脊柱手術(shù)部位感染課件

脊柱手術(shù)部位感染俞武良2016-10-12脊柱手術(shù)部位感染俞武良2016-10-121

手術(shù)部位感染(SurgicalsiteinfectionSSI)是一種相對常見的脊柱手術(shù)并發(fā)癥，發(fā)生率為1%-14%，具有潛在的災(zāi)難性的后果。手術(shù)部位感染(Surgicalsiteinfectio2

美國托馬斯杰斐遜大學(xué)的Radcliff等篩選并總結(jié)了近5年成人脊柱手術(shù)后手術(shù)部位感染的發(fā)生率、危險因素、診斷、預(yù)防及治療的相關(guān)研究，發(fā)表在2015年TheSpineJournal雜志。美國托馬斯杰斐遜大學(xué)的Radcliff等篩選并總結(jié)了近5年31、Incidenceaprospectivelycollecteddatabaseof108,419cases,theoverallinfectionrateforlumbarsurgerywas2.1%(superficial=0.8%,deep=1.3%)1、Incidenceaprospectivelyco4脊柱手術(shù)部位感染課件5TheincidenceofSSIappearstobelowerafterminimallyinvasivespinal(MIS)surgeriesAreviewof1,338MISsurgeriesfrommultipleinstitutionsrevealedaninfectionrateof0.74%infusion/fixationsand0.22%overallareviewbyParkeretalcomparedpostoperativeinfectionafteropenandminimallyinvasivetransforaminallumbarinterbodyfusions.362MISand1,333opensurgeries，infectionrateof4%inopenspinalfusionsversus0.6%afterMIS(p=0.005)

TheincidenceofSSIappearst62、RiskfactorsforinfectionMedicalcomorbidities：anemia,diabetes

mellitus,coronaryarterydisease,diagnosisofcoagulopathy,neoplasmobesityhigherAmericanSocietyofAnesthesiologistscoremalnutrition

2、RiskfactorsforinfectionM7脊柱手術(shù)部位感染課件8diabetes,obesityhasbeenfoundtobeariskfactorforSSIskinfoldthicknessandL4spinousprocess-skin

thicknessarespine-specificSSIriskfactorsindependentofbodymassindexthedistributionofadiposetissueandthedepthofadiposetissueoverlyingtheoperativefieldincreasedtheriskofSSI

diabetes,obesityhasbeenfou9theparticulardiagnosisisaninfectionriskfactorpatientsundergoingsurgeryfordegenerativediseasehavealowerinfectionratecomparedtodeformity(1.4%vs.4.2%)Patientsundergoingsurgeryfortraumahaveahigherriskforinfectioncomparedtospinalfusion(9.4%vs.3.7%)theriskofinfectioniscorrelatedwiththeseverity

ofthetraumatheparticulardiagnosisisan10caseordermaycontributetotherateofSSIafterspinesurgerylumbardecompressionperformedlaterintheday(thirdcase)ledtothreetimeshigherincidenceofSSIcomparedwiththoseperformedastheday’sfirstcasecontaminationoftheoperatingroom,cross-contaminationbetweenhealthcareprovidersduringthecourseoftheday,useofflashsterilization,andmid-dayshiftchanges.caseordermaycontributetot11seasonaleffectontherateofpostoperative

effectSSIincidencepeaksinthesummerandfallwithstatisticallysignificantdropsininfectionrateinthespringandwinterseasonaleffectontherateof12complexproceduresmaypresentahigherriskofperioperativecomplicationsmoreextensivetissuedissectionincreasedbloodlosslongeroperativetimecomplexproceduresmaypresent133、DiagnosisIncreasedwounddrainageapproximately10to14daysthemostcommonearlysignofwoundinfectionpresentin67%ofpatientswithSSIincreasedpainfeverwounderythema

TherearenouniversallyacceptedclinicaldiagnosticcriteriaforSSI.3、DiagnosisIncreasedwounddr14laboratorymarkersC-reactiveprotein(CRP)themostsensitiveandiselevatedinmorethan98%ofcasesCRPrisesandfallsreliablyinnoninfectedpatientsduringthepostoperativeperiodwithapeakoccurringatapproximatelypostoperativeDay3（operativeduration,region,surgerytype,preoperativeCRPlevel,numberoflevels）asecondpeakorfailureofCRPleveltonormalizewasarelativelyaccuratepredictorofpostoperativeinfectionlaboratorymarkersC-reactive15脊柱手術(shù)部位感染課件16laboratorymarkersErythrocytesedimentationrate(ESR)alaterpeakthanCRP,typicallyoccurringaround

postoperativeDay4Absoluteneutrophilcount(ANC)nosignificantdifferencebetweenthenormalandinfectedgroupsupto4dayspostoperativelyasignificantriseintheperiods4to7and8to11dayspostoperativelyintheinfectedpatients

laboratorymarkersErythrocyte17laboratorymarkersSerumamyloid-A(SAA)SAAisasuperiormarkerforinfectioncomparedwithCRPbecauseofthemoredramaticchangeinvalueandearlierreturntobaselinewithsimilarkineticsProcalcitonin(PCT)PCTandCRPshowedstatisticallysignificant

correlationswiththedevelopmentofSSIPCTissuperiortoCRPinearlypredictionofSSIlaboratorymarkersSerumamylo18laboratorymarkersInterleukin-6(IL-6)wellstudiedinjointreplacementsurgeryLeukocyteesterasearecentlyreportedmarkerinperiprosthetickneejointinfection80.6%sensitivityand100%specificityindiagnosingjointinfectionInparticular,fewlaboratorymarkershavebeenvalidatedasa‘‘goldstandard’’inassociationwithculture-positiveSSI.laboratorymarkersInterleukin194、Intraoperativemeasuresintraoperativemeasurestoreduceinfectionsskinpreparationintraoperativebehaviorswoundirrigationtopicalantibioticapplicationwoundclosurepostoperativedrainuse4、Intraoperativemeasuresintr20asignificantlevelofwoundcontaminationoccursintraoperatively23%ofpatientshadpositiveintraoperativecultures.Ofthosethatculturedpositive,

11.5%developedanearlySSIImplantsexposedtotheoperatingroomenvironmentsignificantlyreducedwhentheimplantswerecoveredduringthecasethelevelofcontaminationincreasesdirectlywiththeamountoftimeitisopen

intheoperatingfield.asignificantlevelofwoundc21skinpreparationasignificantdecreaseinSSIratewiththeuseofchlorhexidineversusiodineskinprep？Intraoperativetechniquesandbehaviorstheoperativegownsterileinstrumentdrapinguseofintraoperativefluoroscopyoperativescrubcleanliness

skinpreparation22脊柱手術(shù)部位感染課件23woundirrigationTheonlyirrigationagenttohavebeendemonstratedtoreduceSSIrateispovidone-iodine(PVP-I)SoakedwithdilutePVP-Ifor3minutes（5%0.35%）

Copiouslyirrigatedwithnormalsalinebeforebonedecortication

woundirrigation24significantdecreaseinSSIafterlocaladministrationofvancomycinpowdersignificantdecreaseinSSIaf25Postoperativeprotocolsanincreasedmeannumberofdaysofclosedsuctionwounddrainageinpatientswithinfectionversuspatientswithoutinfectionuseof2-octyl-cyanoacrylateforskinclosuremaydecreasetherateofinfectionPostoperativeprotocols265、TreatmentTreatmentofSSIreliesonearlyidentificationearlydiagnosisearlyevacuationofgrosspurulentmaterial5、TreatmentTreatmentofSSIr27Treatmentoptionsirrigationanddebridementintravenousantibioticsprimaryclosureclosedvacuumsystemhardwareretentionplasticsurgeryreconstruction(rotationalflaps)

Treatmentoptions28PostoperativeInfectionTreatmentScorefortheSpine7–14lowrisk21–33highriskPostoperativeInfectionTreatm296、ConclusionsPostoperativespinalSSIscanbedevastatingcomplicationsforboththepatientandthesurgeonDiagnosisofaSSIaftersurgeryonthespineisstillverymuchaclinicaldiagnosis6、ConclusionsPostoperativesp30amultifacetedapproachtopreventionisthekeytomanaginginfectionrisktheimportanceofstrictsterileconductduringtheoperationisreemphasizedeffortsshouldbemadetominimizetimespentintheoperatingsuite(preoperative

andintraoperative)applyinglocalvancomycintothesurgicalregularuseofantibiosisinhighriskpatientsamultifacetedapproachtopre31后面內(nèi)容直接刪除就行資料可以編輯修改使用資料可以編輯修改使用后面內(nèi)容直接刪除就行32主要經(jīng)營：網(wǎng)絡(luò)軟件設(shè)計、圖文設(shè)計制作、發(fā)布廣告等公司秉著以優(yōu)質(zhì)的服務(wù)對待每一位客戶，做到讓客戶滿意！主要經(jīng)營：網(wǎng)絡(luò)軟件設(shè)計、圖文設(shè)計制作、發(fā)布廣告等33致力于數(shù)據(jù)挖掘，合同簡歷、論文寫作、PPT設(shè)計、計劃書、策劃案、學(xué)習(xí)課件、各類模板等方方面面，打造全網(wǎng)一站式需求致力于數(shù)據(jù)挖掘，合同簡歷、論文寫作、PPT設(shè)計、計劃書、策劃34感謝您的觀看和下載Theusercandemonstrateonaprojectororcomputer,orprintthepresentationandmakeitintoafilmtobeusedinawiderfield感謝您的觀看和下載Theusercandemonstr35脊柱手術(shù)部位感染俞武良2016-10-12脊柱手術(shù)部位感染俞武良2016-10-1236

手術(shù)部位感染(SurgicalsiteinfectionSSI)是一種相對常見的脊柱手術(shù)并發(fā)癥，發(fā)生率為1%-14%，具有潛在的災(zāi)難性的后果。手術(shù)部位感染(Surgicalsiteinfectio37

美國托馬斯杰斐遜大學(xué)的Radcliff等篩選并總結(jié)了近5年成人脊柱手術(shù)后手術(shù)部位感染的發(fā)生率、危險因素、診斷、預(yù)防及治療的相關(guān)研究，發(fā)表在2015年TheSpineJournal雜志。美國托馬斯杰斐遜大學(xué)的Radcliff等篩選并總結(jié)了近5年381、Incidenceaprospectivelycollecteddatabaseof108,419cases,theoverallinfectionrateforlumbarsurgerywas2.1%(superficial=0.8%,deep=1.3%)1、Incidenceaprospectivelyco39脊柱手術(shù)部位感染課件40TheincidenceofSSIappearstobelowerafterminimallyinvasivespinal(MIS)surgeriesAreviewof1,338MISsurgeriesfrommultipleinstitutionsrevealedaninfectionrateof0.74%infusion/fixationsand0.22%overallareviewbyParkeretalcomparedpostoperativeinfectionafteropenandminimallyinvasivetransforaminallumbarinterbodyfusions.362MISand1,333opensurgeries，infectionrateof4%inopenspinalfusionsversus0.6%afterMIS(p=0.005)

TheincidenceofSSIappearst412、RiskfactorsforinfectionMedicalcomorbidities：anemia,diabetes

mellitus,coronaryarterydisease,diagnosisofcoagulopathy,neoplasmobesityhigherAmericanSocietyofAnesthesiologistscoremalnutrition

2、RiskfactorsforinfectionM42脊柱手術(shù)部位感染課件43diabetes,obesityhasbeenfoundtobeariskfactorforSSIskinfoldthicknessandL4spinousprocess-skin

thicknessarespine-specificSSIriskfactorsindependentofbodymassindexthedistributionofadiposetissueandthedepthofadiposetissueoverlyingtheoperativefieldincreasedtheriskofSSI

diabetes,obesityhasbeenfou44theparticulardiagnosisisaninfectionriskfactorpatientsundergoingsurgeryfordegenerativediseasehavealowerinfectionratecomparedtodeformity(1.4%vs.4.2%)Patientsundergoingsurgeryfortraumahaveahigherriskforinfectioncomparedtospinalfusion(9.4%vs.3.7%)theriskofinfectioniscorrelatedwiththeseverity

ofthetraumatheparticulardiagnosisisan45caseordermaycontributetotherateofSSIafterspinesurgerylumbardecompressionperformedlaterintheday(thirdcase)ledtothreetimeshigherincidenceofSSIcomparedwiththoseperformedastheday’sfirstcasecontaminationoftheoperatingroom,cross-contaminationbetweenhealthcareprovidersduringthecourseoftheday,useofflashsterilization,andmid-dayshiftchanges.caseordermaycontributetot46seasonaleffectontherateofpostoperative

effectSSIincidencepeaksinthesummerandfallwithstatisticallysignificantdropsininfectionrateinthespringandwinterseasonaleffectontherateof47complexproceduresmaypresentahigherriskofperioperativecomplicationsmoreextensivetissuedissectionincreasedbloodlosslongeroperativetimecomplexproceduresmaypresent483、DiagnosisIncreasedwounddrainageapproximately10to14daysthemostcommonearlysignofwoundinfectionpresentin67%ofpatientswithSSIincreasedpainfeverwounderythema

TherearenouniversallyacceptedclinicaldiagnosticcriteriaforSSI.3、DiagnosisIncreasedwounddr49laboratorymarkersC-reactiveprotein(CRP)themostsensitiveandiselevatedinmorethan98%ofcasesCRPrisesandfallsreliablyinnoninfectedpatientsduringthepostoperativeperiodwithapeakoccurringatapproximatelypostoperativeDay3（operativeduration,region,surgerytype,preoperativeCRPlevel,numberoflevels）asecondpeakorfailureofCRPleveltonormalizewasarelativelyaccuratepredictorofpostoperativeinfectionlaboratorymarkersC-reactive50脊柱手術(shù)部位感染課件51laboratorymarkersErythrocytesedimentationrate(ESR)alaterpeakthanCRP,typicallyoccurringaround

postoperativeDay4Absoluteneutrophilcount(ANC)nosignificantdifferencebetweenthenormalandinfectedgroupsupto4dayspostoperativelyasignificantriseintheperiods4to7and8to11dayspostoperativelyintheinfectedpatients

laboratorymarkersErythrocyte52laboratorymarkersSerumamyloid-A(SAA)SAAisasuperiormarkerforinfectioncomparedwithCRPbecauseofthemoredramaticchangeinvalueandearlierreturntobaselinewithsimilarkineticsProcalcitonin(PCT)PCTandCRPshowedstatisticallysignificant

correlationswiththedevelopmentofSSIPCTissuperiortoCRPinearlypredictionofSSIlaboratorymarkersSerumamylo53laboratorymarkersInterleukin-6(IL-6)wellstudiedinjointreplacementsurgeryLeukocyteesterasearecentlyreportedmarkerinperiprosthetickneejointinfection80.6%sensitivityand100%specificityindiagnosingjointinfectionInparticular,fewlaboratorymarkershavebeenvalidatedasa‘‘goldstandard’’inassociationwithculture-positiveSSI.laboratorymarkersInterleukin544、Intraoperativemeasuresintraoperativemeasurestoreduceinfectionsskinpreparationintraoperativebehaviorswoundirrigationtopicalantibioticapplicationwoundclosurepostoperativedrainuse4、Intraoperativemeasuresintr55asignificantlevelofwoundcontaminationoccursintraoperatively23%ofpatientshadpositiveintraoperativecultures.Ofthosethatculturedpositive,

11.5%developedanearlySSIImplantsexposedtotheoperatingroomenvironmentsignificantlyreducedwhentheimplantswerecoveredduringthecasethelevelofcontaminationincreasesdirectlywiththeamountoftimeitisopen

intheoperatingfield.asignificantlevelofwoundc56skinpreparationasignificantdecreaseinSSIratewiththeuseofchlorhexidineversusiodineskinprep？Intraoperativetechniquesandbehaviorstheoperativegownsterileinstrumentdrapinguseofintraoperativefluoroscopyoperativescrubcleanliness

skinpreparation57脊柱手術(shù)部位感染課件58woundirrigationTheonlyirrigationagenttohavebeendemonstratedtoreduceSSIrateispovidone-iodine(PVP-I)SoakedwithdilutePVP-Ifor3minutes（5%0.35%）

Copiouslyirrigatedwithnormalsalinebeforebonedecortication

woundirrigation59significantdecreaseinSSIafterlocaladministrationofvancomycinpowdersignificantdecreaseinSSIaf60Postoperativeprotocolsanincreasedmeannumberofdaysofclosedsuctionwounddrainageinpatientswithinfectionversuspatientswithoutinfectionuseof2-octyl-cyanoacrylateforskin