Issues
Host
Wound
Operating room environment
Antibiotics
Operative technique
Post operative
Host
Immunocompromised
RA (0.9 v 2.2%)
Psoriasis
DM (6%)
Poor nutrition
Obesity
UTI
Prednisone
Previous operation
Previous infection
Age
Prolonged pre-op hospitalisation (Admit DOS)
Active concurrent infection (Oral cavity / UTI / chest)
Wound
Shave and prep immediately prior to surgery
Preparation
- alcoholic chlorhexidine best
Drapes
- plastic adhesive +/- impregnated
Breaches in skin (local / distant)
- cover
- delay elective surgery if able
Old scars
- incorporate if able
Wound irrigation +/- antiseptic
Operating Room Environment
Limit Number of personnel / Amount of traffic
Airflow / laminar flow
Helmet / aspirator suit
Gown (goretex, polyproylene)
Hoods and masks
Ultra- clean air
UV light
MRC Trial Lidwell OM, Br Med J 1982
Multicentre study of sepsis after 8000 TKR / THR
- randomised
3 Groups
- conventional theatre clothing
- total joint replacements in a ultra-clean air OT, conventional theatre clothing
- total joint replacements in a ultra-clean air OT, body exhaust suits or utilising plastic patient isolators
Findings
- ultraclean air 1/2 joint infections conventional ventilation
- whole body exhaust suits + ultraclean air 1/4 infection rate
Antibiotics
Pre-operative
- at time of induction
- repeat if operation goes 2+ hours
Antibiotics in cement
- if joint replacement
Post-operative
- little evidence
- many continue for 24 hours
Operative Technique
Prep by gowned assistant
Avoid glove perforations
- double glove & change regularly
Avoid prolonged use of suction tip
Avoid splash bowl for washing instruments
Meticulous technique
- gentle handling, avoid devitilising tissue, don't undermine skin, careful closure and suturing
Minimise operating time
Avoid haematoma
- close deep space
- ? use drain
Post operative
Avoid pressure on wound
Avoid distant pressure areas
Avoid haematomas
Debride / washout expanding haematomas
Superficial skin necrosis / formal debridement
Serous wound drainage (persistent = formal debridement)
Avoid bacteraemia
Minimise IVC, IDC