Treatment of surgical site infection and hypertrophic scars

For the treatment of surgical site infection (SSI), removal of foreign body materials and débridement of infected/necrotized tissues should be performed after careful imaging diagnosis. Then, wound irrigation should be performed everyday. For critically colonized wounds, iodine preparations are useful. If healthy granulation tissues start to grow, wound dressing with the basic fibroblast growth factor (bFGF) spray and/or prostaglandin E? (PGE?) ointment should be recommended. Poor increase in granulation tissues, is a good indication for vacuum assisted closure (VAC) therapy. In Japan, the V.A.C. system is the only device for negative pressure wound therapy (NPWT) that is covered by the health insurance scheme. If entire wounds are covered by healthy granulation, chest wall reconstruction using skin graft or flap can be considered. For the treatment of hypertrophic scars (HSs), multimodal therapies should be performed. Tranilast and/or Saireito are widely used as internal agents in Japan. Corticosteroid ointments/creams/tapes/ injections are useful to decrease chronic inflammation in HSs. Moreover, wound stabilization, compression and keeping the affected area moist are effective to decrease subjective symptoms including itch and pain. Surgery, radiation therapy, pulsed dye laser, neodymium yttrium aluminum garnet(Nd:YAG) laser, make-up therapy such as rehabilitation make-up should be selected on a case-by-case basis.     

Topical modalities for treatment and prevention of postsurgical hypertrophic scars

There is no universally accepted treatment regimen and no evidence-based literature to guide management of hypertrophic scars. This article summarizes the existing literature regarding topical treatments such as silicone gel sheeting and ointment, onion extract, vitamin E, pressure garment therapy, massage therapy, and topical imiquimod 5% cream in the management of hypertrophic scars.     

脊柱手术部位感染的危险因素及预防措施研究进展

随着医疗技术的不断发展,人们对生活质量要求的提高,越来越多的脊柱疾病可以通过外科手术治疗,同时手术所带来的并发症也不容忽视。手术部位感染（surgical site infection,SSI）是脊柱术后常见的并发症之一,它是指无置入物手术30d内、有内置物（如椎弓根螺钉、椎体间融合器、人工椎间盘等）手术后1年内发生的与手术相关感染,包括浅表切口感染、深部切口感染以及器官/组织间隙感染。脊柱术后感染的危险因素很多,包括年龄、美国麻醉医师协会评分（ASA score）、肥胖、糖尿病、吸烟,此外手术入路、内置物、骨移植、手术时间及输血都被认为是SSI的危险因素。脊柱术后SSI发生率在0.7%～12%之间,近些年发病率呈增高趋势,延长了治疗时间,增加了治疗费用,甚至增加了死亡率[1],预防脊柱手术感染,确保医疗安全意义重大。笔者对脊柱手术部位感染的危险因素及预防措施综述如下。     

脊柱围手术期手术部位感染的诊断及预防研究进展

脊柱术后切口部位感染可导致严重的并发症,如内固定失败、骨髓炎、假关节形成、椎间盘炎、瘫痪、败血症甚至死亡。早期诊断和积极采取预防措施对降低脊柱术后感染具有重要意义。近年来,新技术如血清淀粉样-A、氟-18-氟代脱氧葡萄糖PET/CT等不断涌现并逐渐应用于脊柱术后感染诊断,提高了诊断能力。同时,越来越多的文献报道各种预防措施应用于降低术后感染率,包括术前皮肤去定植、预防性使用抗生素、脉冲冲洗、局部应用抗生素、切口负压疗法等。本文针对脊柱手术部位感染的早期诊断及预防措施进行综述。     

手术部位感染预防指南更新的解读

美国疾控中心正式发布手术部位感染的预防指南已有10余年．而去年根据大量研究结果再次发布手术部位感染预防更新,主要针对减少污染、减少污染的影响、改善机体防御机能等方面进行阐述。本文对此更新作一解读,以利于外科医生改进临床实践,进一步减少手术部位感染。     

Implementing 1-dose antibiotic prophylaxis for prevention of surgical site infection

HYPOTHESIS: Replacing a 24-hour regimen with a 1-dose antibiotic prophylaxis for elective surgery would not increase rates of surgical site infection and would decrease costs. DESIGN AND SETTING: Before-after trial in a tertiary, private general hospital in Ribeir?o Preto, S?o Paulo, Brazil. PATIENTS: Surgery was performed on 6140 consecutive patients from February 2002 through October 2002 (period 1) and 6159 consecutive patients from December 2002 through August 2003 (period 2). Studied surgeries included orthopedic, gastrointestinal, urology, vascular, lung, head and neck, heart, gynecologic, oncology, colon, neurologic, and pediatric surgeries. The study excluded patients with infection at the time of surgery. INTERVENTION: Decreasing the 24-hour prophylactic antibiotic regimen to 1-dose antibiotic prophylaxis. MAIN OUTCOME MEASURES: Surgical site infections in both periods measured by in-hospital surveillance and postdischarge surveillance; compliance with 1-dose prophylaxis; and costs with cephazolin. RESULTS: We followed up 12,299 patients during their hospital stay; postdischarge surveillance increased significantly from 2717 patients (44%) to 3066 patients (50%, P<.001). One-dose prophylaxis was correctly followed in 6123 patients (99% compliance).The rate of surgical site infection did not change in either period (2% and 2.1% respectively, P = .67). The number of cephazolin vials purchased monthly decreased from 1259 to 467 with a corresponding monthly savings of $1980. CONCLUSIONS: One-dose antibiotic prophylaxis did not lead to an increase in rates of surgical site infection and brought a monthly savings of $1980 considering cephazolin alone. High compliance to 1-dose prophylaxis was achieved through an educational intervention encouraged by the hospital director and administrative measures that reduced access to extra doses.     

Elastic tissue and hypertrophic scars

Because of the temporary lack of elastic fibres in scars, a histological investigation of the elastic fibres within the granulation tissue was carried out. The correlation between the type of scar developed and the presence of elastic tissue was studied in 342 granulation tissue biopsies of burned children.In the histological sections, elastic-like fibres, most of them fragmented with a degenerative appearance and a frequent giant-cell reaction, were seen at random, particularly in the patients that later developed hypertrophic scars.This response could contribute to the persistency of the chronic inflammatory process usually present in immature hypertrophic scars. On the other hand, the immunological response elicited by the injured elastic fibres could also be interfering with the normal pathway of the biosynthesis of the elastin, resulting in a failure of elastogenesis.     

Meta-analysis of preoperative antiseptic bathing in the prevention of surgical site infection

BACKGROUND: Preoperative bathing with an antiseptic solution is widely used to prevent surgical site infection, but trial results are conflicting. METHODS: Trials were identified by searches of Medline, Embase and the Cochrane controlled trials register. Studies were eligible if they compared an antiseptic solution used in preoperative bathing with a non-antiseptic washing agent or with no bathing and if they reported data on surgical site infection. RESULTS: Six trials with a total of 10 007 patients were included; all of them used 4 per cent chlorhexidine gluconate. Three trials with 7691 patients compared chlorhexidine with placebo. Bathing with chlorhexidine did not reduce surgical site infection rate; the relative risk (RR) was 0.91. Including only trials of high quality, the RR was 0.95. Three trials with 1443 patients compared bar soap with chlorhexidine; no differences in the surgical site infection rates were detected, and the RR was 1.02. Two trials of 1092 patients compared bathing with chlorhexidine with no washing. The surgical site wound infection rate in the two groups was similar, and the RR was 0.70. CONCLUSIONS: The evidence does not support preoperative bathing with chlorhexidine as a means of reducing surgical site wound infection.     

术前消毒剂洗浴对手术切口感染预防作用的Meta分析

手术切口感染在院内感染中位列第三,常规的预防措施是术前应用皮肤消毒剂进行全身洗浴或淋浴.常用消毒剂之4%洗必泰(Chlorhexidine)或三氯生(Triclosan),能够达到消毒的效果.此外,连续数天使用皮肤消毒剂不但能减少细菌数量而且可以减少细菌的繁殖.虽然,以上证据证实了皮肤清洁剂的抗菌效果,但术前消毒剂洗浴是否能够降低手术切口的感染率呢?……     

Wide spread scars, hypertrophic scars, and keloids

Patients with a wide scar may complain of having a "keloid," yet have a hypertrophic or a wide spread scar. The plastic surgeon should make the appropriate clinical diagnosis, because therapy varies depending on the condition present. A wide spread scar is best treated with excision and closure. A buried dermal flap may help to prevent recurrence, which is nevertheless likely to some degree. A hypertrophic scar can be distinguished from a keloid on clinical grounds. Although both may be red, nodular, and itchy, the keloid overgrows the original wound boundary and is much more likely to recur after surgical excision. Nonsurgical treatment of hypertrophic scars and keloids is similar, using repeated intralesional injections of Kenalog 40 mg per cc and sustained pressure on the lesion when possible. Surgical treatment differs for hypertrophic scars or keloids. Scar excision and closure, and selective Z-plasty, may be used in hypertrophic scars. In keloids, aggressive surgery is usually avoided, unless the lesion has a narrow pedicle. Surgery of keloids should be accompanied by intra- and postoperative Kenalog-40 injections, and on occasion by sustained pressure. Very large keloids may be resistant to medical management, and too aggressive for surgery owing to a high likelihood of recurrence. These difficult lesions serve as the impetus for continued biochemical and tissue culture research, seeking a biochemical means of control keloids.     

根本原因分析法在控制骨科手术部位感染中的应用

【摘要】〓目的〓分析骨科手术部位感染危险因素,采取有效措施降低手术部位感染率。方法 采用根本原因分析方法对骨科手术部位感染相关危险因素进行分析,并采取相关措施,对比处理前后的干预效果。结果〓调查阶段共进行骨科手术578例,发生手术部位感染13例,感染率2.2%。干预阶段共进行骨科手术375例,发生手术部位感染2例,感染率0.5%。结论〓应用根本原因分析法干预可有效降低骨科手术部位感染的发生。     

神经外科患儿手术部位感染预防的循证实践

目的 降低神经外科患儿手术部位感染发生率.方法 遵循JBI循证护理中心应用模式,应用循证方法获取最佳证据,制订11条审查标准,以基于证据的持续质量改进模式为理论框架,于2020年11月至2021年4月,按照基线审查、实践变革和证据应用后变革效果的再审查将循证实践应用于神经外科手术患儿,比较循证实践前后医护人员证据应用的依从性和患儿手术部位感染率等.结果 循证实践后,除第6和8条审查指标执行效果不理想外,其余待改进条目中医护人员预防手术部位感染证据应用的依从性均有提高,差异有统计学意义(P＜0.01),临床护理流程更加规范化,患儿手术部位感染率和平均住院天数显著降低(均P＜0.05).医护人员和患儿照护者预防手术部位感染知识知晓程度也有显著提高(均P＜0.01).结论 通过循证实践的持续改进对神经外科手术患儿进行管理,可有效规范围术期医护人员诊疗护理行为,降低手术部位感染率,缩短住院时间,后期仍需持续质量监控及审查.     

Antibiotics in the prevention of the surgical site infection in orthopedic surgery

Surgical site infection is an actual problem of orthopaedic surgery. Despite considerable efforts that have been done during last several decades (e.g. improvements in surgical techniques, preoperative preparation of the surgical site, infection-control practice, use of preventive antibiotics) surgical site infection still affects about 0.5-2% of patients after closed fracture surgery or insertion of prosthetic devices. They are associated with substantial morbidity and mortality. The adherence to the principles of rationale preventive antibiotic therapy has an important role in the prevention of the surgical infection. In addition, it is well known that inappropriate use of antibiotic promote development of resistance, superinfections and increase the cost of the treatment. This paper focuses on the basic principles of rational use of antibiotics, i.e. appropriate selection of drug, dose, and duration of treatment in the prevention of surgical site infections in orthopaedic surgery.