骨科清洁切口手术部位感染监测及危险因素

目的了解骨科清洁切口手术部位感染(SSI)发病率和SSI危险因素。方法对某院2014年4月1日—9月30日实施骨科清洁手术的患者进行SSI监测,分析其危险因素。结果共监测患者665例,发生SSI 14例,SSI发病率为2.11%。单因素分析结果显示,手术类型、皮肤准备方法、ASA评分和手术时间均是骨科清洁切口发生SSI的危险因素(均P0.05)。多因素logistic分析结果显示:传统备皮法、ASA评分Ⅱ级及以上、手术时间≥90 min是骨科清洁手术患者发生SSI的独立危险因素[OR及OR95%CI分别为3.96(1.07-14.70)、6.45(1.97-21.11)、4.08(1.35-12.30)]。结论改良备皮法、ASA评分I级及手术持续时间越短可减少骨科清洁切口SSI的发生,临床在提高患者自身免疫力的前提下,加强医院感染预防与控制,有助于降低骨科清洁切口SSI发病率。     

骨关节术后医院感染病原学及其危险因素

目的探讨骨科关节手术后医院感染的病原菌、药敏性及其危险因素。方法收集2017年2月-2020年3月在浙江萧山医院行骨科关节手术患者524例,按照是否发生医院感染分为感染组(30例)和未感染组(494例),分析医院感染患者感染病原菌分布、药敏性、炎性介质水平,对感染发生的危险因素进行单因素及多因素Logistic回归分析。结果524例患者感染30例(5.73%);30例医院感染患者分离培养病原菌52株,革兰阴性菌29株(55.77%),革兰阳性菌20株(38.46%),真菌3株(5.77%);主要革兰阳性菌对青霉素、红霉素耐药性较强,对万古霉素、替考拉宁较为敏感;主要革兰阴性菌对头孢唑林、阿奇霉素耐药性较强,对西司他丁、美罗培南较为敏感;感染患者血清超敏C-反应蛋白(hs-CRP)、降钙素原(PCT)、红细胞沉降率(ESR)、肿瘤坏死因子-ɑ(TNF-ɑ)水平高于未感染患者(P<0.05);经单因素和多因素分析发现,无指征用抗菌药物、导尿管应用、呼吸机应用是骨科关节手术后医院感染的独立危险因素(P<0.05)。结论骨科关节手术医院感染病原菌中以革兰阴性菌为主,用药前应进行药敏试验,选用合理的抗菌药物进行治疗,炎性因子水平对医院感染评估有一定价值,根据感染的相关危险因素采取措施预防感染。     

预后营养指数在结直肠肿瘤术后手术部位感染的预测作用

目的 :分析预后营养指数(prognostic nutritional index,PNI)与结直肠肿瘤术后发生手术部位感染(SSI)的联系,探讨PNI作为结直肠肿瘤病人预后指标的作用价值。方法 :回顾性收集我院普外科2013年9月至2015年12月行手术治疗的332例经病理确诊结直肠肿瘤病人的临床资料,根据术后是否发生SSI将其分为感染组和对照组,通过单因素和多因素分析评价结直肠肿瘤术后的风险因素,通过ROC曲线评价PNI在SSI的预测价值。结果 :43例病人术后出现SSI,其中浅层或深层手术部位感染36例,器官/腔隙感染7例;ROC曲线分析显示,术前PNI48对预测术后SSI的发生具有显著价值(曲线下面积=0.782,灵敏度81.1%,特异度65.8%)。多因素分析结果显示,手术时间(OR=3.42,95%CI:1.22-8.78,P=0.04)和PNI48(OR=2.35,95%CI:1.20-4.53,P=0.03)是预测术后SSI的独立危险因素。结论 :PNI作为简单并有价值的临床指标,对于结直肠肿瘤术后预测SSI的发生具有重要的意义。     

创伤性骨折围手术期下肢深静脉血栓形成的危险因素分析

目的 探究下肢创伤性骨损伤患者在围手术期下肢深静脉血栓形成(DVT)的危险因素及常见指标对深静脉血栓形成的预测价值分析,以期为临床中及时检测及预防DVT提供参照.方法 选取某医院2016年07月-2019年07月收治的因外伤性股损伤患者为研究对象,纳入的157名患者均接受手术治疗,根据围手术期是否发生DVT将患者分为观...     

Surgical site infection in patients submitted to orthopedic surgery: the NNIS risk index and risk prediction

The applicability of the risk index for surgical site infection of the National Nosocomial Infection Surveillance (NNIS) has been evaluated for its performance in different surgeries. In some procedures, it is necessary to include other variables to predict. Objective: to evaluate the applicability of the NNIS index for prediction of surgical site infection in orthopedic surgeries and to propose an alternative index. The study involved a historical cohort of 8236 patients who had been submitted to orthopaedic surgery. Statistical analysis was performed using multivariate logistic regression to fit the model. The incidence of infection was 1.41%. Prediction models were evaluated and compared to the NNIS index. The proposed model was not considered a good predictor of infection, despite moderately stratified orthopedic surgical patients in at least three of the four scores. The alternative model scored higher than the NNIS models in the prediction of infection.     

骨科手术切口感染的预防

目的 了解骨科手术患者切口感染的相关因素,加强护理管理,降低感染.方法 对医院骨科2009年1月-2010年12月收住的骨科手术住院病例进行回顾性分析.结果 926例患者共发生手术切口J感染18例,切口感染率为1.94％,462例骨科急诊手术患者中,伤口感染15例,感染率为3.25％,464例择期手术患者中,感染3例,感染率为0.65％;切口感染的原因与环境质量、手术时间、伤口污染情况、术前住院天数、医务人员的无菌观念等因素有关.结论 针对各个环节的各种因素,做好骨科手术患者术前预防和术后护理,能有效降低手术切口感染率.     

Predicting nutrition-associated complications for patients undergoing gastrointestinal surgery

We studied 202 patients admitted to two major teaching hospitals for planned gastrointestinal surgery to assess the ability of several techniques of nutritional assessment to predict major postoperative complications (infection and/or wound problems). Subjective global assessment (SGA) and albumin were both of predictive value, and combinations of these variables were useful in differentiating low-risk from high-risk patients. Transferrin, creatinine-height index, percent ideal weight, percent body fat, and total lymphocyte count were not useful in predicting complications. We conclude that SGA and albumin are useful "nutritional assessment techniques" for patients undergoing major gastrointestinal surgery if the purpose of such an assessment is to predict postoperative "nutrition-associated complications." The second major finding of this study was the unexpectedly low rate of complications (10%) which was found in both hospitals. We suggest that these low complication rates may be more generalizable to patient populations derived from a wide community base, rather than those described in other studies in which veterans or patients of lower socioeconomic status comprised the sample.     

Nutrition screening tools and the prediction of postoperative infectious and wound complications: comparison of methods in presence of risk adjustment

OBJECTIVE: We compared four nutritional screening tools, the Nutrition Risk Classification, the Mini-Nutrition Assessment-Short Form, the Malnutrition Screening Tool, and the Nutrition Risk Score in terms of their ability to predict postoperative wound and infectious complications when adjusted for the effects of other risk factors for postoperative infection. METHODS: The 8-mo study was performed on 430 patients undergoing abdominal surgery. Data on the Nutrition Risk Classification, Mini-Nutrition Assessment-Short Form, Malnutrition Screening Tool, Nutrition Risk Score, and risk factors for postoperative complications were collected for all patients. Patients were followed until 30 d after surgery. Nutritional screening tools were compared for their ability to predict postoperative complications by using the area under the receiver operating characteristic curve. Multivariable adjustment for other risk factors was done with multiple logistic regression analysis. RESULTS: The Mini-Nutrition Assessment-Short Form, Nutrition Risk Score, and Nutrition Risk Classification had the larger receiver operating characteristic areas. Only the Nutrition Risk Classification was significantly related to the occurrence of postoperative complications (odds ratio 2.92, 95% confidence interval 1.62 to 5.26) after adjusting for other risk factors of postoperative infection. The other remaining risk factors were serum albumin level and operative time. CONCLUSIONS: The Nutrition Risk Classification seems to be the best nutritional screening tool for use in predicting postoperative infectious and wound complications.     

骨科创伤患者术后多重耐药菌感染风险Nomogram模型构建与验证

 目的 探讨骨科创伤患者术后多重耐药菌(MDRO)感染的危险因素及风险列线图(Nomogram)预测模型的构建。方法 回顾性分析2019年1月—2021年1月某院重症监护病房(ICU)的458例骨科创伤住院患者的临床资料,分别使用单因素和多因素lasso logistic回归分析骨科创伤住院患者术后MDRO感染的独立危险因素。最后纳入筛选出的独立危险因素建立Nomogram预测模型,另选取2021年2—10月224例骨科创伤患者建立验证组,对建模组数据进行验证。结果 458例创伤患者为建模组,其中创伤合并MDRO感染114例,感染率24.89%;非MDRO感染组患者344例。两组患者临床资料进行lasso logistic回归分析,APACHE Ⅱ评分≥20分(OR=2.567,95%CI: 1.593~4.178)、发热日数≥3 d(OR=2.656,95%CI: 1.631~4.361)、住院日数≥10 d(OR=3.563,95%CI: 2.207~5.808)、使用抗菌药物(OR=2.314,95%CI: 1.415~3.848)、联合使用抗菌药物日数≥7 d(OR=2.114,95%CI: 1.329~3.624)是创伤患者术后MDRO感染的独立危险因素。基于回归分析结果中的5项独立危险因素,建立预测创伤术后MDRO感染的Nomogram模型,验证结果显示：Bootstrap内部验证,预测值与实测值基本一致,建模组预测曲线下面积(AUC)为0.877 8,验证组AUC为0.871 8。说明预测模型具有较好的预测能力。决策分析曲线显示该模型有较高的获益性。结论 Nomogram预测模型的建立有利于早期识别创伤患者术后MDRO感染的高危因素,及时采取防控措施,从而降低MDRO医院感染率。     

预防骨科手术患者术后感染的护理

目的：探讨预防骨科手术患者术后感染的护理要点,为临床护理提供依据。方法：对医院2012年1-12月收治的骨科手术936例患者进行目标性监测。结果：共发生无菌手术切口感染者16例,感染率为1.7%;感染部位主要分布在下肢、脊柱、上肢;骨科手术发生感染时间主要为住院3～4周内,发生率为31.3%～37.5%,发生最低为1周内,可见住院时间越长,切口感染率越高。结论：严格加强手术室管理,遵守无菌操作规程、消毒隔离制度,加强病区管理,使医院感染概率降至最低。     

The influence of nutritional status on complications after major intraabdominal surgery

OBJECTIVE: Currently most nutritional assessment techniques are based on their ability to predict clinical outcomes. However, the validity of any of these techniques to truly measure "nutritional risk" has not been proved. We have therefore prospectively assessed the prognostic value of two nutritional assessment techniques and nonnutritional factors in determining outcome after major abdominal surgery. METHODS: At admission and discharge, 100 patients undergoing major abdominal surgery were assessed on the following items: Subjective Global Assessment, Nutritional Risk Index, anthropometric measurements, serum total protein, serum albumin, lymphocyte count, total serum cholesterol. Patients were monitored for postoperative complications until death or discharge. RESULTS: At admission, 44% of the patients were malnourished according to the Subjective Global Assessment, while 61% of the patients were malnourished according to the Nutritional Risk Index. At discharge, these numbers were 67% and 82%, respectively. Higher death rates were found in the malnourished groups. The risk of complication was increased in malnourished patients with both assessment techniques. The odds ratios for the association between malnutrition and complications varied between 1.926 and 9.854 with both assessments. The presence of cancer in the patient was predictive for complication. CONCLUSIONS: Malnutrition is a marker of bad outcomes. Both Subjective Global Assessment and Nutritional Risk Index nutrition tests are predictive for malnutrition and postoperative complications in patients undergoing major abdominal surgery.     

神经胶质瘤术后预后因素的研究

目的：探讨神经胶质瘤患者术后生存规律及其影响因素，并预测患者术后生存情况。方法：以图解法拟合患者术后生存时间的概率分布型；选择符合其分布的Weibull全参数模型分析影响患者术后生存的危险因素；通过残差分析检验所得到Weibull全参数模型，并进一步应用该模型预测患者的术后生存情况。结果：Weibull全参数模型显示性别、年龄、癫痫、肿瘤类型、肿瘤密度、手术方式、手术次数和术后治疗第8个因素是影响神经胶质瘤患者术后生存期的危险因素。根据患者预测值（PV）大小将患者聚为三类：第I类患者1年生存率不足50％；第Ⅱ类患者5年累计生存率接近50％；第Ⅲ类患者5年生存率为80％左右。结论：性别、年龄、癫痫、肿瘤类型、肿瘤密度、手术方式、手术次数和术后治疗等8个因素是影响神经胶质瘤患者术后生存期的危险因素。应用Weibull模型可以预测患者术后生存情况。     

Influence of preoperative emotional state on postoperative pain following orthopedic and trauma surgery

OBJECTIVES:

to analyze the relationship between preoperative emotional state and the prevalence and intensity of postoperative pain and to explore predictors of postoperative pain.

METHOD:

observational retrospective study undertaken among 127 adult patients of orthopedic and trauma surgery. Postoperative pain was assessed with the verbal numeric scale and with five variables of emotional state: anxiety, sweating, stress, fear, and crying. The Chi-squared test, Student''s t test or ANOVA and a multivariate logistic regression analysis were used for the statistical analysis.

RESULTS:

the prevalence of immediate postoperative pain was 28%. Anxiety was the most common emotional factor (72%) and a predictive risk factor for moderate to severe postoperative pain (OR: 4.60, 95% CI 1.38 to 15.3, p<0.05, AUC: 0.72, 95% CI: 0.62 to 0.83). Age exerted a protective effect (OR 0.96, 95% CI: 0.94-0.99, p<0.01).

CONCLUSION:

preoperative anxiety and age are predictors of postoperative pain in patients undergoing orthopedic and trauma surgery.     

The postoperative bacteriuria score: a new way to predict nosocomial infection after prostate surgery.

OBJECTIVE: Urinary tract infections are the leading nosocomial urologic infections and may be a cause of added morbidity and costs, and sometimes sepsis. The aim of this study was to design a predictive score for these complications after prostate surgery. DESIGN: Multicenter prospective survey. SETTING: Eleven French urology centers. PATIENTS: All patients undergoing transurethral resection of prostate (TURP) during a 3-month period. RESULTS: The overall incidence of postoperative bacteriuria was 25.0% (95% confidence interval, 17.7%-29.5%). Almost all patients (95.7%) received antibiotic prophylaxis. A predictive postoperative bacteriuria score (POBS), with a 6-point scale of 0 to 5, was constructed on the basis of independent risk factors identified in multivariate analysis of a test sample of patients (n=135) and tested in a validation sample (n=73). Significantly more infections occurred in patients with a POBS of 2 or higher (87 [8%] vs 48 [50%]; P<.0001). With the test sample, this yielded a sensitivity of 77%, a specificity of 77%, a positive predictive value of 50%, a negative predictive value of 92%, and a global accuracy of 77%. CONCLUSIONS: POBS could be used to distinguish patients at risk of developing infection after TURP. This information might be useful for implementing selective prevention measures or for adjustment for differences in nosocomial infection rates when comparing data between urology centers.     

Extended use of urinary catheters in older surgical patients: a patient safety problem?

OBJECTIVES: To explore the relationship between the extended postoperative use of indwelling urinary catheters and outcomes for older patients who have undergone cardiac, vascular, gastrointestinal, or orthopedic surgery in skilled nursing facilities and to describe patient and hospital characteristics associated with the extended use of indwelling urinary catheters. DESIGN: Retrospective cohort study. SETTING: US acute care hospitals and skilled nursing facilities. PATIENTS: A total of 170,791 Medicare patients aged 65 years or more who were admitted to skilled nursing facilities after discharge from a hospital with a primary diagnosis code indicating major cardiac, vascular, orthopedic, or gastrointestinal surgery in 2001. MAIN OUTCOME MEASURES: Patient-specific 30-day rate of rehospitalization for urinary tract infection (UTI) and 30-day mortality rate, as well as the risk of having an indwelling urinary catheter at the time of admission to a skilled nursing facility. RESULTS: A total of 39,282 (23.0%) of the postoperative patients discharged to skilled nursing facilities had indwelling urinary catheters. After adjusting for patient characteristics, the patients with catheters had greater odds of rehospitalization for UTI and death within 30 days than patients who did not have catheters. The adjusted odds ratios (aORs) for UTI ranged from 1.34 for patients who underwent gastrointestinal surgery (P<.001) to 1.85 for patients who underwent cardiac surgery (P<.001); the aORs for death ranged from 1.25 for cardiac surgery (P=.01) to 1.48 for orthopedic surgery (P=.002) and for gastrointestinal surgery (P<.001). After controlling for patient characteristics, hospitalization in the northeastern or southern regions of the United States was associated with a lower likelihood of having an indwelling urinary catheter, compared with hospitalization in the western region (P=.002 vs P=.03). CONCLUSIONS: Extended postoperative use of indwelling urinary catheters is associated with poor outcomes for older patients. The likelihood of having an indwelling urinary catheter at the time of discharge after major surgery is strongly associated with a hospital's geographic region, which reflects a variation in practice that deserves further study.     

Wound infection rates in clean surgery: a potentially misleading risk classification.

OBJECTIVES: To evaluate the incidence of wound infection in inguinal hernioplasties, incisional hernioplasties, splenectomies, and splenectomies performed in patients with hepatosplenic schistosomiasis, and to examine the relationship of surgical wound infection to antibiotic use, patient age, length of stay in the hospital prior to surgery, and the duration of the operation. DESIGN: Retrospective surveillance study. RESULTS: One thousand five hundred forty-two clean operations were analyzed. Comparing response (wound infection) and explanatory variables (age, length of hospital stay, duration of surgery, antibiotics, and surgery type), we found that age, use of antibiotics, and type of surgery were statistically significant, while length of hospital stay and duration of surgery were not significant. CONCLUSIONS: From these results, we can predict that the probability of wound infection in surgical patients considering these significant variables is lower for patients ages 14 to 30 years and higher for patients ages 31 to 60 years and lower for patients with prophylactic antibiotic use (up to 72 hours of use) and higher for patients with prolonged use (more than 72 hours); and lower for patients undergoing inguinal heria, followed in ascending order by nonschistosomotic patients undergoing splenectomy in schistosomotic patients.     

A prospective study of a new protocol for 'in situ' diagnosis of central venous catheter related bacteraemia

59 patients with suspected central venous catheter related bacteraemia (CRB), while receiving parenteral nutrition, were studied prospectively. 41 (Group 1) were managed conservatively: cultures were taken from the catheter hub lumen, skin at the catheter entry site and peripheral blood; the catheter was then heparinised and locked for 24-48 h. The catheter was withdrawn only if cultures were positive; otherwise parenteral nutrition was resumed. In 18 patients the catheter was immediately withdrawn (Group 2) and the same cultures plus tip culture were performed. 13 patients of Group 1 with positive hub or skin cultures, had their catheters removed and 12 had blood cultures matching for the same micro-organism. Negative skin and hub cultures had a negative predictive value for CRB of 96%. A positive hub culture had a 100% positive predictive value for CRB. CRB was diagnosed in 11 patients out of the 18 in whom catheters were withdrawn immediately (Group 2). Thus, 1 out of 41 catheters and 7 out of 18 catheters were removed unnecessarily in Groups 1 and 2 respectively (p = 0.001, Fisher's test). In all, 24 CRBs were documented and 15 were due to coagulase negative staphylococci. The catheter hub was the commonest origin of CRB followed by the infusate and the skin. In febrile patients on parenteral nutrition, negative skin and hub cultures accurately predict or rule out CRB and should be used more often to avoid withdrawal of sterile catheters.     

Effect of optimized antibiotic prophylaxis on the incidence of surgical site infection.

OBJECTIVE: To compare the rate of surgical site infection (SSI) before and after an intervention period in which an optimized policy for antibiotic prophylaxis was implemented. To demonstrate that a more prudent, restrictive policy would not have a detrimental effect on patient outcomes. DESIGN: Before-after trial with prospective SSI surveillance in the Dutch nosocomial surveillance network (Preventie Ziekenhuisinfecties door Surveillance [PREZIES]), using the criteria of the Centers for Disease Control, including postdischarge surveillance for up to 1 year. METHODS: During a preintervention period and a postintervention period (both 6-13 months), 12 Dutch hospitals collected data on antimicrobial prophylaxis and SSI rates. The study was limited to commonly performed surgical procedures in 4 specialties: vascular, intestinal, gynecological and orthopedic surgery. Selected risk factors for analysis were sex, age, American Society of Anesthesiologists classification, wound contamination class, duration of surgery, length of hospital stay before surgery, and urgency of surgery (elective or acute). RESULTS: A total of 3,621 procedures were included in the study, of which 1,668 were performed before the intervention and 1,953 after. The overall SSI rate decreased from 5.4% to 4.5% (P=.22). Among the procedures included in the study, the largest proportion (55%) were total hip arthroplasty, and the smallest proportion (2%) were replacement of the head of the femur. SSI rates varied from 0% for vaginal hysterectomy to 21.1% for femoropopliteal or femorotibial bypass surgery. Crude and adjusted odds ratios showed that there were no significant changes in procedure-specific SSI rates after the intervention (P>.1). CONCLUSIONS: An optimized and restrictive antibiotic prophylaxis policy had no detrimental effect on the outcome of clean and clean contaminated surgery, as measured by SSI rate.     

心胸外科清洁手术预防性使用抗菌药物的调查

目的 了解某三级甲等医院心胸外科清洁手术预防性使用抗菌药物情况,判断其合理性.方法 对医院2010年1-12月心胸外科清洁手术共106例进行前瞻性的调查,设计统一的表格,逐项填写并录入电脑后进行统计.结果 106例手术患者中,共8例患者发生感染,感染率为7.55％；预防性抗菌药物使用率为100.00％,抗菌药物应用前5位的为:头孢米诺、头孢哌酮/舒巴坦、头孢哌酮/他唑巴坦、头孢克罗、头孢唑林；术前预防性抗菌药物使用给药时间均＞2 h,术中用药占60.8％,术后预防性抗菌药物使用疗程1～39 d,有97.96％病例术后停药时间＞72 h.结论 该院心胸外科清洁手术术前预防性抗菌药物使用给药时间不合理；疗程明显过长；抗菌药物选择档次偏高；应进一步加强抗菌药物的使用管理,以期达到规范化使用.