A 37 year old woman has been listed for abdominal hysterectomy because of menorrhagia and a large fibroid uterus. Critically evaluate the measures that may be taken to minimise the risk of post-operative infection.
Post operative infection is commonest cause of post op morbidity .Abdominal hysterectomy carries a risk of post op infectious morbidity of 20%.
Urinary tract infections, Respiratory tract infections, Wound infection, Pelvic infection are commonest causes of post operative infectious morbidity
Preoperative optimisation of woman\'s condition would reduse risk of post op infection. MSU should be sent for microscope,c/s to identify any preexisting UTI , if so should be treated.
Note if there is any history of respiratory tract problems like Chronic bronchitis, asthma ,Ch.cough. Ask for symptoms of upper respiratory tract infection.If she is a smoker advise her against smoking. Infection combined with suppression of cough post op ,sedative effects of narcotic agents used for post op pain control,immuno suppressive effect of anaesthesia all increase the risk of post op pneumonia so if any Respiratory tract infection is identified surgery should be delayed till treated.
I f woman is at risk of endocarditis consider prophylaxis as per local protocol depending upon her risk.
Good surgical technique& scurpulous sterile technique in operation theatre & on ward is corner stone for reducing post op infection.Strict adherense to basic aseptic principles is essential.
Prepration by surgeon _ Hand washing is an important part of the prevention of wound infection as it removes resident bacteris.All jewellery should be removed as becteria have been shown to reside beneath all rings esp if irregular surfaces. Wearing of face mask is of limited value , but will protect the wearer from blood splashes.
Preparation of surgical site_ It is advisable to shave the abdominal skin immediately preoperatively as this prevents the skin bacteria from having time to multiply in the skin abrasions.Depilatory creams can be used to avoid abrasions but may occasionally cause skin reaction.Skin should be cleaned with antiseptic solution _ chlorhexidine 0.5% , iodine 1%.
Pre op urinary cathetirzation should be performed under aseptic precautions to prevent ascending inrection.
Prophylactic antibiotic use has been shown to reduse the risk of post operative infection by 50% This reduses infection both superficial & deep.Single dose of antibiotic use is as effective as 5 day course of antibiotic use to prevent post op infection.Prophylaxis should be started 1 hr pre op/ within 30 min of induction of anaesthesia.Need for further dosing depends on duration of surgery. I f duration more than 1 hr ,blood loss >1500 ml further dose are advisable post op. Antibiotic selected for prophylaxis must cover the common pathogens both aerobes & anaerobes.Augmentin 1.2 gm or metronidazole 1 gm plus cefuroxime 750 mg are commonly used regimens for prophylaxis. If woman is allergic to pencillin consider clindamycin or erythromycin.
Meticulous haemostasis intra op , avoid any dead spaces during wound closure will reduce post op collections and subsequent infections
Risk of Post op lung infection can be reduced by physiotherapy, early mobilization & good pain control.
Attention to the indications for the use & duration of indwelling catheters may influence frequency of UTI.
Posted by Farzana N.
Postoperative infection is a major cause of morbidity and mortality associated with gynecological surgery.Preventive measures should be taken in the preoperative period and continued through perioperative and postoperative period.
Preoperative measures include ?a thorough assessment of patient and identification of any risk factors ,which would predispose to infections.General measures such as stopping smoking and alcohol would improve general health and immunity to infections.h/o menorrhagia would suggest possibility of anemia which should be corrected by FeSO4 or BT, depending on Hb levels.H/o concurrent medical illnesses and treatment taken to ensure they are optimally controlled before the surgery.e.g DM-if uncontrolled added with the hyperglycemia of operation would predispose to various opportunistic infections and poor wound healing. Respiratory infections will reduce the efficiency of gas exchange in the lungs.URTI combined with immunosuppressive effect of anesthesia,inhibition of postoperative cough and sedative effects of narcotic agents used for pain relief increases the risk of developing post op pneumonia.
H/o Cardiac diseases,-congenital cyanotic heart lesions,prosthetic cardiac valves, h/o endocarditis shd prompt use of prophylactic antibiotics to prevent post op eendocarditis.
H/o of pelvic infection shd be taken and in suspected cases swabs from vagina cervix and urethra shd be sent for culture and sensitivity.Mid stream urine specimen should be sent for microscopy and culture to rule out any urinary infection.
Drug.hist taken if the patient is on any corticoteroids or immunosuppressants .
General examination done. If the bmi is high,>30, she is advised to reduce wt .Obesity puts her at increased risk of post op complications including resp infections such as atelectasis. Any infective skin lesions shoul be treated to prevent wound infection.
PERIOPERATIVE measures include good surgical technique and scrupulous sterile techniques in the theatre and in the ward.
All major gynecological surgeries either vaginal or abdominal carry risk of infection ~20%.PROPHYLACTIC antibiotics reduce this risk by 50%.Single dose at the time of induction of anesthesia would suffice for surgery that lasts for 1hr.If surgery lasts for >1hr ,2further doses shd be given post op.Combination of Metronidazole 1gm orally or rectally with a single i.v dose of first or second generation cephalosporins is given.In those allergic to cephalosporins gentamicin or clindamicin are appropriate.
Bladder catheterization reduces the risk of bladder injury and post operative urinary retention.Fastidious hemostasis and placement of abdominal pelvic drains reduce incidence of hematoma. Vault hematoma is cause in 2/3 of cases of post operative pyrexia.
POSTOPERATIVE Detection and early correction of anemia would improve general health...Risk of RTI is reduced by optimizing lung functions by cessation of smoking .medications and physiotherapy.Cessation of smoking early mobilization with good pain control.Attention should be paid to indication for the use and duration of indwelling catheter that may influence the frequency of UTI.Wound should be kept clean and dry to prevent infection and rapid wound healing.
