BENVENUTI !
1^ Sessione
Moderatori: Sonia Bianchi & Paolo Cappellini
RINGRAZIAMENTI
COMPLICANZE DEL SITO CHIRURGICO
“L’evento avverso non è conseguenza di
un singolo errore umano, ma il frutto di
una interazione tra fattori tecnici,
organizzativi e di processo”
INFEZIONI DEL SITO CHIRURGICO
Impatto Clinico
 INCIDENZA:
• CIRCA IL 15% DI TUTTE LE INFEZIONI NOSOCOMIALI
• CIRCA IL 2% DI TUTTI GLI INTERVENTI CHIRURGICI
• CIRCA IL 10-30% DEI PAZ. SOTTOPOSTI A CHIRURGIA INTESTINALE
 MORTALITA’: 2-4 VOLTE Vs NON INFEZIONI
 DEGENZE: > 7 GIORNI Vs NON INFEZIONI
 FOLLOW-UP POST-PROCEDURA:
• VISITE DI CONTROLLO
•
MATERIALI
• SERVIZI
• HOME-CARE
• RIAMMISSIONI OSPED.
COSTI AUMENTATI
Costo medio x paziente $ 20,785
(JAMA September 2, 2013)
Use of antimicrobical prophylaxis for Mayor Surgery
Dale W. Bratler et al. Arch Surg Vol 140, Feb 2005
MICRO-MEGA
RISCHIO INFETTIVO=
CARICA BATTERIACA x VIRULENZA
RISPOSTA PAZIENTE
 105 batteri/ gr tessuto causano infezione
 1 microgrammo di feci è sufficiente per causare un’ infezione
Mangram et al. Infect Control Hosp Epidemiol 1999; 20: 247
FATTORI DI RISCHIO & PROCEDURA CHIRURGICA
% INFEZIONI
CLASSE
I. PULITA
1-5%
II. PULITA/ CONTAMINATA
2-5%
III. CONTAMINATA
5-18%
IV. SPORCA / INFETTA
20-30%
Da Culver. Am J Med 1991;91 (suppl 3B): 152S
STRATIFICAZIONE DEL RISCHIO INFETTIVO
DEFINIZIONE S.S.I.
1. Superficial Infection:
Infection occurs within 30 days after the operation and
infection involves only skin or subcutaneous tissue of the
incision
2. Deep Infection :
Infection occurs within 30 days after the operation if no
implant is left in place or within 1 year if implant is in place
and the infection appears to be related to the operation
and infection involves deep soft tissues (eg, fascial and
muscle layers) of the incision
3. Organ/space SSI :
Infection occurs within 30 days after the operation if no
implant is left in place or within 1 year if implant is in place
and the infection appears to be related to the operation and
infection involves any part of the anatomy (eg, organs or
spaces), other than the incision, which was opened or
manipulated during an operation
Dis Colon Rectum 2011; 54: 818–825
Centers for Disease Control and Prevention
EFFETTI CLINICI S.S.I.
CHIRURGIA ADDOMINALE
LAPAROCELE
EVISCERAZIONE
TRATTAMENTO DELLE FERITE
 CHIUSURA PRIMARIA: La ferita viene chiusa per approssimazione dei margini.
Vantaggi: Ridotto tempo di guarigione, minor discomfort e miglior risultato estetico.
 CHIUSURA SECONDARIA: La ferita viene lasciata aperta.
Vantaggi: Indicata nelle ferite altamente contaminate o infette e in paz. alto rischio.
Svantaggi: Tempi di guarigione prolungati , discomfort, brutta cicatrice.
 CHIUSURA RITARDATA (O TERZIARIA):
Vantaggi: quelli della chiusura primaria e secondaria insieme.
Svantaggi: Tempi di guarigione prolungati rispetto alla chiusra primaria.
CHIUSURA RITARDATA DELLA FERITA
DELAYED PRIMARY SUTURE OF WOUNDS.
Hepburn, H. H. Brit. Med. Jour., i, I8I-I83, February I5, 1919.
In I917, the French surgeons developed a method of treating
potentially conitamlinated war wounds, called delayed primary
closure. It was applied to all wounds in soft tissue, I5 hours or more
old, except those of the scalp, face and hands. The method consisted
of the usual careful cleansing of skin and deeper aspects of the
wounds; wide debridement; culture of the wound; constaint flooding
of the wound with Dakin's solution or other antiseptic; and wide
packing of the wound with flavine gauze. The patient was then sent to
the Base Hospital, marked for delayed primary closure. Within 24 to
48 hours, the bacterial flora of the wound was known, and if
streptococci were not present, and if there were less than five
colonies per plate, the pack was removed and the wound closed
under anesthesia. The method had many advantages in that the Field
Hospitals and Dressing Stations were emptied rapidly. The first
cultures were available early and infections by the streptococci,whiclh
carried the highest morbidity and mortality, could be sorted outand
treated more adequately. Finally, the surgeon who closed the
woundwas able to follow it personally. Fraser, in I9I8, reported an
incidence of 9.7 per cent failure in 41 cases of primary closure as
compared with 4.5 per cent failure in 63 cases of delayed primary
closure. He also reported 3I bacteriologically negative wounds from
35 contaminated wounds after 48 hours' treatment by delayed primary
closure, employing a flavine pack inthe wound. In I9I8, delayed
primary closure of all soft-tissue wounds, exceptingthose in the scalp,
face and hands, was advised by the surgeons of the American
Expeditionary Force.4 The best results were obtained when the
wounds were closed within 50 hours.
THE DELAYED CLOSURE OF CONTAMINATED WOUNDS:
A PRELIMINARY REPORT
Frederick a.Coller, et al Ann Surg. 1940 August; 112(2): 256–270.
EXPERIENCES WITH DELAYED PRIMARY CLOSURE OF
WAR WOUNDS OF THE HAND IN VIET NAM
by lieutenant colonel william e. burkhalter, bruce butler,
m.d,
Medical Corps, U.S.Army - In the late summer and fall of 1965
Summary
An analysis is presensted of the early results of treatment of
135 high-velocity missile wounds of the hand sustained in the
Republic of Viet Nam. A method of staged-wounds
management, including primary debridement and secondary
closure,is described.
Onlv three acute infections were encountered.
DELAYED WOUND CLOSURE:INDICATIONS AND
TECHNIQUES. War Wounds of Limbs - Surgical Management
Dimick AR. Ann Emerg Med. 1988 Dec;17(12):1303-4.
Experience With Wound VAC and Delayed Primary
Closure of Contaminated Soft Tissue Injuries in Iraq
Leininger, Brian et al.
Journal of Trauma-Injury Infection & Critical Care:
November 2006 - Volume 61 - Issue 5 : 1207-1211
Background: Wartime missile injuries are frequently high-energy wounds that devitalize and contaminate
tissue, with high risk for infection and wound complications. Debridement, irrigation, and closure by secondary
intention are fundamental principles for the management of these injuries. However, closure by secondary
intention was impractical in Iraqi patients. Therefore, wounds were closed definitively before discharge in all
Iraqi patients treated for such injures at our hospital. A novel wound management protocol was developed to
facilitate this practice, and patient outcomes were tracked. This article describes that protocol and discusses
the outcomes in a series of 88 wounds managed with it.
Methods: High-energy injuries were treated with rapid aggressive debridement and pulsatile lavage, then
covered with negative pressure (vacuum-assisted closure [VAC]) dressings. Patients underwent serial
operative irrigation and debridement until wounds appeared clean to gross inspection, at which time they were
closed primarily. Patient treatment and outcome data were recorded in a prospectively updated database.
Results: Treatment and outcomes data from September 2004 through May 2005 were analyzed
retrospectively. There were 88 high-energy soft tissue wounds identified in 77 patients. Surprisingly, for this
cohort of patients the wound infection rate was 0% and the overall wound complication rate was 0%.
Conclusion: This series of 88 cases is the first report of the use of a negative pressure dressing (wound
VAC) as part of the definitive management of high-energy soft tissue wounds in a deployed wartime
environment. Our experience with these patients suggests that conventional wound management
doctrine may be improved with the wound VAC, resulting in earlier more reliable primary closure of
wartime injuries.
Surgical Site Infections
Drop by 19% in the United States
Between 2008 and 2013
DECREASE RATE:

Hip arthroplasty (27%)

Knee arthroplasty (40%)

Colon surgery (8%)

Rectal surgery (21%)

Abdominal hysterectomy (14%)

Vaginal hysterectomy (19%)

Coronary artery bypass graft (40%)

Other cardiac surgery (44%)

Peripheral vascular aneurysm repair (43%)

Abdominal aortic aneurysm repair (70%)
General Surgery
March 2015 | Vol: 42:03
Un'assistenza sanitaria più sicura in Europa
Risoluzione del Parlamento europeo del 19 maggio 2015 su un'assistenza
sanitaria più sicura in Europa: migliorare la sicurezza del paziente e
combattere la resistenza antimicrobica (2014/2207(INI))
Secondo le stime, tra l'8 e il 12% dei pazienti ricoverati negli ospedali
comunitari è vittima di eventi avversi, come le infezioni sanitarie correlate.
E quasi la metà sarebbe evitabile.
Bilanci sanitari ristretti possono danneggiare i pazienti
I deputati evidenziano che l'attuale crisi economica ha creato una forte pressione sui
bilanci sanitari nazionali e ha, quindi, avuto un impatto sulla sicurezza dei pazienti.
S'invitano, pertanto, gli Stati membri a garantire che la sicurezza dei pazienti non sia
messa a rischio dalle misure di austerità e che il sistema sanitario resti adeguatamente
finanziato.