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, MSI and Janet P. Haas, RN, PhD2Department of Orthopaedic Surgery, NYU Hospi

2、tal for J oint Diseases, New York University Langone Medical Cent er, 301 East 17th Street, New York, NY 10003. E-mail ad dress for J. A. Bosco III： Joseph. bosconyumc. org. E-mai 1 address for J. D. Slover： James. slovernyumc. orgInfection Prevention and Control, Westchester Medical Center, 100 Woo

3、ds Road, Macy Pavilion SW246, Valhalla, NY 10595. E-mail address： Haasjwcmc. comAn Instructional Course Lecture, American Academy of Or thopaedic SurgeonsIntroduction引言creased risk of infection with spine surgery. Patients considering or planning surgical weight-loss treatments, such as gastric bypa

4、ss surgery, probably should be adv ised to pursue these procedures first to reduce the ris k of infection at the sites of hardware or prostheses a s a benefit from weight loss. Working with patients and the appropriate consultants to optimize these factorsprior to surgery may improve patient outcome

5、s by loweri ng the risk of infection with high-risk joint-replaceme nt and spine procedures.吸烟和肥胖会增加脊柱手术感染的风险【13。尽管这些因素通 常难以操纵，但仍然应该告知患者，戒烟以及减轻体重关于降低 脊柱手术感染的风险具有重要意义。假如患者正在考虑或打算通 过手术来减轻体重，如胃旁路手术，那么应该建议患者先做减肥 手术，因为如此关于置入内固定物或假体的部位能够减少感染的 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，能够 改善临床结

6、果，降低感染的风险。Another important preoperative consideration is preoper ative bathing. Preoperative bathing has been used to re duce the bacterial load of the skin prior to surgery be cause skin preparation immediately before surgery does not completely sterilize the skin. In addition, direct contaminatio

7、n can occur at the time of surgery. A recen t Cochrane review was performed to assess the informati on in the literature regarding preoperative bathing wit h antiseptics for the prevention of surgical site infec tionl4. Chlorhexidine gluconate is the most commonly us ed antiseptic for preoperative b

8、athing. The Cochrane re view revealed evidence that the bacterial load of resid ent skin flora is reduced by use of chlorhexidine gluco nate preparations for preoperative bathing. Repeated, c onsecutive treatments reduce this load progressively ov er time. However, concerns about the development of

9、res istant organisms and hypersensitivity remain. Therefore, the authors of the review concluded that there is no c lear evidence that preoperative bathing with chlorhexid ine gluconate is superior to preoperative bathing with other products, such as bar soap, for reducing the inci dence of surgical

10、 site infection.手术前另一个重要的考前须知便是术前洗澡。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，假如术前不洗澡，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。随着时刻的延长，反复、持续地 洗浴可使该接种量进行性地下降。然而，如此做也有产生耐药菌 及出现过敏反响的风险。因此，上文作

11、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 f rom contaminating the wound. More recently, hair remova 1 has allowed surgeons to apply occlusive dressings to the skin perioperatively to keep skin flora from direct ly contaminat

12、ing the wound. Three methods used for hair removal include traditional razors, clippers, and hair-removal creams or depilatories. Hairless surgical site s can make the surgery and application of dressings and protective draping easier, but the use of razors to sh ave the surgical site increases the

13、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 clippers or depilatories be used rather than razorsl5. A Cochrane review of th e lite

14、rature on hair removal prior to surgery supportedthe CDC recommendations and added that hair removal can be done on the day of the surgeryl6.以往术前通常都要求去除毛发以幸免污染创口，而最近那么倾向于 让外科大夫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。传统的去毛方式要紧有三种：剃毛、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

15、，通过这些损伤局部原发感染的风 险会明显增加。疾病预防和操纵中心(CDC)建议，应尽量幸免 去毛，假如实在必要，也应该应用电动剪毛刀或脱毛剂，而应幸 免应用剃毛刀【15。有学者对术前去毛相关的文献进行了 Coc hrane综述，其结论与CDC所推举的方案一致，此外，去毛应该 手术当天进行16 oDental care is another preoperative issue to be discuss ed with high-risk orthopaedic patients. All patients, b ut particularly those at high risk for i

16、nfection, shoul d be encouraged to maintain good dental health before a nd after surgery. Bacteremia from a dental infection ca n cause acute hematogenous infection at the site of a t otal joint replacement. Evidence shows that the most cr itical period is the first two years after surgeryl7. T he A

17、merican Academy of Orthopaedic Surgeons (AAOS) in c onjunction with the American Dental Association (ADA) d eveloped guidelines for antibiotic prophylaxis for pati ents with a total joint replacement who require dental proceduresl8. Patients are identified as being at high or low risk depending on t

18、heir medical comorbidities. D ental procedures are categorized as high or low risk de pending on the risk of bacteremia. All patients should receive antibiotic prophylaxis for high-risk dental pro cedures for two years after the joint replacement, and high-risk patients should receive prophylaxis fo

19、r high- risk dental procedures for life. Antibiotic regimens ar e included in the recommendations (Table I).术前处理牙科的疾病关于高风险的骨科患者而言也是一个值得探讨的问题。关于所有患者，而感染风险较高的患者尤其，应鼓 舞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。有证据说明，临界期通 常为手术后的头两年17。美国骨科医师学会（AAOS）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

20、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，而关于高风险的患者而 言，关节置换术后的任何时刻行高风险牙科手术时都应该预防性 应用抗生素。其推举的方案中也包括了抗生素的用法（表1）。TABLE I Antibiotic Prophylaxis for Dental ProceduresMedicationMedicationDosageTimingCephalexinCephradineAmoxicillin2 g orally2 g orally2 g orall

21、y1 hr prior to procedu1 hr prior to procedu1 hr prior to表1牙科手术预防性应用抗生素药物药物剂最用法给药时间头抱氨卡头抱拉定阿莫西林2g I I 服2g 口服2g 2服术前1小时术前1小时硬冽死Antibiotics抗生素Perioperative prophylactic antibiotics are effective in reducing the rate of surgical site infections in high- risk orthopaedic cases. In a 2002 metaanalysis of

22、spin e fusion surgery, Barkerl9 reported that use of antibio tic therapy for such procedures is beneficial even when the infection rates without antibiotics are low. Simil ar studies have demonstrated the efficacy of preoperati ve antibiotics in general orthopaedic surgery and befor e total joint re

23、placement20,21.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me ta分析中，Barker 19指出，在如此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旧如此。 其他类似的研究也证实，在一般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 with a low risk o f methicillin-resistant Staphylococcus aureus colonizat ion

24、 is either cefazolin (1 to 2 g administered intraven ously) or cefuroxime (1. 5 g administered intravenously).These doses must be adjusted for children. For patient s with a beta-lactam allergy, clindamycin (600 mg admin istered intravenously) or vancomycin (1. 0 g administere d intravenously) shoul

25、d be used in lieu of cephalospori ns. Patients who are colonized with methici11 inuresista nt Staphylococcus aureus are at high risk for colonizat ion (e. g. , nursing home residents), or have had a previ ous methicillin-resistant Staphylococcus aureus infecti on have an increased risk for the devel

26、opment of an inf ection with methicillin-resistant Staphylococcus aureus 22,23. Prophylaxis with vancomycin (1. 0 g administered intravenously) should be considered for these patients2 4.关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，头匏嗖琳（1-2g静脉内给药）或头抱吠辛（1.5g静脉内 给药）差不多上能够考虑的，应用于儿童时剂量应作相应的调整。 假如患者对B-内酰胺类药物过敏，可用克林霉素（

27、600mg静脉 内给药）或万古霉素（1.0g静脉内给药）代替头抱菌素。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那么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】oThe proper timing and duration of antibiotic prophylaxi s are imperative for safety and effectiveness. In gener al, antibiot

28、ic therapy should be started within one hou r prior to the surgical incision, and the drugs should be completely infused prior to tourniquet inflation. Th e exception to this recommendation is vancomycin, the a dministration of which may be started up to two hours p rior to the surgical incision. Th

29、is allows a slower inf usion 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 fa cial flushing. Red man syndrome is prevented by the slo w

30、 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刻关于其平安性和 有效性差不多上特不关键的。通常应在做手术切口之前的一个小 时内应用抗生素，同时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，其开始给药的时刻应提早至做 手术切口之前两个小时，如此能够缓慢输注，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 素时缓慢输注，输注时刻达1-2小时可防止发生红人综合征。Antibi

31、otic treatment should be stopped within twenty-fo ur hours after wound closure. Administration of prophyl actic antibiotics for longer than twenty-four hours has not been demonstrated to be effective and may actually lead to superinfection with drug-resistant organisms25. Repeat dosing with antibiot

32、ics is recommended during s urgical procedures that last for longer than four hoursSurgical site infections associated with orthopaedic su rgical procedures are devastating complications. They i ncrease morbidity, mortality, and cost and result in ou tcomes that are worse than those in uninfected ca

33、sesl. Decreasing the incidence of surgical site infections is not only of interest to patients and surgeons, it is aIso a major focus of several groups of interested parti es. These range from payers, including the Centers for Medicare and Medicaid Services (CMS, Baltimore, Marylan d), to institutio

34、ns represented by the Surgical Care Im provement Project (SCIP), a multiple-institution partne rship between major public and private health-care orga nizations, including the Joint Commission on Accreditat ion of Healthcare Organizations (Oakbrook Terrace, Illi nois). Decreasing the incidence of su

35、rgical site infect ions is, and will continue to be, a major focus in medi cine.关于骨科手术而言，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，同时与没有发生 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。没有证据说明预防 性应用抗生素超过24小时是有效的，同时事实上还有可能导致 耐药菌的二重感染【25】o而假如手术持续时刻较长，超过4小 时或术中出

36、血量大于1500ml,那么推举在术中重复给药一次【26】。We recommend that, in order to ensure the proper select ion and timing of antibiotic prophylaxis, the choice of antibiotics and duration of administration be incorpor ated into the surgical ntime-out.Rosenberg et al. reported that compliance with the proper timing and se

37、lect ion of antibiotics increased from 65% to 99% when the p rotocol 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，我们推举，将选择抗生素和确定给药持续时刻都归入 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刻的符合率由65%增加到99%27OSurgical Hand Antisepsis术者手部消毒The o

38、bjective of a preoperative hand scrub is to remove 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 glucon ate 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

39、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 recent Cochrane review28 found alcohol -based rubs containing ethanol, isopropanol, or n-propa nol to be as effective as aqueous solutions for prevent ing surgical site infections in patients29. Hajipour et al.30 reported that alcohol rubs were more ef

40、fective t han either chlorhexidine gluconate or iodine-based scru bs for reducing bacterial colony-forming units (CFUs) o n the hands of surgeons. Other investigators reported t hat the use of scrub brushes had no positive effect on asepsis and may actually increase the risk of infectionas a result

41、of skin damage31. On the basis of this evi dence, the recommended procedure for preoperative surgi cal hand antisepsis is that, preceding the first scrub of the day or when the hands are grossly contaminated, the surgical team should wash with soap and water, use a nail pick to clean under the nails

42、, and dry with pape r towels. They should then use an alcohol-based rub forthree minutes32. An alcohol-based rub should be used f or each subsequent case. The use of scrub brushes is no t recommended.有学者最近的一项Cochrane综述【28】觉察，含有乙醇、异丙 醇或正丙醇的酒精擦剂与水溶液相比，关于预防患者手术部位的 感染具有类似的效果29 o Hajipour等30报道酒精擦剂 比洗必泰葡萄

43、糖酸盐或含碘洗涤剂都更为有效，因为前者可减少 术者手上的细菌菌落形成单位（CFU）。另外还有学者报道应用 毛刷关于手部消毒并没有明显的效果，同时事实上由于会损伤皮 肤反而会增加感染的风险31 o依照这些证据，术者术前手部 消毒推举的方式为，在当天初次刷洗之前或手部严峻污染时，手 术人员应该用肥皂和水洗手，并用指甲签将指甲下方的污物清理 洁净，然后用纸巾擦干。然后，术者再用含酒精的擦剂涂抹3分 钟【32】o后续的手术每次都应该用含酒精的擦剂进行涂抹，但不推举应用毛刷进行刷洗。Surgical Site Preparation 手术部位的消毒Chlorhexidine gluconate-base

44、d solutions have supplanted alcohol and iodine-based solutions for surgical site p reparation. Ostrander et al. 33 examined the residual am ounts of bacteria on feet prepared with a chlorhexidine gluconate, iodine/isopropyl alcohol, or chloroxylenol scrub. They found that chlorhexidine gluconate was

45、 supe rior to the other two preparation solutions in reducing or eliminating bacteria from the feet prior to surgery. Chlorhexidine gluconate skin preparation was superior to either 70% alcohol or iodine in decreasing infection associated with the placement of central venous cathet ers and the drawi

46、ng of blood for culture34,35. Thus, th e current evidence-based recommendations and best-pract ice guidelines call for the use of chlorhexidine glucon ate-based solutions for surgical site preparation and p lacement of central venous catheters.手术部位的消毒液，洗必泰葡萄糖酸盐溶液差不多替代酒精和含 碘的溶液。Ostrander等【33】对洗必泰葡萄糖酸

47、盐、碘/异丙 醇或氯二甲苯酚的擦剂消毒足部后，检测剩余的细菌数量，结果 觉察在术后减少或消除足部细菌的功效上洗必泰葡萄糖酸盐优 于其他两种消毒剂。而在置入中央静脉导管和抽血样做培养等操 作时，应用洗必泰葡萄糖酸盐进行皮肤消毒，相比70%的酒精或 碘剂，均可减少感染的发生率34,35 o因此，在术区消毒以 及置入中央静脉导管时，基于现有证据的建议和最正确操作指南都 提倡应用洗必泰葡萄糖酸盐溶液。Decreasing the Risk of Surgical Site Infection Related to the Operating-Room Environment降低手术部位感染相关的手术室

48、环境Although the arcane details of techniques used to steri lize surgical instruments are beyond the expected knowl edge of most orthopaedic surgeons, many of a surgeon1s actions can adversely affect sterilization and increase the risk of surgical site infections. Flash sterilizat ion is a procedure u

49、sed by operating-room staff to ster ilize instruments or implants with steam, on an as-need ed basis. Flash sterilization is not equivalent to ster ilization in central processing36,37. In central steril e processing, instruments are properly cleaned and all lumens are inspected； the instruments are

50、 then steriliz ed and allowed to dry completely, after which they are delivered in closed containers that ensure maintenance of sterility. Most importantly, the process is performe d by trained, focused professionals. The entire process takes three to four hours. Flash sterilization shouldbe used on

51、ly for dropped instruments or in an emergency situation. Preventable reasons for flash sterilization include an insufficient quantity of instruments, loane r instruments and/or instruments not delivered in time for proper processing, and inaccurate or incomplete sur gical booking requiring the emerg

52、ency, unplanned use of instruments and/or implants.尽管手术器械灭菌方法中专门多不为人知的操作细节并不是大 多数骨科大夫都期望掌握的知识，但外科大夫的专门多做法却可 对灭菌过程产生负面的阻碍，并会增加手术部位感染的风险。快 速灭菌是手术室工作人员常用的一种对手术器械或内置物的灭 菌方式，在一些必要的基座之上，应用蒸汽。快速灭菌并不能等 同于中央灭菌过程136,37】。在中央灭菌处理中，手术器械先 用适当的方法清理洁净，对所有内腔都进行完全的检查，然后在 对器械进行灭菌，并可使其完全干燥，最后手术器械在运送过程 中必须保持密闭的包装，以确保维持其

53、无菌的状态。最为重要的 是，这些操作都由通过专业训练的人员完成，整个过程需要3-4 小时。快速灭菌只有在术中器械掉落或紧急状况下方可应用。有 些因素是能够幸免进行快速灭菌的，包括手术器械数量缺乏，应 用替代性器械和/或器械没有按照合适的操作规程按时送达，手 术预约错误或不完善需要紧急处理，非打算性地应用手术器械和 /或内置物等。To reduce the incidence of flash sterilization, we reco mmend an increase in physician awareness about the inad equacy of the technique

54、； improvement in the accuracy of surgical booking； mandating cooperation from vendors t o ensure timely delivery of equipment, including finane ial penalties for late delivery； purchase of more frequ ently flash-sterilized items； surgical scheduling to ac commodate and mitigate equipment shortages；

55、and, finall y, generation of incident reports when a flash-steriliz ed implant is used in a patient. Adopting these policie s and procedures leads to a decrease in the incidence of flash sterilization38.为了减少快速灭菌，我们建议增强对临床医师的宣传和培训，使 其充分认识到这一方法的缺乏；提高手术预约单的准确性；要求 供货商紧密配合，确保相关设备及时交付到位，关于延迟送达的 应考虑适当给予经济惩

56、办；关于以往经常进行快速灭菌的器械适 当增加购买数量；通过调整手术安排以适应和缓解设备上的不 足，最后，快速灭菌的内置物应用于患者后应写出相关的事件报 告。采纳这些策略和规程可有效降低快速灭菌的使用率【38】。Powderless GlovesTraditionally, surgical gloves contained powder to aid in the manufacturing process and to make donning easier.The powder was either talc or lycopodium spores. Becau se of concer

57、ns about granuloma formation and adhesions associated with the use of these substances, cornstarchis now the powder of choice39. However, cornstarch is not benign. It causes foreign-body granuloma formation and delayed wound-healing and can decrease the amount o f bacteria required to cause a clinic

58、ally apparent infe ction40. Cornstarch also leads to increased latex sensi tivity in health-care workers. Type-I and type-IV hyper sensitivity reactions to latex protein in hospital staf f lead to increases in sick time and decreased job sati sfaction41. Powderless gloves decrease staff absenteeis m

59、 and eliminate the potential for foreign-body granulom a formation. These gloves cost 25% more than powdered g loves, but the added expense is mitigated by increased productivity of the operating-room staff41.无粉手套以往外科手套差不多上有粉的，如此在制造过程中便于操作，同 时也可使穿戴更为方便，粉末的成分为滑石粉或石松子。由于考 虑到应用这些粉末可能会形成肉芽肿以及粘连，因此目前一般都

60、选用玉米淀粉【39。然而，玉米淀粉也不是没有任何危险的， 其可导致创口延迟愈合或形成异物性肉芽肿，同时它可使通常出 现感染相关临床表现所需的细菌数量减少【40】o玉米淀粉还会 使医务人员对橡胶的敏感度增加。医院的工作人员对乳胶蛋白的 I型和IV型过敏反响会使不适时刻延长，并使工作的中意度下 降【41】。无粉手套可减少工作人员的缺勤状况，且可幸免向体 外形成肉芽肿的潜在可能。这些手套比有粉手套贵25%,但由此 增加的费用会随着手术室工作人职员作效率的提高而减少【41】。Antiseptic-Coated SuturesThe use of antiseptic-coated sutures ha