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 

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