Surgical Site Infections Claude Laflamme MD, FRCPC Medical Director Cardiovascular Anesthesia Assistant Professor University of Toronto Faculty, Safer.

Surgical Site Infections

Claude Laflamme MD, FRCPC

Medical Director Cardiovascular Anesthesia

Assistant Professor University of Toronto

Faculty, Safer Health Care Now Campaign

December 4th 2007

Surgical Site Infections

Who cares?? We all do!!

December 4th 2007

The Anesthesiologist’s RoleAnesthesiology 2006; 105:413-21

• Hypothermia

• Hyperoxia

• Fluid Management

• Hyperglycemia

• Blood transfusion

• Antimicrobial Prophylaxis

Efficacy of Protocol Implementation on Incidence

of Wound Infection in Colorectal Operations

J Am Coll SurgVol. 205, No. 3, September 2007

Presentation Outline

• Prophylactic Antibiotics

• Prevention of Hyperglycemia

• Maintain Normothermia

• Hair removal

• Optimize Oxygen Tension

• Sunnybrook’s Experience

• Next Steps

Blood Glucose Control

Cardiac Surgical Patients

Poor Blood Glucose Control• Low Cardiac Output

• Increased inotrope

• Malignant arrhythmias

• Prolonged mechanical ventilation

• Stroke, Encephalopathy

• Renal dysfunction

• Infectious outcome

Blood glucose control Immunosuppression

Leucocytes

Granulocytes Monocytes Lymphocytes

Glucose Control - Mean

6

8

10

12

14

16

18

20

Pre T15 T30 T45 T60 T75 T90 T120 OREND CVICU1

Bypass Time (minutes)

Blo

od

Glu

cose

(m

mo

l/L)

Dr 1

Dr 2

Dr 3

Dr 4

Dr 5

Dr 6

Dr 7

Dr 8

Dr 9

Dr 10

Dr 11

Dr 12

Group

Bode ProtocolEndocrine Practice March/April

2004• (BG mg/dl – 60) X 0.02 = units of insulin/h

• ((BG mmol/L X 18) – 60) X 0.02= units/h

• Target 6.0–8.0mmol/L

• When BG is greater then target, increase multiplier by 0.01

• When BG is less then target, decrease multiplier by 0.01

GROUP MEANBlood Glucose Levels

0

2

4

6

8

10

12

14

200420052006 Jan-May2006 Jun-Aug

mmol/L

Surgical Site InfectionCardiac Surgery

0

2

4

6

8

10

12

2003 2004 2005 2006 Q12007

NNISS

Infection%

Deep SSI in Cardiac Surgery

Deep CV SSI Rates from Q1 06/07 to Q1 07/08

0.00%0.50%1.00%1.50%2.00%2.50%3.00%3.50%4.00%4.50%

Q1 06/07 Q2 06/07 Q3 06/07 Q4 06/07 Q1 07/08

Dee

p S

SI R

ates

Normothermia

Complications of mild hypothermia• Increases duration of hospitalization

• Increases intra-operative blood loss

• Increases adverse cardiac event

• Increases patient shivering in PACU

• Promotes metabolic acidosis

• Increases SSI rates

Complications and treatment of mild hypothermia

Hypothermia

Impairs neutrophilsfunction

Vasoconstriction

Tissue hypoxia

Minimizing hypothermia

• Anesthetics profoundly inhibits central thermoregulation decreasing the vasoconstriction threshold by 2-4ºC

• The second major factor is the magnitude of the core-to-peripheral temperature gradient

• Minimizing the core-to-peripheral temperature gradient and preoperative vasodilatation, is the basis to reduce heat redistribution

• Degree of adiposity, concurrent medication

Hypothermia

• Redistribution: 1.6ºC, 1 Hr

• Linear decrease: 1.1ºC, 2-3Hrs

• Plateau: 34-34.5ºC

Normothermia for colorectal surgery

• A Kurz, NEJM 1996; 334:1209-15• 200 patients, double-blind study• Followed for 2 weeks• 34.7±0.6 Celsius VS 36.6±0.5 Celsius• SSI 18.8% VS 5.8% (p=0.009)• Sutures were removed one day later (p=0.002)• Hospital LOS prolonged by 2.6 days (p=0.01)

Cutaneous warming

• Passive insulation reduces heat loss by approximately 30%

• Active cutaneous heating: efficacy will be proportional to the skin surface warmed Circulating water, Forced air, Radiant warmers

Active cutaneous warming systems

• Forced-air systems

• Circulating-water mattresses

• Resistive heating systems (ICU,trauma) Carbon-fiber patient cover

• Circulating-water garments Water has a conductivity of heat 26 times higher than air

• Infrared radiation

Minimizing hypothermia

• Prewarming: Decreases core-to-peripheral temperature gradient Eventually provokes vasodilatation

• Pharmacologic vasodilatation

Laparatomy

P has e 2 IntraOp T emperature P rog res s ion in C ontrol & P reWarmed P opulations

35.4

35.6

35.8

36

36.2

36.4

InitialIntraOP

15m 30m 45m 1h 75m 90m 2h 2.5h 3h 4h 5h

Tem

per

atu

re (

oC

)

P rewarmed (26.7% finis hed hypothermic ) C ontrol (50% finis hed hypothermic )

Core temperature monitoring

• Pulmonary artery• Nasopharynx• Tympanic membrane

Aural thermocouples probe Infrared thermometer

• Temporal Artery• Distal Oesophagus• Rectal temperature during neuraxial

anesthesia

Surgical Site Infections Project (General Surgery) Compliance Performance Ratings

Monthly Incidence of SSI for All Open Abdominal Elective Surgeries (Wound

Class I & II)

0

5

10

15

20

25

Jan Feb Mar Apr May Jun Jul

Months in 2007

% o

f S

SI