降低感染率的围手术期策略

TheJournalofBoneandJointSurgery(American).2010;92:232-239.PerioperativeStrategiesforDecreasingInfectionAComprehensiveEvidence-BasedApproach降低感染率的围手术期策略：综合性循证医学路径JosephA.Bosco,III,MD1,JamesD.Slover,MD,MS1andJanetP.Haas,RN,PhD21DepartmentofOrthopaedicSurgery,NYUHospitalforJointDiseases,NewYorkUniversityLangoneMedicalCenter,301East17thStreet,NewYork,NY10003.E-mailaddressforJ.A.BoscoIII:[e-mail]:[e-mail]2InfectionPreventionandControl,WestchesterMedicalCenter,100WoodsRoad,MacyPavilionSW246,Valhalla,NY10595.E-mailaddress:[e-mail]Lecture,AmericanAcademyofOrthopaedicSurgeonsIntroduction引言Surgicalsiteinfectionsassociatedwithorthopaedicsurgicalproceduresaredevastatingcomplications.Theyincreasemorbidity,mortality,andcostandresultinoutcomesthatareworsethanthoseinuninfectedcases1.Decreasingtheincidenceofsurgicalsiteinfectionsisnotonlyofinteresttopatientsandsurgeons,itisalsoamajorfocusofseveralgroupsofinterestedparties.Theserangefrompayers,includingtheCentersforMedicareandMedicaidServices(CMS,Baltimore,Maryland),toinstitutionsrepresentedbytheSurgicalCareImprovementProject(SCIP),amultiple-institutionpartnershipbetweenmajorpublicandprivatehealth-careorganizations,includingtheJointCommissiononAccreditationofHealthcareOrganizations(OakbrookTerrace,Illinois).Decreasingtheincidenceofsurgicalsiteinfectionsis,andwillcontinuetobe,amajorfocusinmedicine.对于骨科手术而言，手术部位的感染是一种毁灭性的并发症，往往会导致致残率、致死率以及医疗费用的增加，并且与没有发生感染的病例相比，最终的治疗结果通常也会更差【1】。减少手术部位的感染率，不仅对患者和医生都很有意义，也是利益相关的各方非常关注的问题。如出资方，包括医疗保险与医疗辅助服务中心（CMS，Baltimore,Maryland）；以外科医疗改良项目（SCIP）为代表的相关机构；介于大众公共机构与私人医疗保健机构之间的多机构合作组织，包括医疗机构评审联合委员会（JCAHO，OakbrookTerrace,Illinois）等。减少手术部位的感染率现在是，将来也仍会是，医学领域关注的焦点问题。Toeffectivelypreventsurgicalsiteinfections,theclinicianmustconsiderpreoperative,intraoperative,andpostoperativefactorsandinterventions.Preoperativestrategiesforreductionofinfectionratesincludeidentificationofhigh-riskpatients,screeninganddecolonizationofpatientswithmethicillin-sensitiveStaphylococcusaureusandmethicillin-resistantStaphylococcusaureuscolonization,preoperativepreparationofthepatientwithchlorhexidinegluconate,utilizationofproperhair-removaltechniques,andaddressingpreexistingdentalandnutritionalissuespriortosurgery.为了有效地防止手术部位的感染，临床医生必须审慎地考虑到手术前、手术中以及手术后的相关因素和干预措施。降低感染的术前策略包括识别高风险的患者，对甲氧西林敏感的金黄色葡萄球菌和耐甲氧西林的金黄色葡萄球菌定植的患者进行筛查，并清除定植菌，术前应用洗必泰葡萄糖酸盐进行清洗，应用合适的方法去除毛发，术前妥善处理先前存在的牙齿及营养相关的问题。Thereareavarietyofperioperativestrategiesthatcanandshouldbeemployedtodecreasetheriskofsurgicalsiteinfections.Intraoperativeinterventionsthathavebeenshowntodecreasesurgicalsiteinfectionratesincludetheproperselection,timing,anddosesofprophylacticantibioticsandutilizationofbestpracticesforhandhygieneandsurgicalsitepreparation.Maintainingasterileoperating-roomenvironmentbydecreasingoperating-roomtraffic,monitoringforbreaksinsteriletechnique,anddecreasingtheuseofflashsterilizationisvital.Finally,postoperativestrategiesforthereductionofsurgicalsiteinfectionratesincludetheproperuseanddurationinsituofurinarycathetersandsurgicaldrains;standardizationofwoundcare;useofantibiotic-impregnatedbandages;and,perhapsmostimportantly,maintenanceofproperhandhygiene,isolationprecautions,androomcleaning.有多种围手术期的策略可以并且必须应用以减少手术部位的感染。术中的一些干预因素已经证实可以降低手术部位的感染率，包括选择合适的种类、时机和剂量预防性应用抗生素，手卫生及术区消毒均采用最优化的方案。通过减少手术室的穿行、监视有无违反无菌技术的操作、减少快速消毒的应用对于维持手术的无菌环境是至关重要的。最后，降低手术部位感染率的术后策略包括合理地应用和维持原有的导尿管和术区引流管，对创口进行标准化护理；应用抗生素浸润的绷带，以及，可能最为重要的是，保持正确的手卫生、隔离预防和室内清洁。PreoperativeConsiderations术前注意事项Althougheveryprecautionshouldbetakentopreventinfectionforallorthopaedicpatients,theidentificationofhigh-riskpatientsenablesclinicianstoprovidemaximalpreventionstrategiesforthem.Furthermore,theidentificationofpatientsathighriskforinfectionallowsappropriatepreoperativecounselingforshareddecision-makingandestablishesappropriatepatientexpectationsregardingsurgicalrisks.虽然对于所有骨科患者，都应该采用各种预防措施以防止感染，但临床医生识别出高风险的患者后，便可针对其制定最大限度的防范策略。此外，识别出感染的高风险患者后可进行适当的术前告知谈话，这样可与患者共同制定治疗决策，并使患者对于手术风险树立合理的期望值。Numeroushigh-riskpatientpopulationsandriskfactorsthatplacepatientsathighriskforinfectionaftertotaljointreplacementorspinesurgeryhavebeendescribedintheliterature.Someofthesefactorscanbemodified,whileotherscannot.Anexplanationoftheriskfactorsthatcannotbemodifiedshouldbeincludedwhenpatientsarecounseledabouttheirincreasedriskofinfectionwiththeproposedsurgicalprocedure.Inthisway,patientswillmorecompletelyunderstandtherisksandbenefitswhendecidingonsurgery.Twocommonfactorsthatcannotbemodifiedandthatincreasetheriskofinfectionwithjointreplacementareahistoryofinfectioninthejoint2andahistoryofsteroidinjectionintothejoint3.Factorsthatcannotbemodifiedthatincreasetheriskofinfectioninpatientsundergoingspinesurgeryincludetrauma-relatedsurgery4,useofinstrumentation5,andlumbar6andposterior4surgery.对于关节置换术和脊柱手术的感染，有很多高风险患者人群以及相关的危险因素使患者具有较高感染风险的情况，在以往的文献中都有论述。在这些因素中，有些事可以改善的，而有些则无法改变。对于无法控制的危险因素，在对患者进行术前告知谈话时，应向其说明这样会增加感染的风险。这样，患者在决定做手术时便可更全面地认识到相关的风险和益处。有两个无法控制的因素，既往关节感染病史【2】和既往关节内类固醇注射史【3】，通常会增加关节置换手术的感染风险。而对于进行