脊柱手术部位感染课件.pptx

1、脊柱手术部位感染 俞武良 2016-10-12 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。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。1、Incidence a prospectively collected database of 108,419 cases,the overall infection rate for lumbar surger

2、y was 2.1%(superficial=0.8%,deep=1.3%)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 review by Parker et al compared postoperat

3、ive 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)2、Risk factors for infection Medical comorbidities：anemia,diabetesmellitus,coronary artery disease,diagnosi

4、s of coagulopathy,neoplasm obesity higher American Society of Anesthesiologist score malnutrition 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 independent of body mass index the distribution o

5、f adipose tissue and the depth of adipose tissue overlying the operative field increased the risk of SSI the particular diagnosis is an infection risk factor patients undergoing surgery for degenerative disease have a lower infection rate compared to deformity(1.4%vs.4.2%)Patients undergoing surgery

6、 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 case order may contribute to the rate of SSI after spine surgery lumbar decompression performed later in the day(third case)led to three times higher

7、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.seasonal effect on the rate of postoperativeeffect SSI inciden

8、ce peaks in the summer and fall with statistically significant drops in infection rate in the spring and winter complex procedures may present a higher risk of perioperative complications more extensive tissue dissection increased blood loss longer operative time 3、Diagnosis Increased wound drainage

9、 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.laboratory markers C-reactive protein(CRP)the most sensitive and is elevated in mor

10、e 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 levels）a second peak or failure of CRP level to normalize was a r

11、elatively accurate predictor of postoperative infection laboratory markers Erythrocyte sedimentation rate(ESR)a later peak than CRP,typically occurring aroundpostoperative Day 4 Absolute neutrophil count(ANC)no significant difference between the normal and infected groups up to 4 days postoperativel

12、y a significant rise in the periods 4 to 7 and 8 to 11 days postoperatively in the infected patients laboratory markers Serum amyloid-A(SAA)SAA is a superior marker for infection compared with CRP because of the more dramatic change in value and earlier return to base line with similar kinetics Proc

13、alcitonin(PCT)PCT and CRP showed statistically significantcorrelations with the development of SSI PCT is superior to CRP in early prediction of SSI laboratory markers Interleukin-6(IL-6)well studied in joint replacement surgery Leukocyte esterase a recently reported marker in periprosthetic knee jo

14、int 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.4、Intraoperative measures intraoperative measures to reduce infections skin preparation intraoperative

15、 behaviors wound irrigation topical antibiotic application wound closure postoperative drain use a significant level of wound contamination occurs intraoperatively 23%of patients had positive intraoperative cultures.Of those that cultured positive,11.5%developed an early SSI Implants exposed to the

16、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.skin preparation a significant decrease in SSI rate with the use of chlorhexidine versus iodine skin

17、 prep？Intraoperative techniques and behaviors the operative gown sterile instrument draping use of intraoperative fluoroscopy operative scrub cleanliness wound irrigation agent to have been demonstrated to reduce SSI rate is povidone-iodine(PVP-I)Soaked with dilute PVP-I for 3 minutes（5%0.35%）Copiou

18、sly irrigated with normal saline before bone decortication significant decrease in SSI after local administration of vancomycin powder Postoperative protocols an increased mean number of days of closed suction wound drainage in patients with infection versus patients without infection use of 2-octyl

19、-cyanoacrylate for skin closure may decrease the rate of infection 5、Treatment Treatment of SSI relies on early identification early diagnosis early evacuation of gross purulent material Treatment options irrigation and debridement intravenous antibiotics primary closure closed vacuum system hardwar

20、e retention plastic surgery reconstruction(rotational flaps)Postoperative Infection Treatment Score for the Spine7 14 low risk2133 high risk 6、Conclusions Postoperative spinal SSIs can be devastating complications for both the patient and the surgeon Diagnosis of a SSI after surgery on the spine is

21、still very much a clinical diagnosis 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

22、 local vancomycin to the surgical regular use of antibiosis in high risk patients 后面内容直接删除就行资料可以编辑修改使用资料可以编辑修改使用主要经营：网络软件设计、图文设计制作、发布广告等公司秉着以优质的服务对待每一位客户，做到让客户满意！致力于数据挖掘，合同简历、论文写作、PPT设计、计划书、策划案、学习课件、各类模板等方方面面，打造全网一站式需求The user can demonstrate on a projector or computer,or print the presentation and make it into a film to be used in a wider field