PPI di kamar operasi

Bambang Wahjuprajitno
Dept. of Anesthesiology & Reanimation
Faculty of Medicine - Univ. of Airlangga
ICU - Dr. Soetomo General Hospital
Surabaya - INDONESIA
E-mail: wprano@yahoo.com

Dampak SSI Events

• 2010: estimasi 16 juta pembedahan di RS perawatan akut di
US
• SSIs: tersering healthcare-associated infection (HCAI) 31%
seluruh HAIs
• NHSN (2006-2008): 16,147 SSIs dari 849,659 pembedahan
(SSI rate 1.9%)
• Mortalitas:
• 3 %, resiko kematian 2-11 kali lebih tinggi
• 75% kematian sebagai akibat langsung diantara SSI
• Morbiditas: cacat seumur hidup
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 Dampak SSI Events

• Length of Hospital Stay

• ~7-10 hari tambahan rawat inap
• Biaya
• $3000-$29,000/SSI tergantung prosedur & pathogen
• Sampai $10 juta setiap tahun
• Belum termasuk biaya tambahan rehospitalisasi, biaya
pasca KRS, dan cacat jangka panjang

Luka operasi
• Clean:
• An uninfected operative wound in which no inflammation is encountered
and the respiratory, alimentary, genital, or uninfected urinary tracts are not
entered

• Clean wounds are primarily closed and, if necessary, drained with closed
drainage

• Clean-Contaminated:
• Operative wounds in which the respiratory, alimentary, genital, or urinary
tracts are entered under controlled conditions and without unusual
contamination

• Operations involving the biliary tract, appendix, vagina, and oropharynx are
included in this category, provided no evidence of infection or major break
in technique is encountered

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 Luka operasi
• Contaminated:
• Open, fresh, accidental wounds. In addition, operations with major
breaks in sterile technique (e.g., open cardiac massage) or gross
spillage from the gastrointestinal tract

• Incisions in which acute, nonpurulent inflammation is encountered

including necrotic tissue without evidence of purulent drainage (e.g.,
dry gangrene) are included in this category

• Dirty or Infected:
• Includes old traumatic wounds with retained devitalized tissue and
those that involve existing clinical infection or perforated viscera.

• This definition suggests that the organisms causing postoperative

infection were present in the operative field before the operation

Sumber patogen
Endogen
• Flora pasien
• kulit
• dinding mukosa
• GI tract
• Penularan dari fokus infeksi yang berjauhan
Exogenous
• Personil bedah (ahli bedah & tim))
• Pakaian kotor
• Kelalaian tehnik aseptik
• Hand hygiene kurang adekuat
• Lingkungan dan ventilasi OK
• Peralatan dan bahan-bahan yang dibawa kelapangan op
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 Penelitian-penelitian yang
berhubungan dengan
pembedahan

Importance of Timing of Surgical

Antimicrobial Prophylaxis (AP)
Early AP (2-24 hrs before incision)
Postop AP (3-24 hrs after incision)
Periop AP (< 3 hrs after incision)
Preop AP (<2 hrs before incision)
Infection rate (%)

CDC
8 Classen DC, et al. NEJM 1992;326:281-286
 Timing of Antibiotic Prophylaxis

14/369

15/441

1/41
1/47

1/61

Incision
2/180

5/699
5/1,009

9 Classen, et al. N Engl J Med. 1992;328:281

Timing of Antibiotic Prophylaxis

8
SSI Rate per 100 procedures (%)

7.46
6.83
6

4.69
4
3.33 3.42

2.42
2

0
0-14 15-29 30-44 45-59 60-74 75-120
Timing of Abx (minutes before incision)

10 Weber WP, Ann Surgery, June 2008

 Impact of Prolonged Antibiotic
Prophylaxis Cardiac Surgery
• 2,641 patients undergoing CABG
• Group 1 <48 hours of antibiotics

• Group 2 >48 hours of antibiotics

• SSI rates
• Group 1 9% (131/1,502)
• Group 2 9% (100/1,139)
• Odds ratio 1.0 (95% CI: 0.8–1.3)
• Increased antibiotic resistant pathogens – Group 2
• Odds ratio 1.6 (95% CI: 1.1–2.6)
11 Harbarth S et al. Circulation. 2000;101:2916–2921

Pre-operative Shaving/Hair Removal

8 20
Razor Shaving immediately before
Depilatory Shaving ≤ 24 hours before
No hair removal Shaving >24 hours before

6 15
SSI Rate (%)

SSI Rate (%)

4 10

2 5

0 0
Method of hair removal Timing of hair removal

12 Seropian. Am J Surg. 1971; 121: 251

 Hair-Removal Techniques and SSIs
Discharge 30-days follow-up
(26/260)
10
(23/260)

(18/241)
7.5
(17/266)
Infection (%)

(14/271)
5 10
8.8 (10/250)
7.5 (7/216)
6.4
2.5 5.2
(4/225)
4
3.2
1.8

0
PM Razor AM Razor PM Clipper AM Clipper

13 Alexander JW et al. Arch Surg. 1983;118:347–352

Prevention of SSIs

Temperature Control
Treatment Control
(36.6±0.5°C) (34.7±0.6°C )

No. Patients 104 96

Transfused Pts. 23 (22%) 34 (35%) p < 0.054

SSIs 6 18

Infection Rate 5.8% 18.8% p < 0.009

Control: Routine intraoperative thermal care (mean temperature 34.7°C)
Treatment: Active warming (mean temperature 36.6°C)

14 Kurz et al. NEJM 1996; 334:1209

 Transfusion and Perioperative Infection

• Koval et al. J Orthop Trauma 1997;11:260-266

• 687 geriatric Pts. undergoing ORIF hip fracture
• 27% postop infection rate transfused vs. 15% non-transfused
• Houbiers JG, et al. Transfusion. 1997;37:126-34
• 697 undergoing surgery for colorectal cancer
• 39% postop infection rate transfused vs. 24% non-transfused
• Relative risk 1.6 for 1-3 U; 3.6 for >3 U
15

The Impact of PRBCs on Nosocomial

Infection Rates in ICU

16 n = 416

12
Percentages (%)

8 15.4
n = 1,717

4 n =1,301
5.9
2.9
0
All Patients Transfusion Group Nontransfusion Group

16 Taylor et al. Crit Care Med 2002;30:2249-2254

 Umur darah

17

Perioperative supplemental
oxygen and SSI

18 Greif R, et al. N Engl J Med 2000;342:161-7

 Prevention of SSIs

Glycemic Control
Diabetes (known and undiagnosed)
Without diabetes
Diabetes with HbA1c ≥8%
Diabetes with HbA1c<8%
8

6
Percentage (%)

4 7.9

5.8
2 4

1.5
0

19 Latham R et al. Infect Control Hosp Epidemiol. 2001;22:607–612.

Prevention of SSIs

Glycemic Control
8
Deep Sternal Infection, %

4
6.8

2
2.6
1.4 1.7

0
100 - 150 150 - 200 200 - 250 250 - 300
Day 1 Glucose (mg %)

20 Zerr. Ann Thorac Surg 1997; 63:356

 Surgical Care Improvement Project (SCIP)

Tindakan-tindakan spesifik untuk profilaksis pembedahan:

• Antibiotik profilaksis diberikan dalam 1 jam sebelum insisi
pembedahan
• Pemilihan antibiotik profilaksis yang tepat untuk pasien bedah
• Antibiotik profilaksis dihentikan dalam 24 jam setelah
pembedahan selesai
• Kendalikan glukosa darah pasca bedah pada pasien cardiac
• Rambut dihilangkan dengan cara yang tepat
• Normothermia segera pasca bedah pada pasien bedah colorectal
• Infeksi luka pasca bedah di-diagnosa selama hospitalisasi
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Strategi pencegahan

• Strategi-strategi inti
• Bukti-bukti ilmiah bermutu tinggi evidence
• Menunjukkan layak digunakan (feasibilitas)
• Strategi-strategi tambahan
• Beberapa bukti ilmiah
• Feasibilitas variable

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 Strategi pencegahan inti:
Tindakan-tindakan preop
Berikan profilaksis antimikroba sesuai dengan
standard dan pedoman berbasis bukti ilmiah
• Berikan dalam waktu 1 jam sebelum insisi*
• 2 jam untuk vancomycin dan fluoroquinolones
• Pilih obat berdasarkan
• Prosedur pembedahan
• Patogen SSI tersering sesuai prosedur
• Rekomendasi terpublikasi
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Strategi pencegahan inti:

Tindakan-tindakan preop

• Infeksi diluar tempat pembedahan - bila mungkin:

• Identifikasi dan atasi sebelum prosedur elektif
• Tunda pembedahan sampai infeksi menghilang
• Jangan menyingkirkan rambut pada tempat
pembedahan, terkecuali itu akan mengganggu
pembedahan; jangan menggunakan razor
• Bila perlu, gunakan clipping atau depilatory agent
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 Strategi pencegahan inti:
Tindakan-tindakan preop
• Persiapan kulit
• Gunakan antiseptik dan tehnik yang sesuai untuk
persiapan kulit

• Pertahankan normotermia pada pasca bedah dini

• Colorectal surgery patients
• Persiapan colon (enema, cathartic agents)
• Gunakan non-absorbable obat oral antimikroba dalam
bebrapa dosis pada hari sebelum

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Strategi pencegahan inti:

Tindakan-tindakan intraop

• Lalu lintas kamar bedah

• Pertahankan pintu OK tetap tertutup selama
pembedahan kecuali diperlukan untuk jalan peralatan,
personil dan pasien

• Batasi pergerakan di OK yang berlebihan

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 Strategi pencegahan inti:
Tindakan-tindakan postop
• Surgical Wound Dressing
• Lindungi insisi kulit primer dengan dressing steril untuk 24-48
jam post-op

• Kendalikan blood glucose level selama periode

immediate post-operative (cardiac)*
• Ukur blood glucose level pada jam 6 pagi hari 1 dan 2 pasca
bedah

• Pertahankan post-op blood glucose level pada <200mg/dL

• Hentikan antibiotik dalam 24 jam setelah akhir waktu
pembedahan (48 jam untuk cardiac)
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Strategi pencegahan tambahan:

Tindakan-tindakan periop
• Berikan lagi antibiotik pada 3 hr interval pd
prosedur yang berlangsung >3-4 jam
• Sesuaikan dosis profilaksis antimikroba untuk
pasien obese (body mass index >30)
• Gunakan paling sedikit 50% FiO pada masa
2
intraoperatif dan postoperatif dini pada prosedur-
prosedur tertentu
• Postop: Umpan balik pada ahli bedah tentang laju
infeksi spesifik
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 Tidak boleh dilupakan:
Tehnik pembedahan yang baik
• Membuang jaringan yang mati
• Mempertahankan hemostasis yang effektif
• Memperlakukan jaringan secara hati-hati
• Mencegah terbentuknya dead space
• Menghindari masuk kedalam organ viskus
berongga bila tidak diperlukan
• Menggunakan drains dan bahan jahit secara tepat
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 Tubes, Lines, and Drains

“Medical literature does not support the

continuation of antibiotics until all drains
or catheters are removed and provides no
evidence of benefit when they are
continued past 24 hours.”

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WHO Surgical Safety Checklist

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 SSI Bundle

• Penggunaan antibiotik yang tepat

• Penghilangan rambut yang tepat
• Pengaturan gula darah pasca bedah (Pasien bedah
jantung besar)
• Normothermia pasca bedah (pembedahan
colorectal)

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Safe Surgery Saves Lives

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 Terima kasih atas perhatian anda

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