降低感染率的围手术期策略课程

1、 .The Journal of Bone and Joint Surgery (American). 2010;92:232-239.Perioperative Strategies for Decreasing InfectionA Comprehensive Evidence-Based Approach降低感染率的围手术期策略：综合性循证医学路径 Joseph A. Bosco, III, MD1, James D. Slover, MD, MS1 and Janet P. Haas, RN, PhD2 1 Department of Orthopaedic Surgery, NYU

2、Hospital for Joint Diseases, New York University Langone Medical Center, 301 East 17th Street, New York, NY 10003. E-mail address for J.A. Bosco III: . E-mail address for J.D. Slover: 2 Infection Prevention and Control, Westchester Medical Center, 100 Woods

3、Road, Macy Pavilion SW246, Valhalla, NY 10595. E-mail address: Haasj An Instructional Course Lecture, American Academy of Orthopaedic Surgeons Introduction 引言 Surgical site infections associated with orthopaedic surgical procedures are devastating complications. They increase morbidity, mortality, a

4、nd cost and result in outcomes that are worse than those in uninfected cases1. Decreasing the incidence of surgical site infections is not only of interest to patients and surgeons, it is also a major focus of several groups of interested parties. These range from payers, including the Centers for M

5、edicare and Medicaid Services (CMS, Baltimore, Maryland), to institutions represented by the Surgical Care Improvement Project (SCIP), a multiple-institution partnership between major public and private health-care organizations, including the Joint Commission on Accreditation of Healthcare Organiza

6、tions (Oakbrook Terrace, Illinois). Decreasing the incidence of surgical site infections is, and will continue to be, a major focus in medicine. 对于骨科手术而言，手术部位的感染是一种毁灭性的并发症，往往会导致致残率、致死率以及医疗费用的增加，并且与没有发生感染的病例相比，最终的治疗结果通常也会更差【1】。减少手术部位的感染率，不仅对患者和医生都很有意义，也是利益相关的各方非常关注的问题。如出资方，包括医疗保险与医疗辅助服务中心（CMS，Baltimo

7、re, Maryland）；以外科医疗改良项目（SCIP）为代表的相关机构；介于大众公共机构与私人医疗保健机构之间的多机构合作组织，包括医疗机构评审联合委员会（JCAHO，Oakbrook Terrace, Illinois）等。减少手术部位的感染率现在是，将来也仍会是，医学领域关注的焦点问题。To effectively prevent surgical site infections, the clinician must consider preoperative, intraoperative, and postoperative factors and interventions.

8、Preoperative strategies for reduction of infection rates include identification of high-risk patients, screening and decolonization of patients with methicillin-sensitive Staphylococcus aureus and methicillin-resistant Staphylococcus aureus colonization, preoperative preparation of the patient with

9、chlorhexidine gluconate, utilization of proper hair-removal techniques, and addressing preexisting dental and nutritional issues prior to surgery. 为了有效地防止手术部位的感染，临床医生必须审慎地考虑到手术前、手术中以及手术后的相关因素和干预措施。降低感染的术前策略包括识别高风险的患者，对甲氧西林敏感的金黄色葡萄球菌和耐甲氧西林的金黄色葡萄球菌定植的患者进行筛查，并清除定植菌，术前应用洗必泰葡萄糖酸盐进行清洗，应用合适的方法去除毛发，术前妥善处理先前

10、存在的牙齿及营养相关的问题。There are a variety of perioperative strategies that can and should be employed to decrease the risk of surgical site infections. Intraoperative interventions that have been shown to decrease surgical site infection rates include the proper selection, timing, and doses of prophylactic

11、antibiotics and utilization of best practices for hand hygiene and surgical site preparation. Maintaining a sterile operating-room environment by decreasing operating-room traffic, monitoring for breaks in sterile technique, and decreasing the use of flash sterilization is vital. Finally, postoperat

12、ive strategies for the reduction of surgical site infection rates include the proper use and duration in situ of urinary catheters and surgical drains; standardization of wound care; use of antibiotic-impregnated bandages; and, perhaps most importantly, maintenance of proper hand hygiene, isolation

13、precautions, and room cleaning. 有多种围手术期的策略可以并且必须应用以减少手术部位的感染。术中的一些干预因素已经证实可以降低手术部位的感染率，包括选择合适的种类、时机和剂量预防性应用抗生素，手卫生及术区消毒均采用最优化的方案。通过减少手术室的穿行、监视有无违反无菌技术的操作、减少快速消毒的应用对于维持手术的无菌环境是至关重要的。最后，降低手术部位感染率的术后策略包括合理地应用和维持原有的导尿管和术区引流管，对创口进行标准化护理；应用抗生素浸润的绷带，以及，可能最为重要的是，保持正确的手卫生、隔离预防和室内清洁。Preoperative Consideration

14、s 术前注意事项Although every precaution should be taken to prevent infection for all orthopaedic patients, the identification of high-risk patients enables clinicians to provide maximal prevention strategies for them. Furthermore, the identification of patients at high risk for infection allows appropriat

15、e preoperative counseling for shared decision-making and establishes appropriate patient expectations regarding surgical risks. 虽然对于所有骨科患者，都应该采用各种预防措施以防止感染，但临床医生识别出高风险的患者后，便可针对其制定最大限度的防范策略。此外，识别出感染的高风险患者后可进行适当的术前告知谈话，这样可与患者共同制定治疗决策，并使患者对于手术风险树立合理的期望值。Numerous high-risk patient populations and risk f

16、actors that place patients at high risk for infection after total joint replacement or spine surgery have been described in the literature. Some of these factors can be modified, while others cannot. An explanation of the risk factors that cannot be modified should be included when patients are coun

17、seled about their increased risk of infection with the proposed surgical procedure. In this way, patients will more completely understand the risks and benefits when deciding on surgery. Two common factors that cannot be modified and that increase the risk of infection with joint replacement are a h

18、istory of infection in the joint2 and a history of steroid injection into the joint3. Factors that cannot be modified that increase the risk of infection in patients undergoing spine surgery include trauma-related surgery4, use of instrumentation5, and lumbar6 and posterior4 surgery. 对于关节置换术和脊柱手术的感染

19、，有很多高风险患者人群以及相关的危险因素使患者具有较高感染风险的情况，在以往的文献中都有论述。在这些因素中，有些事可以改善的，而有些则无法改变。对于无法控制的危险因素，在对患者进行术前告知谈话时，应向其说明这样会增加感染的风险。这样，患者在决定做手术时便可更全面地认识到相关的风险和益处。有两个无法控制的因素，既往关节感染病史【2】和既往关节内类固醇注射史【3】，通常会增加关节置换手术的感染风险。而对于进行脊柱手术的患者而言，会增加感染的风险并且无法控制的因素包括创伤相关的手术【4】，需要应用内置物【5】，以及腰椎【6】和后路【4】手术。Other factors that increase t

20、he risk of infection are potentially modifiable and, therefore, provide the opportunity for patient optimization prior to elective orthopaedic procedures. For example, patients with inflammatory arthritis7, sickle-cell disease8, diabetes9, renal failure10, and human immunodeficiency virus (HIV)11 ha

21、ve increased infection rates with joint replacement. Although these risk factors cannot be eliminated, the risks can be minimized. For example, patients with inflammatory arthritis should have a preoperative consultation with their rheumatologist about reducing or discontinuing immunosuppressive med

22、ications perioperatively. Patients with sickle-cell disease should be screened for skin ulcerations or potential sources of osteomyelitis, which can cause seeding of the site of a prosthetic joint. Diabetic patients should have their hemoglobin A1C levels checked and normalized (to <6.9%, which r

23、eflects long-term glucose control) prior to surgery; consultation with an endocrinologist may be necessary. Patients with renal failure certainly should have their renal function optimized prior to surgery, and patients with HIV should be placed on regimens that achieve an undetectable viral load, i

24、f possible, prior to joint replacement. Malnutrition is associated with an increased risk of infection; therefore, preoperative optimization, with the assistance of a nutritionist if necessary, is beneficial12.其他的一些可能增加感染风险的因素通常都是可以控制的，因此，对于骨科的择期手术而言，术前通常可以使相关的因素达到最优化的状态。例如，患者合并有炎症性的关节炎【7】，镰状细胞性贫血症【

25、8】，糖尿病【9】，肾功能衰竭【10】和人免疫缺陷症病毒（HIV）感染【11】会增加关节置换的感染率，虽然这些风险因素无法消除，但相关的风险则可以降至最低。比如，患者炎症性关节炎的患者，可以在术前请风湿科医生进行诊治，在围手术期尽量减少或停用免疫抑制类药物。如患者合并有镰状细胞性贫血症，则应仔细筛查皮肤溃疡或骨髓炎的潜在病源，否则容易导致播散至关节假体处引起感染。糖尿病患者应检查其血红蛋白A1C水平，在术前调至正常（<6.9%，可反映长期的血糖控制情况），必要时请内分泌科医生会诊。肾功能衰竭的患者当然也应在术前将肾功能调整至最佳水平，而感染HIV的患者，在关节置换之前，如果可能的话应通过

26、药物治疗使其病毒载量达到检测不到的程度。营养不良也会增加感染的风险，因此，必要时在营养师的帮助下，在术前进行优化也是很有好处的【12】。 Smoking and obesity increase the risk of infection with spine surgery13. Although these factors are often difficult to modify, patients should be counseled that a benefit of smoking cessation and weight reduction is a decreased ris

27、k of infection with spine surgery. Patients considering or planning surgical weight-loss treatments, such as gastric bypass surgery, probably should be advised to pursue these procedures first to reduce the risk of infection at the sites of hardware or prostheses as a benefit from weight loss. Worki

28、ng with patients and the appropriate consultants to optimize these factors prior to surgery may improve patient outcomes by lowering the risk of infection with high-risk joint-replacement and spine procedures. 吸烟和肥胖会增加脊柱手术感染的风险【13】。虽然这些因素通常难以控制，但仍然应该告知患者，戒烟以及减轻体重对于降低脊柱手术感染的风险具有重要意义。如果患者正在考虑或计划通过手术来减

29、轻体重，如胃旁路手术，那么应该建议患者先做减肥手术，因为这样对于置入内固定物或假体的部位可以减少感染的风险。与患者充分沟通，提出合理化的建议，在手术前尽量优化这些因素，对这些关节置换和脊柱手术的高风险人群而言，可以改善临床结果，降低感染的风险。Another important preoperative consideration is preoperative bathing. Preoperative bathing has been used to reduce the bacterial load of the skin prior to surgery because skin pr

30、eparation immediately before surgery does not completely sterilize the skin. In addition, direct contamination can occur at the time of surgery. A recent Cochrane review was performed to assess the information in the literature regarding preoperative bathing with antiseptics for the prevention of su

31、rgical site infection14. Chlorhexidine gluconate is the most commonly used antiseptic for preoperative bathing. The Cochrane review revealed evidence that the bacterial load of resident skin flora is reduced by use of chlorhexidine gluconate preparations for preoperative bathing. Repeated, consecuti

32、ve treatments reduce this load progressively over time. However, concerns about the development of resistant organisms and hypersensitivity remain. Therefore, the authors of the review concluded that there is no clear evidence that preoperative bathing with chlorhexidine gluconate is superior to pre

33、operative bathing with other products, such as bar soap, for reducing the incidence of surgical site infection. 手术前另一个重要的注意事项便是术前洗澡。由于术前即刻的皮肤消毒并不能完全杀灭所有细菌，因而通常都通过术前洗澡以减少皮肤的细菌接种量。此外，如果术前不洗澡，手术时也可能发生直接的污染。最近的一项Cochrane综述对术前应用消毒剂洗澡预防手术部位感染的相关信息进行了评价【14】。洗必泰葡萄糖酸盐是术前洗澡时应用最多的消毒剂。Cochrane综述的相关证据显示术前洗澡时应用洗必

34、泰葡萄糖酸盐进行消毒可使体表常居菌的细菌接种量明显减少。随着时间的延长，反复、持续地洗浴可使该接种量进行性地下降。然而，这样做也有产生耐药菌及出现过敏反应的风险。因此，上文作者的结论认为，为了减少手术部位感染的发生率，在术前洗澡时，并没有明确的证据证实应用洗必泰葡萄糖酸盐优于其他的产品，如肥皂等。Hair removal has been used traditionally to keep hair from contaminating the wound. More recently, hair removal has allowed surgeons to apply occlusive

35、 dressings to the skin perioperatively to keep skin flora from directly contaminating the wound. Three methods used for hair removal include traditional razors, clippers, and hair-removal creams or depilatories. Hairless surgical sites can make the surgery and application of dressings and protective

36、 draping easier, but the use of razors to shave the surgical site increases the risk of introducing primary infections through microscopic injuries to the skin. The Centers for Disease Control and Prevention (CDC) recommend that hair removal be minimized and that, when it is necessary, electric clip

37、pers or depilatories be used rather than razors15. A Cochrane review of the literature on hair removal prior to surgery supported the CDC recommendations and added that hair removal can be done on the day of the surgery16. 以往术前通常都要求去除毛发以避免污染创口，而最近则倾向于让外科医生在术前应用密闭的敷料覆盖皮肤，从而防止皮肤菌群直接污染创口。传统的去毛方式主要有三种：剃

38、毛、剪毛和脱毛膏或脱毛药物。手术部位去毛后通常可使手术操作更为方便，并使贴膜和防护膜的应用也更为简便，但应用剃刀刮除手术部位的毛发会对皮肤产生微小的损伤，通过这些损伤局部原发感染的风险会明显增加。疾病预防和控制中心（CDC）建议，应尽量避免去毛，如果实在必要，也应该应用电动剪毛刀或脱毛剂，而应避免应用剃毛刀【15】。有学者对术前去毛相关的文献进行了Cochrane综述，其结论与CDC所推荐的方案一致，此外，去毛应该手术当天进行【16】。Dental care is another preoperative issue to be discussed with high-risk orthopa

39、edic patients. All patients, but particularly those at high risk for infection, should be encouraged to maintain good dental health before and after surgery. Bacteremia from a dental infection can cause acute hematogenous infection at the site of a total joint replacement. Evidence shows that the mo

40、st critical period is the first two years after surgery17. The American Academy of Orthopaedic Surgeons (AAOS) in conjunction with the American Dental Association (ADA) developed guidelines for antibiotic prophylaxis for patients with a total joint replacement who require dental procedures18. Patien

41、ts are identified as being at high or low risk depending on their medical comorbidities. Dental procedures are categorized as high or low risk depending on the risk of bacteremia. All patients should receive antibiotic prophylaxis for high-risk dental procedures for two years after the joint replace

42、ment, and high-risk patients should receive prophylaxis for high-risk dental procedures for life. Antibiotic regimens are included in the recommendations (Table I). 术前处理牙科的疾病对于高风险的骨科患者而言也是一个值得探讨的问题。对于所有患者，而感染风险较高的患者尤其，应鼓励其在手术前后保持良好的口腔卫生。源自牙齿感染的菌血症可导致全关节置换部位的急性血源性感染。有证据表明，临界期通常为手术后的头两年【17】。美国骨科医师学会（A

43、AOS）联合美国牙科协会（ADA）对全关节置换的患者进行牙科手术时预防性应用抗生素制定了指南【18】。按照内科合并症的情况将患者分为高或低风险人群；按照菌血症的风险将牙科手术分为高风险或低风险手术。关节置换术后2年内的所有患者在进行高风险的牙科手术时，都应该预防性地应该抗生素，而对于高风险的患者而言，关节置换术后的任何时间行高风险牙科手术时都应该预防性应用抗生素。其推荐的方案中也包括了抗生素的用法（表1）。Antibiotics 抗生素 Perioperative prophylactic antibiotics are effective in reducing the rate of su

44、rgical site infections in high-risk orthopaedic cases. In a 2002 meta-analysis of spine fusion surgery, Barker19 reported that use of antibiotic therapy for such procedures is beneficial even when the infection rates without antibiotics are low. Similar studies have demonstrated the efficacy of preo

45、perative antibiotics in general orthopaedic surgery and before total joint replacement20,21. 对高风险的骨科患者而言，围手术期预防性应用抗生素可有效地降低手术部位的感染率。在2002年一项关于脊柱融合手术的meta分析中，Barker【19】指出，在这样的手术中应用抗生素是有益的，即使在不用抗生素时感染率也较低的情况下依然如此。其他类似的研究也证实，在普通的骨科手术和全关节置换手术之前应用抗生素都有着良好的效果【20,21】。The choice of antibiotic for patients w

46、ith a low risk of methicillin-resistant Staphylococcus aureus colonization is either cefazolin (1 to 2 g administered intravenously) or cefuroxime (1.5 g administered intravenously). These doses must be adjusted for children. For patients with a beta-lactam allergy, clindamycin (600 mg administered

47、intravenously) or vancomycin (1.0 g administered intravenously) should be used in lieu of cephalosporins. Patients who are colonized with methicillin-resistant Staphylococcus aureus are at high risk for colonization (e.g., nursing home residents), or have had a previous methicillin-resistant Staphyl

48、ococcus aureus infection have an increased risk for the development of an infection with methicillin-resistant Staphylococcus aureus22,23. Prophylaxis with vancomycin (1.0 g administered intravenously) should be considered for these patients24. 对于耐甲氧西林金黄色葡萄球菌定植风险较低的患者选择抗生素时，头孢唑啉（1-2g静脉内给药）或头孢呋辛（1.5g

49、静脉内给药）都是可以考虑的，应用于儿童时剂量应作相应的调整。如果患者对-内酰胺类药物过敏，可用克林霉素（600mg静脉内给药）或万古霉素（1.0g静脉内给药）代替头孢菌素。如患者居住在耐甲氧西林金黄色葡萄球菌较多的环境中，发生菌群定植的风险往往较高（如敬老院的住户），而曾经感染上述耐甲氧西林金黄色葡萄球菌的患者则发生耐甲氧西林金黄色葡萄球菌感染的风险会明显增加【22,23】，对这些患者应用考虑预防性应用万古霉素（1.0g静脉内给药）【24】。The proper timing and duration of antibiotic prophylaxis are imperative for s

50、afety and effectiveness. In general, antibiotic therapy should be started within one hour prior to the surgical incision, and the drugs should be completely infused prior to tourniquet inflation. The exception to this recommendation is vancomycin, the administration of which may be started up to two

51、 hours prior to the surgical incision. This allows a slower infusion and decreases the likelihood of red man syndrome. Red man syndrome occurs when hypersensitivity to vancomycin causes degranulation of mast cells and a release of histamine. The histamine leads to hypotension and facial flushing. Re

52、d man syndrome is prevented by the slow administration of vancomycin over a period of one to two hours. 预防性应用抗生素注意合适的时机和持续时间对于其安全性和有效性都是非常关键的。通常应在做手术切口之前的一个小时内应用抗生素，并且止血带充气之前药物必须输注完毕。对这一建议而言，万古霉素是个例外，其开始给药的时间应提前至做手术切口之前两个小时，这样可以缓慢输注，减少红人综合征的发生率。万古霉素过敏时可导致肥大细胞脱颗粒并释放组胺从而出现红人综合征，组胺可导致低血压和颜面部发红。应用万古霉素时缓

53、慢输注，输注时间达1-2小时可防止发生红人综合征。Antibiotic treatment should be stopped within twenty-four hours after wound closure. Administration of prophylactic antibiotics for longer than twenty-four hours has not been demonstrated to be effective and may actually lead to superinfection with drug-resistant organisms25

54、. Repeat dosing with antibiotics is recommended during surgical procedures that last for longer than four hours or when there is >1500 mL of blood loss26. 抗生素应在创口闭合后的24小时之内停药。没有证据表明预防性应用抗生素超过24小时是有效的，并且事实上还有可能导致耐药菌的二重感染【25】。而如果手术持续时间较长，超过4小时或术中出血量大于1500ml，则推荐在术中重复给药一次【26】。We recommend that, in or

55、der to ensure the proper selection and timing of antibiotic prophylaxis, the choice of antibiotics and duration of administration be incorporated into the surgical "time-out." Rosenberg et al. reported that compliance with the proper timing and selection of antibiotics increased from 65% t

56、o 99% when the protocol was incorporated into the time-out27. 在预防性应用抗生素时为了确保合理选择抗生素并确定适当的给药时机，我们推荐，将选择抗生素和确定给药持续时间都归入到手术的“time-out”（手术划刀前暂停核对各项信息）方案中。Rosenberg等曾报道，将相关的内容并入到“time-out”方案中之后，选择抗生素以及用药时间的符合率由65%增加到99%【27】。Surgical Hand Antisepsis术者手部消毒The objective of a preoperative hand scrub is to re

57、move or kill as many bacteria as possible from the hands of the surgical team. Aqueous scrub solutions consisting of water-based solutions of either chlorhexidine gluconate or povidone-iodine have been traditionally used. 术前洗手的目的是为了尽可能多地去除或杀死手术人员手部的细菌。通常应用的液态洗涤剂大多为洗必泰葡萄糖酸盐或聚维酮碘的水溶液。The authors of a

58、recent Cochrane review28 found alcohol-based rubs containing ethanol, isopropanol, or n-propanol to be as effective as aqueous solutions for preventing surgical site infections in patients29. Hajipour et al.30 reported that alcohol rubs were more effective than either chlorhexidine gluconate or iodi

59、ne-based scrubs for reducing bacterial colony-forming units (CFUs) on the hands of surgeons. Other investigators reported that the use of scrub brushes had no positive effect on asepsis and may actually increase the risk of infection as a result of skin damage31. On the basis of this evidence, the recommended procedure for preoperative surgical hand antisepsis is that, p