脊柱手术部位感染课件.ppt

1、脊柱手术部位感染 1开心不仅仅是心里的感觉，而是因为你有了开心的感觉，于是别人可以开心不仅仅是心里的感觉，而是因为你有了开心的感觉，于是别人可以从你的脸上读到微笑，读到开心。如果你在生活中比较细心的话，你就会知从你的脸上读到微笑，读到开心。如果你在生活中比较细心的话，你就会知道世间最美丽的表情就是微笑，如果你天天想拥用世间最美丽的表情，那么道世间最美丽的表情就是微笑，如果你天天想拥用世间最美丽的表情，那么请把开心当成一种习惯吧！请把开心当成一种习惯吧！快乐活在当下，尽心就是完美快乐活在当下，尽心就是完美很小很小的时候，我就感觉到花是非常奇怪的，因为在家院的庭前种了很小很小的时候，我就感觉到花是

2、非常奇怪的，因为在家院的庭前种了桂花、玉兰和夜来香，到了晚上，香气随同四散，流动在家屋四周，可是这桂花、玉兰和夜来香，到了晚上，香气随同四散，流动在家屋四周，可是这些香花都是白色的。反而那些极美丽的花卉，像兰花、玫瑰之属，就没有什些香花都是白色的。反而那些极美丽的花卉，像兰花、玫瑰之属，就没有什么香味了。么香味了。长大以后，才更发现这种截然不同的风格，凡香气极盛的花，桂花、玉长大以后，才更发现这种截然不同的风格，凡香气极盛的花，桂花、玉兰花、夜来香、含笑花、水姜花、月桃花、百合花、栀子花、七里香，都是兰花、夜来香、含笑花、水姜花、月桃花、百合花、栀子花、七里香，都是白色，即使有颜色也白色，即使

3、有颜色也 是非常素淡，而且它们开放的时候常成群结队的，热闹是非常素淡，而且它们开放的时候常成群结队的，热闹纷繁。那些颜色艳丽的花，则都是孤芳自赏，每一枝只开出一朵，也吝惜着纷繁。那些颜色艳丽的花，则都是孤芳自赏，每一枝只开出一朵，也吝惜着香气一般，很少有香味的。香气一般，很少有香味的。“香花无色，色花不香香花无色，色花不香”这真是一个惊人的发现；这真是一个惊人的发现；“素朴的花喜欢成群结队，素朴的花喜欢成群结队，美艳的花喜欢幽然独处美艳的花喜欢幽然独处”也是惊人的发现。也是惊人的发现。依照植物学家的说法，白花为了吸引蜂蝶传播花粉，因此放散浓厚的芳依照植物学家的说法，白花为了吸引蜂蝶传播花粉，因

4、此放散浓厚的芳香；美丽的花则不必如此，只要以它的颜色就能招蜂引蝶了香；美丽的花则不必如此，只要以它的颜色就能招蜂引蝶了 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。2 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。31、Incidence a prospectively collected database of 108,419 cases,the o

5、verall infection rate for lumbar surgery was 2.1%(superficial=0.8%,deep=1.3%)45 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

6、review by Parker 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)62、Risk factors for infection Medical comorbidities：anemia,diabet

7、esmellitus,coronary artery disease,diagnosis of coagulopathy,neoplasm obesity higher American Society of Anesthesiologist score malnutrition 78 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 factors ind

8、ependent of body mass index the distribution of adipose tissue and the depth of adipose tissue overlying the operative field increased the risk of SSI 9 the particular diagnosis is an infection risk factor patients undergoing surgery for degenerative disease have a lower infection rate compared to d

9、eformity(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 10 case order may contribute to the rate of SSI after spine surgery lumbar decompression performed lat

10、er 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 shift changes.11 seasonal

11、 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 12 complex procedures may present a higher risk of perioperative complications more extensive tissue dissection increased blood loss l

12、onger operative time 133、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 for SSI.14laboratory markers C-r

13、eactive 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 type,preoperative CRP level,number of leve

14、ls）a second peak or failure of CRP level to normalize was a relatively accurate predictor of postoperative infection 1516laboratory markers Erythrocyte sedimentation rate(ESR)a later peak than CRP,typically occurring aroundpostoperative Day 4 Absolute neutrophil count(ANC)no significant difference b

15、etween 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 17laboratory markers Serum amyloid-A(SAA)SAA is a superior marker for infection compared with CRP because of the more dramatic change

16、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 18laboratory markers Interleukin-6(IL-6)well studied in joint replacement surgery Le

17、ukocyte 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 association with culture-positive SSI.194、Intraoperative measures intra

18、operative measures to reduce infections skin preparation intraoperative behaviors wound irrigation topical antibiotic application wound closure postoperative drain use20 a significant level of wound contamination occurs intraoperatively 23%of patients had positive intraoperative cultures.Of those th

19、at 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 amount of time it is open in the operating field.21 skin preparation a signi

20、ficant 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 cleanliness 2223 wound irrigation agent to have been demonstrated to reduce SSI ra

21、te is povidone-iodine(PVP-I)Soaked with dilute PVP-I for 3 minutes（5%0.35%）Copiously irrigated with normal saline before bone decortication 24significant decrease in SSI after local administration of vancomycin powder25 Postoperative protocols an increased mean number of days of closed suction wound

22、 drainage in patients with infection versus patients without infection use of 2-octyl-cyanoacrylate for skin closure may decrease the rate of infection 265、Treatment Treatment of SSI relies on early identification early diagnosis early evacuation of gross purulent material 27 Treatment options irrig

23、ation and debridement intravenous antibiotics primary closure closed vacuum system hardware retention plastic surgery reconstruction(rotational flaps)28Postoperative Infection Treatment Score for the Spine7 14 low risk2133 high risk 296、Conclusions Postoperative spinal SSIs can be devastating compli

24、cations for both the patient and the surgeon Diagnosis of a SSI after surgery on the spine is still very much a clinical diagnosis 30 a multifaceted approach to prevention is the key to managing infection risk the importance of strict sterile conduct during the operation is reemphasized efforts should be made to minimize time spent in the operating suite(preoperative and intraoperative)applying local vancomycin to the surgical regular use of antibiosis in high risk patients 31