic or radiologic examination
pus 4. Diagnosis of a deep incisional SSI by a surgeon or attending
Transection of clean tissue for the purpose of physician
surgical
access to a collection of pus Notes:
Traumatic wound with retained devitalized tissue, 1. Report infection that involves both superficial and deep incision
foreign sites as deep incisional SSI
2. Report an organ/space SSI that drains through the incision as a
bodies, fecal contamination, or delayed treatment, or
deep incisional SSI
all of these; or from dirty source
Organ/space SSI
Adapted from Cruse PJE: Wound infections:
Infection occurs within 30 days after the operation if no implant*
Epidemiology and clinical characteristics. In Howard RJ,
is left in place or within 1 yr if implant is in place and the infection
Simmons RL (eds): Surgical Infectious Disease 2nd ed.
appears to be
Norwalk, CT, Appleton & Lange, 1988.
related to the operation, and infection involves any part of the
anatomy (e.g., organs or spaces), other than the incision, which
Table 5 Criteria for Defining a Surgical Site Infection (SSI)71
was opened or
Superficial incisional SSI
manipulated during an operation, and at least one of the
Infection occurs within 30 days after the operation, and
following:
infection involves only skin or subcutaneous tissue of the
incisions, and at least one of the
1. Purulent drainage from a drain that is placed through a stab
following:
wound into the organ/space
1. Purulent drainage, with or without laboratory confirmation,
2. Organisms isolated from an aseptically obtained culture of fluid
from the superficial incision
or tissue in the organ/space
2. Organisms isolated from an aseptically obtained culture of fluid
3. An abscess or other evidence of infection involving the
or tissue from the superficial incision
organ/space that is found on direct examination, during
3. At least one of the following signs or symptoms of infection:
reoperation, or by histopathologic or radiologic examination
pain or tenderness, localized swelling, redness, or heat; and
4. Diagnosis of an organ/space SSI by a surgeon or attending
superficial incision is deliberately opened by surgeon, unless
physician
incision is culture negative
4. Diagnosis of superficial incisional SSI by the surgeon or
attending physician
*National Nosocomial Infection Surveillance definition: a 8. candidiasis
nonhuman-derived implantable foreign body (e.g., prosthetic
heart valve, nonhuman vascular graft, mechanical heart, or hip Fever after 1 week post-op:
prosthesis) that is permanantly placed in a patient during surgery. 1. drug allergy
If the area around a stab wound becomes infected, it is not an 2. leaking anastomosis
SSI. It is considered a skin or soft tissue infection, depending on its 3. intraabdominal abscess
depth. 4. Deep SSI
th
Principles of Anitbiotic Prophylaxis: Schwartzs 7 ed (pp 133, Wound Classification: ACS 2005, Vol I, pp 100
table 5.6) Clincal Features Tetanus-Prone Non Tetanus-
1. Choose an antibiotic effective against the pathogens Prone
most likely to be encountered Age of wound > 6hrs 6 hrs
2. Choose an antibiotic with SAFE, NON-TOXIC, low
Configuration Stellate, avulsion, Linear
toxicity
abrasion
3. The half-life of the antibiotic selected must be long
Depth > 1 cm 1cm
enough to maintain adequate tissue levels throughout
the operation. Mechanism of Missile, crush, Sharp surface (
4. A single preoperative dose that is of the same strength injury burn, frostbite glass, knife)
as a full therapeutic dose is adequate in most Signs of infection Present Absent
instances. Administer a single, fully therapeutic dose
Devitalized Tissue Present Absent
intravenously 30-60 min preoperatively
5. administer a second dose of antibiotic if the operation Contaminants ( Present Absent
lasts longer than 4 hrs or twice the half-life of the dirt, feces, soil,
antibiotic saliva)
6. Give 2-3 doses post-Op. There is no need to extend History of TT HTIG TT HTIG
administration beyond 24 hrs Immunization
7. Use of antibiotics is appropriate when infection is (doses)
frequent or when consequences of infection would be Unknown or < 3 Yes Yes Yes No
unusually severe + ++
3 or more No No No No
+
CLEAN CASES Yes, if > than 5 years since last dose
++
Prophylactic antibiotics are not indicated in clean Yes, if more than 10 years since last dose
operations if the patient has no host risk factors or if
the operation does not involve placement of prosthetic Sutures:
materials. in the face removed at day 4 or 5
other areas where skin tension is limited 7
Respiratory infections: occurs between 4-7 POD days
Fever with in 24 hrs:
1. Atelectasis Maximum safe dose of lidocaine: ACS 2005 vol I, pp 106
4mg/kg without epinephrine
High fever ( T > 38.9C) within 48 hrs Post-Op: 7mg/kg with epinephrine
1. Atelectasis
2. peritonitis 2 to leaking viscus ASA Classification
3. Invasive wound infection ( Necrotizing fasciitis, Class I (0 to 5 points) has a 0.9% risk of serious cardiac event or
clostridial myositis, cellultitis) death
Class II (6 to 12 points) has a 7.1% risk
Fever at 24-48 hrs: Class III (13 to 25 points) has a 16.0% risk
1. Respiratory complications Class IV (>26 points) has a 63.6% risk
2. Catheter related problems COMPUTATION OF PULMONARY RESERVE:
1
Mortality
ASA class IV (or III if the systemic disease is not under
control, as with
43%
2 unstable angina, asthma, diabetes mellitus, and
85% morbid obesity)
3 Known coagulation problems, including the use of
100% anticoagulants
Grading of Hepatic Encephalopathy:
Stage Neurologic Changes Inadequate abillity or understanding on the part of
caretakers with
Stage Mild confusion, euphoria or depression, decreased respect to requirements for postoperative care
I attention span, slowing of ability to perform mental
tasks, irritability, disorder of sleep pattern
Surgical Categories
Stage Drowsiness, lethargy, gross deficit in ability to Category 1
II perform mental tasks, obvious personality changes, Generally noninvasive procedures with minimal blood
inappropriate behaviour, intermittent and short- loss and with minimal risk to the patient independent
lived disorientation of anesthesia
Anticipated blood loss less than 250 ml
Stage Somnolent but arousable, unable to perform mental
III tasks, disorientation with respect to time, palce and Limited procedure involving skin, subcutaneous, eye,
person, amnesia, occasional fits of rage, speech or superficial lymphoid tissue
present but incomprehensible Entry into body without surgical incision