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Prevention of surgical site neutrophils and continuation of normal wound healing or the
development of a wound infection. The classical symptoms of
SURGERY 32:9 468 Crown Copyright Ó 2014 Published by Elsevier Ltd. All rights reserved.
WOUND MANAGEMENT
I Clean No entry into viscus or tract Joint replacement, breast, hernia 1e2 1e2
II Clean- Hollow viscus opened but with minimal Cholecystectomy, elective colorectal <10 30
contaminated contaminated spillage resection, uncomplicated appendicectomy
III Contaminated Viscus or tract opened with significant Accidental enterotomy 15e20 <60
spillage or inflammatory process
IV Dirty Gross contamination secondary to pus or Perforated diverticular disease <40 60
perforation, incision through an abscess
Table 1
SURGERY 32:9 469 Crown Copyright Ó 2014 Published by Elsevier Ltd. All rights reserved.
WOUND MANAGEMENT
Cardiac
Neurosurgery
Breast
Ophthalmic
Orthopaedic
Vascular
Gastroduodenal Oropharyngeal anaerobes
Biliary
Colorectal
Head and neck Oropharyngeal anaerobes
Obstetric and Enterococci, group B streptococci
gynaecological
Urological
Foreign material
Table 3
surgeon or if transmission to the patient would be especially 300 air changes per hour are generated and bacterial load is
hazardous, for example with joint replacements. reduced.16
Table 4
SURGERY 32:9 470 Crown Copyright Ó 2014 Published by Elsevier Ltd. All rights reserved.
WOUND MANAGEMENT
there is insufficient evidence to make definite recommendations 3 Coello R, Charlett A, Wilson J, Ward V, Pearson A, Borriello P. Adverse
on technique or the type of suture.7 New studies are investigating impact of surgical site infections in English hospitals. J Hosp Infect
the use of antimicrobial impregnated suture materials. Haemo- 2005; 60: 93e103.
stasis is important to limit haematoma formation which can act 4 Pathogenesis of SSI. http://www.medscape.org/viewarticle/448981_2
as a nidus for subsequent infection; this can be achieved by local (accessed 21 Feb 2014).
techniques and by maintaining adequate oxygenation, perfusion, 5 Culver D, Horan T, Gaynes R, et al. Surgical wound infection rates by
temperature and glucose control.7 The use of drains is not rec- wound class, operative procedure, and patient risk factors. Am J Med
ommended routinely7,19 and if needed should preferentially be a 1991; 91: S152e7.
low vacuum system exiting at a distance to the wound. There is 6 Mangram A, Horan T, Pearson M, et al. Guideline for the prevention of
no evidence to support the use of topical antiseptics or antimi- surgical site infection, 1999. Hospital Infection Control Advisory
crobials prior to wound closure.7 Committee. Infect Control Hosp Epidemiol 1999; 20: 250e80.
7 Surgical site infection: prevention and treatment of surgical site
Postoperative measures infection NICE. 2008, http://www.nice.org.uk/nicemedia/live/11743/
42378/42378.pdf.
Wound care
8 Neumayer L, Hosokawa P, Itani K, El-Tamer M, Henderson W, Khuri S.
Wounds are covered with a sterile dressing. Dressings are
Multivariable predictors of postoperative surgical site infection after
initially changed using an aseptic technique.7 Patients are
general and vascular surgery: results from the patient safety in sur-
encouraged to allow the wound to dry up before immersing it
gery study. J Am Coll Surg 2007; 204: 1178e87.
when bathing.
9 Tanner J, Woodings D, Moncaster K. Preoperative hair removal to
reduce surgical site infection. Cochrane Database Syst Rev 2006; 19.
Complex wound care
CD004122.
Complex wounds should be managed in conjunction with a tis-
10 Andersen B, Kallehave F, Andersen H. Antibiotics versus placebo for
sue viability team7 who can advise and assist with dressing types
and management. Wound healing is affected by both local and prevention of postoperative infection after appendicectomy.
systemic factors, as discussed and listed in Table 2. Contami- Cochrane Database Syst Rev 2005; 3. CD001439.
nated wounds are left to heal by secondary intention and may be 11 Bode L, Kluytmans J, Wertheim H, et al. Preventing surgical-site in-
packed with interactive dressings such as alginate, or gauze. fections in nasal carriers of Staphylococcus aureus. N Engl J Med
They require monitoring and planned dressing changes. Wounds 2010; 362: 9e17.
may dehisce and heal by secondary intention. Necrotic tissue 12 Sivanandan I, Bowker K, Bannister G, Soar J. Reducing the risk of
surgical site infection: a case controlled study of contamination of
should be debrided.7 This can be autolytic, shedding aided by
theatre clothing. J Perioper Pract 2011; 2: 69e72.
dressings, using biological agents (larvae) or surgical debride-
13 Tanner J, Swarbrook S, Stuart J. Surgical hand antisepsis to reduce
ment using a scalpel. Topical Negative Pressure (TNP) therapy
surgical site infection. Cochrane Database Syst Rev 2008; 1.
(or Vacuum Assisted Closure e VAC) can be used to aid the
CD004288.
closure of large wounds. A foam dressing is inserted into the
wound cavity, covered by an occlusive dressing and attached to a 14 Darouiche R, Wall M, Itani K, et al. Chlorhexidine-alcohol versus
vacuum pump. This removes exudates and promotes povidone-iodine for surgical-site antisepsis. N Engl J Med 2010; 362:
granulation.20 18e26.
15 Misteli H, Weber W, Reck S, et al. Surgical glove perforation and the
Conclusion risk of surgical site infection. Arch Surg 2009; 144: 553e8.
16 Damani N, Emmerson A. Manual of infection control procedures. 2nd
Surgical site infections are an important and significant health- edn. Greenwich Medical Media, 2003.
care problem causing morbidity and a strain on resources. 17 Alexander J, Solomkin J, Edwards M. Updated recommendations for
Standards of care at each point of the operative journey should control of surgical site infections. Ann Surg 2011; 253: 1082e93.
be maintained to reduce the risk of an infection occurring. A 18 Ly J, Mittal A, Windsor J. Systematic review and meta-analysis of
cutting diathermy versus scalpel for skin incision. Br J Surg 2012; 99:
613e20.
REFERENCES
19 McHugh S, Hill A, Humphreys H. Intraoperative technique as a
1 Surgical site infection event chapter. January 2014. Centres for Dis-
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pscManual/9pscSSIcurrent.pdf?agree¼yes&next¼Accept (accessed
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21 Feb 2014).
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SURGERY 32:9 471 Crown Copyright Ó 2014 Published by Elsevier Ltd. All rights reserved.