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Inflammation, Wound Healing, and Infection

Inflammation, Wound Healing, and Infection. Anne McConville, MD. Why do we care?. Wound infection and failure remain common complications Prolong hospitalization Increased resource consumption Increased costs Increased mortality Influenced by patient factors and perioperative management.

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Inflammation, Wound Healing, and Infection

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  1. Inflammation, Wound Healing, and Infection Anne McConville, MD

  2. Why do we care? Wound infection and failure remain common complications Prolong hospitalization Increased resource consumption Increased costs Increased mortality Influenced by patient factors and perioperative management

  3. Infection Control: Hand Hygiene • Hand Hygiene • Often neglected • Semmelweis first noted in with 1847: puerperal infections • Resident vs. Transient flora • Even “clean” procedures can result in contamination

  4. Infection Control:Hand Hygiene • Various Hand Hygiene Products • Plain soap and water • Alcohol-based rinses and gels • Chlorhexidine • Iodine and iodophors • Choice depends on expected pathogen, acceptability of HCW’s, and cost (usually $1/patient day).

  5. Infection Control: Hand Hygiene • Barriers to hand hygiene • Skin irritation • Inaccessibility • HCW acceptance

  6. Infection Control:Antisepsis Masks Caps Sterile gloves Drapes Decrease OR traffic Site of line placement

  7. Infection Control:Antibiotic Prophylaxis Miles et. al used guinea pig model as proof of principle for antibiotic prophylaxis Knighten et. al assessed the use of high inspired oxygen alone and in addition to prophylactic antibiotics Classen et. al prospective human study showed same results as Miles. Standard for surgeries in which greater than minimal risk of infection

  8. Infection Control:Antibiotic Prophylaxis THA, TKA, extraduralortho and neuro spine, CT, vascular, kidney transplant: Cefazolin Cranial and intradural spine: Ceftriaxone Liver transplantation: Ceftriaxone Colon surgery: Cefotetan Vaginal and abdominal Hysterectomy: Cefazolin or Cefotetan (if bowel involved) Dosing depends on weight, redosing interval depends on durgs used. Discontinued by 24 hours postoperatively

  9. Surgical Site Infections Superficial Incisional (SSI) Deep Incisional SSI Organ/Space SSI

  10. Mechanism of Wound Repair Inflammation Matrix production Angiogenesis Epithelization Remodeling

  11. Initial Response to Injury Starts with skin incision creating a wound Phases: hemostasis, inflammation, proliferation, and remodeling Each phase is mediated by contaminants, interaction between cells, cytokines, and other chemical mediators

  12. Initial Response to Injury: Hemostasis Platelet aggregation and degranulation Release of chemoattractants and growth factors Coagulation results

  13. Initial Response to Injury: Inflammation Bradykinin, complement and histamine released by mast cells PMN’s arrive almost immediately followed by macrophages in 1-2 days WBC’s continue cycle of inflamamtion Characterized by erythema and edema of wound edges

  14. Proliferation • Begins about 4 days after injury • Neovasularization • Angiogenesis • Vasculogenesis • Collagen and Extracellular Matrix Deposition • Oxygen dependent process • Epithelization

  15. Maturation and Remodeling Ongoing remodeling of granulation tissue and increasing tensile wound strength Wound will never achieve tensile strength of uninjured skin/tissue Hypertrophic and keloid scars

  16. Wound Perfusion and Oxygenation • Ischemic or hypoxic tissue susceptible to infection and poor healing • Wound tissue oxygenation dependent on: • Perfusion • Arterial oxygen tension • Hemoglobin dissociation conditions • Local oxygen consumption • Carrying capacity

  17. Wound Perfusion and Oxygenation • Avoid vasoconstrictors • Keep patient warm

  18. Preoperative Management Address modifiable risk factors Optimize cardiopulmonary function Treat vasoconstriction Treat existing infection Administer appropriate antibiotics Glucose control

  19. Intraoperative Management Administer appropriate antibiotics and re-dose at indicated intervals Maintain normothermia Elevate PaO2 Gentle surgical technique Keep wound moist Antibiotic irrigation Delay closure for contaminated wounds Use appropriate suture and dressings Judicious fluid administration

  20. Postoperative Management Pain control Maintain adequate blood volume Keep patient warm Avoid vasoactive substances Maintain PaO2 Maintain glycemic control

  21. Summary Anesthesiologists have opportunity to enhance wound healing during perioperative management

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