Vi-ilmu Bedah_ssi Fkg

8/13/2019 Vi-ilmu Bedah_ssi Fkg

1/43


2/43


3/43

2010 : 16 million operative procedures wereperformed (US).

Recent prevalence study : SSIs were the mostcommon healthcare-associated infection,31% of all HAIs among hospitalized patients.

NHSN data : 2006-2008 (16,147 SSIs -849,659 procedures) showed an overall SSIrate of 1.9%.


4/43

Advances have been made in infectioncontrol practices; improved operating roomventilation, sterilization methods, barriers,

surgical technique, and availability ofantimicrobial prophylaxis

SSIs remain a substantial cause of morbidityand an associated mortality rate of 3% hasbeen attributed to them.

Of this, 75% of the mortality rate has beendirectly related to the SSI.


5/43

Surveillance of SSI w/ feedback ofappropriate data to surgeons - shown to bean important component of strategies to

reduce SSI risk. A successful surveillance program includes

the use of epidemiologically-sound infectiondefinitions and effective surveillancemethods, stratification of SSI rates accordingto risk factors associated with SSIdevelopment, and data feedback.


6/43

Definition

The Centers for Disease Control and Prevention(CDC) term for infections associated with surgical

procedures was changed from surgical woundinfection to surgical site infection in 1992

These infections are classified into incisional, organ,or other organs and spaces manipulated during anoperation; incisional infections are further divided

into superficial (skin and subcutaneous tissue) anddeep (deep soft tissue-muscle and fascia)

These definitions should be followed universally forsurveillance, prevention, and control of surgical site

infections.


7/43

Operative Procedure

Procedure that is performed on a patient whois an inpatient or an outpatient; and

takes place during an operation (defined as asingle trip to the operating room [OR] wherea surgeon makes at least one incision throughthe skin or mucous membrane, including

laparoscopic approach, and closes theincision primarily* before the patient leavesthe OR)


8/43

ASA Score

Assessment by the anesthesiologist of thepatients preoperative physical condition usingthe American Society of Anesthesiologists (ASA)Classification of Physical Status

1. Normally healthy patient2. Patient with mild systemic disease

3. Patient with severe systemic disease that is notincapacitating

4. Patient with an incapacitating systemic diseasethat is a constant threat to life

5. Moribund patient (< 24hr)


9/43

Surgical Wound Classif ication

Class Iclean. Uninfected operative wound withno inflammation and in which the respiratory,gastrointestinal (GI), genital and urinary tracts were

not entered. Clean wounds are closed at surgery and,if necessary, drained with closed drainage.

Class IIclean-contaminated. Wound in which therespiratory, GI, genital or urinary tract(s) were

entered under controlled conditions but withoutunusual contamination or spillage of contents.


10/43

Surgical Wound Classif ication

Class IIIcontaminated. Open, fresh accidentalwound or an operation with a major break(s) inaseptic technique (e.g., open cardiac massage) or

gross spillage from the GI tract. Also included areincisions in which acute, nonpurulent inflammationis found.

Class IVdirty or infected. Old wounds with dead

tissue and those that involve existing clinicalinfection or a perforated bowel, suggesting that the

pathogens causing the postoperative infection werepresent in the wound before the surgery.


11/43


12/43

Superf icial I ncisional SSI

must meet one of the following criteria:

Infection occurs within 30 days after the operativeprocedure and involves only skin and subcutaneous

tissue of the incision and patient has at least one ofthe following:

purulent drainage from the superficial incision.

organisms isolated from an aseptically obtainedculture of fluid or tissue from the superficialincision.


13/43

Superficial Incisional SSI

at least one of the following signs or symptoms of

infection: pain or tenderness, localized swelling,

redness, or heat, and superficial incision isdeliberately opened by surgeon, and is culture-positive or not cultured. A culture-negative finding

does not meet this criterion.

diagnosis of superficial incisional SSI by the

surgeon or attending physician


14/43

Deep Incisional SSI

must meet one of the following criteria:

Infection occurs within 30 days after the operative procedureif no implant is left in place or within one year if implant is

in place and the infection appears to be related to the operative

procedure and involves deep soft tissues (e.g., fascial andmuscle layers) of the incision

and patient has at least one of the following:


15/43

Deep Incisional SSI

purulent drainage from the deep incision but not from theorgan/space component of the surgical site

a deep incision spontaneously dehisces or is deliberatelyopened by a surgeon and is culture- positive or not cultured

and the patient has at least one of the following signs orsymptoms: fever (>38C), or localized pain or tenderness. Aculture-negative finding does not meet this criterion.

an abscess or other evidence of infection involving the deep

incision is found on direct examination, during reoperation,or by histopathologic or radiologic examination

diagnosis of a deep incisional SSI by a surgeon or attendingphysician


16/43

Organ / Space SSI

An organ/space SSI must meet one of the followingcriteria:

Infection occurs within 30 days after the operative

procedure if no implant is left in place or within oneyear if implant is in place and the infection appearsto be related to the operative procedure

And infection involves any part of the body,excluding the skin incision, fascia, or muscle layers,that is opened or manipulated during the operative

procedure

and


17/43

Organ / Space SSI

patient has at least one of the following:

purulent drainage from a drain that is placed througha stab wound into the organ/space

organisms isolated from an aseptically obtainedculture of fluid or tissue in the organ/space

an abscess or other evidence of infection involvingthe organ/space that is found on direct examination,during reoperation, or by histopathologic orradiologic examination

diagnosis of an organ/space SSI by a surgeon or

attending physician.


18/43

Prevention

Preparation of the Patient

Ventilation

Hand/forearm antisepsis for surgical team members

Management of infected or colonized surgicalpersonnel

Antimicrobial Prophylaxis

Surgical Attire and Drapes

Preoperative Hand & Forearm Antisepsis


19/43


Identify and treat all infections remote to thesurgical site before elective operation andpostpone elective operations on patients with

remote site infections until the infection hasresolved. Category IA

Do not remove hair preoperatively unless the

hair at or around the incision site will interferewith the operation. Category IA


20/43


If hair is removed, remove immediatelybefore the operation, preferably with electricclippers. Category IA

Adequately control serum blood glucoselevels in all diabetic patients and particularlyavoid hyperglycemia perioperatively.

Category IB


21/43


Stopping use of tobacco products. At minimum,instruct patients to abstain for at least 30 daysbefore elective operation from smoking

cigarettes, cigars, pipes or any other form oftobacco consumption (e.g., chewing/ dipping).Category IB

Do not withhold necessary blood productsfrom surgical patients as a means to prevent SSI.Category IB


22/43


Require patients to shower or bathe with anantiseptic agenton at least the night before theoperative day. Category IB

Thoroughly wash and clean at and around theincision site to remove gross contaminationbefore performing antiseptic skin preparation.

Category IB


23/43


Use an appropriate antiseptic agent for skinpreparation (Table 6). Category IB

Keep preoperative hospital stay as short aspossible while allowing for adequatepreoperative preparation of the patient.Category II


24/43

Ventilation

Maintain positive-pressure ventilation in theoperating room with respect to the corridorsand adjacent areas. Category IB

Maintain a minimum of 20 air changes perhour, of which at least 4 should be fresh air.Category IB

Filter all air, recirculated and fresh, throughthe appropriate filters per the AmericanInstitute of Architects recommendations.Category IB


25/43

Ventilation

Introduce all air at the ceiling, and exhaustnear the floor. Category IB

Do notuse UVradiation in the operatingroom to prevent SSI. Category IB

Keep operating room doors closed except asneeded for passage of equipment, personnel

and the patient. Category IB


26/43

Ventilation

Consider performing orthopedic implantoperations in operating rooms supplied withultraclean air. Category II

Limit the number of personnel entering theoperating room to necessary personnel.Category II


27/43

Hand/forearm antisepsis for

surgical team members

Keep nails short and do not wear artificial nails.Category IB

Perform a preoperative surgical scrub for at least2 to 5 minutes using an appropriate antiseptic.Scrub the hands and forearms up to the elbows.Category IB


28/43

Hand/forearm antisepsis for

surgical team members

After performing the surgical scrub, keephands up and away from the body (elbows inflexed position) so that water runs from thetips of the fingers toward the elbows. Dryhands with a sterile towel and put on a sterilegown and gloves. Category IB


29/43

Management of infected or

colonized surgical personnel

Educate and encourage surgical personnel whohave signs and symptoms of a transmissible

infectious illness to report conditions promptly totheir supervisory and occupational health servicepersonnel.Category IB


30/43



Develop well-defined policies concerning patientcare responsibilities when personnel havepotentially transmissible infectious conditions.These policies should govern: (a) personnelresponsibility in using the health service andreporting illness, (b) work restrictions, and (c)

clearance to resume work after an illness thatrequired work restriction. The policies also shouldidentify persons who have the authority toremove personnel from duty.Category IB


31/43



Exclude from duty surgical personnel who havedraining skin lesions until infection has beenruled out or personnel have received adequate

therapy and infection has resolved. CategoryIBDo not routinely exclude surgical personnel whoare colonized with organisms such as S. aureus

(nose, hands or other body site) or group AStreptococcus, unless such personnel have beenlinked epidemiologically to dissemination of theorganism in the healthcare setting. Category IB


32/43


Administer a prophylactic antimicrobial agentonly when indicated, and selectit based on itsefficacy against the most common pathogenscausing SSI for a specific operation and published

recommendations. Category IA

Do notroutinely use vancomycin forantimicrobial prophylaxis. Category IB


33/43


Administer by the intravenous route theinitial doseof prophylactic antimicrobialagent, timedsuch that a bactericidal

concentration of the drug is established inserum and tissues when the incision is made.Maintain therapeutic levels of the agent inserum and tissues throughout the operation

and until, at most, a few hours after theincision is closed in the operating room.Category IA


34/43


Before elective colorectal operations in additionto above, mechanically prepare the colon by useof enemas and cathartic agents. Administer

nonabsorbable oral antimicrobial agents individed doses on the day before the operation.Category IA

For high-risk cesarean section, administer the

prophylactic antimicrobial agent immediatelyafter the umbilical cord is clamped. Category IA


35/43


Wear a surgical mask that fully covers the mouthand nose when entering the operating room if anoperation is about to begin or already under way

or if sterile instruments are exposed. Wear themask throughout the operation.Category IB

Wear a cap or hoodto fully cover hair on thehead and face when entering the operating

room.Category IB

Do not wear shoe covers for the prevention ofSSI.Category IB


36/43


Wear sterile gloves if a scrubbed surgical teammember. Put on gloves after putting on a sterilegown.Category IB

Use surgical gowns and drapes that areeffective barriers when wet(i.e., materials thatresist liquid penetration).Category IB

Change scrub suits that are visibly soiled,contaminated and/or penetrated by blood orother potentially infectious materials.Category IB


37/43

Asepsis and Surgical Technique

Adhere to principles of asepsis when placingintravascular devices, spinal or epiduralanesthesia catheters, or when dispensing and

administering intravenous drugs.Category IAHandle tissue gently, maintain effectivehemostasis, minimize devitalized tissue andforeign bodies (i.e., sutures, charred tissues,

necrotic debris) and eradicate dead space at thesurgical site.Category IB


38/43

Asepsis and Surgical Technique

Use delayed primary skin closure or leave anincision open to heal by second intention if thesurgeon considers the surgical site to be heavily

contaminated (e.g., Class III and Class IV).Category IB

If drainage is necessary, use a closed suctiondrain. Place a drain through a separate incision

distant from the operative incision. Remove thedrain as soon as possible. Category IB


39/43

Postoperative Care

Protect with a sterile dressingfor 24 to 48 hourspostoperatively an incision that has been closedprimarily. Category IB

Wash hands before and after dressing changesand any contact with the surgical site. CategoryIB

When an incision dressing must be changed, usesterile technique. Category II

Educate the patient and family regarding properincision care, symptoms of SSI, and the need to

report such symptoms. Category II


40/43

Data Analyses

Basic SSI Risk Index. The index used in NHSNassigns surgical patients into categories based on the

presence of three major risk factors:

1. Operation lasting more than the duration cut point

hours, where the duration cut point is theapproximate 75th percentile of the duration of

surgery in minutes for the operative procedure (1)

2. Contaminated (Class 3) or Dirty/infected (Class 4)

wound class (1)

3. ASA classification of 3, 4, or 5 (1)

sum of the number of these factors present at

the time of the operation


41/43

Data Analyses

The SSI rates per 100 operative procedures are

calculated by dividing the number of SSIs by the

number of specific operative procedures and

multiplying the results by 100


42/43

???


43/43

Vi-ilmu Bedah_ssi Fkg

Documents

Transcript of Vi-ilmu Bedah_ssi Fkg