脊柱手術(shù)部位感染

1、脊柱手術(shù)部位感染,俞武良 2016-10-12,,手術(shù)部位感染(Surgical site infection SSI)是一種相對(duì)常見的脊柱手術(shù)并發(fā)癥，發(fā)生率為1%-14%，具有潛在的災(zāi)難性的后果。,,美國托馬斯杰斐遜大學(xué)的Radcliff等篩選并總結(jié)了近5年成人脊柱手術(shù)后手術(shù)部位感染的發(fā)生率、危險(xiǎn)因素、診斷、預(yù)防及治療的相關(guān)研究，發(fā)表在2015年The Spine Journal雜志。,1、Incidence,a prospect

2、ively collected database of 108,419 cases, the overall infection rate for lumbar surgery was 2.1% (superficial=0.8%, deep=1.3%),,The incidence of SSI appears to be lower after minimally invasive spinal (MIS) surgeries A

3、 review of 1,338 MIS surgeries from multiple institutions revealed an infection rate of 0.74% in fusion/fixations and 0.22% overall a review by Parker et al compared postoperative infection after open and minimally inva

4、sive 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),2、Risk factors for infection,Medical comorbidities：anemia, diabet

5、esmellitus, coronary artery disease, diagnosis of coagulopathy, neoplasmobesityhigher American Society of Anesthesiologist scoremalnutrition,,,diabetes, obesity has been found to be a risk factor for SSI skin fold t

6、hickness and L4 spinous process-skinthickness 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 increase

7、d the risk of SSI,,the particular diagnosis is an infection risk factor patients undergoing surgery for degenerative disease have a lower infection rate compared to deformity (1.4% vs. 4.2%) Patients undergoing surger

8、y 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,,case order may contribute to the rate of SSI after spine surge

9、ry lumbar decompression performed later in the day (third case) led to three times higher incidence of SSI compared with those performed as the day’s first case contamination of the operating room, cross-contamination

10、between health care providers during the course of the day, use of flash sterilization, and mid-day shift changes.,,seasonal effect on the rate of postoperativeeffect SSI incidence peaks in the summer and fall with sta

11、tistically significant drops in infection rate in the spring and winter,,complex procedures may present a higher risk of perioperative complications more extensive tissue dissection increased blood losslonger operativ

12、e time,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 feverwound erythema,There are no universally

13、accepted clinical diagnostic criteria for SSI.,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 po

14、stoperative period with a peak occurring at approximately 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

15、 relatively accurate predictor of postoperative infection,,,laboratory markers,Erythrocyte sedimentation rate (ESR) a later peak than CRP, typically occurring aroundpostoperative Day 4 Absolute neutrophil count (ANC)

16、no significant difference between the normal and infected groups up to 4 days postoperativelya significant rise in the periods 4 to 7 and 8 to 11 days postoperatively in the infected patients,laboratory markers,Serum

17、 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 stati

18、stically significantcorrelations with the development of SSIPCT is superior to CRP in early prediction of SSI,laboratory markers,Interleukin-6(IL-6)well studied in joint replacement surgery Leukocyte esterase a rec

19、ently reported marker in periprosthetic knee joint infection 80.6% sensitivity and 100% specificity in diagnosing joint infection,In particular, few laboratory markers have been validated as a ‘‘gold standard’’ in assoc

20、iation with culture-positive SSI.,4、Intraoperative measures,intraoperative measures to reduce infections skin preparation intraoperative behaviors wound irrigation topical antibiotic application wound closure post

21、operative drain use,,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 expos

22、ed to the operating room environment significantly reduced when the implants were covered during the case the level of contamination increases directly with the amount of time it is open in the operating field.,,skin p

23、reparation a significant decrease in SSI rate with the use of chlorhexidine versus iodine skin prep ？Intraoperative techniques and behaviors the operative gown sterile instrument draping use of intraoperative fluo

24、roscopy operative scrub cleanliness,,,,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%） Copiousl

25、y irrigated with normal saline before bone decortication,,,,significant decrease in SSI after local administration of vancomycin powder,,Postoperative protocols an increased mean number of days of closed suction wound d

26、rainage in patients with infection versus patients without infectionuse of 2-octyl-cyanoacrylate for skin closure may decrease the rate of infection,5、Treatment,Treatment of SSI relies on early identification early

27、 diagnosis early evacuation of gross purulent material,,Treatment options irrigation and debridement intravenous antibioticsprimary closure closed vacuum systemhardware retentionplastic surgery reconstruction(rot

28、ational flaps),Postoperative Infection Treatment Score for the Spine,7 – 14 low risk21–33 high risk,6、Conclusions,Postoperative spinal SSIs can be devastating complications for both the patient and

29、 the surgeon Diagnosis of a SSI after surgery on the spine is still very much a clinical diagnosis,,a multifaceted approach to prevention is the key to managing infection risk the importance of strict sterile conduct d

30、uring the operation is reemphasizedefforts should be made to minimize time spent in the operating suite(preoperative and intraoperative) applying local vancomycin to the surgicalregular use of antibiosis in high risk