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A United States Army Medical Department continuing

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education program.

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Postoperative wound infection with J.

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Wesley alexander,

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MD.

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Associate professor of Surgery,

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University of Cincinnati.

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I think that most of you working in the area

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of dialysis and transplantation are already well

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aware that infection is the biggest cause of

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death in these patients.

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It accounts for about 75% of deaths in renal

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transplants and fully

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60% of renal transplants developed

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some kind of infection during their post operative

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period at least.

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That's true in our series and the reported

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series that I have been able to see

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the incidence of wound infection is

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certainly one of the most preventable kinds

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and it occurs in a

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incidents of between 1%

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and about 75%.

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Depending upon the exact kind of one we're talking about

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for a primary transplant wound.

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The incident should be fairly low

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Reported between .5 and

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five And of a reopened

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wound is up to about 20%.

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But if one reopens the wound for hematoma

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during the first two weeks after transplant

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and the majority of these actually become infected

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and I think relates to the fact that the sutures are still in

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place.

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The patient has a a large amount

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of de vitalized tissue being

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blood and plots within the wound

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and and there is still

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opportunity to completely sterilize the skin.

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I think that anyone,

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I would have to agree the general technique is

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probably the best means of

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preventing one infection in this area as

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well as others.

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In addition,

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quite a number of technical aspects that need.

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You mentioned one of these is the skin prep.

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We routinely user

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10-12 minutes prep for these.

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We do not use the use of impervious

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towels on the skin.

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Thinking that this actually increases the number of

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organisms on the skin.

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We do feel it's important to use an antiseptic.

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As I'm sort the one that we prefer

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in most patients is tincture of iodine.

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Even those individuals they do

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not have any skin lesions which made

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predisposed to it infection.

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We feel that anyone with a predisposing skin

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lesion or pimples or abscesses anywhere in the area

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should not receive a renal transplant.

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And because of the possibility of wound infection,

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it is a disaster when it occurs.

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The technical details to control of

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bleeding and of lymphatic drainage

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into the wounds are also important and

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related to this is a question which comes up to the

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use of drains in our opinion,

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drainage,

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free drainage to the outside should not be

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established.

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Ever in one of these transplant wounds,

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it is a primary non infected wound,

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but it is true that many of these wounds

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will collect a relatively large amount of

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flood.

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Unfortunately,

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we have the use of closed suction devices

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For this and I would only mention that we have

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used the move act now for this

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purpose for the last 100 50 or

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so transplants with no difficulties

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except for one exception.

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This one exception being when their

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hospital supply people

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decided to give us only the human of acts

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with the large tubes.

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And we had two consecutive serious

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problems.

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The only two that we've had with those large tubes.

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This being retrograde infection down the track

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where the exit wound of the tube occurred.

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In one plotting of the tubes and the other.

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These tubes tend to clot actually

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more readily than the small tubes do

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for reasons that aren't apparent to me,

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except they are made from different materials.

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The next technical consideration,

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I think of importance is the

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choice of situ material and transplant wounds.

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Certainly we should try and pick a suitable

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material which tends to mm hmm,

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accentuate the development of infections to the least

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degree in this type of situation.

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Material must be than inert and a mono filament

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nature of the available materials.

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We feel that the pro lean

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sutures are preferable to any other currently

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available on the market for closure.

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one other technical aspect is to

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attack the fat with rather large suture

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bites and subcutaneous tissue to the

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underlying fashion so that there is no

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opportunity for the development of aromas

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and hematomas in the subcutaneous tissue.

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There these can become secondarily infected

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if hematomas and strong

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do form,

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it is our experience and a running suture

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probably causes less problems and

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potentially ation of wound infections

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than interrupted sutures because there is

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less opportunity to cause necrosis of

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tissue at the site where the sutures are

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tight and since these are running suture,

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the tightness is

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distributed throughout the length of the wound rather than at

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focal points next to

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areas which I would like to comment upon

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relating to the development of wound infections and

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transplant patients is the use of systemic

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antibiotics.

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There has been much controversy about the use of systemic

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antibiotics and surgery and I think it is now fair

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to say that some relatively clear guidelines

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can be placed.

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That is systemic antibiotics are of

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value in contaminated wounds

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where the probable contaminant can be

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estimated,

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especially if they are given before the time of

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contamination are at the contaminant time of

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contamination and continued for a sharp period of time

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thereafter there is a large body of both

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experimental and clinical data now

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to indicate that this is true.

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However,

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in the transplant wound,

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these wounds are potentially contaminated but

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usually not actually.

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So they are contaminated from the bladder

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if they are contaminated with a known

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organism.

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And it's our experience.

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And I think most of the experience of the most

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transplant centers over the country that if there is pure

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Linz in the bladder at the time of the proposed

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operation,

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that the operation should be canceled and that

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individual treated until he has negative

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cultures.

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If we place in a catheter,

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obtain a cloudy flood with a gram stain on that

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If there are organisms,

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which means there are 10 to the fifth organisms per mil.

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A leader are more in that flood,

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then the operation will not proceed

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if there are no organisms or if the fluid

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is clear,

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we will instill an antibiotic solution in

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our institution,

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Kenny mason,

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About 200 ml of a solution of

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1% or 1000 micrograms per

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millimeter clamp the tube so that this

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stays in the bladder as an

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arrogant or savage if you will,

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until the time the bladder is opened for

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insertion of the ureter,

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there are selected instances where

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it may be very difficult to

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completely sterilize the bladder.

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And it is our feeling in those very rare

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instances that a ureter or ureter

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rasta me should be employed rather than opening the

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contaminated bladder.

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The use of topical antibiotics.

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Uh we'll go back to systemic antibiotics

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then we,

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if we can virtually sterilize the

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inside of the bladder,

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we feel then that there is no probable.

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And it's been true that in clean wounds,

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metra logically clean wounds.

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That is where the

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organisms should be in very low

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numbers or cannot be predicted

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that the incidents of wound infection actually

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goes up with the use of systemic

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antibiotics.

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This is true in a number of cases such as hernias and

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thyroids and I think in transplant wounds

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as well.

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The fact that the patient is immuno

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suppressed and at an increased risk to infection

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is not an indication for prophylactic

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antibiotics.

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And I feel they should be condemned in these patients,

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not only because they're ineffective but also

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because the increase in many instances the

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risk of infection because of an adverse

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influence on host defense mechanisms

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predominantly the complement system and

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of an adverse effect on the

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nose.

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A comal in flora and the endogenous flora

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to that particular individual.

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Now prophylactic systemic antibiotics

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are given then can prophylactic topical

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antibiotics be of use and I think the

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answer is yes.

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Belzer published a series not too long

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ago,

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which indicated about an 80%

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reduction.

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As I recall in a double blind

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series in which prophylactic

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topical antibiotics were used.

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That is as an irrigation to

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the wound at the time of closure

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and we feel fairly strongly that this is

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an added benefit.

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In fact,

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We've had three wound infections

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In the last 150 or so transplant

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wounds.

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One of them was related to the fact that it was elected

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not to give news local topical

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antibiotics and the patient

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when I was not at the operating table because

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there was some concern that it might

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increase the problem of

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giving muscle relaxants in a patient who was already

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and in two other patients,

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we use the large him evac tubes.

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So I think if we use proper skin preparation,

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no systemic antibiotics,

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local wound irrigation at the time of

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closure and such materials

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which will provide a resistance to

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infection that the incidence of infection

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in primary transplant winning

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decisions can be virtually eliminated.

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Now,

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the next problem comes up.

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What about their reopened wounds?

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While the incidents of infections and reopened

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wounds varies from about 5-20%

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if it's a reopened wound late during the course,

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they really shouldn't have too much more of an

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infection rate than in the primary one infection is

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predominantly those that are reopened while the

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sutures are still in while the patients under high

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immunosuppressive doses and most

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especially those when there is a hematoma

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involved or bleeding in the wound.

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In these instances I think that every effort should

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be made to degrees as much clout as

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possible.

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And in addition the wound

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should be painted with aydin

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sutures removed and should be repainted with Aydin

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let dry vibrate placed on and then

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wound tales sutured inside the wound

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over those places where the future holds

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because those areas are extremely

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difficult to eradicate of organisms and

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then again,

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extensive local antibiotic irrigation should be

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used at the time of closure.

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I think with this technique that the that the

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incidents of when infections can be kept to an acceptable

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level.

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Even in these very difficult patients.

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Postoperative wound infection

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with J.

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Wesley alexander,

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MD,

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Associate professor of Surgery,

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University of Cincinnati

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was produced through the mobile facilities of the television

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division,

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Academy of Health Sciences,

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United States Army Fort Sam Houston

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texas