5. Wearing rings does not increase overall bacterial levels measured on the hands of health care workers. Therefore, it remains unclear whether transmission of infection could be reduced by prohibiting health care workers from wearing rings.
B. Antisepsis
1. Masks have long been advocated as preventing surgical site infection (SSI); however, data suggest that wearing a head cover is useful for preventing SSIs but wearing a mask is not.
2. Masks do serve the purpose of protecting the health care provider, particularly when combined with eye protection, and thus should most likely be used during tracheal intubation and at other times when protection from body fluids is appropriate.
3. Most postoperative surgical infections are caused by flora that are endogenous to the patient; environmental and airborne contaminants may also play a causative role.
4. An important but frequently overlooked consideration is the role that traffic patterns into an operating room can play in patient exposure to airborne organisms. Current recommended practices are that traffic patterns should limit the flow of people through an operating room that is in use and that no more people than necessary should be in an operating room during a procedure.
5. Gowning, gloving, careful aseptic technique, and use of a wide sterile field should be routine for placement of central venous lines.
6. Epidural abscess formation is an extremely rare but potentially catastrophic complication of neuraxial anesthesia and epidural catheter placement. The most important consideration is preventing contamination of the needle and catheter.
a. Hand washing, skin preparation, and draping and maintenance of a sterile field should be used.
b. Gowning and wearing a mask, however, are unlikely to reduce the risk of infection.
c. Epidurals should probably be avoided in patients known or suspected to have bacteremia or should be deferred until after appropriate antibiotics have been administered.
C. Antibiotic Prophylaxis (Tables 13-2 and 13-3)
1. Antibiotic prophylaxis is standard for surgeries in which there is more than a minimum risk of infection.
2. Recommendations published in 2004 by the National Surgical Infection Prevention Project emphasize timing and choice of appropriate agents.
TABLE 13-2 RECOMMENDED DRUGS FOR COMMON PROCEDURES
1. Vancomycin is indicated for patients transferred from an skilled nursing facility (SNF), prison, or long-term care facility for cardiac surgery; see protocol. Vancomycin is indicated for patients transferred from an SNF, prison, or long-term care facility or who have been hospitalized within 6 months for joint replacement; see protocol (http://intranet.uuhsc.utah.edu/orders/categories/Orthopaedics/Pre-Op%20Orders%20For%20Total%20Joint%20Service.pdf).
2. Note that ciprofloxacin is infused over an hour. Ideally, the infusion should be completed before incision, but Centers for Medicaid and Medicare Services (CMS) guidelines consider starting the infusion before incision adequate.
NOTE:
• Always confirm with surgeons at the time out or earlier.
• The surgeon may wish to delay antibiotics until after culture.
• Antibiotics may not be indicated (low-risk, elective procedures such as laparoscopic cholecystectomy or breast biopsy in which implants will not be used).
• Make sure to record the reason for not giving antibiotics on the record.
• Ideally, an antibiotic infusion should be completed before incision, but CMS guidelines consider starting the infusion before incision adequate. When possible, for drugs requiring slow (>30 minutes) infusion, the infusion should be initiated before surgery.
• When a tourniquet is used, the dose must be completed at least 5 minutes before the tourniquet is inflated.
• Additional intraoperative doses should be given when there is significant blood loss (approximately half to one blood volume). Use the recommended second dose for this purpose.
• When therapeutic antibiotics are given for an infection or presumed infection (e.g., acute appendicitis), prophylactic antibiotics are not required. Each situation should be examined individually: When was the antibiotic given? Which antibiotic was used? In some cases, coverage of skin flora may be appropriate before skin incision, but often continuation of the therapeutic antibiotics is all that is required.
ED = emergency department; ESWL = extracorporeal shockwave lithotripsy.
TABLE 13-3 DRUGS AND DOSES AVAILABLE ROUTINELY FOR ANTIBIOTIC PROPHYLAXIS (DRUGS TO BE GIVEN IN THE OPERATING ROOM BY AN ANETHESIOLOGIST)
a. The agent selected for antibiotic prophylaxis must cover the most likely spectrum of bacteria presented in the surgical field.
b. The most commonly used antibiotic for surgical prophylaxis is cefazolin, a first-generation cephalosporin, because the potential pathogens for the vast majority of surgeries are gram-positive cocci from the skin.
3. The exact timing for the administration of the antibiotic depends on the pharmacology and half-life of the drug. Ideally, administration of the prophylaxis should be within 30 minutes to 1 hour of incision. In general, it is considered acceptable if the infusion is started before incision. When a tourniquet is used, the infusion must be complete before inflation of the tourniquet.
a. Administration of antibiotics is uncomplicated when the drug can be given as a bolus dose (cephalosporins) or as an infusion over a few minutes (clindamycin) and thus provides tissue levels within minutes.
b. For drugs such as vancomycin that require infusion over an hour, coordination of administration is more complex.
c. Depending on their half-lives, antibiotics should be repeated during long operations or operations with large blood loss. (Cefazolin is normally dosed every 8 hours, but the dose should be repeated every 4 hours intraoperatively.)
d. Prophylactic antibiotics should be discontinued by 24 hours after surgery because prolonging the course of prophylactic antibiotics does not reduce the risk of infection but does increase the risk of adverse consequences of antibiotic administration.
4. Methicillin-resistant Staphylococcus aureus (MRSA) is becoming a more common pathogen. Hand hygiene is among the most effective means of preventing development of MRSA because when used properly, alcohol-based gel kills more than 99.9% of all transient pathogens, including MRSA. There does not appear to be a justification for using antibiotics effective against MRSA for prophylaxis in most clinical settings.
5. Anesthesiologists should work in consultation with surgeons to use guidelines determined by the local infection control committee to take initiative for administering prophylactic antibiotics.
TABLE 13-4 FACTORS THAT MAY IMPAIR WOUND HEALING
Oxygen Supply to the Wound (most important element)
Systemic Factors
Medical comorbidities
Nutrition
Sympathetic nervous system activation
Age
Local Environmental Factors
Bacterial load
Degree of inflammation
Moisture content
Oxygen tension
Vascular perfusion
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