A United States Army Medical Department continuing
education program.
Postoperative wound infection with J.
Wesley alexander,
MD.
Associate professor of Surgery,
University of Cincinnati.
I think that most of you working in the area
of dialysis and transplantation are already well
aware that infection is the biggest cause of
death in these patients.
It accounts for about 75% of deaths in renal
transplants and fully
60% of renal transplants developed
some kind of infection during their post operative
period at least.
That's true in our series and the reported
series that I have been able to see
the incidence of wound infection is
certainly one of the most preventable kinds
and it occurs in a
incidents of between 1%
and about 75%.
Depending upon the exact kind of one we're talking about
for a primary transplant wound.
The incident should be fairly low
Reported between .5 and
five And of a reopened
wound is up to about 20%.
But if one reopens the wound for hematoma
during the first two weeks after transplant
and the majority of these actually become infected
and I think relates to the fact that the sutures are still in
place.
The patient has a a large amount
of de vitalized tissue being
blood and plots within the wound
and and there is still
opportunity to completely sterilize the skin.
I think that anyone,
I would have to agree the general technique is
probably the best means of
preventing one infection in this area as
well as others.
In addition,
quite a number of technical aspects that need.
You mentioned one of these is the skin prep.
We routinely user
10-12 minutes prep for these.
We do not use the use of impervious
towels on the skin.
Thinking that this actually increases the number of
organisms on the skin.
We do feel it's important to use an antiseptic.
As I'm sort the one that we prefer
in most patients is tincture of iodine.
Even those individuals they do
not have any skin lesions which made
predisposed to it infection.
We feel that anyone with a predisposing skin
lesion or pimples or abscesses anywhere in the area
should not receive a renal transplant.
And because of the possibility of wound infection,
it is a disaster when it occurs.
The technical details to control of
bleeding and of lymphatic drainage
into the wounds are also important and
related to this is a question which comes up to the
use of drains in our opinion,
drainage,
free drainage to the outside should not be
established.
Ever in one of these transplant wounds,
it is a primary non infected wound,
but it is true that many of these wounds
will collect a relatively large amount of
flood.
Unfortunately,
we have the use of closed suction devices
For this and I would only mention that we have
used the move act now for this
purpose for the last 100 50 or
so transplants with no difficulties
except for one exception.
This one exception being when their
hospital supply people
decided to give us only the human of acts
with the large tubes.
And we had two consecutive serious
problems.
The only two that we've had with those large tubes.
This being retrograde infection down the track
where the exit wound of the tube occurred.
In one plotting of the tubes and the other.
These tubes tend to clot actually
more readily than the small tubes do
for reasons that aren't apparent to me,
except they are made from different materials.
The next technical consideration,
I think of importance is the
choice of situ material and transplant wounds.
Certainly we should try and pick a suitable
material which tends to mm hmm,
accentuate the development of infections to the least
degree in this type of situation.
Material must be than inert and a mono filament
nature of the available materials.
We feel that the pro lean
sutures are preferable to any other currently
available on the market for closure.
one other technical aspect is to
attack the fat with rather large suture
bites and subcutaneous tissue to the
underlying fashion so that there is no
opportunity for the development of aromas
and hematomas in the subcutaneous tissue.
There these can become secondarily infected
if hematomas and strong
do form,
it is our experience and a running suture
probably causes less problems and
potentially ation of wound infections
than interrupted sutures because there is
less opportunity to cause necrosis of
tissue at the site where the sutures are
tight and since these are running suture,
the tightness is
distributed throughout the length of the wound rather than at
focal points next to
areas which I would like to comment upon
relating to the development of wound infections and
transplant patients is the use of systemic
antibiotics.
There has been much controversy about the use of systemic
antibiotics and surgery and I think it is now fair
to say that some relatively clear guidelines
can be placed.
That is systemic antibiotics are of
value in contaminated wounds
where the probable contaminant can be
estimated,
especially if they are given before the time of
contamination are at the contaminant time of
contamination and continued for a sharp period of time
thereafter there is a large body of both
experimental and clinical data now
to indicate that this is true.
However,
in the transplant wound,
these wounds are potentially contaminated but
usually not actually.
So they are contaminated from the bladder
if they are contaminated with a known
organism.
And it's our experience.
And I think most of the experience of the most
transplant centers over the country that if there is pure
Linz in the bladder at the time of the proposed
operation,
that the operation should be canceled and that
individual treated until he has negative
cultures.
If we place in a catheter,
obtain a cloudy flood with a gram stain on that
If there are organisms,
which means there are 10 to the fifth organisms per mil.
A leader are more in that flood,
then the operation will not proceed
if there are no organisms or if the fluid
is clear,
we will instill an antibiotic solution in
our institution,
Kenny mason,
About 200 ml of a solution of
1% or 1000 micrograms per
millimeter clamp the tube so that this
stays in the bladder as an
arrogant or savage if you will,
until the time the bladder is opened for
insertion of the ureter,
there are selected instances where
it may be very difficult to
completely sterilize the bladder.
And it is our feeling in those very rare
instances that a ureter or ureter
rasta me should be employed rather than opening the
contaminated bladder.
The use of topical antibiotics.
Uh we'll go back to systemic antibiotics
then we,
if we can virtually sterilize the
inside of the bladder,
we feel then that there is no probable.
And it's been true that in clean wounds,
metra logically clean wounds.
That is where the
organisms should be in very low
numbers or cannot be predicted
that the incidents of wound infection actually
goes up with the use of systemic
antibiotics.
This is true in a number of cases such as hernias and
thyroids and I think in transplant wounds
as well.
The fact that the patient is immuno
suppressed and at an increased risk to infection
is not an indication for prophylactic
antibiotics.
And I feel they should be condemned in these patients,
not only because they're ineffective but also
because the increase in many instances the
risk of infection because of an adverse
influence on host defense mechanisms
predominantly the complement system and
of an adverse effect on the
nose.
A comal in flora and the endogenous flora
to that particular individual.
Now prophylactic systemic antibiotics
are given then can prophylactic topical
antibiotics be of use and I think the
answer is yes.
Belzer published a series not too long
ago,
which indicated about an 80%
reduction.
As I recall in a double blind
series in which prophylactic
topical antibiotics were used.
That is as an irrigation to
the wound at the time of closure
and we feel fairly strongly that this is
an added benefit.
In fact,
We've had three wound infections
In the last 150 or so transplant
wounds.
One of them was related to the fact that it was elected
not to give news local topical
antibiotics and the patient
when I was not at the operating table because
there was some concern that it might
increase the problem of
giving muscle relaxants in a patient who was already
and in two other patients,
we use the large him evac tubes.
So I think if we use proper skin preparation,
no systemic antibiotics,
local wound irrigation at the time of
closure and such materials
which will provide a resistance to
infection that the incidence of infection
in primary transplant winning
decisions can be virtually eliminated.
Now,
the next problem comes up.
What about their reopened wounds?
While the incidents of infections and reopened
wounds varies from about 5-20%
if it's a reopened wound late during the course,
they really shouldn't have too much more of an
infection rate than in the primary one infection is
predominantly those that are reopened while the
sutures are still in while the patients under high
immunosuppressive doses and most
especially those when there is a hematoma
involved or bleeding in the wound.
In these instances I think that every effort should
be made to degrees as much clout as
possible.
And in addition the wound
should be painted with aydin
sutures removed and should be repainted with Aydin
let dry vibrate placed on and then
wound tales sutured inside the wound
over those places where the future holds
because those areas are extremely
difficult to eradicate of organisms and
then again,
extensive local antibiotic irrigation should be
used at the time of closure.
I think with this technique that the that the
incidents of when infections can be kept to an acceptable
level.
Even in these very difficult patients.
Postoperative wound infection
with J.
Wesley alexander,
MD,
Associate professor of Surgery,
University of Cincinnati
was produced through the mobile facilities of the television
division,
Academy of Health Sciences,
United States Army Fort Sam Houston
texas