THIS WEEK'S ARTICLES
Keeping Surgical Wounds Infection-Free
The latest devices and techniques help surgeons reduce SSIs by better managing incisions.
Nothing is more devastating than a preventable surgical site infection (SSI) complicating an otherwise perfectly executed procedure, which is why effective management of a surgical wound is as important as the surgery itself. Wound care should be a top priority, not an afterthought. Thankfully, multiple advances in closure devices and closing techniques are helping OR teams keep their infection rates low while helping patients recover more quickly.
The three tenets. Safe and efficient wound care based on tight closures, adequate blood flow and sterile dressings are the keys, according to J. Gabriel Horneff III, MD, FAAOS, an assistant professor of clinical orthopedic surgery in the shoulder and elbow division at Penn Medicine in Philadelphia. "For open surgeries, I recommend a thorough washout using approximately three liters of irrigant," says Dr. Horneff. "If the case involves treating a previous infection, use a total of six to nine liters. I primarily use sterile saline mixed with tobramycin or another triple antibiotic, which can be administered in multiple ways."
Pulse irrigation, which works particularly well for orthopedic cases, involves a battery-powered gun that shoots the irrigation mixture into the wound in jet spurts, says Dr. Horneff. "This method irrigates the wound and achieves a good mechanical debridement that is needed in cases involving concerns about a wound's healing capabilities," he says.
Closures and dressings. Dr. Horneff believes layered closures are the best way to prevent surgical wound infections in open surgeries. "Vicryl sutures for the deeper fascial and subcutaneous layers are best, followed by Monocryl suture for the skin layer," he says. "Both options are absorbable, but Vicryl suture is braided and lasts a little longer than Monocryl suture, which is made of monofilament. After placing the suture, surgeons should bury the knots in the tissue."
Vacuum suction dressings. Negative pressure therapeutic wound-care devices have improved significantly over the last 10 years and have impacted core ideas on wound healing. These battery-powered devices, no bigger than a purse, keep wounds sterile while using negative pressure to suck fluids from the wound and enhance blood flow to the area. Surgeons place a vacuum sponge atop closed incisions, and patients can remove the tube that connects the dressing and the device when they take a shower and reattach it afterward.
"The most important thing when caring for a fresh wound is minimizing what the patient must do to manage it," says Dr. Horneff. "Any solution that eliminates the patient's need to remove dressings or make sure their stitches aren't protruding from the skin is a good thing."
That's where absorbable sutures, waterproof dressings and other products and devices come in. They eliminate potential sources of aggravation during recoveries by allowing surgeons to close off incisions from the environment, ensure healthy blood flow to the wound and keep everything covered and sterile. "All of that is best performed by providers, not patients," says Dr. Horneff.
Preventing Infections During Hip Procedures
Paying close attention to skin antisepsis and wound care helps the healing process.
The National Association of Orthopedic Nurses (NAON) recently released a best practice guideline for improving the care of hip replacement patients. Focusing on key elements of the guideline, particularly skin antisepsis and wound care, will improve outcomes for more satisfied patients.
The guideline recommends implementing nasal decolonization and skin antisepsis protocols because they help decrease the rate of SSIs in hip replacement patients. "Screen patients for Staphylococcus aureus colonization of the nares two to four weeks before surgery," says Carrie Coppola, MSN, RN-BC, ONC, an orthopedic service line coordinator at Cleveland Clinic Martin Health in Stuart, Fla. "Patients who are carriers should apply mupirocin topical ointment to the nares twice a day and bathe with chlorhexidine gluconate (CHG) once a day during the week leading up to surgery." While no unanimity exists regarding which skin prepping agent is best, evidence shows that CHG provides a sufficient barrier against Staphylococcus aureus bacteria.
Patients should also receive CHG wipes before procedures with instructions to apply the antiseptic solution to the skin on the front and back of their trunk and arms and legs. They should use the wipes the night before their procedure and the morning of surgery. Additionally, patients should not bathe with soap or use creams, lotions or powders after applying the CHG.
Incisions begin to heal just hours after surgery is complete. "Patients and their care partner need to be educated on how to care for their wound specific to the type of dressing they received," says Ms. Coppola. "Patients should know how to keep the incision clean and dry, when to bathe, and how to spot and report signs and symptoms of infection."
The Importance of Standardization of Care in Orthopedics Procedures and Wound Care
Skin antiseptics and proper wound irrigation may help promote patient satisfaction and offers the road to a reduction in post-procedure complications.
Orthopedic surgery comes with risks including the potential of post-procedure complications and intraoperative contamination. The OR team working in the outpatient setting works very hard to keep their patients safe from these occurrences and pays close attention to protocols and practical solutions during patient's surgical journey. Outpatient Surgery Magazine spoke to Javad Parvizi, MD, FRCS, James Edward Professor of orthopedic surgery at the Rothman Orthopedic Institute at Thomas Jefferson University in Philadelphia, to shed some light on the challenges and outlook for standardization of patient care, in particular wound irrigation and its importance.
Q: Why is the practice of wound irrigation so important in the surgical process?
Regardless of how hard we try microorganisms and debris find their way into the surgical site. Wound irrigation can mechanically remove the debris and microorganisms which in my opinion could lead to better outcomes
Q: What are the risks of "back-table" compounding of sterile solutions for the OR team?
Back-table compounding fails to meet the proper standards in numerous ways, most importantly being terminally sterile, and is discouraged by the FDA and Joint Commission. In addition, the concentration of the product (formulation) can be variable, either being too low and lacking efficacy or being too high and carrying cytotoxicity.
Q: Is there a standard of care when it comes to your hip and knee arthroplasties?
Yes. I have specific protocols that are intended to limit surgical complications that I follow for every patient. One of the ten steps that I follow includes the use of a pre-mixed, ready to use surgical irrigation solution.
Q: Is there a product available today that addresses the challenges of sterile wound irrigation?
Yes. Surgiphor™ is a terminally sterilized (by gamma irradiation), pre-made, and consistent concentration (0.5%) PVP-I irrigation solution that was produced to meet the standards of care and mitigates issues that exist with back-table compounding.
Q: Can the packaging of a sterile wound irrigation product be ergonomic, and how does that help the end user and with workflow?
Yes. The bottle that houses the Surgiphor solution is designed such that it delivers the irrigation solution at higher pressures, making it very effective in mechanical debridement of the wound.
Q: How important is it to achieve efficient and consistent delivery of wound irrigation to a surgical site?
The delivery mechanism needs to allow constant stream of solution to be delivered in a relatively higher pressure. Surgiphor bottles were designed to do just that.
Q: Are there any trends that the physician and OR teams need to pay attention to?
Yes. surgical complication continues to become an ever more important issue. All hospital systems are moving towards implementation of protocols that are known to reduce the incidence of post-procedure complications.
Note: for more information including additional safety information for BD Surgiphor™ Sterile Wound Irrigation System please go to www.bd.com/simplersolutions
Worry-Free Wound Care
Antibacterial irrigation and dressings can give providers and their patients peace of mind.
The chances of patients ending up with a surgical site infection (SSI) that stemmed from a common outpatient procedure like a total knee arthroplasty are low, but those odds aren't zero. That's why the most conscientious surgeons go above and beyond to infection-proof their patients, with those efforts including the use of antibacterial irrigation and antibacterial dressings.
Antibacterial irrigation generally takes place at the end of procedures when surgeons treat wounds with antibiotic or antimicrobial solutions. The tactic removes debris and contaminants from the incision and can reduce SSI risk. Providers have an array of antibiotics available that are placed directly in irrigation solutions: bacitracin, cefazolin and vancomycin, among others. These solutions can even be used to target bacteria that's most likely to cause infection in specific types of wounds.
Finding the right irrigation solution is a facility-specific decision that depends on a variety of factors, but the irrigation itself is a crucial wound-care process that providers shouldn't skip. As Rojeh Melikian, MD, a board-certified orthopedic spine surgeon at DISC Sports & Spine Center in Newport Beach, Calif., succinctly puts it, "Prior to closure, the surgical wound should be flushed."
Wound care can also be improved by applying dressings with antibacterial components directly into the incision site. These options include silver or alternatives to silver that promote healing, says Brian J. Cole, MD, MBA, a sports medicine specialist at Midwest Orthopedics at Rush in Chicago.
Dr. Cole believes wound closure practices ultimately come down to surgeon and patient acceptance, efficacy and cost. He urges facility leaders to make sure physicians are on board with any wound closure method because they can be particular about the methods and products they use, whether due to a comfort level with a certain technique or loyalty to a product they used during training. "Make sure you have a high level of surgeon buy-in," he says.
Saving the Limbs of Patients With Diabetes
Treating diabetic wounds in a timely fashion prevents amputations linked to the disease.
A multidisciplinary team at UT Southwestern Medical Center in Dallas is preventing the amputation of limbs due to diabetic infection through coordinated interventions and innovative treatments.
Peripheral artery disease, the narrowing of arteries in the extremities, is a common condition in patients with Type 1 and Type 2 diabetes. When blood flow is limited to legs and toes, relatively ordinary cuts and blisters can evolve into dangerous infections. Patients can also suffer from neuropathy, which prevents them from feeling their wounds and seeking treatment for them. Each year, according to UT Southwestern, 73,000 amputations of lower limbs occur on patients with diabetes.
Dane Wukich, MD, a professor and chair of orthopedic surgery at UT Southwestern, champions the limb salvaging program and is an expert in treating diabetic foot wounds, a procedure many fellow surgeons avoid. "These are really difficult surgeries with high complication rates," he says. "Healing wounds, even from surgery, is a challenge for these patients, and they can't feel any chafing or blisters caused by the rigid dressings we use. We see them several times post-op and then annually for the rest of their lives."
Dr. Wukich works with orthopedic, plastic and vascular surgeons, and experts in infectious diseases and physical medicine and rehabilitation in UT Southwestern's Wound Care Clinic. The providers team up to provide the early intervention that treats diabetic foot infections before leg amputation is needed. Over nearly a decade, the diabetic limb salvage program has reduced the percentage of patients who undergo a leg amputation from approximately 75% to 35%.
"Primary care physicians have to start routinely examining the feet of every patient with diabetes," says Dr. Wukich. "The sooner we can intervene, the more limbs we can save, and that translates into lives."