Intraoperative Risk Factors

Optimize your patients' preoperative risk factors to reduce postoperative complications and improve outcomes.

Most surgical site infections (SSIs) happen at the time of surgery, with our patient’s skin being the most common cause, as well as airborne organisms.

Pre- and perioperative antibiotics along with MRSA screening and proper skin preparation of surgical site are proven to reduce the risks of superficial and deep wound infections.

Surgeon Tools/Recommendations:

The Centers for Disease Control and Prevention (CDC) and Musculoskeletal Infection Society (MSIS) current recommendations for prevention of SSI incorporate the following:

  • Risk mitigation by host optimization
  • Appropriate selection of perioperative antibiotics
  • Preoperative skin preparation
  • Operative environment
  • Wound management
  • MSIS recently held the international consensus meeting and have provided recommendations for SSI prevention, diagnosis, and treatment.

Overview of relevant recommendations can be found: 2017 CDC Guidelines for Prevention of Surgical Site Infection

Irrigation irrigation techniques used during surgery are commonly used to:

  • Reduce contamination by removing particles and bacteria
  • Remove nonviable tissue 
  • Expose healthy tissue 
  • Wound irrigation with antiseptic solutions has been shown to be effective for prevention of SSI.

Surgeon Tools/Recommendations:

Ways to irrigate a wound during surgery:

  • Pulsatile lavage (high and low pressure)
  • bulb-syringe lavage

Types of Irrigation solutions:

  • detergents
  • antibiotic laden lavage
  • antiseptic agents
  • sterile normal saline

Sterile dilute povidone-iodine (betadine): Some evidence suggests that betadine is the optimal solution for reducing bacteria while maintaining healthy tissue.

  • Before closure of the wound, irrigation with sterile dilute betadine (0.35%) has been shown to decrease risk of SSI in joint replacement and spine procedures with no adverse reported outcomes.
  • CDC identified as a method of SSI prevention on during lower extremity arthroplasty procedure.
  • There are other intraoperative irrigation and wound lavage systems currently being utilized and researched for efficacy of SSI prevention, including 0.05% chlorhexidine gluconate as well as various solvents, pH modifiers and surfactant combinations.

Pulse Lavage: Different types of pulse lavage systems with varying pressure settings, important to consider specific pulse lavage systems and the pressure setting available.

  • higher-pressure settings can potentially damage healthy or viable tissue.
  • potential spread of bacteria especially in the setting of grossly contaminated wounds.

Incidence of infection with staphylococcal and non-staphylococcal bacteria has been shown to decrease with preoperative screening for Methicillin-Resistant Staphylococcus aureus species (MRSA) and Methicillin-Susceptible Staphylococcus Aureus  (MSSA) species  along with decolonization methods. Despite confirmed and adequate treatment of MRSA carriers. There is a risk of SSI. 

Surgeon Tools/Recommendations:

-Screen for Staphylococcus aureus (MRSA and MSSA) preoperatively for procedures, especially arthroplasty procedures. 

-Intranasal mupirocin is a topical antimicrobial that has been shown to significantly decrease bacterial burden in 85% of those who complete a course of treatment 

- Patient compliance is a concern with the use of mupirocin as it requires the patient to apply the topical solution to their nares 3 times a day for 5 days. 

Decolonization Methods (MRSA and MSSA)

  • Short-term nasal application of mupirocin prior to joint replacement surgery (3 times a day for 5 days).
  • Recent studies demonstrate support for universal decolonization protocols without screening for patients undergoing a total joint arthroplasty procedure, especially in high-risk patients.

The goal of giving antibiotics prior to incision is to allow enough time for the antibiotic to diffuse into the tissues and to develop optimal concentrations of antibiotics in the body.

The CDC has identified 20-50% of all antibiotics given in the United States are either unnecessary or inappropriate.

Risks:

The timing and administration of appropriate antibiotics is very important to successful prevention of SSIs.

Surgeon Tools/Recommendations:

Recommendations for optimal timing of antibiotic prophylaxis:

  • Within 1 hour prior to surgical procedure, with most surgeons opting for within 30 minutes of incision.
  • Vancomycin and fluoroquinolones may be infused up to 2 hours before surgery due to extended infusion times and long half-lives
  • Intraoperative redosing of cefazolin is recommended every 4 hours. Alternatives for patients with a true Penicillin allergy (anaphylaxis breathing issues) include clindamycin and vancomycin.
  • Important to review antibiograms or consult with infectious disease team members when deciding on a preferred perioperative antibiotic strategy targeted for patient within a specific area or regions. 

Alternatives for patients with a true Penicillin allergy (anaphylaxis, breathing issues) include clindamycin and vancomycin.

Important to consider the best surgical site preparation routine:

  • hair removal 
  • preoperative and intraoperative  skin preparation solutions
  • sterile draping 

Preparation is extended well beyond the surgical margins to ensure that the areas surrounding the incisions are properly sterilized.

Iodine, alcohol, and chlorhexidine based preparations have been shown to reduce bacterial burden at various surgical sites.

Awareness of the recommended skin preparation solution based on anatomic location of surgery is warranted due to local microbiome and skin flora (ie: shoulder area higher bacterial burden of Cutibacterium acnes which chlorhexidine solution is recommend.)

Surgeon Tools/Recommendations

Hair Removal:

  • Remove hair with a dedicated clipping device with a prepackaged razor in the preoperative area the same day as surgery before entrance into the sterile operating room setting.
  • Proper disposal of the razor after each patient is advised

Preoperative/Preadmission Skin Preparation:

  • Recommend patient perform specific cleanses of surgical site while at home the day before and morning of surgery.
    • Includes shower with chlorhexidine solution or using wipes at home.
  • On the day of surgery, gently wipe the skin with either an alcohol or chlorhexidine based solution (i.e. 70% isopropyl alcohol, chlorhexidine gluconate) in the preoperative area or in the operating room to provide a preliminary cleanse of the entire surgical field.
  • Consider the fire risk associated with isopropyl alcohol in the operating room.
    • May be required to isolate surgical field with clear drapes to ensure that the alcohol-based solutions do not saturate cloth or fabric to reduce the risk of fire.
  • Allow optimal drying time for specific initial preparatory solution to maximize adhesion and technique or proper sterile draping.

Intraoperative Skin Preparation:

  • Iodine, alcohol, and chlorhexidine based solutions are used after the surgical site has been appropriately isolated, marked and the team has appropriate visualization and working area to successfully complete the procedure.
  • Allow each of the skin preparation solutions adequate time to dry
    • Follow manufacture’s recommendations for drying time.
  • Be aware that some surgical skin preparation solutions have been shown to have a greater propensity for erasing surgical markings than others.

Sterile Draping:

  • Once the solution of choice is dry, drape the sterile field.
  • Often, surgeons will choose to use iodine impregnated sticky drapes or incise drapes either along the edges of the sterile drapes or over the entire surgical field.

Evidence shows that iodine impregnated sticky drapes adhere better to certain skin preparation solutions than others.

Evidence is lacking in orthopaedic surgery to support the use of topical antibiotics prior to and after wound closure.

The role of putting powdered antibiotics into a wound needs to be researched further.

Surgeon Tools/Recommendations:

CDC Recommendations:

  • Against the use of applying antimicrobial agents to surgical incisions.
    • A recommendation cannot be made for or against the use of antimicrobial dressings applied to the surgical incision after closure.

Techniques to control intra-operative and postoperative bleeding for various orthopedic procedures including: Cell savage, antifibrinolytic agents (TXA), anesthetic techniques, patient positioning, surgical techniques, and local agents.

    Some procedures recognized with increased risk for blood loss include:

  • Spine deformity correction
  • Pelvic osteotomies
  • Revision procedures of the hip and knee

Surgeon Tools/Recommendations:

Preoperative Considerations:
  • Important that management of potential blood loss begins before the patient enters the operating room
  • Awareness of medication and supplements patient is taking at home that can increase risk of bleeding:
    • Blood thinners: Aspirin, Plavix, warfarin, Xarelto, lovenox
    • NSAIDs: Ibuprofen, naproxen, meloxicam, Celebrex
    • Supplements: Garlic, ginkgo, ginseng, fish oil, flax seed oil, and saw palmetto


8-Step Checklist for Pre-, Intra-, Post-operative Reduction of Blood Loss in Total Knee and Total Hip Replacement

  1. Normalize preoperative hemoglobin
  2. Discontinue NSAIDs and anticoagulants before surgery
  3. Injection of IV TXA (10mg/kg) 30 minutes preoperatively and 4 hours postoperatively
  4. Local injection of ropivacaine, adrenaline and ketorolac before incision
  5. Careful hemostasis - dry wound
  6. Bone wax after femoral neck osteotomy (THA)
  7. Avoid hypertension throughout the anesthesia
  8. Efficient surgery with shortened operative times
If you have any questions, please contact Meghan Eigenbrod, eigenbrod@aaos.org and Isabel S. Montoya, montoya@aaos.org.

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