Guideline for Prevention of Surgical Site Infection, 1999 ☆ ☆☆ ★ ★★

The “Guideline for Prevention of Surgical Site Infection, 1999” presents the Centers for Disease Control and Prevention (CDC)'s recommendations for the prevention of surgical site infections (SSIs), formerly called surgical wound infections. This two-part guideline updates and replaces previous guidelines.Part I, “Surgical Site Infection: An Overview,” describes the epidemiology, definitions, microbiology, pathogenesis, and surveillance of SSIs. Included is a detailed discussion of the pre-, intra-, and postoperative issues relevant to SSI genesis.

/pdf/guideline-for-prevention-of-surgical-site-infection-1999-2k3en33kqw.pdf

Guideline for Prevention of Surgical Site Infection, 1999

National Nosocomial Infections Surveillance (NNIS) System Report, data summary from January 1992 through June 2003, issued August 2003.

Objective. —Define the epidemiology of the four recently classified syndromes describing the biologic response to infection: systemic inflammatory response syndrome (SIRS), sepsis, severe sepsis, and septic shock. Design. —Prospective cohort study with a follow-up of 28 days or until discharge if earlier. Setting. —Three intensive care units and three general wards in a tertiary health care institution. Methods. —Patients were included if they met at least two of the criteria for SIRS: fever or hypothermia, tachycardia, tachypnea, or abnormal white blood cell count. Main Outcomes Measures. —Development of any stage of the biologic response to infection: sepsis, severe sepsis, septic shock, end-organ dysfunction, and death. Results. —During the study period 3708 patients were admitted to the survey units, and 2527 (68%) met the criteria for SIRS. The incidence density rates for SIRS in the surgical, medical, and cardiovascular intensive care units were 857,804, and 542 episodes per 1000 patient-days, respectively, and 671,495, and 320 per 1000 patient-days for the medical, cardiothoracic, and general surgery wards, respectively. Among patients with SIRS, 649 (26%) developed sepsis, 467 (18%) developed severe sepsis, and 110 (4%) developed septic shock. The median interval from SIRS to sepsis was inversely correlated with the number of SIRS criteria (two, three, or all four) that the patients met. As the population of patients progressed from SIRS to septic shock, increasing proportions had adult respiratory distress syndrome, disseminated intravascular coagulation, acute renal failure, and shock. Positive blood cultures were found in 17% of patients with sepsis, in 25% with severe sepsis, and in 69% with septic shock. There were also stepwise increases in mortality rates in the hierarchy from SIRS, sepsis, severe sepsis, and septic shock: 7%, 16%, 20%, and 46%, respectively. Of interest, we also observed equal numbers of patients who appeared to have sepsis, severe sepsis, and septic shock but who had negative cultures. They had been prescribed empirical antibiotics for a median of 3 days. The cause of the systemic inflammatory response in these culture-negative populations is unknown, but they had similar morbidity and mortality rates as the respective culture-positive populations. Conclusions. —This prospective epidemiologic study of SIRS and related conditions provides, to our knowledge, the first evidence of a clinical progression from SIRS to sepsis to severe sepsis and septic shock. ( JAMA . 1995;273:117-123)

The Natural History of the Systemic Inflammatory Response Syndrome (SIRS): A Prospective Study

https://www.amjmed.com/article/0002-9343(91)90361-Z/pdf

Surgical wound infection rates by wound class, operative procedure, and patient risk index

The American Society of Anesthesiologists' (ASA) Physical Status Classification was tested for consistency of use by a questionnaire sent to 304 anesthesiologists. They were requested to classify ten hypothetical patients. Two hundred fifty-five (77.3 percent) responded to two mailings. The mean number of patients rated consistently was 5.9. Four patients elicited wide ranges of responses. Age, obesity, previous myocardial infarction, and anemia provoked controversy. There was no significant difference in responses from different regions of the country. Academic anesthesiologists rated a greater number identical than did those in private practice (P less than 0.01). There was no difference in ratings between those who used the classification for billing purposes and those who did not. The ASA Physical Status Classification is useful but suffers from a lack of scientific precision.

ASA Physical Status Classifications: A Study of Consistency of Ratings

American Society of Anesthesiologists Physical Status Classification System Is Not a Risk Classification System William Owens; Anesthesiology

American Society of Anesthesiologists Physical Status Classification System Is Not a Risk Classification System

During intra-abdominal surgery, plasma levels of norepinephrine in peripheral venous blood were higher in 11 patients who received fentanyl-nitrous oxide-oxygen than in 10 patients who received enflurane-nitrous oxide-oxygen [703 +/- 95 vs 463 +/- 38 (SEM) pg/ml]. At the same time, systolic blood pressure (143 +/- 6 vs 121 +/- 4 torr), mean blood pressure (108 +/- 4 vs 98 +/- 3 torr), and pulse rate (87 +/- 3 vs 98 +/- 4 beats per minute) also differed significantly (p less than 0.05); plasma levels of epinephrine (235 +/- 61 vs 113 +/- 21) did not. These values did not differ significantly between the two groups before induction of anesthesia, after induction but before skin incision, or in the recovery room. These data support the concept that enflurane anesthesia blocks the sympathetic response to surgical stress more effectively than low dose fentanyl anesthesia.

Plasma epinephrine and norepinephrine levels during anesthesia: enflurane-N2O-O2 compared with fentanyl-N2O-O2.

Lumbosacral plexus block is a valuable anesthetic technic in the hands of an experienced anesthesiologist. However, as illustrated by this case report, anesthetic dosage must he selected with great care, and patients unable to describe paresthesias should be excluded from use of this procedure.

An unusual complication of lumbosacral plexus block: a case report.

CASE REPORTS Patient No. 1-A 54-year-old white female scheduled for an exploratory laparotomy had a history of 8 previous anesthetics, 3 for gynecologic procedures and 5 for mastoidectomies and tympanoplasties on the left ear. The most recent operation was a revision of a mastoidectomy on the left side performed 3 years prior to this admission. No details of the anesthetic technic were available. Her chief complaint was abdominal pain. Review of systems was noncontributory except for decreased hearing in the left ear. Physical examination revealed an

William D. Owens

Papers

ASA Physical Status Classifications: A Study of Consistency of Ratings

American Society of Anesthesiologists Physical Status Classification System Is Not a Risk Classification System

Plasma epinephrine and norepinephrine levels during anesthesia: enflurane-N2O-O2 compared with fentanyl-N2O-O2.

An unusual complication of lumbosacral plexus block: a case report.

Tympanic membrane rupture with nitrous oxide anesthesia.