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surgical site infection

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Limb surgery requires a bloodless field; blood needs to be shifted from the limb (exsanguination) and an arterial block created by using a pneumatic tourniquet. However, this procedure is not without complications; incomplete exsanguination can lead to pulmonary or cerebral emboli and ineffective cleansing of contaminated equipment can lead to surgical site infection (SSI).

Emboli
Pneumatic tourniquets are thought to cause emboli in two ways1:

  • the increase in compartment pressure as the tourniquet is inflated may dislodge a pre-existing thrombosis
  • venous stasis results in local thrombosis which move after deflation of the tourniquet

Zhang et al2 undertook a meta-analysis of 13 randomised controlled trials in order to demonstrate the effects of a tourniquet in total knee arthroplasty (TKA). The studies were divided into 2 groups; the tourniquet group (351 knees) and the non-tourniquet group (338 knees). Results showed that the use of a tourniquet increased the risk of thrombotic events (risk ratio (RR), 5.00; 95% CI, 1.31 to 19.10; P = 0.02).

Gavriely’s3 literature review of haemodynamic events around limb exsanguination, tourniquet placement and release during TKA showed; only 70% of the limb’s blood was exsanguinated; that blood remaining inside the vessels of an occluded limb coagulates; that echogenic material, consisting of fresh thrombi, was present in all patients approximately 30 seconds after tourniquet release.

Infection
Despite a plethora of evidence, non-sterile surgical tourniquets and exsanguinators continue to be used. In practice, the tourniquet is usually placed away from the incision site – for example, on the thigh for foot surgery – and covered by a sterile drape which creates a bacterial barrier when intact. However, Blom et al4 suggest that organisms such as Staphylococcus epidermidis and Streptococcus sanguis can strike-through dry polyester/cotton drapes within 30 minutes, less if the drapes are soaked with normal saline or blood. Potentially, organisms can contaminate the tourniquet.

Several studies have demonstrated bacterial growth on tourniquets even after disinfection. Brennan et al5 (2009) assessed tourniquets and exsanguinators for the presence of bacterial pathogens in 3 orthopaedic hospitals after usual decontamination, which included alcohol-free wipes, 70% isopropyl alcohol-based wipe and Hydrex Surgical Scrub (with tap water and unsterile paper towels). The devices were dried for 15 minutes – exsanguinator inner and outer surfaces were exposed to air approximately every 7 min and then the 4 locations were re-swabbed prior to decontamination. No colony forming units were following decontamination with the non-alcohol based wipes, 1 swab (1/28) produced a positive culture following decontamination with alcohol-based wipes, and 8 of 28 swabs were positive following decontamination with soap and water.
In Thompson et al’s study6 of elective orthopaedic lower limb surgery, patients were randomised prospectively to a non-sterile pneumatic tourniquet or sterile elastic exsanguination tourniquet group. Samples were taken from the ties of the non-sterile tourniquet prior to surgery and from the sterile exsanguination tourniquets at the end of the opera¬tion in a sterile fashion. Results showed that of the 34 non-sterile tourniquets sampled prior to surgical application, twenty-three (68%) were contami¬nated with organisms including coagulase-negative Staphylococcus spp, Staphylococcus aureus, Sphin-gomonas paucimobilis, Bacillus spp, and coliforms. In the 36 sterile exsanguination tourniquets used, no contamination was seen.

Gottlieb et al7 collected, incubated and sub-cultured 100 reusable tourniquets from a Sydney teaching hospital. Tourniquet colonisation rate was 78%, including non-multi-resistant Gram- positives, Enterococcus species and MRSA amongst those found.

Gavriely and Murdoch’s8 position paper included a review of the literature pertaining to contamination of non-sterile reusable pneumatic tourniquet cuffs, which showed that of the studies included, nearly all non-sterile tourniquets were contaminated with pathogens. Another study of the use of tourniquets in total knee arthroscopy9 demonstrated that when a non-sterile pneumatic tourniquet was replaced by a sterile elastic exsanguination tourniquet:

  • the incidence of surgical site infection reduced from 1.3% to 0.4% (p=0.11)
  • the incidence of deep infection was lower in the study group (sterile tourniquet) (0.78%, n=2 vs 2.6%, n=6, p=0.111)
  • the incidence of superficial infection was also lower in the study group (0.96%, n=5 vs 4.85%, n=11, p=0.076)

The Solution
A novel product, the HemaClear® sterile, single use only surgical tourniquet has been shown to both reduce the incidence of tourniquet-associated deep vein thrombosis and the incidence of contamination. It is comprised of a silicon ring wrapped in a stockinet sleeve with pull straps and is available in limb circumferences ranging from 14cm – 90cm and a maximum systolic blood pressure under 190mmHg. The size required is determined after measuring the limb circumference at the required occlusion site. After surgical sterile draping, the ring is simply placed on the patient’s fingers or toes and the straps proximally pulled, displacing over 95% of blood from the limb10. The stockinet sleeve unrolls onto the limb at the same time. The ring acts as the tourniquet, exerting supra-systolic pressure on the limb and blocking arterial blood flow. This process takes less than 12 seconds.

The main practical advantages of this device are:

  • Superior exsanguination: The rolling action of the occlusive silicone ring forces 95% of the standing blood out of the surgical field; Esmarch bandages only clear up to 70%
  • Creates a sterile field: This sterile, single use tourniquet reduces post-operative infection rates as it eliminates the need for reusable cuffs, which have been shown to be contaminated
  • Increases the surgical field: The 1” wide, narrow profile enables a wider and sterile field
  • Simple and cost- effective: Easy application reduces preparation time and eliminates the need for tourniquet machines, contaminated reusable cuffs and Esmarch bandages
  • Produces axial and radial pressure gradients that result in less force on inner tissue than traditional wide-cuff products

In addition, because of the superior level of exsanguinations, ischaemic by-products stay in the tissue and do not accumulate in the blood. Therefore, when the ring is cut and new blood enters the leg, the ischaemia products are gradually washed, rather than causing sudden flooding of the central circulation and the heart, which can contribute to emboli.

Conclusion
Surgical site infection and post-limb surgery embolus are unwanted. The traditional methods of exsanguinations and arterial block has been shown to be a source of infection and largely ineffective in exsanguination, leading to emboli.

The HemaClear is single-use, easy to use and provides more effective exsanguinations, thereby eliminating side-effects.

 

For ordering information about the HemaClear – All-in-One Exsanguination Device contact Pentland Medical Ltd.

If you would like to comment on any of the issues raised by this article, particularly from your own experience or insight, Healthcare-Arena would welcome your views.

 

References

  1. Desai S, Prashantha PG, Torgal SV, Rao R. Fatal pulmonary embolism subsequent to the use of Esmarch bandage and tourniquet: A case report and review of literature. Saudi J Anaesth. 2013 Jul-Sep;7(3): 331–335
  2. Zhang W, Ning Li N, Chen S, Tan Y. The effects of a tourniquet used in total knee arthroplasty: a meta-analysis. J Orthop Surg Res. 2014; 9:13
  3. Gavriely N. Incomplete Leg Exsanguination: A Hemodynamic Cause of Post Total Knee Arthroplasty (TKA) Cognitive Deficit (CD). The Bone and Joint Journal. Volume 95-B, Issue SUPP 15 / March 2013
  4. Blom AW, Gozzard C, Heal J, Bowker K, Estela CM. Bacterial strike-through of re-usable surgical drapes: the effect of different wetting agents. J Hosp Infection 2002; 52: 52–5
  5. Brennan SA, Walls RJ, Smyth E, et al. Tourniquets and exsanguinators: a potential source of infection in the orthopedic operating theatre? Acta Orthop. 2009 Apr 29; 80(2): 251–255
  6. Thompson SM, Middleton M, Forrok M, et al. The effect of sterile versus non-sterile tourniquets on microbiological colonisation in lower limb surgery. 2011. Ann R Coll Surg Engl. 93: 589–590
  7. Gottlieb T, Phan T, Cheong EYL, Sala G. Reusable tourniquets. An underestimated means for patient transfer of multi-resistant bacteria. BMC Proc. 2011; 5(Suppl 6): P38
  8. Gavriely N, Murdoch L. The Use of Non-Sterile Pneumatic Tourniquets in Limb Operations: A Position Paper. Data on file.
  9. Demirkale I, Tecimel O, Hakkan S, et al. Nondrainage Decreases Blood Transfusion Need and Infection Rate in Bilateral Total Knee Arthroplasty. Arthroplasty. 2014. 29(5):993–997
  10. Bourquelot P, Levy BI. Narrow elastic disposable tourniquet (Hemaclear®) vs. traditional wide pneumatic tourniquet for creation or revision of hemodialysis angioaccesses. J Vasc Access. 2016 May 7;17(3):205-9

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Image: ©Rocter/iStock #10848284

Physicians and healers have been sucking poisons and toxins (for example, snake bite venom) from wounds for about 2,500 years [1]. Cupping, a procedure thought to stimulate blood flow, has also been used for many centuries. In effect therefore, negative pressure wound therapy (NPWT), also known as topical negative pressure (TNP) and vacuum assisted closure (VAC), is not new. The first mention of a ‘vacuum’ wound treatment appeared in the Russian literature in the 1980’s [1]. Further developments finally led to the Vacuum Assisted Closure (VAC™) [2], the forerunner of most modern systems.

The mode of action in open wounds
A closed drainage system applies controlled suction (negative pressure) to the wound bed. The wound bed is covered firstly with a wound contact layer (WCL), then a wound filler. As the pre-determined negative pressure is applied, the filler compresses into the surface of the wound, reducing microvascular blood flow at the wound bed and contraction at the wound margins (macro-deformation). Negative pressure is often applied at -125mmHg, although pressure may be tailored to the patient’s risk of ischaemia and pain tolerance [3].

Fillers include open-pore polyurethane foam or saline-moistened gauze – the choice depends upon the wound, the system used, and patient preference. Gauze is more conformable (good for large and/or irregular wounds) [4], is thought to minimise scarring [4]. and produces thinner, dense granulation tissue [5]. Foam filler produces thick, hypertrophic granulation tissue (Borgquist et al, 2009), and if used without a WCL, can facilitate in-growth of granulation tissue, causing pain and/or bleeding upon removal, disruption of the wound bed tissue, and potentially acting as a focus for infection [5].

Effectiveness of NPWT
There is a plethora of studies indicating the clinical effectiveness and financial/patient benefits of NPWT in both dehisced wounds (abdomen, sternum) and chronic wounds such as pressure ulcers and leg ulcers. These include meta-analyses [6], systematic reviews [7], literature critiques [8] and evidence based recommendations [9].

Benefits include:

  • Rapid wound healing [10], through exudate management, reduction of oedema [11], and direct stimulation of granulation tissue [12]
  • Fewer dressing changes, therefore less clinician time required [13], leading to reduced wound management costs and length of stay [14]
  • Improvement in patient quality of life (QoL) [15]

Incisional NPWT (iNPWT)
Single-use products for reducing closed incision complications in high risk patients have been developed over the past decade. This has been in response to the increasing incidence and cost of treating incisional complications (SSCs) such as surgical site infection (SSI) and dehiscence, which increase length of stay and costs, may require repeat surgeries, and poor patient outcomes, particularly as infection can present several days post-discharge and can affect long-term survival [16]. Tanner et al’s study [17] identified a higher SSI percentage that that reported in the literature (27% incidence, vs. 19.4%), most of which manifested post-discharge. SCC’s present a large financial burden and may devastate (or even kill) the patient, so along with assessing risk factors, prevention strategies must be considered.

Incisional NPWT is emerging as a possible prophylactic measure against SSCs. Studies both published and currently being undertaken demonstrate decreased SSI, wound dehiscence and better scar quality in:

  • Breast surgery [18]
  • Cardiothoracic surgery [19]
  • Trauma [20,21]
  • Orthopaedic surgery [22]
  • Abdominal surgery [7, 23]
  • Diabetic foot wounds [24]

On-going iNPWT studies have also been presented at a recent expert meeting [25].

The cost-effectiveness of iNPWT has been demonstrated [8]. In an earlier study, Stannard et al [26] estimated that the application of INPWT costs less than $500 for the mean 2.5 days of therapy, making it a cost-effective intervention due to shortened hospital stay and prevention of postoperative surgical site infection.

To date, many of the studies have centred on patients with high risk factors for SSC – those who are obese, use steroids, have had previous radiation exposure (or awaiting radiotherapy), or who smoke. Other risk factors include the actual procedure and use of implants. Further studies are needed to explore any clinical and/or cost benefits in low-risk patients undergoing high-risk procedures.

iNPWT mode of action
How exactly iNPWT works is not entirely clear; Stannard et al [21] suggests that the reduction in haematoma and seroma, accelerated wound healing, increased removal of oedema and splinting of the incisional area, appear contribute to its effectiveness, but further studies are required to ascertain the exact mechanisms of action.

Conclusion

While further studies are required to determine iNPWTs exact mechanism of action, early indications are that it is a useful prophylactic tool for the prevention of surgical site complications.

If you would like to comment on any of the issues raised by this article, particularly from your own experience or insight, Healthcare-Arena would welcome your views.

References

  1. Kubek EW, Badeau A, Materazzi S, et al. Negative-pressure wound therapy and the emerging role of incisional negative pressure wound therapy as prophylaxis against surgical site infections. In: Microbial pathogens and strategies for combating them; science, technology and education. 2013. (Mendez-Villas A, (Ed.). Formatex Research Center. Available at: http://www.formatex.info/microbiology4/vol3/1833-1846.pdf Accessed July 2015
  2. Argenta LC, Morykwas MJ. Vacuum-assisted closure: a new method for wound control and treatment: clinical experience. Annals of Plastic Surgery. 1997. 38:563-576
  3. Malmsjö M, Borgquist O. NPWT Settings and Dressing Choices Made Easy. Wounds International. 2010. 1; 3. Available at: http://www.woundsinternational.com/other-resources/view/npwt-settings-and-dressing-choices-made-easy Accessed July 2015
  4. Jeffrey S. Advanced wound therapies in the management of severe military lower limb trauma: a new perspective. Eplasty. 2009. 9:e28. Available at: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2714221/ Accessed July 2015
  5. Borgquist O, Gustafsson L, Ingemansson R, et al. Tissue ingrowth into foam but not into gauze during negative pressure wound therapy. Wounds. 2009. 21; 11:302-9. http://www.woundsresearch.com/images/Borgquist_NEW-Nov09.pdf (to access pdf) Accessed July 2015
  6. Zhang J, Hu ZC, Chen D, et al.) Effectiveness and safety of negative-pressure wound therapy for diabetic foot ulcers: a meta-analysis. Plast Reconstr Surg. 2014. 134; 1:141-51. Available at: http://www.ncbi.nlm.nih.gov/m/pubmed/24622569/ Accessed July 2015
  7. Bruhin A, Ferreira F, Charika M et al. Systematic review and evidence based recommendations for the use of Negative Pressure Wound Therapy in the open abdomen Int J Surg. 2014. 12; 10:1105-14. Available at: http://www.journal-surgery.net/article/S1743-9191%2814%2900881-4/abstract Accessed July 2015
  8. Stannard JP, Gabriel A, Lehner B. Use of negative pressure wound therapy over clean, closed surgical incisions. Int Wound J. 2012b 9(Suppl. 1): 32–39 Available at: http://onlinelibrary.wiley.com/doi/10.1111/j.1742-481X.2012.01017.x/pdf Accessed July 2015
  9. National Institute for Health and Care Excellence (NICE) Negative pressure wound therapy for the open abdomen. NICE Interventional Procedure Guidance [IPG467]. 2014. Available at: www.nice.org.uk/guidance/ipg467 Accessed July 2015
  10. Armstrong DG, Lavery LA. Diabetic foot study consortium. Negative pressure wound therapy after partial diabetic foot amputation: a multicentre, randomised controlled trial. The Lancet. 2005. 366; 9498: 1704–1710. Available at:
  11. Diabetic Foot Study Consortium. Negative pressure wound therapy after partial diabetic foot amputation: a multi-centre randomized controlled trial. http://www.researchgate.net/publication/7477570_Diabetic_Foot_Study_Consortium.Negative_pressure_wound_therapy_after_partial_diabetic_foot_amputation_a_multicntre_randomized_controlled_trial Accessed July 2015
  12. Webb LX New techniques in wound management: vacuum-assisted wound closure. J Am Acad Orthop Surg. 2002. 10:303-311
  13. Mouës CM, van den Bemd GJ, Meerding WJ, et al. An economic evaluation of the use of TNP on full-thickness wounds. J Wound Care. 2005. 14; 5:224–227
  14. Searle R, Milne J Tools to compare the cost of NPWT with advanced wound care: an aid to clinical decision-making. Wounds UK. 2010. 6; 1:106–109
  15. Ousey KJ, Milne J, Cook L, et al A pilot study exploring quality of life experienced by patients undergoing negative-pressure wound therapy as part of their wound care treatment compared to patients receiving standard wound care. Int Wound J. 2014. 11; 4:357-6. Available at: http://eprints.hud.ac.uk/15024/1/IWJ_QoL_NPWT_repository%5B1%5D.pdf Accessed July 2015
  16. Artinyan A, Orcutt ST, Anaya DA, Richardson P, et al. Infectious post-operative complications decrease long-term survival in patients undergoing curative surgery for colorectal cancer. Ann Surg. 2015. 261; 3:497-505
  17. Tanner J, Padley W, Kiernan M, Leaper D, et al., A benchmark too far: findings from a national survey of surgical site infection surveillance. Journal of Hospital Infection 2013. 83; (2): 87-01.
  18. Holt R, Murphy JA. PICO™ incision closure in oncoplastic breast surgery: a case series. Jour Hosp Med. 2015. 76; 4:217-23
  19. Grauhan O, Navasardyan A, Tutkun B, Hennig F, et al. Effect of surgical incision management on wound infections in a poststernotomy patient population. International Wound Journal. 2014. 11: 6–9. To access pdf go to: http://www.researchgate.net/publication/262609088_Effect_of_surgical_incision_management_on_wound_infections_in_a_poststernotomy_patient_population Accessed July 2015
  20. Krug E, Berg L, Lee C, Hudson D, et al..,Evidence-based recommendations for negative pressure wound therapy in traumatic wounds and reconstructive surgery: Steps towards an international consensus. Injury. 2011 42; s1 – s12.
  21. Stannard J, Volgas DA, McGwin G 3rd, Stewart RL et al., Incisional NPWT After High Risk Lower Extremity Fractures; J Orthop Trauma. 2012a. 26: 37-42 13
  22. Karlakki S, Brem M, Giannini S, Khanduja V, et al., (2013). Negative pressure wound therapy for management of the surgical incision in orthopaedic surgery: A review of evidence and mechanisms for an emerging indication. Bone & Joint Research. 2; 12:276–84. Available at: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3884878/ Accessed July 2015
  23. Fry DE. The Prevention of Surgical Site Infection in Elective Colon Surgery. Review Article. Scientifica. 2013. Available at: http://dx.doi.org/10.1155/2013/896297. Accessed July 2015
  24. Faroqui L, Mills JL, Rogers LC, et al. Use of an Incision-Line Negative Pressure Wound Therapy Technique to Protect High-Risk Diabetic Foot Wounds, Postoperatively. The Journal of Diabetic Foot Complications. 2013. Issue 5, 2; 3:44-47. Available at: http://jdfc.org/2013/volume-5-issue-2/use-of-an-incision-line-negative-pressure-wound-therapy-technique-to-protect-high-risk-diabetic-foot-wounds-postoperatively/ Accessed July 2015
  25. Smith & Nephew. 6th International NPWT Expert Meeting. Highlights. Berlin, 2015. Available at: http://www.smith-nephew.com/documents/education%20and%20evidence/videos/2015/npwt%20experts%202015/npwt%20expert%20panel%202015%20-%20highlights%20booklet.pdf. Accessed July 2015
  26. Stannard JP, Robinson JT, Anderson ER, et al. Negative pressure wound therapy to treat hematomas and surgical incisions following high-energy trauma. J Trauma. 2006. 60; 6:1301–6

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