脊柱手术部位感染课件

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

2、fection rate for lumbar surgery was 2.1% (superficial=0.8%, deep=1.3%),脊柱手术部位感染,脊柱手术部位感染,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 0.2

3、2% overall a 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),脊柱手术部位感染,2、Risk factors for infection,Medical c

4、omorbidities：anemia, diabetesmellitus, coronary artery disease, diagnosis of coagulopathy, neoplasm obesity higher American Society of Anesthesiologist score malnutrition,脊柱手术部位感染,脊柱手术部位感染,diabetes, obesity has been found to be a risk factor for SSI skin fold thickness and L4 spinous process-skinthi

5、ckness are spine-specific SSI risk factors independent of body mass index the distribution of adipose tissue and the depth of adipose tissue overlying the operative field increased the risk of SSI,脊柱手术部位感染,the particular diagnosis is an infection risk factor patients undergoing surgery for degenerat

6、ive disease have a lower infection rate compared to deformity (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,脊柱手术部位感染,case order may contribute to the

7、 rate of SSI after spine surgery lumbar decompression performed later 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 th

8、e day, use of flash sterilization, and mid-day shift changes.,脊柱手术部位感染,seasonal 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,脊柱手术部位感染,complex procedures may present a higher risk o

9、f perioperative complications more extensive tissue dissection increased blood loss longer operative time,脊柱手术部位感染,3、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,Th

10、ere are no universally accepted clinical diagnostic criteria for SSI.,脊柱手术部位感染,laboratory markers,C-reactive 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 approx

11、imately 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 relatively accurate predictor of postoperative infection,脊柱手术部位感染,脊柱手术部位感染,laboratory markers,Erythrocyte sedimentation rate (ESR

12、) 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 postoperatively a significant rise in the periods 4 to 7 and 8 to 11 days postoperatively in the infected patients,脊柱手术

13、部位感染,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 Procalcitonin (PCT) PCT and CRP showed statistically significantcorrelations with the development

14、of SSI PCT is superior to CRP in early prediction of SSI,脊柱手术部位感染,laboratory markers,Interleukin-6(IL-6) well studied in joint replacement surgery Leukocyte esterase a recently reported marker in periprosthetic knee joint infection 80.6% sensitivity and 100% specificity in diagnosing joint infection

15、,In particular, few laboratory markers have been validated as a gold standard in association with culture-positive SSI.,脊柱手术部位感染,4、Intraoperative measures,intraoperative measures to reduce infections skin preparation intraoperative behaviors wound irrigation topical antibiotic application wound clos

16、ure postoperative drain use,脊柱手术部位感染,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 operating room environment significantly reduced when the

17、 implants were covered during the case the level of contamination increases directly with the amount of time it is open in the operating field.,脊柱手术部位感染,skin preparation a significant decrease in SSI rate with the use of chlorhexidine versus iodine skin prep ？ Intraoperative techniques and behaviors

18、 the operative gown sterile instrument draping use of intraoperative fluoroscopy operative scrub cleanliness,脊柱手术部位感染,脊柱手术部位感染,wound irrigation The only 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%） Copiously

19、irrigated with normal saline before bone decortication,脊柱手术部位感染,significant decrease in SSI after local administration of vancomycin powder,脊柱手术部位感染,Postoperative protocols an increased mean number of days of closed suction wound drainage in patients with infection versus patients without infection

20、use of 2-octyl-cyanoacrylate for skin closure may decrease the rate of infection,脊柱手术部位感染,5、Treatment,Treatment of SSI relies on early identification early diagnosis early evacuation of gross purulent material,脊柱手术部位感染,Treatment options irrigation and debridement intravenous antibiotics primary closure closed vacuum system hardware retention plastic surgery reconstruction(rota