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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
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
Poor Blood Glucose Control• Low Cardiac Output
• Increased inotrope
• Malignant arrhythmias
• Prolonged mechanical ventilation
• Stroke, Encephalopathy
• Renal dysfunction
• Infectious outcome
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
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
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
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