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Summary: WHO Recommendations for Surgical Site Infection Prevention (December 2016)

Surgical site infections (SSIs) are one of the most preventable of all healthcare associated infections,. Prevention is complex and relies on many factors, an integration of a wide range of measures before during and after surgery. In fact SSIs are the most frequent healthcare associated infection in low income countries (second in Europe and USA). Below are the current recommendations from the World Health Organisation that are all aimed at reduced SSIs.

1. Don't discontinue immunosuppressive medications before surgery. It can induce a flare of disease activity and interruption of therapy may induce anti-drug antibodies. There is low quality evidence that there may be a reduction in SSIs with anti-TNF drug discontinuation only. 
2. Give multiple nutrient-enhanced nutritional formulas to underweight patients undergoing major surgery.
3. Patients should bathe or shower before surgery with either plain or antimicrobial soap. Either type of soap can be used based on the evidence. 
4. Patients with known nasal carriage of Staphylococcus Aureus should recieve intranasal applications of mupirocin 2% ointment. The ointment should be applied nasally twice daily for five days. S.aureus carriage is a risk factor for SSIs. There is evidence for effectiveness of this for only cardiothoracic and orthopedic procedures but the panels suggests for all types of surgery. The ointment is only for KNOWN carriers to prevent unnecessary treatment and resistance spread. 
5. Adult patients undergoing colorectal procedures should have preoperative antibiotics combined with mechanical bowel preparation (MBP) prior to surgery. The use of MBP reduces the intraluminal faecal mass and therefore bacterial load, alongside further bacterial load reduction with antibiotics. The potential harms of MBP should be considered; patient discomfort, electrolyte abnormalities, dehydration, acute phosphate nephropathy. Most common antibiotic regime in the evidence was aminoglycosides combined with anaerobic coverage (metronidazole). 
6. Hair removal should be with clippers NOT with shaving. This is because microscopic trauma to the skin can increase SSI risk. 
7. Surgical antibiotic prophylaxis should be done within 120 minutes before skin incision. The evidence showed increased SSIs if the antibiotics were given after skin incision or before 120minutes (note the evidence was of low quality though). Antibiotics with a short half life such as cefazolin or cefoxitin should be given closer to the skin incision time e.g. less than 60min before. 
8. Surgical hand preparation is vitally important! scrubbing should be done with either antiseptic soap or an alcohol based hand rub (ABHR). There was no difference between povidone-iodine or chlorohexidine. ABHR reduced the number of colony forming units more than antiseptic soap. 
9. Alcohol based antiseptic solution based on chlorhexidine-gluconate should be used for skin preparation. Alcohol solutions were shown to be more effective than aqueous solutions. Although alcohol based solutions should not be used on neonates and caution should be exercised to prevent contact with eyes, mucosa or accumulation for its flammable nature. Chlorhexidine should absolutely be kept away from the brain, meninges, eyes and middle ear.
10. Antimicrobial sealants should not be used. There was no benefit for their use in the literature in preventing SSIs. 
11. Adult patients undergoing general anaesthesia with endotracheal intubation should receive an 80% fraction of inspired oxygen intraoperatively and if feasible in the immediate postoperative period for 2-6 hours. Infected tissue tends to have a lower oxygen tension than tissue that is non-infected, perhaps due to enhanced oxidative killing by neutrophils. In the postoperative period this benefit was observed with use of a high-flux mask and when normovolemia and normothermia was maintained. 
12. Normothermia should be maintained with the use of warming devices during the procedure. There are many adverse effects from a hypothermic state (<36degrees); increased cardiac complications, impaired coagulation, impaired wound healing, decreased drug metabolism, decreased immune metabolism and increased SSI incidence. 
13. Intensive perioperative glucose control. Using an intensive protocol reduced the SSIs although neither an optimal target glucose concentration or timing of control coudl be defined by thepanel. Blood glucose must be closely monitored and hypoglycemia avoided at all costs. 
14. Sterile disposable or reusable drapes and gowns should be used (Duh!). Although interesting the panel says plastic adhesive incise drapes should be avoided something we use regularly in my unit hmm (apparently they don't effect SSI incidence at all, yeah maybe they dont effect skin edge infection rates but im sure they can help prevent graft infection rates if you are using non native prothesis or grafts, a question for another time, let me find out). 
15. Wound protector device use should be considered. These devices, small clips that cover the wound edge have been associated with significantly reduced risk of SSI. 
16. You should irrigate the incisional wound with an aquaous povidone-iodine solution before closure. It removes cellular debris and dliutes possible contamination, results were heterogenous, favouring wound irrigation slightly.
17. High risk wounds should be treated with prophylactic negative-pressure wound therapy (pNPWT). PNPWT was shown to significantly reduced SSIs compared to conventional dressings in abdominal and cardiac high risk insicions. A high risk incision is one with  poor tissue perfusion, decreased blood flow, hematoma or obvious dead space. 
18. Antibiotic coated/triclosan coated sutures should be used. Evidence showed that ticlosan coated sutures had a significant effect in reducing SSIs, although there was a statment over possible study limitations due to industry sponsorship. 
19. Laminar airflow ventilation has no benefit compared to conventional operating room ventilation and shouldn't be used to reduce SSIs.
20. Antibiotic prophylaxis should not be prolonged for presence of a wound drain and drains should be removed when clinically indicated. drains can adversly effect the outcomes by affecting anastomotic healing and propagating infections.  
21. Advanced dressings should not be used over standard surgical dressings for purpose of SSI prevention. There was no evidence that advanced dressings (e.g. silver impregnated) had any benefit over standard gauze dressings. 
22. Surgical antibiotic prophylaxis (SAP) should not be prolonged after the operation. Most guidelines recommend a maximum SAP duration of 24 hours, infact a single preoperative dose might be non inferior. Surgeons are regularly documented prolonging SAP, this is unnesscary and risks increasing antibiotic reisstance rates. Author does note that prolonging SAP may have a benefit in cardiac and orthognathic surgery only. 

The links to the papers where all this was taken from:

Part 1: https://www.ncbi.nlm.nih.gov/pubmed/27816413

Part 2: https://www.ncbi.nlm.nih.gov/pubmed/27816414

Burns

Over 175000 patients visit the emergency department every year with a burns injury in the UK. Burns can be life threatening in the acute phase and severely affect quality of life in the chronic phase with scarring and sometimes even loss of limbs and body parts. Care in the first hours can have a massive impact on the long term outcome, so here is the facts on burns! 

FIRST AID:

If you approach a burns patient outside of hospital adopt the SAFE approach first always.
SAFE: Shout for help, Assess scene (is it safe?), ensure its Free from danger before you approach, Evaluate the casualty (ABCDE)). Pay particular attention to the A for Airway in your primary and secondary surveys and look for signs of inhalation injury (listed below).

After you have done a general assessment of the patient with ABCD, remove any clothing and jewellery around the injury unless they are stuck to the wound, then leave it. 

Manage the burn with the 3 C's:

COOL CALL COVER

Cool the burn with normal running tap water for at least 20 minutes, the water should be around 15 degrees. Cooling is beneficial up to three hours after the burn. The rule is to cool the burn but warm the patient! so make sure the rest of the patient is well covered up, you must prevent hypothermia at all costs. Don't use ice. 

Call an ambulance. 

Cover the injury, use loose clingfilm, on the face you should use wet gauze instead. 

EXAMINATION AND HISTORY:

The severity of a burn is judged by the percentage total body surface affected (%TBSA) and the depth of the burn.

3 methods for Judging %TBSA: 
- Wallaces rule of nines (adults, picture below)
- Lund and Bowder chart (accounts for age differences)
- Number of hands (Area of palmar surface of hand is equal to1%)
Include all burnt areas in the surface area but NOT very superficial burns, with no blistering and only red and dry.

Judging depth of burn, four levels of depth:
(-Superficial (dry, red and painful, normal capillary refill)
-Superficial dermal (erythematous, small blistering, moist, painful, brisk capillary refill)
-Mid-dermal (dark pink, blistered, sluggish capillary refill, dull sensation)
-Deep-dermal (blotchy red, may be blisters still, no refill, no sensation)
-Full thickness (white or black, eschar often present, no refill and insensate)

This system has largely superceded the degrees system but is roughly the same:
superficial dermal=first degree burn
mid-dermal and deep dermal= second degree burn
full thickness= third degree burn
note that deep dermal and full thickness burns will not heal!

You should pay pay aprticular attention to signs of impending airway obstruction; hoarseness, stridor, snoring and smoke induced inhalation injury which can result in airway oedema and obstruction. So look for signs of burns to mouth, nose, face, singed nasal hairrs, carbonacous sputum. 

If any of the burns are circumferential in nature, they could act as a tourniquet with scarring and tissue swelling underneath. This could lead to limb ischemia or even respiratory compromise if the chest wall is involved. You need to look out for this! To preserve the limb the patient may need an 'echarotomy' a surgical incision of the burnt tissue to allow the tissue to expand. 

FLUIDS:

Loss of water from the burnt area and generalised oedema caused by systemic inflammation can cause a life threatening hypovolemia and organ failure.
Start fluids with all burns greater than 15% TBSA using m-Parkland formula below
and aim for a urine output of 0.5ml per kg body weight.
Remember inhalation burns also lead to fluid losses! (you cannot see the extent of internal burns).

The Modified Parkland Formula:
-give 3-4ml Hartmanns solution per kg body weight per %TBSA over 24hours (half given over first 8hours, over half given over next 16hours).

Dilutional hyponatremia is common and so is hyperkalemia with extensive muscle damage. Electrocution burns can cause rhadbomyolysis and myoglobinuria. You may need to increase the fluid resuscitation to prevent acute tubular necrosis from kidney myogobin overload.

MANAGEMENT and pearls:

Inhalation injury management:
-establish patent airway early and consider intubation early. oxygenate and ventilate. Get arterial blood gases and CO levels.

Get tetanus status

Gastroparesis is common and you should consider inserting a NGT.

Patients are often in pain and emotional distress so give IV analgesia early. Consider opioids as first line (titrated to effect).

Avoid antiseptics and dress wounds with non-adherent dressings and gauze, applie covering bandge very loosely. In a first aid setting clingfilm works very well.
-Paraffin gauze and silver sulfadiazine cream, covered with gauze and bandage.

Consider non-accidental injury and abuse, (does the pattern of injury fit the story).

Antibiotics not indicated in early care

Children: start fluids with 10% TBSA burns and aim for urine output of 1ml per kg body wt.

When to refer to a burns specialist/burns centre:

• Any chemical or electrical burn
• Any burn to face, perineum/genitalia, hands and feet
• TBSA greater than 25% second degree burn
• All full thickness burns

Main complications of full thickness/third degree burns:

• Infections, sepsis
• Tetanus
• Hypothermia
• Hypovolemia

Chemical burn management:

-Brush off any powder first, flush the area with copious amounts of water for 20-30minutes. Note duration of exposure and whether chemical is acid or base. 

Surgical management:

(generally by  a plastic surgeon or burns specialist)

Dressing, Escharotomy, Escharectomy, Flaps, Graft

-late escharectomy has better aesthetic outcomes but early escharotomy may be necessary for circulation or ventilation problems. 

Sources:

-Emergency medicine secrets 6th edition Dr Vincent Markovchick 2016

-Student BMJ January 2016 volume 24

-Lecture notes Prof Klinger Humanitas University 2016 and seminar 2015

Milky Chance - Blossom (Official Audio)