Time Of Surgical Debridement Research Articles

Relationship between Time to Surgical Debridement and Rate of Wound Infection in Open Tibia Fracture in a Tertiary Care Hospital

Background: The most frequent open long bone injury requiring immediate surgical intervention is an open tibial fracture. Within 6 hours of the injury, emergent surgical debridement of an open tibia fracture is advised by current guidelines. Recently, the 6-hour rule became challenged and delaying in debridement of an open fracture may be unethical. Methods: This cross-sectional study was carried out to assess the relationship between time of surgical debridement and rate of infection after open fracture tibia at National Institute of Traumatology and Orthopedic Rehabilitation (NITOR) on 608 patients with open fracture tibia (all Gustilo types) within 24 hours of injury from January 2018 to October 2019. Results: The mean age of the 608 patients was 36.2±15.5 years. The foremost mechanism of injury was road traffic accident (72.0%) and among the associated injuries, concomitant soft tissue injury (32.5%) was prevalent. Gustilo III was predominant injury (72.1%) and infection rates among the Gustilo subtype II was predominant (31.3%). After debridement 73 (12.0%) patients were contamination free. A significant association was found in the contamination rate between surveillance culture and post-debridement culture (p=0.000). Positive correlation found between debridement done ≥6 hours and infection present in 3rd culture from ward (r=0.237). Conclusion: The study insights that injury characteristics, infection pattern and infection rate of open fracture tibia. Delay in debridement has a significant relationship with wound infection, with more virulent multidrug resistance phenotypes.

Preoperative Antibiotics Influence Culture Yield in the Treatment of Hand, Wrist, and Forearm Infections.

We conducted a retrospective review of 470 consecutive patients who underwent debridement for a presumed acute infection of the hand, wrist, or forearm at a single tertiary care center between January 2015 and May 2020. Data including patient demographics, mechanism of infection and affected body part(s), and details of antibiotic administration, including type and timing with respect to culture acquisition, were collected. Three hundred and forty-one patients (73%) received preoperative antibiotics prior to debridement and culture acquisition. The rate of positive cultures among patients who received preoperative antibiotics was 81% compared with 95% among patients who did not receive preoperative antibiotics (p < 0.01; odds ratio, 4.73). Even a single dose of antibiotics imparted a significantly increased risk of obtaining negative intraoperative cultures, and an incremental increase in the likelihood of obtaining negative cultures was seen with each preoperative dose given up to 7 doses. We did not identify a "safe" interval of time between antibiotic administration and culture acquisition such that culture yield was not affected. Patients who received preoperative antibiotics for the treatment of upper-extremity infections were approximately 5 times more likely to have negative cultures at the time of debridement than those who did not receive preoperative antibiotics. This effect persisted regardless of the number of doses given or the interval between antibiotic administration and culture acquisition. Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

The Effect of Delayed Surgical Debridement in the Management of Open Tibial Fractures: A Systematic Review and Meta-Analysis.

Introduction: Open tibial fractures are complex injuries with variable outcomes that significantly impact patients’ lives. Surgical debridement is paramount in preventing detrimental complications such as infection and non-union; however, the exact timing of debridement remains a topic of great controversy. The aim of this study is to evaluate the association between timing of surgical debridement and outcomes such as infection and non-union in open tibial fractures. Materials and Methods: We performed a systematic review and meta-analysis of the literature to capture studies evaluating the association between timing of initial surgical debridement and infection or non-union, or other reported outcomes. We searched the MEDLINE, PubMed Central, EMBASE, SCOPUS, Cochrane Central and Web of Science electronic databases. Our methodology was guided by the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement and the Cochrane handbook for systematic reviews of interventions. Results: The systematic review included 20 studies with 10,032 open tibial fractures. The overall infection rate was 14.3% (314 out of 2193) and the overall non-union rate 14.2% (116 out of 817). We did not find any statistically significant association between delayed debridement and infection rate (OR = 0.87; 95% CI, 0.68 to 1.11; p = 0.23) or non-union rate (OR = 0.70; 95% CI, 0.42 to 1.15; p = 0.13). These findings did not change when we accounted for the effect of different time thresholds used for defining early and late debridement, nor with the Gustilo–Anderson classification or varying study characteristics. Conclusion: The findings of this meta-analysis support that delayed surgical debridement does not increase the infection or non-union rates in open tibial fracture injuries. Consequently, we propose that a reasonable delay in the initial debridement is acceptable to ensure that optimal management conditions are in place, such that the availability of surgical expertise, skilled staff and equipment are prioritised over getting to surgery rapidly. We recommend changing the standard guidance around timing for performing surgical debridement to ‘as soon as reasonably possible, once appropriate personnel and equipment are available; ideally within 24-h’.

An Updated Evidence About the Role of Timing to Debridement on Infection Rate of Open Tibial Fractures: A Meta-Analysis.

Background and objectivesRecent experimental and clinical evidence supporting early debridement for open fractures has been questioned. Therefore, this systematic review and meta-analysis aimed to summarize and evaluate the current evidence regarding the timing of surgical debridement of open tibial fractures.MethodsA systematic review and meta-analysis were conducted on studies compared the infection rate following early versus late debridement of open tibial fractures. We performed an online, bibliographic, search through the period from January 2000 to June 2020 in five bibliographic databases: Cochrane Central Register of Controlled Trials (CENTRAL), Medline via PubMed, Web of Science, Scopus, and EBSCO host.ResultsNine retrospective studies and six prospective studies were included in the present meta-analysis study. The pooled effect estimate showed no statistically significant difference between early and late debridement regarding the overall infection rate (RD 0.02, 95% CI [0 - 0.04], p = 0.94); there was no significant heterogeneity in the pooled estimate (I2 = 5%). The subgroup analysis showed that the non-significant difference was consistent regardless of the definition of early and late timing to debridement. Likewise, the pooled effect estimate showed no statistically significant difference between early and late debridement regarding the deep infection rate (RD 0.01, 95% CI [-0.01 - 0.03], p = 0.92); there was no significant heterogeneity in the pooled estimate (I2 = 0%). The pooled effect estimate showed no statistically significant difference between early and late debridement regarding the nonunion rate as well. The funnel lots showed little evidence of asymmetry by visual inspection.ConclusionIn conclusion, the current evidence demonstrates no impact of timing to surgical debridement on the infection rate following open tibial fractures in the adult population. Our results demonstrated that the risks of infection, deep infection, and nonunion were similar between patients who underwent delayed versus early debridement.

PO 18105 - Diabetic foot ulcer PEDIS III

Introduction: Infectious agents are associated with amputation of the infected diabetic foot if not promptly treated. It is estimated that 25% of patients with diabetes will present with a foot ulcer at some point of their lives. Our hypothesis is that the microbiological profile isolated from chronic osteomyelitis (CO) secondary to neuropathic foot ulcers is different from the standard profile relayed in the literature. Objective: To determine the microbiological profile and antimicrobial susceptibility patterns of organisms isolated from chronic osteomyelitis (CO) secondary to neuropathic foot ulcers. Furthermore, we aimed to describe the clinical outcomes of 52 patients admitted to a referral diabetic foot center. Methods: Medical charts of 52 patients with clinically infected neuropathic foot ulcers between 2005 and 2013 were reviewed. Osteomyelitis was diagnosed based on suggestive changes on radiographs and magnetic resonance imaging (MRI), and confirmed with a microbiological exam. All cases were followed for at least six months. Only results of bone culture obtained at the time of surgical debridement following antisepsis were considered for microbiological characterization. Results: One hundred and eleven bacterial isolates were identified as causative agents of infection, with a mean 2.13 isolates per patient. There was a predominance of Gram-positive cocci (51%), followed by Gram-negative bacilli (GNB) (43%). The most prevalent agents were Staphylococcus aureus (18%), Enterococcus faecalis (18%) and coagulase-negative Staphylococci (CoNS) (14%). Among S. aureus isolates, the prevalence of methicillin resistance (MRSA) was 48%, and 77% CoNS were methicillin resistant (MRCoNS) with 100% susceptibility to sulfamethoxazole/trimethoprim (SMT/TMP). At 6-month follow-up, 75% of patients were in remission, without signs of infection, 23% of patients presented recurrence of infection, and 2% were lost to follow-up. Conclusion: In diabetic patients with chronic osteomyelitis secondary to neuropathic ulcers, S. aureus, E. faecalis and CoNS were the most frequent agents. The occurrence of MRSA and MRCoNS was high, but with 100% susceptibility to SMT/TMP. Extensive surgical debridement associated with prolonged antimicrobial therapy led to infection remission in 77% of patients after 6 months of follow-up.

Translational research to improve the treatment of severe extremity injuries

ObjectivesSevere extremity injuries are the most significant injury sustained in combat wounds. Despite optimal clinical management, non-union and infection remain common complications. In a concerted effort to dovetail research efforts,...

A New Cost-effective Method of NPWT in Diabetic Foot Wound.

Diabetic foot wounds present a great challenge to surgeons. They are difficult to heal and are a significant risk factor for non-traumatic foot amputation besides being a huge financial burden. NPWT systems commercially available (VAC™ system, KCI Inc., USA) are costly precluding widespread use. To determine whether negative-pressure wound therapy (NPWT) would afford quicker wound recovery as compared to saline-moistened gauze in the treatment of diabetic foot wounds. Sixty patients were randomized into either the experimental NPWT group or conventional dressing group (control). All patients were given medical therapy for diabetes and antibiotics given according to culture and sensitivity patterns. All foot ulcers were surgically debrided prior to initiation of NPWT or conventional treatment. In the NPWT group, dressings were changed every 48-72h. In the control group, conventional dressings were applied at the time of surgical debridement and changed twice a day thereafter. End point of study was when wound was ready for either skin grafting or secondary suturing. End point was achieved in the NPWT group in 17.2(SD ± 3.55) days, compared to 34.9 (SD ± 5.96) days in the control group (p < 0.001). Number of dressing applied were 7.46(SD ± 2.25) in NPWT group versus 69.8(SD ± 11.93) in conventional dressing group (p < 0.001). Ninety percent cases were successfully treated in NPWT Group as compared to 76.6% in conventional group. Rate of healing of ulcer is faster in NPWT group as compared to conventional group. Economically modified NPWT is more cost-effective to the patients in our setup.

Enhancement Effect of Trypsin on Permeation of Clindamycin Phosphate Through Third-degree Burn Eschar.

Antimicrobial therapy remains to be the most important method of wound infection treatment. Systemically administered antimicrobials may not achieve therapeutic level in wound. On the other hand, in the absence of surgical debridement (due to any reason), most topically applied antimicrobials cannot penetrate the wound in therapeutic amount due to the presence of eschar. Burn eschar is a proteinous structure with some lipid components in which proteins seems to play an important role in the barrier effects of eschar. Therefore, in this study the effect of protein-acting enhancer (trypsin) on permeation of hydrophilic model drug (clindamycin phosphate) was investigated. To perform this investigation, permeation of saturated clindamycin phosphate was studied at 32°C through trypsin-treated and untreated eschar samples for 12 h using home-made static diffusion cells. Third-degree burn eschar samples were separated at the time of surgical debridement (7-14 days post burn) from burned patients. Before each experiment, eschar was hydrated for 12 h and samples were then treated with trypsin solution (1%, w/v) for 4 and 24 h. Clindamycin was measured by a HPLC method developed here. Results showed that after trypsin-treatment for 4 and 24 h, clindamycin phosphate permeation flux was increased significantly by about 1.5 and 2 times and permeation lag-time was decreased by about 2 and 1.3 times respectively. The present results show that permeation of drugs through burn eschar can be increased considerably by trypsin.

Tissue-Conserving, yet Radical Surgery for Extensive Gas-Forming Soft Tissue Infections Arising from Perirectal Abscess: Report of a Case

Perirectal abscess is encountered commonly in surgical practice, and simple incision and drainage usually is sufficient. However, life-threatening sepsis may occur. In such instances, the high morbidity and mortality rates from the severe systemic inflammatory response syndrome (SIRS) associated with rapidly evolving necrotizing and gas-forming soft tissue infections are of major concern. Case report and review of pertinent literature. A rare case of extensive necrotizing fasciitis of the torso arising from a perirectal abscess, in which the principles of radical surgical debridement were adhered to while minimizing disfigurement, is reported in a 19-year-old female. In some cases, despite the life-threatening nature of necrotizing fasciitis, it is possible to minimize tissue loss without compromising patient survival. Planning of the patient's site rehabilitation for maximum cosmetic outcome commences at the time of surgical debridement and is especially important for the young patient.

Negative pressure wound therapy for the treatment of sternal wound infections after cardiac surgery

We retrospectively collected and analysed data from patients with sternal wound infections between 1995 and 2001, which were treated with different wound management strategies, and compared them with our patients from 2002 to 2011, who were treated with the sternal negative pressure wound therapy (NPWT). From 1995 to 2001, a total of 198 patients (group A) with a mean age of 65 ± 10 years developed sternal wound infection (67% deep) after cardiac surgery. Wound management consisted of surgical debridement and immediate sternal closure or open packing. From 2002 to 2011, a total of 326 patients (group B) (71% deep) were managed with NPWT at the time of surgical debridement. Total mortality was 10% in group A and 3·6% in group B. Recurrence rates were 34 and 8·5%, respectively, for the groups A and B. The meantime of NPWT was 11 days. In group B patients, 75% proceeded to sternal closure. With the introduction of NPWT, the treatment of sternal wound infections could be substantially improved. Particularly, the high recurrence rates could be minimised; furthermore, the goal to salvage the sternal bone is facilitated.

Clostridium septicum myonecrosis complicating diarrhea-associated hemolytic uremic syndrome

We report the case of a 19-month-old male child with diarrhea-associated hemolytic uremic syndrome (HUS) who developed swelling of the right arm at the site of a peripherally inserted central venous catheter (PICC), fever, and later, ecchymosis. Wound cultures at the time of surgical debridement grew Clostridium septicum. The child subsequently required amputation of the right arm and prolonged therapy with parenteral penicillin and clindamycin. Clostridium septicum infections in children with HUS have been associated with a high rate of mortality. Along with colon cancer, diarrhea-associated HUS comprises a clinical entity which appears to predispose to atraumatic C. septicum infection, where acidic and anaerobic conditions in the diseased colon favor C. septicum invasion. Though not well recognized among pediatric nephrologists, C. septicum infection constitutes a severe, albeit rare, complication of diarrhea-associated HUS, but one in which a high index of suspicion is warranted as aggressive surgical and antibiotic therapy may be life-saving.

Usefulness of Routine Epicardial Pacing Wire Culture for Early Prediction of Poststernotomy Mediastinitis

Poststernotomy mediastinitis (PSM) is one of the most serious complications of cardiac surgery, and its associated morbidity and mortality demand early recognition for emergency therapy. In this study, we investigated the usefulness of epicardial pacing wire (EPW) cultures for the prediction of PSM. Among 2,200 patients who underwent a cardiac surgical procedure at our hospital between 1 January 1999 and 31 December 2001, 82 (3.7%) had PSM; Staphylococcus aureus was the organism (45.1%) most frequently isolated at the time of surgical debridement. EPWs from 1,607 (73.0%) patients, 73 (4.5%) of whom developed PSM, were cultured. EPW cultures from 466 (29.0%) were positive, most often (74.9%) for coagulase-negative Staphylococci. EPW cultures were truly positive in 26 cases, truly negative in 1,106 cases, falsely positive in 428 cases, and falsely negative in 47 cases (with sterile cultures in 35 cases and a culture positive for an organism different from that isolated at the time of debridement in 12 cases). EPW culture had a positive predictive value of only 5.7% and a high negative predictive value (95.9%) for the diagnosis of PSM, with an accuracy of 70.4%. However, the likelihood ratio of positive (1.27) and negative (0.89) tests indicated only small changes in pretest-to-posttest probability. Therefore, a strategy of routine culture of EPWs to predict PSM seems questionable.

Primary management of maxillofacial hard and soft tissue gunshot and shrapnel injuries

Purpose: A 10-year retrospective study was undertaken of all patients treated for facial gunshot and shrapnel wounds at our medical center to evaluate the outcomes and assess the results of simultaneous management to treat the hard and soft tissue injuries primarily. Patients and Methods: A total of 44 patients were treated. Medical documentation of the patients was compiled. All maxillofacial gunshot, shrapnel, and warfare injuries were treated by the oral and maxillofacial surgeon. Other concomitant bodily injuries were treated by pertinent consultant specialists. Patients ranged in age from 8 to 53 years, with a mean age of 24.7 years. Maxillofacial hard and soft tissue injuries were treated definitively in the first operation except when gross contamination, infection, extensive comminution, or general condition precluded this. Results: There were 2 shotgun, 28 bullet, 10 shrapnel, 3 land mine, and 1 breech block injuries. Overall postadmission mortality in this series was 2.2%. Of the 97.7% of the patients who had an injury to the underlying craniofacial skeleton, all required surgical intervention. The soft tissue and underlying bony injuries were addressed concomitantly (in a single stage at the time of primary surgical debridement) in 86.3% of the patients. Nine percent of the patients had a tracheostomy emergently for management of the airway, 6.8% had an intracranial injury, and 2.2% of them required neurosurgery. In the series, 4.5% of the patients had neck wounds that required exploration. Comprehensive treatment was rendered in 1 to 3 major operations (average, 1.5). Conclusion: All patients in this series required surgical intervention for treatment of their facial gunshot wounds. Primary treatment of hard and soft tissue injuries of the face at the time of surgical debridement was possible in the majority of our patients. This minimized the number of admissions and did not bear a higher complication rate than other reported series that advocate multiple staged operations to treat such injuries despite the fact that, in our series, flaps were also mobilized for wound closure in the primary phase.

Surgical-site complications associated with a morphine nerve paste used for postoperative pain control after laminectomy.

To identify risk factors that might explain a sudden increase in the rate of surgical-site complications following laminectomy. Retrospective cohort study. Patients who underwent laminectomy at a 120-bed hospital from August 1 through October 15, 1996 (the epidemic period). A case-patient was defined as a patient with postoperative surgical-site complications (surgical-site drainage, edema, or swelling) requiring surgical debridement. Of the 148 patients who underwent a laminectomy during the epidemic period, 17 (11%) met our case definition. The rate of postoperative surgical debridement was 7.6-fold higher during the epidemic period than the preceding 19-month period (17/148 vs 15/995, P<.001). Development of surgical-site complications was associated with intraoperative receipt of morphine nerve paste (relative risk [RR], 11; P<.001), preoperative shaving by nurses rather than surgeons (RR, 6.6; P=.006), procedures done by a certain surgeon (RR, 3.1; P=.022), or receipt of iodine rather than povidone-iodine for preoperative skin antisepsis (RR, 5.1; P=.002). In multivariate analysis, only receipt of morphine nerve paste remained as a risk factor (RR, 18; P=.011). The paste was used to control postoperative pain and was applied directly to exposed dura and surrounding tissues. At the time of surgical debridement (median, 24 days postsurgery), the original surgical sites showed residual paste and a lack of healing. Ten of 16 cultures from surgical sites were positive; all but three grew skin commensals. Histological examination of surgical specimens showed a foreign-body reaction, but no marked acute inflammation. The intraoperative use of morphine nerve paste may delay wound healing and increase postoperative morbidity. When new products are introduced, standardized protocols should be developed for their use, and systematic surveillance should be done to monitor for potential adverse outcomes.

Tophaceous Gout Simulating Infection about a Stainless Steel Plate

A 55-year-old man developed acute symptoms suggestive of a late, deep infection 8 years after uncomplicated open reduction and internal fixation of fractures to the left ulnar and radial shafts. At the time of surgical debridement, tophaceous material was found surrounding the radial plate. Acute tophaceous gout surrounding fracture fixation devices has not been previously reported and is difficult to distinguish from a deep infection.

Tophaceous Gout Simulating Infection about a Stainless Steel Plate

Summary: A 55-year-old man developed acute symptoms suggestive of a late, deep infection 8 years after uncomplicated open reduction and internal fixation of fractures to the left ulnar and radial shafts. At the time of surgical debridement, tophaceous material was found surrounding the radial plate. Acute tophaceous gout surrounding fracture fixation devices has not been previously reported and is difficult to distinguish from a deep infection.