SSI Evidence – a Surgeon’s Perspective

SSI Evidence–

a Surgeon’s Perspective

E. Patchen Dellinger, MDUniversity of Washington

Caring for theCritically Ill Patient

ABC = airway, breathing, circulation

Preventing Surgical Site Infections (SSI)

ABC = airway, breathing, circulation

= temperature, oxygen, fluidsABCD - Add drugs (antibiotics)

Add - glucose controlproper hair removalsurgical techniqueteamworkother ??

Prophylactic AntibioticsQuestions

• Which cases benefit?• Which drug should you use?• When should you start?• How much should you give?• How long should antibiotics be

continued?

Relative Benefit from Antibiotic Surgical Prophylaxis

Operation Prophylaxis (%) Placebo (%) NNT*Colon 4-12 24-48 3-5Other (mixed) GI 4-6 15-29 4-9Vascular 1- 4 7-17 10-17Cardiac 3-9 44-49 2-3Hysterectomy 1-16 18-38 3-6Craniotomy 0.5-3 4-12 9-29Spinal operation 2.2 5.9 27Total joint repl 0.5-1 2-9 12-100Brst & hernia ops 3.5 5.2 58

Antibiotic ProphylaxisDemonstrated Benefit: All Procedures??

• Review of prophylaxis meta-analyses suggests that there is a consistent relative risk of wound infection less than one associated with antibiotic prophylaxis.

• This is independent of the type of operation or the baseline (placebo) rate of infection.

Bowater. Ann Surg 2009;249: 551–556



continued?

Surgical Antibiotic ProphylaxisMy Choices

Bacteroides expectedCefazolin 2 g + Metronidazole 1g, IV

in ORRepeat cefazolin q 3 h during

procedureBacteroides not expected

Cefazolin 2 g, IV in ORRepeat q 3 h during procedure

AlternativesCefazolin

Other first generation cephalosporinCefuroxime, cefamandole, cefonicidOxacillin, etc

Cefazolin plus metronidazoleErtapenemAminoglycoside or quinolone plus

clindamycin or metronidazole


Which cases benefit?Which drug should you use?When should you start?How much should you give?How long should antibiotics

be continued?

Burke. In: Hunt, ed. Wound Healing and Wound Infection, New York: Appleton, 1980:242.

Decisive Period For Development Of Wound Infection

Lesion Age (hrs)

Lesio

n Si

ze, (

mm

)

Efficacy Of Prophylaxis Is Independent Of The Specific Antibiotic

Age of Lesion at Antibiotic Injection (Hours)

Lesi

on S

ize,

mm

(24

Hou

rs)

0

5

10

Penicillin, 40,000 U

Staph + PenicillinControl

Chloramphenicol, 0.1 mg/Kg

Erythromycin, 0.1 mg/Kg

Tetracycline, 0.1 mg/Kg

0 2 4 6-2 0 2 4 6-2

0

5

10

0

5

10

0

5

10

Control Control

ControlStaph + Erythromycin

Staph + TetracyclineStaph + Chloramphenicol

Burke JF. Surgery. 1961;50:161.

0

1

2

3

4

≤-3 -2 -1 0 1 2 3 4 ≥5

Classen. NEJM. 1992;328:281.

Perioperative Prophylactic Antibiotics

Timing of AdministrationIn

fect

ions

(%)

Hours From Incision

14/369

5/6995/10092/180

1/81

1/411/47

15/441

Prophylactic AntibioticsTiming - Cefazolin

Serum Levels (mg/L)On Call Anesth

Incision 87 1481 hour 37 572 hours 25 39

DiPiro. Arch Surg 1985;120:829

Prophylactic AntibioticsTiming – Cefazolin

IncisionWound closureNo Drug Dectectable

97

38%

1711

14%

On Call Anesth

Muscle Levels

DiPiro JT et al. Arch Surg. 1985;120:829-832.

Prophylactic AntibioticsAdministration in the O.R.

Drugs Given I.V. Push over 5-10 Min

CefazolinDrug to incision 17 (7-29) minMuscle levels 76 (9-245) mg/kg

CefoxitinDrug to incision 22 (14-27) minMuscle levels 24 (13-45) mg/kg

DiPiro. Arch Surg 1985;120:829DiPiro. Personal Communication

Timing of Prophylactic Antibiotic Administration – Cardiac, Arthroplasty,

Hysterectomy

Steinberg. TRAPE. Ann Surg 2009; 250:10

Repeat Antibiotic Prophylaxis Doses in Gastrointestinal Procedures

01234567

Cefaz x 1 Cefaz x 2 Cefotetan

< 3 hr> 3 hr

Surgical Site Infections

Per

cent

Scher. Am Surg 1997;63:59



continued?

Cardiac Surgery ProphylaxisEffect of Serum Levels

None

Present

3/11

2/175

Serum Levelat Wound Closure Infection

Goldmann. J Thorac Cardiovasc Surg. 1977;73:470-479.

P = .002

Cardiac Surgery ProphylaxisEffect of Atrial Appendage Levels

YesNo

613

InfectedCephalothin (mg/l)

Platt. Ann Intern Med. 1984;101:770-774.

P = .02

Prophylactic AntibioticsSize of Patient and Size of Dose

• Morbidly obese patients having bariatric operation with a high infection rate

• Cefazolin levels lower than in non-obese patients at same dose

• Cefazolin dose changed from 1 g to 2 gInfection rate at 1g: 16.5%Infection rate at 2g: 5.6%

Forse RA. Surgery 1989;106:750

Gentamicin Levels andSSI Risk for Colectomy

Closing Gent level (mg/L) D.M. (%) Stoma (%) Age

SSI 1.3+1.0 29 50 59+14

No SSI 2.1+0.9 2 24 55+19

p 0.02 0.02 0.04 0.05

Gent level < 0.5 at close had 80% SSI rate (p=0.003).

Zelenitsky. Antimicrob Ag Chemother 2002;46:3026-30

Dose of Antibiotic for Prophylaxis

• Always give at least a full therapeutic dose of antibiotic.

• Consider the upper range of doses for large patients and/or long operations.

• Repeat doses for long operations.

New ASHP / IDSA / SHEA / SIS Antibiotic Prophylaxis

Guidelines

Cefazolin< 80 kg 2 g> 120 kg 3 g

Vancomycin 15 mg/kg

Gentamicin 5 mg/kgdosing wgt = ideal wgt + 40% of excess wgt

Bratzler. Surgical Infections2013;14:73-156


• Which cases benefit?• Which drug should you use?• When should you start?• How much should you give?• How long should antibiotics

be continued?

Antibiotic ProphylaxisDuration

Most studies have confirmed efficacy of

12 hrs.Many studies have shown efficacy of a

single dose.Whenever compared, the shorter

course has been as effective as the longer course.

Duration of ProphylaxisColorectal

Author Drug Duration InfectionTörnqvist 1981doxycycline 1 dose 10%

3 days 19%Juul 1987 amp/metronid 1 dose 6%

3 days 6%

Duration of ProphylaxisJoint Replacement

Author Drug Duration InfectionPollard 1979 cephaloridine 12 hours 1.4%

(hips) flucloxacillin 14 days 1.3%

Heydemann 1986 cefazolin 1 dose 0(hips and knees) 24 hours 1%

48 hours 0 7 days 1.5%

Duration of Prophylaxis:Infection and Antibiotic Resistance

Risk in Cardiac Surgery< 48 hr >48 hr OddsShort LongRatio

Number 1502 1139SSI 131 (8.7%) 100(8.8%) 1.0 (0.8-1.3)Acq Ab Res 6% 1.6 (1.1-2.6)

Harbarth. Circulation 2000;101:2916

Single vs Multiple Dose Surgical Prophylaxis: Systematic Review

0.01

0.1

1

10

100

McDonald. Aust NZ J Surg 1998;68:388

All

stud

ies,

fixe

dA

ll st

udie

s, ra

ndom

Mul

ti >

24h

Mul

ti <

24h

Favo

rs s

ingl

e do

seFa

vors

mul

tiple

dos

e

Relative Benefit from Antibiotic Surgical Prophylaxis

Operation Prophylaxis (%) Placebo (%) NNT*

Colon 4-12 24-48 3-5Other (mixed) GI 4-6 15-29 4-9Vascular 1-4 7-17 10-17Cardiac 3-9 44-49 2-3Hysterectomy 1-16 18-38 3-6Craniotomy 0.5-3 4-12 9-29Spinal operation 2.2 5.9 27Total joint repl 0.5-1 2-9 12-100Brst & hernia ops 3.5 5.2 58

When I started my residency in 1970 all

patients having colectomy got a bowel prep

as inpatients before their operation, and we

had just seen the first widely believed paper

that demonstrated a beneficial effect of

parenteral prophylactic antibiotics for

patients having GI operations. Oral

antibiotics were not used.

Effect of Mechanical Bowel Prep on Colon Flora (log 10)

Coliforms Bacteroides Clostridia

No Prep 4.5 – 7.5 7.9 – 9.5 1.8 – 3.6

Prep 3.0 – 4.3 7.8 – 9.0 0.7 – 2.5

Nichols. Dis Col & Rect 1971; 14: 123-7

Antibiotic and Mechanical Bowel Prep for Colectomy (48 hrs)

Any SSI

Placebo (63) 27 (43%)

Neomycin (68) 28 (41%)

Neo + Tetracycline (65) 3 (5%)

p<0.01

Washington. Ann Surg 1974;180:567-71

Antibiotic and Mechanical Bowel Prep for Colectomy (18

hrs)Any SSI

Placebo (56) 26 (43%)

Neo + Erythro (56) 5 (9%)p=0.0001

Clarke. Ann Surg 1977; 186:251-9


Any SSIPlacebo (59) 25 (42%)

Neo + Metronidazole (51) 9 (18%)p<0.01

Matheson. Br J Surg 1978; 65:597-600


Any SSIPlacebo (39) 16 (41%)

Kanamycin + Erythro (38) 3 (8%)p<0.001

Wapnick. Surgery 1979; 85:317-21

Antibiotic and Mechanical Bowel Prep for Colectomy (18 - 48 hrs)

Bowel Prep + Placebo Oral Ab197443% 5%197743% 9%197842% 18%197941% 8%

Sometime in the 1980’s most American and Canadian surgeons adopted oral antibiotic regimens while most European surgeons abandoned oral antibiotics.

Parenteral Alone vs Parenteral and Oral Antibiotics – All with Bowel

Prep for Colectomy

Lewis. Can J Surg 2002; 45: 173-80

Parenteral only

Parenteral + Oral

p < 0.002

Parenteral Alone vs Parenteral and Oral Antibiotics – All with Bowel Prep

for Colectomy – Meta-Analysis

Lewis. Can J Surg 2002; 45: 173-80

Parenteral only

Parenteral + Oral

MBP – yes / no?Antibiotics – oral / I.V. / both?

Guenaga. Cochrane Database Syst Rev,2009(1):p.C001544Nelson. Cochrane Database Syst Rev, 2009,(1): p.CD001181

SS

I Rat

e

N G

Bowel Preparation Prior to Elective Colectomy in Michigan (n=1648)

Overall SSI Rate in Michigan is 8.0%

Englesbe. Ann Surg 2010;252: 514–520

All patientsGet I.V. antibiotics

Surgical Site Infection Rates following Elective Colectomy

The Michigan Surgical Quality Collaborative

Propensity Matched Analysis(n=740)


n=195


0%

5%

10%

15%

C.difficile colitis Prolonged Ileus

No Oral Antibiotics

Oral Antibiotics

Per

cent

of p

atie

nts

* P < 0.05

Oral Antibiotics with a Bowel Preparation A Propensity Matched Analysis (n=740)



“Evidence Based” Bundle to Prevent SSI in Colorectal Surgery

Process Measure Study ControlMechanical Bowel Prep No Yes

Oral Antibiotics No YesPreOp Warming Yes No

IntraOp Warming Yes YesFiO2 80% 30%

Wound Protector Yes NoSCIP Parenteral Antibiotics Yes Yes

Any SSI* 45% 24%

Anthony. Arch Surg 2010; 146: 263-9

“Evidence Based” Bundle to Prevent SSI in Colorectal

Surgery1. Appropriate SCIP IV prophylactic

antibiotics2. Postop normothermia (T>98.6/37)3. Oral antibiotics and bowel prep4. Minimally invasive surgery5. Short operative duration (<100 min)

Waits (MSQC). Surgery 2014;epub

“Evidence Based” Bundle to Prevent SSI in Colorectal

Surgery

Waits (MSQC). Surgery 2014;epub

Oral Antibiotics Without Bowel Prep?

VASQIP, 9940 patients, 112 hospitalsIncidence SSI

Bowel prep, no oral Ab 39% 20%No prep at all, no oral Ab 20% 18%Bowel prep + oral Ab 34% 9%No prep + oral Ab (n=723) 7% 8%

Cannon. Dis Col Rectum 2012; 55: 1160-6

Oral Antibiotics for Colorectal Operations

Cannon. Dis Col Rectum 2012; 55: 1160-6

Differential Parenteral Efficacyand Addition of Oral

AntibioticsAgent Odds Ratio RangeCefaz/Metron 1.0 ReferenceAmp/Sulbactam 2.16 1.35 - 3.58Cefotetan 2.53 1.51 - 4.22Cefoxitin 2.56 1.73 - 3.81Add Oral Ab* 0.37 0.29 - 0.46

Deierhoi. JACS 2013; 217:763-9*P < 0.0001

Most Recent Cochrane Review

Comparison Odds Ratio Range

Ab Proph vs none 0.34 0.28 – 0.41

Oral + I.V. vs I.V. 0.56 0.43 – 0.74

Oral + I.V. vs Oral 0.56 0.40 – 0.76Greater than 2300 pts in each comparison

GRADE evidence quality HIGHNelson RL, Cochrane Rev 2014; #5: CD001181

Conclusions - ?• If you are not going to give any oral

antibiotics then the MBP is not necessary and there is a suggestion of harm along with more GI symptoms.

• However, if you are going to take my colon out I will suffer through the bowel prep and take oral antibiotics in advance of the operation for the lowest SSI rate!

Oxygen and SSI

Hunt. Am J Med. 1981;70:712.

Influence of Oxygen on the Development of Wound Infection

Hours After Innoculation

Diam

eter

Infe

ctio

us

Necr

osis

(mm

)

Wound Oxygen Tension & SSI

-15%-10%-5%0%5%

10%15%20%25%

40-4

9

50-5

9

60-6

9

70-7

9

80-8

9

90-1

29

Obs

erve

d-Ex

pect

ed S

SI R

ate

Maximum wound pO2

Hopf. Arch Surg 1997;132:997

3324

19 15

25

14

Near InfraRed O2 Saturation inthe Surgical Incision at 12 hrs

Ives. Br J Surg 2007;94:87-91

p < 0.04

Abdominal Operations

Oxygen and SSI• Oxygen tension in the wound

is important.

• How to translate that into clinical practice that lowers SSI is less obvious.

Temperature and SSI

(Oxygen)

Temperature and Tissue O2 tension

• Subcut temp increase 4° C• Subcut O2 tension increase 40 torr• Linear correlation between

temperature and O2 tension• Threefold increase in local perfusion

Rabkin. Arch Surg 1987;122:221

Temperature and SSI Following Colectomy

Normo (104) Hypo (96) PSSI 6 18 .009

Kurz. NEJM 1996;334:1209

Local Warming and SSI after Clean Operations

Local Systemic ControlSSI* 5 (4%)8 (6%)19 (14%)Post-op antibiotics* 9 (7%)9 (7%)22 (16%)

Melling. Lancet 2001;358:876* p < 0.01

Perioperative Warming, Intraoperative Temperature and Complications

----

Open Abdominal Bowel Resections

Wong. Br J Surgery 2007; 94: 423-6

PeriopN=47

StandardN=56 P value

Blood loss 200 ml 400 ml 0.011

Any complication 32% 54% 0.027

SSI 13% 33% 0.09

Redistribution Hypothermia

Core37°C

Vasoconstricted

Periphery31-35°C

Anesthesia

Periphery33-35°C

Core36°C

Vasodilated

Keeping Your Patient Warm in the O.R.

• Prewarming and active warming in the O.R. is much more important than the O.R. room temperature.

• If you raise O.R. room temperature from 20o to 27o, you still have an 10o gradient between the patient’s temperature and the room temperature and everyone in the room is miserable.

Prewarming at UWMC &First Postoperative TemperaturePost Anesthesia Care Unit (PACU) 2006

> 36o 7836/8132 (96.4%)

> 36o & < 36.5o 1047/2647 (40%)

> 36.5o1491/2647 (56%)

Oxygen (FiO2)

and SSI

Spinal Surgery, FiO2, & SSI

Maragakis. Anesthesiol 2009; 110:556-62

Meta-Analysis: FiO2 & SSI

Qadan. O2 & SSI.Review. Arch Surg 2009; 144:359-66

Mayzler

Pryor

Greif

Belda

Myles

FiO2, SSI, Atelectasis, & Respiratory Failure

PROXI Trial

Outcome80% FiO2

N=68530% FiO2

N=701Adjusted

Odds Ratio P

SSI 131 (19.1%) 141 (20.1%) 0.910.69 – 1.20

0.51

Atelectasis 54 (7.9%) 50 (7.1%) 1.130.75 – 1.72

0.56

Resp Failure 38 (5.5%) 31 (4.4%) 1.220.74 – 2.03

0.44

Meyhoff. JAMA 2009; ;302:1543-50

FiO2, SSI, Atelectasis, & Respiratory Failure

PROXI Trial

Outcome80% FiO2

N=68530% FiO2

N=701Adjusted

Odds Ratio P

SSI 131 (19.1%) 141 (20.1%) 0.910.69 – 1.20

0.51

Atelectasis 54 (7.9%) 50 (7.1%) 1.130.75 – 1.72

0.56

Resp Failure 38 (5.5%) 31 (4.4%) 1.220.74 – 2.03

0.44

Meyhoff. JAMA 2009; ;302:1543-50

Simply Increasing FiO2 isNot Enough

Oxygen has to get to the incision to make a difference* FiO2 * Regional anesth* Temperature * Fluid replacement* Cardiac output * Vasopressors* Vasoconstriction * etc.

Glucose and SSI

Diabetes, Glucose Control, and SSIs

After Median Sternotomy

0

5

10

15

20

<200 200-249 250-299 >300

% In

fect

ions

Latham. ICHE 2001; 22: 607-12

Hyperglycemia and Risk of SSI after Cardiac Operations

• Hyperglycemia - doubled risk of SSI• Hyperglycemic:

48% of diabetics12% of nondiabetics30% of all patients

• 47% of hyperglycemic episodes were in nondiabetics

Latham. Inf Contr Hosp Epidemiol. 2001;22:607Dellinger. Inf Contr Hosp Epidemiol. 2001;22:604

Deep Sternal SSI and Glucose

012345678

100-150 150-200 200-250 250-300

Day 1 Glucose (mg%)

% D

eep

Ster

nal I

nfec

tion

Zerr. Ann Thorac Surg 1997;63:356

Furnary et al. Ann Thorac Surg 1999:67:352

Glucose Control and Deep Sternal Wound Infections

Early (48h) Postoperative Glucose Levels and SSI after Vascular Surgery

Vriesendorp. Eur J Vasc Endovasc Surg 2004; 28:520-5

<103 mg%

103-117 mg%

117-151 mg%

>151 mg%

Postop Glucose (within 48h) and SSI – General Surgery

Ata. Arch Surg 2010: 145: 858-864

Glucose

Risk Adjusted Odds Ratios for Infection and Operative Intervention

Colectomy and Bariatric Operations

Kwon. Ann Surg. 2013; 257: 8-14

Composite Infection in Hyperglycemic Patients With

and Without Use of Insulin

Kwon. Ann Surg. 2013; 257: 8-14

Glucose in NonDiabetics having Colectomy at Cleveland Clinic

Highest Gluc N (%)< 125 mg% 816 (33%)126-200 mg% 1289 (53%)200 mg% 342 (14%)

All patients 2447 (100%)

Kiran, Ann Surg 2013;258:599–605

67%

Glucose in NonDiabetics having Colectomy at Cleveland Clinic

Kiran, Ann Surg 2013;258:599–605

Per C

ent i

ncid

ence

<125 126-200 >2000

1

2

3

4

5

6

7

8

Mort+Sepsis¤SSI*Reop¤

*p<0.03, ¤ p<0.01, + p<0.05

Preoperative Glucose as a Screening Tool for Patients

Without Diabetes• Random glucose within 30 days of operation• Average 8 days before operation• 16% within one day and 29% within 3 days• 6683 patients

• <70 384 pts• 70-99 4251 pts• 100-139 1801 pts• 140-179 187 pts• >180 60 pts

Wang. J Surg Res. 2014; 186: 371-8

31%

Preoperative Glucose as a Screening Tool for Patients

Without Diabetes

<70 70-99 100-139 140-179 >1800

5

10

15

20

25

InfectionComplication

Wang. J Surg Res. 2014; 186: 371-8

Glucose Levels & SSI• The exact “best” level of glucose control in

the perioperative period is not known.• High glucose levels unequivocally increase

the risk of SSI and other perioperative infections.

• Tight glucose control in the perioperative period is tricky.

• Hypoglycemia increases the risk of morbidity and mortality.

Some Things New

Teamwork,Communication,and Discipline

BMRI = Behavioral Marker Risk IndexBriefing, Information sharing, Inquiry, Vigilance and Awareness

Prior to Skin Incision: Briefing

Nursing/Tech reviews:Equipment issues

(instruments ready, trained on, requested implants available, gas tanks full)

Sharps management plan

Other patient concerns

Anesthesia reviews:Airway or other

concerns Special meds (beta

blockers, etc.) Allergies Conditions affecting

recovery

All Team Members (Attending Surgeon Leads):Each person introduces self by

name and roleSurgeon, Anesthesia team and

Nurse confirm patient (at least 2 identifiers), site, procedure

Personnel exchanges: timing, plan for announcing changes

Description of procedure and anticipated difficulties

Expected duration of procedure

Expected blood loss & blood availability

Need for instruments/supplies/IV access beyond those normally used for the procedure

Questions/issues from any team member and invitation to speak up at any time in the procedure

Prior to Skin Incision:Process Control

If case expected to be ≥ 1 hour, add:

Surgeon reviews: Glucose checked for

diabetics Insulin protocol initiated

if needed DVT/PE

chemoprophylaxis and/or mechanical prophylaxis plan in place

If patient on beta blocker, post-op plan formulated

Re-dosing plan for antibiotics

Specialty-specific checklist

Surgeon reviews (as applicable): Essential imaging

displayed; right and left confirmed

Antibiotic prophylaxis given in last 60 minutes

Active warming in place Special instruments

and/or implants

After Skin Closure Complete: No Retained Objects, Debriefing, Care Transition

Surgeon and Anesthesia:Key concerns for patient

recoveryWhat is the plan for pain

mgmt?What is the plan for

prevention of PONV?Does patient need special

monitoring (time in RR, ICU, tele?)

If patient has elevated blood glucose, plan for insulin drip formulated

If patient on beta blocker, post-op continuation plan formulated

All Team Members (Attending Surgeon Leads):Confirm final

needles/sponges/ instruments count correct

Nursing/Tech show Surgeon and Anesthesia all sponges and laps in holders (“Show Me Ten”)

Confirm name of procedure If specimen, confirm label

and instructions (e.g., orientation of specimen, 12 lymph nodes for colon CA)

Equipment issues to be addressed?

Response planned (who/when)

What could have been better?

Improvement planned (who/when)

Checklist and Complications

Before Aftern=3773 n=3955

SSI 6.2% 3.4%Unplan Return-O.R. 2.4% 1.8%Any Complic 11.0% 7.0%Death 1.5% 0.8%

Haynes. NEJM 2009; 360: 491-9

Checklist and Complications

Before Aftern=3760 n=3820

SSI 3.8% 2.7%Complic/100 pts 27.3 16.7Pts with Complic 15.4% 10.6%Death 1.5% 0.8%

de Vries. NEJM 2010; 363: 1928-37

Checklist Completion and Complications

Checklist Completion Complic

Above median 7.1%Below median11.7%

de Vries. NEJM 2010; 363: 1928-37

Checklist Completion and Mortality

Adjusted Odds RatioMortality

All patients 0.85 (0.73-0.98)

van Klei. Ann Surg 2012; 255: 44-9

Checklist Completion and Mortality

Adjusted Odds RatioMortality

All patients 0.85 (0.73-0.98)

Completed 0.44 (0.28-0.70)

Partial 1.09 (0.78-1.52)

Not done 1.16 (0.86-1.56

van Klei. Ann Surg 2012; 255: 44-9

JAMA 2010; 304:1693-1700

Neily. JAMA 2010; 304:1693-1700

Team Training and Mortality

Not Discussed Due to Timebut probably or possibly(?) important

• Screening and decolonizing S. aureus• Skin prep• Sterile technique• “Wound protectors?”• Impregnated sutures?• Prevention of “nonsurgical” infections• Management of the incision after

operation?

Preventing SSI• Have good teamwork at all times• Prewarm the patient• Enough of the right antibiotic at the

right time and repeat if necessary• Don’t shave• Thorough skin prep• Warm the patient in the O.R.• High FiO2

• Control glucose• Good teamwork

Slide Set and References available

by request

Send request to [email protected]

Documents

SSI Evidence – a Surgeon’s Perspective