《脊柱手术部位感染》

1、脊柱手术部位感染 俞武良 2016-10-12整理课件 手术部位感染(Surgical site infection SSI)是一种相对常见的脊柱手术并发症，发生率为1%-14%，具有潜在的灾难性的后果。整理课件 美国托马斯杰斐逊大学的Radcliff等筛选并总结了近5年成人脊柱手术后手术部位感染的发生率、危险因素、诊断、预防及治疗的相关研究，发表在2015年The Spine Journal杂志。整理课件1、Incidence a prospectively collected database of 108,419 cases, the overall infection rate for

2、 lumbar surgery was 2.1% (superficial=0.8%, deep=1.3%) 整理课件整理课件 The incidence of SSI appears to be lower after minimally invasive spinal (MIS) surgeries A review of 1,338 MIS surgeries from multiple institutions revealed an infection rate of 0.74% in fusion/fixations and 0.22% overall a review by Pa

3、rker et al compared postoperative infection after open and minimally invasive transforaminal lumbar interbody fusions. 362 MIS and 1,333 open surgeries，infection rate of 4% in open spinal fusions versus 0.6% after MIS (p=0.005) 整理课件2、Risk factors for infection Medical comorbidities：anemia, diabetesm

4、ellitus, coronary artery disease, diagnosis of coagulopathy, neoplasm obesity higher American Society of Anesthesiologist score malnutrition 整理课件整理课件 diabetes, obesity has been found to be a risk factor for SSI skin fold thickness and L4 spinous process-skinthickness are spine-specific SSI risk fact

5、ors independent of body mass index the distribution of adipose tissue and the depth of adipose tissue overlying the operative field increased the risk of SSI 整理课件 the particular diagnosis is an infection risk factor patients undergoing surgery for degenerative disease have a lower infection rate com

6、pared to deformity (1.4% vs. 4.2%) Patients undergoing surgery for trauma have a higher risk for infection compared to spinal fusion (9.4% vs. 3.7%) the risk of infection is correlated with the severityof the trauma 整理课件 case order may contribute to the rate of SSI after spine surgery lumbar decompr

7、ession performed later in the day (third case) led to three times higher incidence of SSI compared with those performed as the days first case contamination of the operating room, cross-contamination between health care providers during the course of the day, use of flash sterilization, and mid-day

8、shift changes.整理课件 seasonal effect on the rate of postoperativeeffect SSI incidence peaks in the summer and fall with statistically significant drops in infection rate in the spring and winter 整理课件 complex procedures may present a higher risk of perioperative complications more extensive tissue diss

9、ection increased blood loss longer operative time 整理课件3、Diagnosis Increased wound drainage approximately 10 to 14 days the most common early sign of wound infection present in 67% of patients with SSI increased pain fever wound erythema There are no universally accepted clinical diagnostic criteria

10、for SSI. 整理课件laboratory markers C-reactive protein (CRP) the most sensitive and is elevated in more than 98% of cases CRP rises and falls reliably in noninfected patients during the postoperative period with a peak occurring at approximately postoperative Day 3（ operative duration, region, surgery t

11、ype, preoperative CRP level, number of levels ） a second peak or failure of CRP level to normalize was a relatively accurate predictor of postoperative infection 整理课件整理课件laboratory markers Erythrocyte sedimentation rate (ESR) a later peak than CRP, typically occurring aroundpostoperative Day 4 Absol

12、ute neutrophil count (ANC) no significant difference between the normal and infected groups up to 4 days postoperatively a significant rise in the periods 4 to 7 and 8 to 11 days postoperatively in the infected patients 整理课件laboratory markers Serum amyloid-A (SAA) SAA is a superior marker for infect

13、ion compared with CRP because of the more dramatic change in value and earlier return to base line with similar kinetics Procalcitonin (PCT) PCT and CRP showed statistically significantcorrelations with the development of SSI PCT is superior to CRP in early prediction of SSI 整理课件laboratory markers I

14、nterleukin-6(IL-6) well studied in joint replacement surgery Leukocyte esterase a recently reported marker in periprosthetic knee joint infection 80.6% sensitivity and 100% specificity in diagnosing joint infection In particular, few laboratory markers have been validated as a gold standard in assoc

15、iation with culture-positive SSI. 整理课件4、Intraoperative measures intraoperative measures to reduce infections skin preparation intraoperative behaviors wound irrigation topical antibiotic application wound closure postoperative drain use整理课件 a significant level of wound contamination occurs intraoper

16、atively 23% of patients had positive intraoperative cultures. Of those that cultured positive,11.5% developed an early SSI Implants exposed to the operating room environment significantly reduced when the implants were covered during the case the level of contamination increases directly with the am

17、ount of time it is open in the operating field. 整理课件 skin preparation a significant decrease in SSI rate with the use of chlorhexidine versus iodine skin prep ？ Intraoperative techniques and behaviors the operative gown sterile instrument draping use of intraoperative fluoroscopy operative scrub cle

18、anliness 整理课件整理课件 wound irrigation agent to have been demonstrated to reduce SSI rate is povidone-iodine(PVP-I) Soaked with dilute PVP-I for 3 minutes（5% 0.35%） Copiously irrigated with normal saline before bone decortication 整理课件significant decrease in SSI after local administration of vancomycin p

19、owder整理课件 Postoperative protocols an increased mean number of days of closed suction wound drainage in patients with infection versus patients without infection use of 2-octyl-cyanoacrylate for skin closure may decrease the rate of infection 整理课件5、Treatment Treatment of SSI relies on early identification early diagnosis early evacuation of gross purulent material 整理课件 Treatment options irrigation and debridement intravenous antibiotics primary closure closed vacuum system hardware retention plastic surgery reconstruction(