Showing papers on "Surgical wound published in 1995"

Nasal Carriage of Staphylococcus Aureus as a Major Risk Factor for Wound Infections after Cardiac Surgery

Abstract: To evaluate the importance of nasal carriage of Staphylococcus aureus as a risk factor for the development of wound infection at the sternotomy site after cardiac surgery, a case-control study was done. The study population consisted of 1980 consecutive patients. Cases were all patients who developed a sternal wound infection from which S. aureus was cultured. Forty cases were identified, and 120 controls were selected. Preoperative nasal carriage of S. aureus, insulin-dependent diabetes mellitus, and younger age were identified as significant risk factors. The crude odds ratio of nasal carriage was 9.6 (95% confidence interval, 3.9-23.7). The median postoperative length of hospital stay for cases was 30 days longer than for controls. Mortality was also significantly higher for cases than for controls (10.0% and 0.8%, respectively).

Temporary closure of open abdominal wounds: the vacuum pack.

Abstract: Temporary closure of abdominal surgical wounds is occasionally required when conditions of the abdominal wall or peritoneal cavity prevent closure or when early re-exploration is planned. The optimal temporary closure should contain and protect the contents of the peritoneal cavity from external contamination and injury; preserve the integrity of the abdominal wall; be simple to perform and maintain; provide ease of reentry; and have minimal adverse physiologic effects. Based on these criteria, a method of temporary abdominal wound closure (termed the vacuum pack) has been designed and evaluated. The operative technique includes 1) placement of a fenestrated polyethylene sheet between the abdominal viscera and anterior parietal peritoneum; 2) placement of a moist, sterile laparotomy towel over the polyethylene sheet; 3) placement of two closed suction drains over the towel; 4) placement of an adhesive backed drape over the entire wound, including a wide margin of surrounding skin; and 5) suction applied to the drains, creating a vacuum and rigid compression of the layers of closure material. This creates a tight, external seal of the adhesive backed drape and facilitates drainage of the peritoneal cavity. From April 1992-December 1993, this temporary abdominal wound closure was performed 56 times in 28 patients, ages 6-78 years, for periods of 1-11 days. The procedure was used in 17 trauma patients and 11 non-trauma patients. Indications for use included increased intra-abdominal pressure in nine, mandatory re-exploration in 10, and a combination of these indications in nine patients. Pre- and postprocedural airway and systemic blood pressures were unaffected by this closure.(ABSTRACT TRUNCATED AT 250 WORDS)

Unnecessary laparotomies for trauma: a prospective study of morbidity.

Abstract: Objective Despite advances in diagnostic techniques, unnecessary laparotomies (no repairs/no drains) are still performed in trauma centers. The true risks of such procedures are unclear. Our hypothesis was that the overall incidences of complications after an unnecessary laparotomy for trauma that have been reported in the literature were significant underestimates because of flaws in study design. To test our hypothesis, a prospective study to record all perioperative complications in patients undergoing an unnecessary laparotomy for trauma was performed. Design Prospective case series. Measurements and main results The main outcome measures were perioperative complications. An unnecessary laparotomy was performed in 254 patients who sustained trauma. The mechanism of injury was a penetrating wound in 98% of the patients. Complications occurred in 41.3% of the patients (n = 105) and included atelectasis (15.7%), postoperative hypertension that required medical treatment (11.0%), pleural effusion (9.8%), pneumothorax (5.1%), prolonged ileus (4.3%), pneumonia (3.9%), surgical wound infection (3.2%), small bowel obstruction (2.4%), urinary infection (1.9%), and others. Complication rates for patients who did (n = 111) and did not (n = 143) have an associated injury were 61.3% and 25.9%, respectively (p = 0.0001). Complications occurred in 19.7% of 81 patients who did not have an associated injury and who did not have intraperitoneal or retroperitoneal penetration. The mortality rate for the entire series was 0.8% and was unrelated to the unnecessary laparotomies. Conclusions Unnecessary laparotomies for trauma result in a significant morbidity when complications are recorded prospectively. Current efforts to reduce the incidence of these unnecessary procedures without increasing that of missed injuries are obviously worthwhile.

Factors influencing wound dehiscence after midline laparotomy

Abstract: Purpose: To identify patients who have high risk of wound dehiscence and who might benefit from the use of internal retention sutures Patients and methods: Forty-eight patients with midline abdominal wound dehiscence were compared with 48 control patients standardized by sex, age, and operative indication Results: The mean hospital stay was significantly prolonged in the dehiscence group, resulting in a higher total cost of hospital treatment The variables that were significantly associated with wound dehiscence included hypoalbuminemia, anemia, malnutrition, chronic lung disease, and emergency procedure The additional postoperative factors that were found to be significant were vomiting, prolonged intestinal paralysis, repeated urinary retention, and increased coughing Obesity, chronic heart disease, diabetes, alcoholism, preoperative intestinal obstruction, jaundice, systemic and local infection, use of steroids, type of incision, operating time, and type of wound closure were nonsignificant variables The number of wound dehiscences increased significantly ( P = 00001) when the number of risk factors increased from zero to five Conclusion: We recommend using internal retention sutures for patients who have three or more risk factors

A composite skin substitute (graftskin) for surgical wounds. A clinical experience.

Abstract: BACKGROUND. Bioengineered skin substitutes offer tissue replacement without requiring a donor site and might produce better healing. OBJECTIVE. To evaluate the recipient's response to grafting a bioengineered skin equivalent onto acute surgical wounds. METHODS. Graftskin, which is made of : 1) a bovine collagen matrix containing human fibroblasts, and 2) an overlying sheet of stratified human epithelium, was grafted onto the excision sites of 15 patients. RESULTS. Blood and cell studies for toxicity were negative. Graftskin proved easy to handle, and a typical clinical appearance of the skin substitute during take was detected. Compared with expectations improved healing occurred. Twelve of 15 patients had initial clinical takes. CONCLUSION. Graftskin was not clinically rejected and was not toxic. It often appeared to take and produced better than expected healing.

Risk factors for complications in clean-contaminated head and neck surgical procedures

Abstract: Background. Contamination of a head and neck surgical wound with oropharyngeal secretions has been shown to dramatically increase the incidence of wound complications. Appropriate perioperative antibiotic prophylaxis has significantly reduced contaminated wound infection rates in several previous reports. The current study examined multiple patient parameters to determine risk factors for all perioperative complications following clean-contaminated head and neck surgical procedures. Methods. Retrospective review of medical records from 159 patients who underwent clean-contaminated major head and neck surgical procedures at the University of Washington between 1985 and 1991. More than 30 preoperative and operative parameters were evaluated, and all complications were recorded. The data were examined using a multivariate statistical analysis. Results. An overall complication rate of 63% included 22% with wound infections (oro/pharyngocutaneous fistula or purulent drainage), 22% with other types of infections, and 51% with noninfectious complications. The overall perioperative mortality rate was 1.2% (two patients). Prior radiotherapy, operative time, perioperative transfusion, and flap reconstruction were all associated with a significantly higher overall complication rate (p ≤ 0.05). Only prior radiotherapy therapy correlated with an increase in wound infection rate (p = 0.05). Conclusions. Prior radiotherapy significantly increases the risk of perioperative complications and wound infections following clean-contaminated head and neck surgical procedures. Other factors reflecting the complexity of the procedure also influence the overall complication rate. © 1995 Jons Wiley & Sons, Inc.

Unnecessary laparotomies for trauma : a prospective study of morbidity

Abstract: Objective: Despite advances in diagnostic techniques, unnecessary laparotomies (no repairs/no drains) are still performed in trauma centers. The true risks of such procedures are unclear. Our hypothesis was that the overall incidences of complications after an unnecessary laparotomy for trauma that have been reported in the literature were significant underestimates because of flaws in study design. To test our hypothesis, a prospective study to record all perioperative complications in patients undergoing an unnecessary laparotomy for trauma was performed. Design: Prospective case series. Measurements and Main Results: The main outcome measures were perioperative complications. An unnecessary laparotomy was performed in 254 patients who sustained trauma. The mechanism of injury was a penetrating wound in 98% of the patients. Complications occurred in 41.3% of the patients (n=105) and included atelectasis (15.7%), postoperative hypertension that required medical treatment (11.0%), pleural effusion (9.8%), pneumothorax (5.1%), prolonged ileus (4.3%), pneumonia (3.9%), surgical wound injection (3.2%), small bowel obstruction (2.4%), urinary injection (1.9%), and others. Complication rates for patients who did (n=111) and did not (n=143) have an associated injury were 61.3% and 25.9%, respectively (p=0.0001). Complications occurred in 19.7% of 81 patients who did not have an associated injury and who did not have intraperitoneal or retroperitoneal penetration. The mortality rate for the entire series was 0.8% and was unrelated to the unnecessary laparotomies. Conclusions: Unnecessary laparotomies for trauma result in a significant morbidity when complications are recorded prospectively. Current efforts to reduce the incidence of these unnecessary procedures without increasing that of missed injuries are obviously worthwhile

Development of wound infection or separation after cesarean delivery. Prospective evaluation of 2,431 cases.

Abstract: Wound infections are a common surgical complication, often requiring a prolonged hospital stay and leading to increased costs. Over a one-year period, 2,431 patients were followed after cesarean delivery with prompt evaluation and culture of all suspicious wounds. Seventy subjects (2.8%) developed confirmed wound infection, and 42 (1.7%) developed noninfected open surgical wounds. Seven (0.3%) fascial dehiscences were diagnosed, requiring surgical repair. Forty of 63 (64%) infected wounds had positive bacterial cultures, with Staphylococcus epidermidis (29%), Enterococcus faecalis (17%), Staphylococcus aureus (17%), Escherichia coli (11%) and Proteus mirabilis (10%) the most frequent isolates. Only 7 of 42 (17%) noninfected wounds had positive cultures, with only S aureus, S epidermidis and Corynebacterium species isolated. Ninety-five percent of the noninfected wounds had blood or serous collections present. Rupture of membranes lasting longer than six hours, emergency cesarean delivery and morbid obesity were associated with a statistically increased likelihood of the development of infected wounds. Emergency cesarean delivery and morbid obesity, but not prolonged rupture of membranes, were associated with an increased likelihood of the development of noninfected wounds. Therefore, it appears that at least two mechanisms are responsible for the development of postcesarean open wounds: (1) increased amniotic fluid and wound colonization due to prolonged rupture of membranes, resulting in a wound infection containing one or more bacterial species derived from the cervicovaginal flora, and (2) increased exogenous bacterial contamination and flora consistent with skin species or breaks in sterile technique, often accompanying difficult or emergency surgery.

Can ultrasound probes and coupling gel be a source of nosocomial infection in patients undergoing sonography? An in vivo and in vitro study.

Abstract: At our institution, ultrasound probes are wiped with a clean, dry, soft, absorbent paper towel after each procedure as a basic standard of probe disinfection. However, it was unclear if this provided a sufficient level of decontamination. This study was designed to determine if the ultrasound probe and coupling gel can act as a vector of nosocomial infection and to describe a cost-effective method of probe handling that allows optimal control of infection.In the first part of the study, the ultrasound probe was exposed to the disrupted skin of patients recruited from our inpatient population, using our routine scanning technique to look for subcutaneous collections. Twenty-seven patients were scanned: 17 with surgical wounds, seven with surgical drains, four with enteric stomas, three with biopsy sites, and three with ulcers or excoriation. Fifteen patients had a discharge associated with their disrupted skin, and seven patients had culture-proved skin infections. Each probe was wiped with a clean, dry pa...

Evaluation of a carboxymethylcellulose sponge for prevention of postoperative adhesions.

Abstract: Background A novel lyophilized carboxymethylceflulose (CMC) sponge has been developed for prevention of surgical wound adhesions. One potential mechanism for preventing abdominal adhesion is suppression of the cytokine transforming growth factor beta (TGF-β) and other macrophage derived fibroblast stimulating factors that partially mediate adhesion formation. Methods To study the efficacy and mechanisms of action of the CMC sponge, we performed standard cecal denudation and abdominal wall apposition on rats. A CMC sponge or a commercially available adhesion preventive barrier (Interceed) was placed on the denuded surface. After 14 days, adhesion severity was graded blindly on a scale ranging from 0 (no adhesion) to 5 (severe adhesion). TGF-β expression was determined by immunocytochemical staining. To assess the secretion of macrophage derived fibrogenic factors in control and CMC rats, labeled thymidine and proline uptake and hydroxyproline production were measured in NRK rat fibroblasts cultured with conditioned medium of peritoneal macrophages. Results The severity of adhesions in the CMC sponge group (0.7 ± 0.3) was significantly lower than in the Interceed or control groups (2.2 ±0.3; 4.6 ± 0.1). In control animals TGF-β expression in endothelium and fibroblasts was maximal on day 3. Neither CMC nor Interceed reduced this expression. Conditioned media derived from sponge-exposed postsurgical peritoneal macrophages did not inhibit fibroblast growth or collagen formation. Conclusions In this model the CMC sponge was more effective than Interceed in preventing postoperative adhesions. Its action was not due to inhibition of TGF-β expression or macrophage derived fibrogenic factors. These data highlight the primary importance of local barrier effect in adhesion prevention.

Intraocular pressure rise after phacoemulsification with posterior chamber lens implantation: effect of prophylactic medication, wound closure, and surgeon's experience.

Abstract: AIMS--A prospective clinical trial was carried out to evaluate the effect of prophylactic medication, the technique of wound closure, and the surgeon's experience on the intraocular pressure rise after cataract extraction. METHODS--In 100 eyes, the intraocular pressure was measured before as well as 2-4, 5-7, and 22-24 hours after phacoemulsification and posterior chamber lens implantation. Each of 25 patients received either 1% topical apraclonidine, 0.5% topical levobunolol, 500 mg oral acetazolamide, or placebo. Forty four eyes were operated with sclerocorneal sutureless tunnel and 56 eyes with corneoscleral incision and suture. Sixty three operations were performed by experienced surgeons (more than 300 intraocular operations) and 37 by inexperienced surgeons (less than 200 intraocular operations). RESULTS--The pressure increase from baseline to the maximum 5-7 hours after surgery did not differ significantly (p = 0.8499) for apraclonidine (9.5 mm Hg), levobunolol (7.2 mm Hg), acetazolamide (7.8 mm Hg), and placebo (8.6 mm Hg). The increase was significantly (p = 0.0095) lower in eyes with corneoscleral tunnel (5.5 mm Hg) than in eyes with corneoscleral suture (10.5 mm Hg) and significantly (p = 0.0156) lower for experienced (6.6 mm Hg) than for inexperienced surgeons (11.2 mm Hg). CONCLUSIONS--The intraocular pressure rise after phacoemulsification and posterior chamber lens implantation depends strongly on the technique of wound closure and the surgeon's experience. Compared with these two factors, the effect of prophylactic medication can be neglected.

Risk factors for early wound complications after orthopedic surgery for rheumatoid arthritis

Abstract: Objective. To identify risk factors for the occurrence of early wound complications following orthopedic surgery in patients with rheumatoid arthritis (RA). Methods. We reviewed records of patients with RA undergoing joint surgery to identify predictors of the following early postoperative surgical outcomes : (1) prolonged drainage ; (2) wound cellulitis; (3) wound dehiscence ; (4) suture abscess ; and (5) superficial or deep wound infection. Results. During the study, 204 patients with RA underwent 119 total knee replacements, 105 total hip replacements and 143 procedures of other joints, for a total of 367 orthopedic surgeries. A total of 57 complications were observed (15.9%) of which 26 were considered major (7%). Of the 230 total arthroplasties of the hip, knee, shoulder or elbow, 3 were followed by early deep wound infections (1.3 %). In univariate analyses, factors significantly related to the occurrence of complications included Hispanic ethnicity [relative risk (RR) 1.43, 95% confidence interval (CI) 1.16 to 1.78], and preoperative use of azathioprine (RR 2.13, 95% CI 1.04 to 4.37). Complications were less frequent among patients given methotrexate, but the difference was not significant. Operative blood loss was inversely related to the occurrence of complications. In the multivariate model, the only significant predictors of complications were Hispanic ethnicity (RR 2.86, 95% CI 1.43 to 5.56) and operative blood loss (RR 0.50/liter lost, 95% CI 0.29 to 0.86). Conclusions. We were unable to demonstrate an independent effect of antirheumatic therapy at the time of surgery on the occurrence of postoperative wound complications. Our study suggests that patients with RA of Hispanic ethnicity may be at increased risk of developing postoperative wound complications following orthopedic surgery. Further study is necessary to explain the mechanism of increased complications in this population.

Nosocomial Outbreak of Candida albicans Sternal Wound Infections following Cardiac Surgery Traced to a Scrub Nurse

Abstract: From August 1988 through October 1989, 15 patients at 1 hospital developed Candida albicans sternal wound infections after cardiac surgery. An investigation found that case-patients were more likely than cardiac surgery patients without sternal wound infections to have surgeries lasting > 165 min (11/15 vs. 20/45; odds ratio [OR], 5.0; 95% confidence interval [CI], 1.5-16.3) or exposure to first scrub nurse A (15/15 vs. 22/45; OR, infinity; 95% CI, 2.5, infinity). Molecular typing of 5 case-patient C. albicans isolates revealed a common strain. Nurse A had a history of recurrent vaginal infections responding to topical antifungal agents; however, cultures of multiple samples from nurse A, beginning 3 weeks after the last infected patient's surgery, failed to yield C. albicans. Following her voluntary transfer from cardiac surgery, no additional infections of case-patients were detected. This study demonstrates the utility of combining epidemiologic methods and molecular typing in investigating C. albicans infection clusters and suggests that a common exogenous source can be responsible for C. albicans surgical wound infections.

Post-operative infection following hand surgery. Guidelines for antibiotic use

Abstract: An audit was designed to analyse the risk factors for developing post-operative wound infection following hand surgery. 249 consecutive patients were prospectively entered into the study. 236 (95%) patients were available for follow-up. Infection was diagnosed by clinical criteria. There was an infection rate of 10.7% in elective operations and 9.7% in emergency operations. There was no significant reduction in infection rate in the elective group with the use of antibiotics (P = 0.5). In the emergency group of patients peri-operative antibiotic administration was associated with an 8.5-fold reduction in infection rate (P = 0.014). The presence of a dirty wound was associated with a 13.4-fold increase in post-operative wound infection rate (P = 0.002). A postal questionnaire of members of the British Society for Surgery of the Hand revealed a wide variation in antibiotic usage. Guidelines for antibiotic use in patients undergoing hand surgery are presented.

Abdominal wall metastasis and peritoneal carcinomatosis after laparoscopic assisted colectomy for colon cancer

Abstract: We report a case of a port-site recurrence with diffuse peritoneal carcinomatosis after laparoscopic-assisted right hemicolectomy. The interval between resection of the colonic adenocarcinoma and diagnosis of the recurrence was short (1 month), suggesting that intraperitoneal dissemination and tumour implantation on surgical wounds may represent the principal mechanism of recurrence after laparoscopic surgery. Review of the literature shows an alarming increase in the occurrence of this devastating complication. Although beneficial to the patient in the immediate post-operative period, the adequacy of laparoscopic-assisted colectomy in tumour is increasingly under question.

Surgical fluid suction accumulator and volume measurement device

Abstract: An apparatus for minimizing trauma to a medical fluid while transporting the medical fluid from a surgical wound by reducing the air to fluid interface during transport. The apparatus includes a suction wand for collecting medical fluid and tubing for transporting the medical fluid to a reservoir. The reservoir repeatedly accumulates the medical fluid and discharges it in a bolus when a predetermined volume is achieved. The reservoir comprises a fluid inlet, a fluid outlet, and a gas outlet. A siphon is disposed inside the reservoir for removing the bolus of medical fluid once the predetermined fluid volume is accumulated. The siphon includes a first end for suctioning the medical fluid and a second end exiting the reservoir through the fluid outlet, thereby defining an external siphon length. A pump is attached to the second siphon end to provide suction to the system. A bypass line connects the reservoir, from its gas outlet, to the external siphon length thereby removing air from the reservoir and, thus, increasing the reduction of the air to fluid interface during transport of the medical fluid.

A prospective, randomized surveillance study of postoperative wound infections after plastic surgery: a study of incidence and surveillance methods.

Abstract: In a postoperative wound infection study in plastic surgery, 315 patients were randomized to either outpatient wound control after 30 days (group I) or self-control by questionnaire (group II). We present a new definition of wound infection based on physiologic wound healing. The surveillance of pos

Methods to decrease the morbidity of abdominoperineal resection.

Abstract: Recent reports stress that abdominoperineal resections (APR) are associated with many complications, including hemorrhage, long hospitalization, and delayed closure of an open perineal wound. Thirty-five patients underwent an abdominoperineal resection for cancer at Kaiser Permanente Medical Center, Los Angeles, from January 1989 to December 1993. All patients, except two, had their perineal wound closed after closure of the peritoneum and insertion of closed system suction catheters. Ninety-one per cent of patients achieved successful primary healing. Three patients (8.5%) suffered perineal wound dehiscence. Overall morbidity was 55 per cent, with urinary retention being the most common, occurring in 23 per cent of patients. This was managed successfully by early in-and-out self catheterization. There was no incidence of urinary tract infections. There were no operative deaths. Length of stay averaged 8.6 days, with a median of 7 days. Five patients had previous radiation therapy. Of those, two (40%) had perineal wound dehiscence, compared to only one of 33 (3.3%) patients without previous radiation. APRs can be done with minimal mortality, although with an increased morbidity in irradiated patients. Primary closure and drainage of the perineal wound significantly lowers the complication rate, as does early Foley removal and self in-and-out catheterization.

An experimental model to determine the effect of irradiated tissue on neutrophil function.

Abstract: Complications of irradiated tissue include infections and impaired healing. Although fibrosis and hypovascularity contribute, a cellular mechanism has not been identified. This study examines the effect of radiation (10 to 30 Gy) on neutrophil function in a rabbit wound cylinder model. At 3 to 12 weeks after radiation, subcutaneous wound cylinders were implanted in both irradiated and control fields in 19 rabbits. Wound neutrophils were subsequently assayed for phagocytosis ( 3 H-labeled Staphylococcus aureus assay), superoxide production (cytochrome c reduction assay), and surface Mac-1 expression (flow cytometric assay using MHM 23 monoclonal antibody). Phagocytosis of 3 H-labeled S. aureus was significantly lower in neutrophils from irradiated fields compared with controls at 6 and 12 weeks after radiation (6.5 versus 18.9 bacteria per neutrophil at 12 weeks ; p = 0.027). Stimulated neutrophils from irradiated tissue could not increase superoxide production or Mac-1 expression as much as controls, with differences increasing as postirradiation time increased. The diminished phagocytosis, superoxide production, and Mac-1 expression provide a cellular mechanism that may account for susceptibility to infection and poor healing in irradiated tissues.