Classification of Operative Wounds

1. Clean (class I) (1.55.1%) Do not report the following conditions as SSI:

1. Stitch abscess (minimal inflammation and discharge confined to
Nontraumatic
the points of suture penetration)
No inflammation encountered
2. Infection of an episiotomy or newborn circumcision site
No break in technique
3. Infected burn wound
Respiratory, alimentary, or genitourinary tract not
4. Incisional SSI that extends into the fascial and muscle layers
Entered
(see deep incisional SSI)
2. Clean-contaminated (class II) (7.710.8%) Note: Specific criteria are used for identifying infected episiotomy
Gastrointestinal or respiratory tract entered without and circumcision sites and burn wounds
significant spillage
Appendectomy Deep incisional SSI
Oropharynx entered Infection occurs within 30 days after the operation if no
Vagina entered implant* is left in place or within 1 yr if implant is in place and
Genitourinary tract entered in absence of infected the infection appears to be related to the operation, and
urine infection involves deep soft tissues (e.g., fascial and muscle
Biliary tract entered in absence of infected bile layers) on the incision, and at least one of the
Minor break in technique following:

3. Contaminated (class III) Major break in 1. Purulent drainage from the deep incision but not from the
technique(15.216.3%) organ/space component of the surgical site
Major break in technique 2. A deep incision spontaneously dehisces or is deliberately
Gross spillage from gastrointestinal tract opened by a surgeon when the patient has at least one of the
Traumatic wound, fresh following signs or symptoms: fever (> 38 C [100.4 F]),
Entrance of genitourinary or biliary tracts in presence localized pain, or tenderness, unless site is culture negative
of infected urine or bile 3. An abscess or other evidence of infection involving the deep
4. Dirty and infected (class IV) (28.040.0%) incision is found on direct examination, during reoperation, or
Acute bacterial inflammation encountered, without by histopathologic or radiologic examination
pus 4. Diagnosis of a deep incisional SSI by a surgeon or attending
Transection of clean tissue for the purpose of physician
surgical
access to a collection of pus Notes:
Traumatic wound with retained devitalized tissue, 1. Report infection that involves both superficial and deep incision
foreign sites as deep incisional SSI
2. Report an organ/space SSI that drains through the incision as a
bodies, fecal contamination, or delayed treatment, or
deep incisional SSI
all of these; or from dirty source
Organ/space SSI
Adapted from Cruse PJE: Wound infections:
Infection occurs within 30 days after the operation if no implant*
Epidemiology and clinical characteristics. In Howard RJ,
is left in place or within 1 yr if implant is in place and the infection
Simmons RL (eds): Surgical Infectious Disease 2nd ed.
appears to be
Norwalk, CT, Appleton & Lange, 1988.
related to the operation, and infection involves any part of the
anatomy (e.g., organs or spaces), other than the incision, which
Table 5 Criteria for Defining a Surgical Site Infection (SSI)71
was opened or
Superficial incisional SSI
manipulated during an operation, and at least one of the
Infection occurs within 30 days after the operation, and
following:
infection involves only skin or subcutaneous tissue of the
incisions, and at least one of the
1. Purulent drainage from a drain that is placed through a stab
following:
wound into the organ/space
1. Purulent drainage, with or without laboratory confirmation,
2. Organisms isolated from an aseptically obtained culture of fluid
from the superficial incision
or tissue in the organ/space
2. Organisms isolated from an aseptically obtained culture of fluid
3. An abscess or other evidence of infection involving the
or tissue from the superficial incision
organ/space that is found on direct examination, during
3. At least one of the following signs or symptoms of infection:
reoperation, or by histopathologic or radiologic examination
pain or tenderness, localized swelling, redness, or heat; and
4. Diagnosis of an organ/space SSI by a surgeon or attending
superficial incision is deliberately opened by surgeon, unless
physician
incision is culture negative
4. Diagnosis of superficial incisional SSI by the surgeon or
attending physician
*National Nosocomial Infection Surveillance definition: a 8. candidiasis
nonhuman-derived implantable foreign body (e.g., prosthetic
heart valve, nonhuman vascular graft, mechanical heart, or hip Fever after 1 week post-op:
prosthesis) that is permanantly placed in a patient during surgery. 1. drug allergy
If the area around a stab wound becomes infected, it is not an 2. leaking anastomosis
SSI. It is considered a skin or soft tissue infection, depending on its 3. intraabdominal abscess
depth. 4. Deep SSI
th
Principles of Anitbiotic Prophylaxis: Schwartzs 7 ed (pp 133, Wound Classification: ACS 2005, Vol I, pp 100
table 5.6) Clincal Features Tetanus-Prone Non Tetanus-
1. Choose an antibiotic effective against the pathogens Prone
most likely to be encountered Age of wound > 6hrs 6 hrs
2. Choose an antibiotic with SAFE, NON-TOXIC, low
Configuration Stellate, avulsion, Linear
toxicity
abrasion
3. The half-life of the antibiotic selected must be long
Depth > 1 cm 1cm
enough to maintain adequate tissue levels throughout
the operation. Mechanism of Missile, crush, Sharp surface (
4. A single preoperative dose that is of the same strength injury burn, frostbite glass, knife)
as a full therapeutic dose is adequate in most Signs of infection Present Absent
instances. Administer a single, fully therapeutic dose
Devitalized Tissue Present Absent
intravenously 30-60 min preoperatively
5. administer a second dose of antibiotic if the operation Contaminants ( Present Absent
lasts longer than 4 hrs or twice the half-life of the dirt, feces, soil,
antibiotic saliva)
6. Give 2-3 doses post-Op. There is no need to extend History of TT HTIG TT HTIG
administration beyond 24 hrs Immunization
7. Use of antibiotics is appropriate when infection is (doses)
frequent or when consequences of infection would be Unknown or < 3 Yes Yes Yes No
unusually severe + ++
3 or more No No No No
+
CLEAN CASES Yes, if > than 5 years since last dose
++
Prophylactic antibiotics are not indicated in clean Yes, if more than 10 years since last dose
operations if the patient has no host risk factors or if
the operation does not involve placement of prosthetic Sutures:
materials. in the face removed at day 4 or 5
other areas where skin tension is limited 7
Respiratory infections: occurs between 4-7 POD days
Fever with in 24 hrs:
1. Atelectasis Maximum safe dose of lidocaine: ACS 2005 vol I, pp 106
4mg/kg without epinephrine
High fever ( T > 38.9C) within 48 hrs Post-Op: 7mg/kg with epinephrine
1. Atelectasis
2. peritonitis 2 to leaking viscus ASA Classification
3. Invasive wound infection ( Necrotizing fasciitis, Class I (0 to 5 points) has a 0.9% risk of serious cardiac event or
clostridial myositis, cellultitis) death
Class II (6 to 12 points) has a 7.1% risk
Fever at 24-48 hrs: Class III (13 to 25 points) has a 16.0% risk
1. Respiratory complications Class IV (>26 points) has a 63.6% risk
2. Catheter related problems COMPUTATION OF PULMONARY RESERVE:

Fever after 48-72 hrs:

1. thrombophlebitis
2. wound infection usually between 5th to 8th POD
3. UTI
4. pneumonitis
5. acute acalculus cholecystitis
6. idiopathic post-op pancreatitis
7. drug allergy
Child-Pugh Classification:
Points 1 2 3 Selected Surgical Procedures Stratified by Degree of Cardiac Risk

Encephalopathy None Stage I or II Stage III or IV Degree of Type of Procedure

Cardiac
Risk
Ascites Absent Controlled Uncontrolled
Low (< 1%) Endoscopic procedures
Ambulatory procedures
Bilirubin mg/dl <2 2-3 >3
Ophthalmic procedures
Aesthetic procedur
Albumin g/dl > 3.5 2.8 3.5 < 2.8 Intermediate Minor vascular procedures (e.g., carotid endarterectomy)
(1%5%) Abdominal procedures
Nutritional Excellent Good Poor Thoracic procedures
Status Neurosurgical procedures
Child-Turcotte-Pugh Classification Otolaryngologic procedures
Orthopedic procedures
Urologic procedures
Protime High (> 5%) Emergency procedures (intermediate or high risk)
prolongation < 4 sec 4-6 sec 6 sec Major vascular procedures (e.g., peripheral vascular
INR < 1.7 1.7 2.3 > 2.3 surgery, AAA repair)
Extensive surgical procedures with profound estimated
blood loss, large fluid shifts, or both
Unstable hemodynamic situations
Operative 2% 10% 50%
Mortality
Relative Contraindications to Outpatient Surgery
Operative Mortality (One point for each): Procedures with an anticipated significant blood loss
Bilirubin > 2.0 mg/dl
Albumin < 3.0 g/dl
Procedures associated with significant postoperative
pain
Protime > 16s
Encepahlopathy Procedures necessitating extended postoperative I.V.
total points therapy

1
Mortality
ASA class IV (or III if the systemic disease is not under
control, as with
43%
2 unstable angina, asthma, diabetes mellitus, and
85% morbid obesity)
3 Known coagulation problems, including the use of
100% anticoagulants
Grading of Hepatic Encephalopathy:
Stage Neurologic Changes Inadequate abillity or understanding on the part of
caretakers with
Stage Mild confusion, euphoria or depression, decreased respect to requirements for postoperative care
I attention span, slowing of ability to perform mental
tasks, irritability, disorder of sleep pattern
Surgical Categories
Stage Drowsiness, lethargy, gross deficit in ability to Category 1
II perform mental tasks, obvious personality changes, Generally noninvasive procedures with minimal blood
inappropriate behaviour, intermittent and short- loss and with minimal risk to the patient independent
lived disorientation of anesthesia
Anticipated blood loss less than 250 ml
Stage Somnolent but arousable, unable to perform mental
III tasks, disorientation with respect to time, palce and Limited procedure involving skin, subcutaneous, eye,
person, amnesia, occasional fits of rage, speech or superficial lymphoid tissue
present but incomprehensible Entry into body without surgical incision

Excludes the following:

Stage Coma
V
 Open exposure of internal body organs, repair of Fasting Recommendations* to Reduce Risk of
vascular or neurologic structures, or placement of Pulmonary Aspiration
prosthetic devices
Entry into abdomen, thorax, neck, cranium, or Ingested Material Minimum Fasting
extremities other than wrist, hand, or digits Period (hr)
Placement of prosthetic devices Clear liquids 2
Postoperative monitored care setting (ICU, ACU) Breast milk 4
Infant formula 6
Nonhuman milk 6
Category 2 Light meal 8
Procedures limited in their invasive nature, usually with
minimal to mild blood loss and only mild associated risk Disposition of Current Medications before Outpatient Surgery97
to the patient independent of anesthesia
Anticipated blood loss less than 500 ml Continue Discontinue or withhold
Limited entry into abdomen, thorax, neck, or Antihypertensives Diuretics
extremities for diagnostic or minor therapy without Beta blockers Insulin
removal or major alteration of major organs Calcium channel Digitalis
Extensive superficial procedure blockers
ACE inhibitors Anticoagulants (may change
Excludes the following:
Vasodilators to short-acting agent such as
Open exposure of internal body organs or repair of
heparin
vascular or
Bronchodilators
neurologic structures
Placement of prosthetic devices Antiseizure meds
Postoperative monitored care setting (ICU, ACU), with Tricyclic
no open exposure of abdomen, thorax, neck, cranium, antidepressants
or extremities other MAO inhibitors
than wrist, hand, or digits (controversial)
Category 3 Corticosteroids
More invasive procedures and those involving Thyroid preparations
moderate blood loss with moderate risk to the patient Anxiolytics
independent of anesthesia
Anticipated blood loss 5001,500 ml Modified Aldrete Phase I Postanesthetic Recovery Score42,43
Open exposure of the abdomen Patient Sign Criterion Score
Reconstructive work on hip, shoulder, knees Activity Able to move 4 extremities* 2
Able to move 2 extemities* 1
Excludes the following: Able to move 0 extremities* 0
Open thoracic or intracranial procedure Respiration Able to breathe deeply and cough 2
Major vascular repair (e.g., aortofemoral bypass) Dyspnea or limited breathing 1
Major orthopedic reconstruction (e.g., spinal fusion) Apneic, obstructed airway 0
Planned postoperative monitored care setting (ICU, Circulation BP 20% of preanesthetic value 2
ACU) BP 20%49% of preanesthetic value 1
BP 50% of preanesthetic value 0
Category 4 Consciousness Fully awake 2
Procedures posing significant risk to the patient Arousable (by name) 1
independent of anesthesia or in one or more of the Nonresponsive 0
following categories: Oxygen SpO2 > 92% on room air 2
Procedure for which postoperative intensive care is saturation Requires supplemental O2 to 1
planned maintain SpO2 > 90%
Procedure with anticipated blood loss greater than SpO2 < 90% even with O2 supplement 0
1,500 ml *Either spontaneously or on command.
Cardiothoracic procedure SpO2pulse oximetry
Intracranial procedure
Major procedure on the oropharynx
Major vascular, skeletal, or neurologic repair
POST-OP MANAGEMENT Measure hemoglobin concentration: < 6 g/dL,
Issues to Address in Postoperative Instructions transfusion usually required; 610 g/dL, transfusion
Activity dictated by clinical circumstance; >10 g/dL, transfusion
Medication rarely required.
Diet Measure vital signs/tissue oxygenation when
Wound care hemoglobin is 6 to 10 g/dL and extent of blood loss is
Pain relief unknown. Tachycardia and hypotension refractory to
Possible complications or side effects (of procedure, volume suggest the need for transfusion; O2 extraction
anesthesia, or medications) ratio > 50%, VO2 decreased, suggest that transfusion
Follow-up testing or treatments usually is needed.
Emergency contacts, including surgeon and acute care
facility

Assessment of the patient's airway patency (openness of the

airway), vital signs, and level of consciousness are the first
priorities upon admission to the PACU. The following is a list of
other assessment categories:
surgical site (intact dressings with no signs of overt
bleeding)
patency (proper opening) of drainage tubes/drains Alterations In Metabolic Rate:
body temperature (hypothermia/hyperthermia) No post-op complications, fistula without
patency/rate of intravenous (IV) fluids infection = normal
circulation/sensation in extremities after vascular or Elective major surgery : 24%
orthopedic surgery Mild peritonitis, long bone fracture or mild
level of sensation after regional anesthesia to moderate injury = add 25% of BEE
pain status Skeletal trauma : 34%
nausea/vomiting Blunt Trauma: 37%
Head trauma/Steroids: 61%
Reasons for Notification of Surgeon37 Sepsis: 79%
Unstable Vitals signs Severe injury or infection in ICU patient,
Persistent nausea and vomiting MOF = add 50% of BEE
Bleeding Burn of 40% - 100% TBSA = add 100-132%
of BEE
Fever (usually > 101 F [38.3 C])
BMI:
Persistent uncontrolled pain
M: BEE( Kcal/day) = 66 + ( 13.7 x wt. in kg) +
Excessive redness or drainage from incision
(5 x ht. in cm) (6.8 x age in yrs)
Urinary retention/ decreased urine output
F: BEE ( Kcal/day) = 665 + ( 9.6 x wt. in kg) +
( 1.7 x ht. in cm) (4.7 x age in yrs)
Indications for Nutritional Intervention:
For most non-trauma, ICU patients: give 35kcal/kg body
The patient has been without nutrition for 10 days
weight/day
Nutritional deficits occur after 7-10 days of partial
CHON = 0.8 g/kg/day or 1.5 -2.0 g/kg/day for critically ill patients
starvation
1 gram Nitrogen: 150 Kcal
The duration of illness is anticipated to be longer than 10 days
- contraindications to high protein diet:
E.g. peritonitis, pancreatitis, injury severity score > 15,
Renal failure before dialysis ( BUN >
burns > 20% TBSA
40mg/dl)
The patient is malnourished ( loss of > 10% of usual body weight
Hepatic encephalopathy
over 3 months)
Give nutritional support when weight loss approaches
DEFINITION OF TERMS:
or exceeds 15% of usual body weight:
SIRS: ( 2 or more of the ff. are required)
%weight loss = Usual weight present weight X 100
1. Temp > 38 C ( 100.4 F) or , 36 C ( 96.8F)
Usual weight
2. HR > 90 bpm
3. RR > 20 cpm
Guidelines for Red Blood Cell Transfusion for Acute Blood Loss *
4. WBC > 12, 000/cumm3, < 4, 000/cumm or > 10%
Evaluate risk of ischemia. bands
Estimate/anticipate degree of blood loss. Less than
30% rapid volume loss probably does not require
transfusion in a previously healthy individual.
SEPSIS: Base Deficit > 4meq/L
SIRS + Clinically likely source of infection BUN Increase > 5mg/dl
Hematocrit fall > 10%
SEVERE SEPSIS Fluid Sequestration > 6,000ml
SEPSIS + hemodynamic instability
necessitating fluid resuscitation Total Body Water:
(hypoperfusion, hypotension, lactic 75-80% in newborns
acidosis, oliguria, mental status changes) 65% at 1 yr of age
SEPTIC SHOCK 60% lean body weight in young men 15%
SEVERE SEPSIS + Hemodynamic instability 50% in young women and older men 15%
necessitating inotropic support 45% in older women
2/3 intracellular or 30-40% - largest
proportion in skeletal muscle mass
Phases of wound healing: ACS 2005 pp 110-115 ECF = 20% body weight
1. hemostasis vasoconstriction Plasma = 5%
2. inflammation 24 hrs -5-7 days Interstitial = 15%
3. migratory phase
a. angiogenesis begins at 2nd -3rd day Average Insensible water loss/day ( pure-water, electrolyte-free)=
b. epithelialization begins approx 24 hrs 500-600cc
after wounding Skin, lungs ( increased by fever,
4. proliferative phase begins on 5th day hyperventilation)
a. wound contraction most active for 12-15 Increased renal excretion: diabetic insipidus
days until wound edges meet Water of oxidation = 125 800cc/day
5. late phase ( Remodelling) begins 3weeks after Avearge Sensible Water losses:
wounding, continues for 6-12 months; tensile strength Urine = 800- 1500cc, minimum of
plateaus at 6 weeks post injury 300cc
Intestinal = 0-250cc
Wound Dehiscence:
separation within the fascial layer Composition of GI Secretions:
serosanguinous discharge on days 5-8 Type of Volume Tonicity Major
Causes: Secretion ( ml/24hrs) electrolytes
increasing age Salivary 500-2000 cc, Hypotonic HCO3, K
technical factors Ave = 1500
malnutrition Gastric 100- 4000cc; Hypotonic Cl, Na
hypoproteinemia Ave = 1500
uremia Duodenum 100-2000cc; Isotonic Na, Cl
diabetes Ileum 100-9000cc Isotonic Na, Cl
increased abdominal pressure ( coughing, ascites) Ave = 3000
jaundice Colon Hypotonic Na, Cl
cancer Pancreas 100-800cc Isotonic Na, HCO3, Cl
local factors:
Bile 50-800cc Isotonic Na, Cl
- hemorrhage
Hypotonic losses:
- Infection
Sweat
- excessive suture material
Vomiting, NGT suction
- poor surgical technique
Osmotic cathartics: lactulose, sorbitol
Osmotic diuretics: mannitol, glycosuria
Ransons Criteria ( objective signs of severity of acute
WaterDeficit = Normal body water ( 1 serum Sodium/140)
pancreatitis)
IV Fluid challenge: present weight x 0.07 L/kg x 0.10 = IV bolus to
On Admission:
be given
Age > 55 y.o
give 10% of estimated circulating
Glucose > 200mg/dl
volume
WBC > 16,000/cumm
blood is 7% of body weight
LDH > 350 IU/L
65%-75% of infused fluids leaves the
AST > 250 U/L
vascular compartment within 30 min
After Initial 48 hrs
Serum Ca++ < 8mg/dl
Arterial PO2 < 60mmHg