降低感染率的围手术期策略

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 Hos

2、pital 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: joseph.bosco. E-mail address for J.D. Slover: james.slover2 Infection Prevention and Control, Westchester Medical Center, 100 Woods Road, Macy Pavilion S

3、W246, 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, and cost and result in

4、 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 Medicare and Medicaid

5、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 Organizations (Oakbrook Terra

6、ce, 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，Baltimore, Maryland）；以外科医疗改良

7、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. Preoperative strategi

8、es 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 chlorhexidine glucona

9、te, 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，术前妥善处理先前存在的牙齿及营养相关的问题。There a

10、re 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 antibiotics and utili

11、zation 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, postoperative strategies for th

12、e 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 precautions, and room

13、 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 Considerations 术前注意事项Although ever

14、y 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 appropriate preoperative counse

15、ling 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 factors that place pat

16、ients 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 counseled about their inc

17、reased 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 history of infection i

18、n 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，有很多高风险患者人群以及相关的危险因素使

19、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 the risk of infection

20、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 have increased infectio

21、n 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 medications perioperativ

22、ely. 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 reflects long-term glucose

23、 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, if possible, prior to join

24、t 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【8】，糖尿病【9】，肾功能衰竭【10】和人免疫缺陷

25、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（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

26、血量大于1500ml，则推荐在术中重复给药一次【26】。We recommend that, in order 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 selec

27、tion of antibiotics increased from 65% to 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 objecti

28、ve 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 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

29、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-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 tha

30、n either chlorhexidine gluconate or iodine-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 damage

31、31. On the basis of this evidence, the recommended procedure for preoperative surgical 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, and dry with p

32、aper towels. They should then use an alcohol-based rub for three minutes32. An alcohol-based rub should be used for each subsequent case. The use of scrub brushes is not recommended. 有学者最近的一项Cochrane综述【28】发现，含有乙醇、异丙醇或正丙醇的酒精擦剂与水溶液相比，对于预防患者手术部位的感染具有类似的效果【29】。Hajipour等【30】报道酒精擦剂比洗必泰葡萄糖酸盐或含碘洗涤剂都更为有效，因为前

33、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对于手部消毒并没有明显的效果，并且事实上由于会损伤皮肤反而会增加感染的风险【31】。根据这些证据，术者术前手部消毒推荐的方式为，在当天初次刷洗之前或手部严重污染时，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干净，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】。后续的手术每次都应该用含酒精的擦剂进行涂抹，但不推荐应用毛刷进行刷洗。Surgical Site Preparation手术部位的消毒Chlorhexidine gluconate-based solutions have supplant

34、ed alcohol and iodine-based solutions for surgical site preparation. Ostrander et al.33 examined the residual amounts of bacteria on feet prepared with a chlorhexidine gluconate, iodine/isopropyl alcohol, or chloroxylenol scrub. They found that chlorhexidine gluconate was superior to the other two p

35、reparation 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 catheters and the drawing of blood for culture34,35.

36、Thus, the current evidence-based recommendations and best-practice guidelines call for the use of chlorhexidine gluconate-based solutions for surgical site preparation and placement of central venous catheters. 手术部位的消毒液，洗必泰葡萄糖酸盐溶液已经替代酒精和含碘的溶液。Ostrander等【33】对洗必泰葡萄糖酸盐、碘/异丙醇或氯二甲苯酚的擦剂消毒足部后，检测残余的细菌数量，结果发

37、现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】。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佳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环境Although the arcane details of technique

38、s used to sterilize surgical instruments are beyond the expected knowledge of most orthopaedic surgeons, many of a surgeons actions can adversely affect sterilization and increase the risk of surgical site infections. Flash sterilization is a procedure used by operating-room staff to sterilize instr

39、uments or implants with steam, on an as-needed basis. Flash sterilization is not equivalent to sterilization in central processing36,37. In central sterile processing, instruments are properly cleaned and all lumens are inspected; the instruments are then sterilized and allowed to dry completely, af

40、ter which they are delivered in closed containers that ensure maintenance of sterility. Most importantly, the process is performed by trained, focused professionals. The entire process takes three to four hours. Flash sterilization should be used only for dropped instruments or in an emergency situa

41、tion. Preventable reasons for flash sterilization include an insufficient quantity of instruments, loaner instruments and/or instruments not delivered in time for proper processing, and inaccurate or incomplete surgical booking requiring the emergency, unplanned use of instruments and/or implants. 虽

42、然手术器械灭菌方法中很多不为人知的操作细节并不是大多数骨科医生都期望掌握的知识，但外科医生的很多做法却可对灭菌过程产生负面的影响，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【36,37】。在中央灭菌处理中，手术器械先用适当的方法清理干净，对所有内腔都进行彻底的检查，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，以确保维持其无菌的状态。最为重要的是，这些操作都由经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

43、方可应用。有些因素是可以避免进行快速灭菌的，包括手术器械数量不足，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，非计划性地应用手术器械和/或内置物等。To reduce the incidence of flash sterilization, we recommend an increase in physician awareness about the inadequacy of the technique; improvement in the accuracy of surgical booking; mandating cooperati

44、on from vendors to ensure timely delivery of equipment, including financial penalties for late delivery; purchase of more frequently flash-sterilized items; surgical scheduling to accommodate and mitigate equipment shortages; and, finally, generation of incident reports when a flash-sterilized impla

45、nt is used in a patient. Adopting these policies 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不足；提高手术预约单的准确性；要求供货商密切配合，确保相关设备及时交付到位，对于延迟送达的应考虑适当给予经济惩罚；对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。采用这些

46、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. Because of concerns about granuloma formation and adhesions associated with the use of these substa

47、nces, cornstarch is 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 of bacteria required to cause a clinically apparent infection40. Cornstarch also leads to increased latex sensitivity in

48、 health-care workers. Type-I and type-IV hypersensitivity reactions to latex protein in hospital staff lead to increases in sick time and decreased job satisfaction41. Powderless gloves decrease staff absenteeism and eliminate the potential for foreign-body granuloma formation. These gloves cost 25%

49、 more than powdered gloves, but the added expense is mitigated by increased productivity of the operating-room staff41. 无粉手套以往外科手套都是有粉的，这样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，并且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】。玉米淀粉还会使医务人员对橡胶

50、的敏感度增加。医院的工作人员对乳胶蛋白的I型和IV型过敏反应会使不适时间延长，并使工作的满意度下降【41】。无粉手套可减少工作人员的缺勤状况，且可避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员工作效率的提高而减少【41】。Antiseptic-Coated SuturesThe use of antiseptic-coated sutures has generated increased interest. These sutures are typically coated with the antiseptic triclosan. Ed

51、miston et al. demonstrated the effectiveness of coated sutures in inhibiting bacterial growth and contamination in an in vitro model42. In a randomized controlled trial, Rozzelle et al. reported a significant reduction in surgical site infection rates following cerebral spinal-fluid-shunt surgery wi

52、th the use of antiseptic-coated sutures as compared with the rate following the same procedure without the use of such sutures43. These sutures cost 7% to 10% more than their uncoated counterparts. To our knowledge, no cost-effectiveness analysis has been published; however, the use of these sutures

53、 in high-risk patients may be justified. 具有抗菌表层的缝线应用具有抗菌表层的缝线越来越被人们所重视，这种缝线通常涂有一层抗菌的三氯生。Edmiston等曾报道，在体外实验中，这种有涂层的缝线可有效抑制细菌的繁殖和污染【42】。在另一项随机对照试验中，Rozzelle等报道在脑脊液分流术后应用具有抗菌表层的缝线与没有应用这种缝线的病例相比，手术部位的感染率明显下降【43】。这种缝线相比没有涂层的类似缝线要贵7%至10%。据我们所知，目前尚未发表相关的效价分析，但是在高风险的患者中应用这样的缝线还是合理的。Operating-Room TrafficMai

54、ntaining a disciplined operating-room culture can reduce the risk of surgical site infections. Unnecessary operating-room traffic increases the rate of infections44. In a study of spine surgery, Olsen et al. reported that two or more residents participating in the operative procedure was an independ

55、ent risk factor for surgical site infections, with an odds ratio of 2.245. Babkin et al. found that the rate of surgical site infections associated with left knee replacements was 6.7 times higher than that associated with right knee replacements performed during the same time period and in the same

56、 operating rooms46. When the door on the left side of the operating room was locked, preventing ingress or egress, the surgical site infection rate associated with the left knee replacements rapidly decreased to that associated with the right knee replacements, a finding that supports the importance

57、 of limiting operating-room traffic. 手术室的交通在手术室保持遵守职业规范的习惯可减少手术部位感染的风险，在手术室内不必要的穿行会使感染率增加【44】。在一项有关脊柱手术的研究中，Olsen等报道在手术过程中2个或更多的人员加入进去是手术部位感染的一个独立的风险因素，优势比2.245。Babkin等发现，在相同时期内在同一手术间进行手术，左膝关节置换手术部位感染的发生率为由膝关节置换的6.7倍【46】，而当手术室左侧的门锁上以后，避免进出，左膝关节置换的术区感染率便很快下降到与右膝关节置换相当的水平，这一发现也证实了限制手术室交通的重要性。Drains an

58、d Blood TransfusionsWhether to use drains at the end of orthopaedic surgical procedures is a decision that surgeons make on the basis of their training, opinions, and personal experience, in addition to research findings. A recent Cochrane review on this topic that included findings from thirty-six

59、studies (5464 patients) revealed that the use of closed drains reduced bruising and the need for reinforcement of dressings47. However, the use of closed drains was also associated with an increased need for transfusion, a risk factor that is discussed below. There was no difference in surgical site

60、 infection rates between drained and undrained wounds. The authors concluded that closed suction drains were of doubtful benefit.创口引流与输血在骨科手术临结束时是否放置引流管除了参考相关的研究结果以外，还需要术者根据他们所接受的训练、观点以及个人的经验来决定。最近有一项针对这一问题的Cochrane综述，共纳入了36项研究（5464例患者），结果显示应用封闭式引流可减少瘀伤，同时还可减少加包辅料的需要【47】。不过，应用封闭式引流会相应地增加输血的需求，风险因子如下