infectiile de plaga chirurgicala in ortopedie - spcin.ro · fisa bloc operator ortopedie protezare...
TRANSCRIPT
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INFECTIILE DE PLAGACHIRURGICALA IN ORTOPEDIE
AS. LILIANA CONSTANTIN, DR. MIHAELA VARTIC
Spitalul Clinic de Urgenta Bucuresti
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IAAM – TIPURI
SPIF 16-17 mai2019
• INFECTII DE TRACT URINAR
• INFECTII DE PLAGA CHIRURGICALA
• INFECTII SISTEM SANGVIN
• INFECTII TRACT RESPIRATOR
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INFECTIILE DE PLAGA CHIRURGICALA
SPIF 16-17 mai2019
• 9,5% chirurgia colonului
• 3,5% bypass cu grefe arteriale
• 2.9% cezariene
• 1.4% colecistectomii
• 1.0% proteze de sold
• 0.8% laminectomii
• 0.75% proteze genunchi
The European Centre for Disease Prevention and Control (ECDC) - data on SSI surveillance for 2010-
2011
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SPIF 16-17 mai2019
PREVIZIUNI
Artroplastiile totale de sold – de la 1 % la 2,4%Artroplastiile totale de genunchi – de la 0,75% la 1,6%Chirurgia colonului – de la 9,5% la 20%
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INFECTIILE DE PLAGA CHIRURGICALA IN ORTOPEDIEIMPACT
SPIF 16-17 mai 2019
• Crestere zile de spitalizare – media 8 zile / in ortopedie 20 zile
• Antibiorezistenta- 50% din pacientii infectati - MRSA
• Readmisie – reinternari repetate
• Cost cu 300% (1,6 mild $ SUA)- cele mai costisitoare – implant de revizie
• PACIENTII CU PROTEZE DE REVIZIE – 25% fac SSI
• Supraveghere durata pana la 1 an
• Risc mare mortalitate si morbiditate
• Impact psihologic extrem – amputatie
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SPIF 16-17 mai2019
2016 2018
EXISTA SOLUTII ?
PROGRAM PREVENTIE
REZULTAT ??
REDUCERE SSI 40%- 60 %
SSI=surgical site infections
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SPIF 16-17 mai 2019
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SPIF 16-17 mai 2019
FISA PACIENTULUI - BLOC OPERATOR ORTOPEDIE
FISA BLOC OPERATOR ORTOPEDIE PROTEZARE SOLD
DR. APOSTOLESCU ROBERT
DATA………………………………..SECTIA………………………………
PROTEZA TOTALA SOLD CIMENTATA SI NECIMENTATA
PACIENT
NUME………………………………………… PRENUME……………………………………………. VARSTA ………………….ani Inaltimea ……………… cm Greutatea ……………… kg F.O………………
DATA INTERNARII
MEDIC CURANT
DIAGNOSTIC
………………………………………………………………………………………………………………………………………………………………… …………………………………………………………………………………………………………………………………………………………………
INTERVENTIA CHIRURGICALA PROPUSA
………………………………………………………………………………………………………………………………………………………………… ………………………………………………………………………………………………………………………………………………………………….
INTERVENTIA CHIRURGICALA EFECTUATA
………………………………………………………………………………………………………………………………………………………………… ………………………………………………………………………………………………………………………………………………………………….
ECHIPA CHIRURGICALA
1. CHIRURG…………………………………………………………..
2. CHIRURG…………………………………………………………..
3. CHIRURG……………………………………………………………..
4. MEDIC ANESTEZIST………………………………………………
5. ASISTENT MEDICAL INSTRUMENTAR…………………………………………..
TIP ANESTEZIE
□ generala □ bloc axial – epi/spinala □ bloc plex / nerv MONITORIZARE TIMP
Ora primire in sala………………Ora anesteziei………………………….Ora inciziei……………………… Ora sutura completa………………Ora trezire anestezie…………..Ora iresire din sala……………..
PREGATIRE PREOPERATORIE
PREGATIRE TEGUMENTE
□ Dus corporal efectuat preoperator □ DA □ NU
Metoda de indepartare a parului □ tuns □ epilat ; Executat in SALON/SALA OPERATII/ salon
preoperator de…………………………….………… Identificarea zonei de incizie prin marcarea vizibila folosind skin marker
□ sold □ drept □ stang
Ciorap antiembolie membrul inferior □ stg □ drept □ NU DOCUMENTE SI INVESTIGATII
□ foaia de observatii □ radiografii □ RMN □ CT □ planning preop □ consimtamant
semnat □ grup sangvin □ analize sange □ urocultura □ exudat naso-faringian
Status infectios actual : □HCV □HBV □HIV altele……………………………………….
Alergie □ DA □ NU ; factori alergeni cunoscuti…………………………………………………………
Diabet □ DA □ NU ; □ tip I □ tip II
MEDICATIE PREOPERATORIE
□ ANTIBIOPROFILAXIE cu …………………………………………………..□ test alergie antibiotic efectuat □ ora administrarii antibiotic………………..executat de………………………………………………………… (antibioticul trebuie administrat cu max. 30 minute inaintea inciziei)
□ ora administrarii ACID TRANEXAMIC □ doza 1 …………. □ doza 2 ……………… (doza = 1g; se administreaza PRIMA DOZA INAINTEA INCEPERII interventiei chirurgicale _ maxim 30 min inaintea inciziei - si A DOUA- INAINTE DE INCHIDEREA PLAGII)
□ terapia durerii cu combinatie de antiinflamator, antialgic (Perfalgan, Tramadol) si numai la
nevoie opioid.
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PREOPERATOR – DUSUL/BAIA SI INDEPARTAREA PARULUI
SPIF 16-17 mai 2019CHG = gluconate de clorhexidina
SCUB = Spitalul Clinic de Urgenta Bucuresti
SCUB – sapun CHG sau servetele umede in ATI
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PREOPERATOR – HAIR CLIPPERS
SPIF 16-17 mai 2019
SCUB – masina tuns
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PREOPERATOR – HAIR CLIPPERS
METODA DE INDEPARTARE A PARULUI
RAS = 5.6% RATA SSI
TUNS /EPILAT = 0.6% RATA SSI
NO HAIR REMOVAL = 0.6% RATA SSI
TIMPUL INDEPARTARII PARULUI
IMEDIAT INAINTE = 3.1% RATA SSI
24 ORE INAINTE = 7.1% RATA SSI
>24 ORE INAINTE = 20% RATA SSI
CDC – CENTERS FOR DISEASE CONTROL AND PREVENTIONSPIF 16-17 mai 2019
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SPIF 16-17 mai 2019
PREOPERATOR-DECOLONIZAREA
NASO-FARINGIANA
•Mupirocin 2% cu/fara
baie cu sapun CHG
SCUB – ortopedie - pentru
toate interventiile elective si
cu risc mare de infectie
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SPIF 16-17 mai 2019
SCUB – ortopedie – min 30’-max 60’ inaintea
inciziei sau 60’ inaintea benzii Tourniquet
-comunicare eficienta cu echipa anestezica
PREOPERATOR – ANTIBIOPROFILAXIACHIRURGICALA
TIP ANESTEZIE
□ generala □ bloc axial – epi/spinala □ bloc plex / nerv MONITORIZARE TIMP
Ora primire in sala………………Ora anesteziei………………………….Ora inciziei……………………… Ora sutura completa………………Ora trezire anestezie…………..Ora iresire din sala……………..
PREGATIRE PREOPERATORIE
PREGATIRE TEGUMENTE
□ Dus corporal efectuat preoperator □ DA □ NU
Metoda de indepartare a parului □ tuns □ epilat ; Executat in SALON/SALA OPERATII/ salon
preoperator de…………………………….………… Identificarea zonei de incizie prin marcarea vizibila folosind skin marker
□ sold □ drept □ stang
Ciorap antiembolie membrul inferior □ stg □ drept □ NU DOCUMENTE SI INVESTIGATII
□ foaia de observatii □ radiografii □ RMN □ CT □ planning preop □ consimtamant
semnat □ grup sangvin □ analize sange □ urocultura □ exudat naso-faringian
Status infectios actual : □HCV □HBV □HIV altele……………………………………….
Alergie □ DA □ NU ; factori alergeni cunoscuti…………………………………………………………
Diabet □ DA □ NU ; □ tip I □ tip II
MEDICATIE PREOPERATORIE
□ ANTIBIOPROFILAXIE cu …………………………………………………..□ test alergie antibiotic efectuat □ ora administrarii antibiotic………………..executat de………………………………………………………… (antibioticul trebuie administrat cu max. 30 minute inaintea inciziei)
□ ora administrarii ACID TRANEXAMIC □ doza 1 …………. □ doza 2 ……………… (doza = 1g; se administreaza PRIMA DOZA INAINTEA INCEPERII interventiei chirurgicale _ maxim 30 min inaintea inciziei - si A DOUA- INAINTE DE INCHIDEREA PLAGII)
□ terapia durerii cu combinatie de antiinflamator, antialgic (Perfalgan, Tramadol) si numai la
nevoie opioid.
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SPIF 16-17 mai 2019
PREOPERATOR- MARCAJ ZONA DE INCIZIE
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SPIF 16-17 mai 2019
PREOPERATOR- ZONA DE INCIZIE
Solutie pe baza de alcool /
solutie antiseptica apoasa?
CHG= gluconate de clorhexidina
PI = povidone iodine
• Timpul de actiune si remanenta al
antisepticului
• START aplicare de la zona de incizie spre
periferie
• NU substanta in exces
• ALERGII !!!
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SPIF 16-17 mai 2019
PREOPERATOR- SPALAREA CHIRURGICALA A MAINILOR
SCUB - solutie apoasa cu PVI sau CHG
- solutie alcoolizata
CONDITII ESENTIALE
- mainile sa fie USCATE inainte de a imbraca manusile sterile
- NU APLICA ALCOOL PE MAINI UMEDE !!!
- NU STERGE ALCOOLUL !!! LASA-L SA ACTIONEZE!!!
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SPIF 16-17 mai 2019
PREOPERATOR- SPALAREA CHIRURGICALA A MAINILOR
• INTERZISE UNGHIILE APLICATE, LACUITE!!!
• Fara INELE, BRATARI, CEAS DE MANA, bijuterii
multiple si voluminoase la baza gatului sau atranand,
fara CERCEI VOLUMINOSI, se admite FARD DECENT!
• educatia pacientilor conduce la REFUZUL
acestora de a fi ingrijiti de personalul
care nu respecta aceste reguli
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SPIF 16-17 mai 2019
PREOPERATOR – ECHIPAMENTUL STANDARD DE PROTECTIE IN BO
- DEZINFECTIA MAINILOR INAINTE DE A INTRA IN BLOCUL
OPERATOR
- Masca –pt uz chirurgical
- Purtata pe nas
- Boneta chirurgicala – acopera parul in intregime
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SPIF 16-17 mai 2019
METODA INCHISA DE IMBRACARE A MANUSILOR STERILE
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SPIF 16-17 mai 2019
INTRAOPERATOR – MANUSA DUBLA CU INDICATOR
- MANUSA DUBLA IN
ORTHO
- PRIMA MANUSA se
schimba la interval de
1 ora
- Nu se “dezinfecteaza”
manusile cu alcool
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SPIF 16-17 mai 2019
POSTOPERATOR – INDEPARTAREA HALATULUI SI A MANUSILORSTERILE
Nu se atinge masca –
filtrul incarcat microbian =
contaminarea mainilor
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SPIF 16-17 mai 2019
PREOPERATOR- PROCESAREA INSTRUMENTARULUI CHIRURGICAL
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SPIF 16-17 mai 2019
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SPIF 16-17 mai 2019
INTRAOPERATOR- PROCESAREA INSTRUMENTARULUICHIRURGICAL
Prevenirea biofilmului – stergere
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SPIF 16-17 mai 2019
INTRAOPERATOR- MANIPULAREA IMPLANTULUI
- SCUB – implantul se manipuleaza cu MANUSA
CURATA
- La interval de 1 ora, manusile se schimba
- Se stabileste POZITIA UNICA a implantului pe
masa de instrumentar
- Daca se cere repozitionarea lui , se sterg urmele
de sange se IMPLANTEAZA CURAT
- Biofilmul de pe implant poate declansa infectie in
intervalul de 1AN de la implantare
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SPIF 16-17 mai 2019
INTRAOPERATOR- CIMENTARE PROTEZA – METODA IN VID
SCUB- Toate protezele se
cimenteaza cu ciment care contine
antibiotic
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SPIF 16-17 mai 2019
INTRAOPERATOR – LAVAJUL PLAGII
- LAVAJ PULSATIL cu ser fiziologic inainte de implantare
dar si a plagilor inainte de a incepe sutura
- NU se face lavaj cu ANTIBIOTIC ca masura de
prevenire a SSI
- Este permis lavajul cu SOLUTIE APOASA de PVI C%
0,35%
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SPIF 16-17 mai 2019
INTRAOPERATOR- NORMOTERMIA
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SPIF 16-17 mai 2019
INTRAOPERATOR- CAMPURI SI HALATE STERILE
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SPIF 16-17 mai 2019
INTRAOPERATOR – TRAFICUL SI DISCIPLINA IN BO
• Limitarea
numarului de
persoane
prezente la
interventie
• Usile permanent
inchise
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- Nu se prelungeste
antibioterapia in post-
operator
- Dren /sonda urinara – doar
daca este necesar si numai
24 ore
- NU pansament aditional
nejustificat – hidrocoloid,
argint,etc.
- In plagi cu potential septic-
pansament cu pres negativa
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SPIF 16-17 mai 2019
MANAGEMENT CORECT – CURATENIA BO
• Intre interventii
• Curatenia terminala
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FACTORI DE RISC VARIABILI SI CONTROLABILI
VARSTA
SEX
ASA SCORE
CLASIFICAREA PALGII
TIPUL DE TRAUMATISM
TIP DE ANESTEZIE
URGENTA VS INTERVENTIE ELECTIVA
DURATA INTERVENTIEI
DURATA POSTOPERATORIE
ZONA INFECTIEI (PIELE/TESUTURI SUBCUTAN, CAVITATE ORGAN )
AGENT PATHOGEN
GRAD MORTALITATE
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SPIF 16-17 mai 2019
• LOCUL 1 in tarile slab-mediu
dezvoltate- afecteaza pana la 1/3 din
pacientii chirurgicali
• in Europa 500 000 pac. – 19 mild
EU/an
• USA – 400 000 extra-zile spitalizare
• anual add-cost 10 mild $
INFECTIILE DE PLAGA CHIRURGICALAIMPACT
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SPIF 16-17 mai2019
2016 2018
EXISTA SOLUTII ?
PROGRAM PREVENTIE
REZULTAT ??
REDUCERE SSI 40%- 60 %
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ECHIPA MULTIDISCIPLINARA SI PROGRAM DE CONTROL SI SUPRAVEGHERE
SPIF 16-17 mai 2019
• MANAGER, CHIRURG, ANESTEZIST, EPIDEMIOLOG,
INFECTIONIST, ASISTENTI SEFI BOP, ATI, SECTII,
STERILIZARE, STAFF CURATENIE, FARMACIE, SPALATORIE,
etc
• PROGRAM DE SUPRAVEGHERE SI CONTROL
• Evaluarea realitatii – bune practici si proceduri
• Rata de infectii reala
• Training si pregatire
• Monitorizare si reevaluarea punctelor slabe
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PREVENIREA INFECTIILOR INCEPE DE LA BAZA
SPIF 16-17 mai 2019
BAZA =
CONSTIINTA
SPITAL CURAT
EDUCATIE CIVICA si PROFESIONALA - scoala
COMPLIANTA MARE A IGIENEI MAINILOR
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VA MULTUMESC!