Keys To Managing Postoperative Wound Infections

Start Page: 42
48
Author(s): 
Ryan Fitzgerald, DPM, FACFAS

   As I noted above, the presence of diabetes is an independent risk factor for the development of surgical site infections. As the epidemic of diabetes increases, there has been increasing interest in various surgical techniques for the treatment of the diabetic foot. Armstrong and colleagues developed and later validated a diabetic foot surgery classification system designed to assist the surgeon in assessing risk when determining a rationale for foot and ankle surgery in this high-risk population.10,11 This system included class 1 (elective), class 2 (prophylactic), class 3 (curative) and class 4 (emergency) surgery. There is an increase in postoperative infection with each increasing class of foot surgery.11

   There are risk factors associated with the procedures surgeons are performing as well. It is a reality that certain types of procedures are simply more prone to the development of surgical site infections. Infection rates increase in complicated reconstructive surgery, types of diabetic foot surgery, open fractures and traumatic wounds.12-16 Additional surgical procedure-related risk factors include poor surgical technique, the duration of operation, the use of drains (closed drain systems reportedly reduce the risk of surgical site infections), hematoma formation, excessive use of electrocautery and accidental cross contamination, commonly either from bowel or infected tissue.17 Furthermore, researchers have demonstrated that inappropriate antibiotic prophylaxis and inadequate skin prep prior to surgery increase the risk of the development of postoperative infection, especially in high-risk surgical patients, immunocompromised patients, those living with diabetes, and patients suffering from vascular disease.18,19

   Extrinsic risk factors are those factors associated with the operating room, the operative equipment and all potential factors that are not directly related to the patient or the surgical procedure. The literature has demonstrated that these factors, in combination with intrinsic factors, can often contribute to the development of postoperative wound infections.20 These factors include the number of individuals in the operating room, inadequate sterilization/disinfection of surgical equipment, reuse of inadequately sterilized invasive devices, prolonged preoperative stay, inappropriate dressing techniques and the length of the surgical procedure. Prolonged surgical time increases the risk for surgical site infections and extended tourniquet time may cause tissue ischemia that enhances infection. With every hour of operating time, the infection rate doubles.21

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