Evidence update on prevention of surgical site infection

Purpose of review: surgical site infection (SSI) is a common health care associated infection and complicates up to 10-20% of operations with considerable health care resources. Apart from the widely adopted use of appropriate hair removal, antibiotic prophylaxis, avoidance of hypothermia and peri-operative glycaemic control to reduce SSIs this review has considered new research and systematic reviews, and whether their findings should be included in guidelines. Recent findings: The efficacy of preoperative bathing/showering, antibiotic prophylaxis for clean surgery and perioperative oxygen supplementation to reduce the risk of SSI is still in doubt. By contrast, the use of 2% chlorhexidine in alcohol skin preparation, postoperative negative pressure wound therapy and antiseptic surgical dressings do show promise. Antimicrobial sutures in independent meta-analyses were found to reduce the risk of SSI after all classes of surgery (except dirty) whereas the use of wound guards, or diathermy skin incision (compared with scalpel incision), did not. Summary: The incidence of SSI after surgery is not falling. Based on this review of published trials and evidence-based systematic reviews some advances might be included into these care bundles. More research is needed together with improved compliance with care bundles

Deep learning for accurately recognizing common causes of shoulder pain on radiographs

Objective: Training a convolutional neural network (CNN) to detect the most common causes of shoulder pain on plain radiographs and to assess its potential value in serving as an assistive device to physicians. Materials and methods: We used a CNN of the ResNet-50 architecture which was trained on 2700 shoulder radiographs from clinical practice of multiple institutions. All radiographs were reviewed and labeled for six findings: proximal humeral fractures, joint dislocation, periarticular calcification, osteoarthritis, osteosynthesis, and joint endoprosthesis. The trained model was then evaluated on a separate test dataset, which was previously annotated by three independent expert radiologists. Both the training and the test datasets included radiographs of highly variable image quality to reflect the clinical situation and to foster robustness of the CNN. Performance of the model was evaluated using receiver operating characteristic (ROC) curves, the thereof derived AUC as well as sensitivity and specificity. Results: The developed CNN demonstrated a high accuracy with an area under the curve (AUC) of 0.871 for detecting fractures, 0.896 for joint dislocation, 0.945 for osteoarthritis, and 0.800 for periarticular calcifications. It also detected osteosynthesis and endoprosthesis with near perfect accuracy (AUC 0.998 and 1.0, respectively). Sensitivity and specificity were 0.75 and 0.86 for fractures, 0.95 and 0.65 for joint dislocation, 0.90 and 0.86 for osteoarthrosis, and 0.60 and 0.89 for calcification. Conclusion: CNNs have the potential to serve as an assistive device by providing clinicians a means to prioritize worklists or providing additional safety in situations of increased workload

Wounds with complicated shapes tend to develop infection during negative pressure wound therapy

Introduction: While negative pressure wound therapy (NPWP) has been shown to be useful, we felt that patients with wounds of complicated shapes were likely to develop infection during performing NPWT. We conducted an investigation to determine the factors of wound shape responsible for the occurrence of infection. Materials and methods: A total of 55 patients with wounds were treated using NPWT in our unit in 2011. Eight whose wounds formed a pocket, 7 whose wounds were deep, and 40 whose wounds did not come under the above 2 types were eligible for this retrospective study. Results: Fifteen patients (27.3%) with NPWT showed a relapse of local infection. Six of the 8 patients (75.0%) in the wound with pocket group, 5 of the 7 (71.4%) in the deep wound group, and 4 of the 40 (10.0%) in the other wounds developed infection. The wound infection development ratio of the wound with pocket and deep wound groups was significantly higher than that of the other wound group. Conclusion: Wounds with complicated shapes are more likely to develop infectious complications during the management of NPWT. More careful observation is required when negative pressure therapy is used for wounds with a complicated shape

Tremendous bleeding complication after vacuum-assisted sternal closure

Vacuum-assisted closure (VAC) of complex infected wounds has recently gained popularity among various surgical specialties. The system is based on the application of negative pressure by controlled suction to the wound surface. The effectiveness of the VAC System on microcirculation and the promotion of granulation tissue proliferation are proved. No contraindications for the use in deep sternal wounds in cardiac surgery are described. In our case report we illustrate a scenario were a patient developed severe bleeding from the ascending aorta by penetration of wire fragments in the vessel. We conclude that all free particles in the sternum have to be removed completely before negative pressure is used

Closed incision negative pressure therapy:international multidisciplinary consensus recommendations

Surgical site occurrences (SSOs) affect up to or over 25% of patients undergoing operative procedures, with the subset of surgical site infections (SSIs) being the most common. Commercially available closed incision negative pressure therapy (ciNPT) may offer surgeons an additional option to manage clean, closed surgical incisions. We conducted an extensive literature search for studies describing ciNPT use and assembled a diverse panel of experts to create consensus recommendations for when using ciNPT may be appropriate. A literature search of MEDLINE, EMBASE and the Cochrane Central Register of Controlled Trials using key words \u2018prevention\u2019, \u2018negative pressure wound therapy (NPWT)\u2019, \u2018active incisional management\u2019, \u2018incisional vacuum therapy\u2019, \u2018incisional NPWT\u2019, \u2018incisional wound VAC\u2019, \u2018closed incisional NPWT\u2019, \u2018wound infection\u2019, and \u2018SSIs\u2019 identified peer-reviewed studies published from 2000 to 2015. During a multidisciplinary consensus meeting, the 12 experts reviewed the literature, presented their own ciNPT experiences, identified risk factors for SSOs and developed comprehensive consensus recommendations. A total of 100 publications satisfied the search requirements for ciNPT use. A majority presented data supporting ciNPT use. Numerous publications reported SSI risk factors, with the most common including obesity (body mass index 6530 kg/m2); diabetes mellitus; tobacco use; or prolonged surgical time. We recommend that the surgeon assess the individual patient's risk factors and surgical risks. Surgeons should consider using ciNPT for patients at high risk for developing SSOs or who are undergoing a high-risk procedure or a procedure that would have highly morbid consequences if an SSI occurred

Major bleeding during negative pressure wound/V.A.C.® - therapy for postsurgical deep sternal wound infection - a critical appraisal

Negative-pressure wound therapy, commercially known as vacuum-assisted closure (V.A.C.®) therapy, has become one of the most popular (and efficacious) interim (prior to flap reconstruction) or definite methods of managing deep sternal wound infection. Complications such as profuse bleeding, which may occur during negative-pressure therapy but not necessarily due to it, are often attributed to a single factor and reported as such. However, despite the wealth of clinical experience internationally available, information regarding certain simple considerations is still lacking. Garnering information on all the factors that could possibly influence the outcome has become more difficult due to a (fortunate) decrease in the incidence of deep sternal wound infection. If more insight is to be gained from fewer clinical cases, then various potentially confounding factors should be fully disclosed before complications can be attributed to the technique itself or improvements to negative-pressure wound therapy for deep sternal wound infection can be accepted as evidence-based and the guidelines for its use adapted. The authors propose the adoption of a simple checklist in such cases

Screening and Assessment of the Donor Heart

Why screening? Thirty years ago most donors suffered from head trauma ("Morbus Kawasaki") and a donor older than 35 years was beyond the pale, i.e. donors were young and healthy, and since these early days of transplantation donor hearts have been regarded as healthy "per definitionem"(1). However, due to the general organ shortage the criteria for the acceptance of donor hearts have been widely liberalized. According to the current quarterly data report of the International Society for Heart and Lung Transplantation (ISHLT) nearly two thirds of donors in Europe (64.3%) were older than 35 years, more than a quarter (26.0%) were even older than 50 years and less than 10% of organ donors suffered from head trauma (2). Meanwhile the average (European) donor is 45 years old and is suffering from intracranial bleeding, i.e. the so-called "donor pool" represents a subpopulation with significantly elevated risk for cardiac diseases such as coronary atherosclerosis and hypertension-related myocardial hypertrophy ( Key words: organ donor, heart donor, donor management, screening, coronary angiography, organ transplantation, heart transplantation Screening und Beurteilung des Spenderherzens Wozu Screening? Noch vor dreißig Jahren starben die meisten Spender an einem Schädeltrauma ("Morbus Kawasaki") und ein über 35-jähriger Spender galt als völlig inakzeptabel, d. h. die Spender waren jung und gesund. Seit diesen Anfängen der Transplantationsmedizin wurden Spenderherzen "per Definition" als gesund angesehen (1). Infolge des allgemeinen Organmangels wurden die Kriterien für die Akzeptanz von Spenderherzen jedoch weitgehend liberalisiert und nach dem aktuellen vierteljähr-lichen Datenbericht der International Society for Heart and Lung Transplantation (ISHLT) sind fast zwei Drittel der Spender in Europa (64.3%) älter als 35 Jahre, mehr als ein Viertel (26.0%) sogar älter als 50 Jahre und weniger als 10 % der Organspender sind an einem Schädeltrauma gestorben (2). Heute ist der typische (europäische) Spender 45 Jahre alt und an einer "spontanen" intracerebralen Blutung verstorben, d. h. der sogenannte "Spenderpool" rekrutiert sich aus einer Gruppe von Menschen, die ein signifikant erhöhtes Risiko für kardiale Erkrankungen aufweisen, wie z. B. für koronare Atherosklerose und Bluthochdruck-bedingte myokardiale Hypertrophie (Abb. 1). Leider zeigt die tägliche Erfahrung, dass das Screening der Spenderherzen an diese Entwicklung nicht angepasst worden ist (3). Die Frage "Wozu Screening?" ist daher keineswegs so trivial, wie es scheinen mag: Die Spender-Koronarangiographie ist immer noch eine Ausnahme (wird nur bei 5 -10 % der Spender durchgeführt), obwohl [1] die Prävalenz einer signifikanten atherosklerotischen Koronararterienerkrankung (KHK) im Spenderpool bei etwa 20 % liegt, [2] das Risiko einer Übertra-gung der KHK ohne Angiographie trotz Inspektion des Organs durch den entnehmenden Operateur bei ungefähr 5 -10 % liegt und [3] das Risiko eines frühen Transplantatversagens bei einer versehentlich mitübertragenen signifikanten KHK dreimal so hoch ist wie mit einem gesunden Graft (4,5)