P A R T T H R E E

BURN INJURIES

I. OVERVIEW OF BURN INJURY MANAGEMENT

RESUSCITATIVE PERIOD DEFINITIVE MANAGEMENT PERIOD
(First 48 hours) (>48 hours)
• Assessment of burn injury • Excision and grafting
• Classification of burn injury • Control of infection
• Criteria for admission • Nutrition

• Initial (ER) management • Rehabilitation

• Fluid resuscitation • Complication

• Wound dressing

• Monitoring

Source: Consultants and Residents ofthe Alfredo T. Ramirez Memorial 811rt1 Cenler at the UP·PGJI.· 2015.

II. ASSESSMENT OF BURN INJURY

A. Estimation of Burn Size
• Burn size is expressed as percent total body surface area burned (%TBSA)
• Count only those areas with partial (second degree) or full thickness (third degree) burns
• For estimating smaller. irregularly placed burns: consider the area of the open hand (including the
palm and extended fingers) of the patient to be approximately 1% ofTBSA
• Other tools are available to estimate burn size (see below):

1. "Rule of Nines" or "Rule of Wallace"

• Assesses the percentage burn, used to help guide nuid resuscitation
• Rough estimate only (not accurate in children)
• The number corresponds to the % involvement (usually 9%) for that body part: 9% for each arm,

18% for each leg. 18% for the front of torso (chest & abdomen), 18% for back of torso (upper &
lower back), 9% for head, and 1% for groin
• Zones can be broken down into smaller sections or added together (i.e., front & back of the arms
are 4.5% each)
• Example: an adult with burn injury to both legs (18% x 2), groin (1 %), chest (9%). and abdomen
(9%) would involve 55% of the body

%BSA
AREA
(Adults)
Head 9%

Chest 9%
9 Abdomen 9%

Upper Back 9%

Lower Back or
9%
Buttocks

Right Ann 9%

Len Arm 9%

Right thigh and Leg 18%

Left thigh and Leg 18%

Genitalia or Perineum 1%

1�1
 2. Lund and Browder Chart
• More accurate method of
assessing burn extent for
children
• Takes into consideration
the age of the patient,
with decreasing o/oBSA for
the head and increasing
%BSA for the legs as the
child ages
• There are three zones
of the body that varies
depending on age (e.g.,
head, thighs, & lower legs)
• Example: A 5 year old
female with burns in her
right buttocks and entire
ANTERIOR POSTERIOR
right thigh has a 10.5%
BSA involvement (8% for
entire right thigh and 2.5%
for right buttocks)

Source: Lund C.et a/. Surgery. Gynaecology and Obstetrics; 1944.

3. Berkow Diagram to Estimate Burn Size (%) Based on Area of Burn in an Isolated Body Part
• For estimation of the extent of burn, one should use a burn diagram (Berkow diagram) in which
the percentage of total body surface represented by anatomic parts at various ages is reflected
• Example: A 6 year old male was seen at the ER for burn injury. Half of his anterior trunk is burned.
Using the chart below, o/oBSA burned is 6.5% (1/2 of 13%)

AREA Birth - 1 yr 1 - 4 yrs 5 - 9 yrs 1 0 - 14 yrs 15 yrs Adult

Head 19 17 13 11 9 7

Neck 2 2 2 2 2 2

Anterior Trunk 13 13 13 13 13 13

Posterior Trunk 13 13 13 13 13 13

Right Buttock 2.5 2.5 2.5 2.5 2.5 2.5

Left Buttock 2.5 2.5 2.5 2.5 2.5 2.5

Genitalia 1 1 1 1 1 1

Right Upper Arm 4 4 4 4 4 4

Left Upper Arm 4 4 4 4 4 4

Right Lower Arm 3 3 3 3 3 3

Left Lower Arm 3 3 3 3 3 3

Right Hand 2.5 2.5 2.5 2.5 2.5 2.5

Left Hand 2.5 2.5 2.5 2.5 2.5 2.5

Right Thigh 5.5 6.5 8 8.5 9 9.5

Left Thigh 5.5 6.5 8 8.5 9 9.5

RightLeg 5 5 5.5 6 6.5 7

Left Leg 5 5 5.5 6 6.5 7

Right Foot 3.5 3.5 3.5 3.5 3.5 3.5

Left Foot 3.5 3.5 3.5 3.5 3.5 3.5

162
B. Assessment of Burn Depth
1ST DEGREE 2ND DEGREE 3RD DEGREE
4TH DEGREE
BURN BURN BURN
BURN
(Epidermal) (Partial-Thickness) (Full-Thickness)

• Tissue damage • Involves epidermis, • Damages

• Involves the
restricted to dermis, and underlying
Description epidermis and
epidermis & involves the bone, muscles,
part of the dermis
upper dermis subcutaneous tissue tendons

• Contact with hot • Contact with hot • Prolonged

• Flash flame,
liquids or solids, liquids or solids, contact
Cause ultraviolet
flash flame or flame, chemical, with flame,
(sunburn)
direct flame, UV electrical electrical

• Dry with leathery • Same as

• Dry, noblisters, eschar until 3rd degree,
Surface • Moist blebs,
no or minimal debridement possibly with
appearance blisters
edema • Charred vessels are seen bone,
visible muscle, tendon

• Mottled white to • Mixed white, waxy; • Same as 3rd

Color • Erythematous
pink, cherry red dark, khaki, charred degree

• Decreased sensation, • Little or no pain

Sensation • Painful • Very painful intact deep·pressure (because ne•ves
sensation are destroyed)

Healing
• 3 to 6 days • 10 to 21 days • More than 21 days • Grafts needed
time
Source: Modifiedfrom Grabb ondSmilh"s P/aslic Surgery. 6lh Edilion; 2007.

III. CLASSIFICATION OF BURN INJURY

TYPE REMARKS
• Most common cause for hospital admission
• Highest mortality (primary related to association with structural fires and
Flame burn accompanying inhalational injury)
• House fires, improper use of flammable liquids. kerosene lamps, careless smoking.
vehicular accidents, clothing ignited from stove

• Explosions of natural gas propane, gasoline and other flammable liquids causing
Flash burn
intense heat for a very brief period of time

• Injury from electrical current classified as high voltage (greater than one thousand
Electrical volts) or low voltage (less than one thousand volts)
burn • Concern with electrical burns: cardiac arrhythmias, compartment syndrome with
rhabdomyolysis

• Burns caused by hot liquids most commonly hot water, soups, and sauces which are
Scald burn
thicker in consistency, remain in contact with the skin for a longer period of time

• Caused by strong alkali or acids; these cause progressive damage until chemical is
deactivated with reaction with tissue or reaction with water.
• Acid burns: more self limiting than alkali burns; acid tend to tan the skin

Chemical creating an impermeable barrier which limits further penetration.

burn • Alkali burns: combine with cutaneous lipids to create soap and thereby

continue to dissolve the skin until they are neutralized

• Most important components of initial therapy: removal of toxic substance and
irrigation of affected area with water (minimum of30 minutes)

Contact • Results from hot metals, plastic, glass or hot coals; usually limited in extent but very
burn deep

• Exposure to radiation may be from laboratory accidents or damage from x-ray

Radiation
machines, meltdown of a nuclear power plant, and detonation of a nuclear device
IV. JACKSON ZONES OF BURN INJURY

ZONE DESCRIPTION
• Occupies the central area
Coagulation • Area ofmost severe burn injury
• No capillary blood flow

• Surrouds the zone of coagulation

• Area of moderate degree of injury
Stasis
• Sluggish capillary blood flow
• Salvageable by appropriate resuscitation

• Outermost area surrounding the zone of stasis

Hyperemia • Related to vasodilation from inflammation surrounding the burn wound
• Contains viable tissues from which the healing process begins

V. BURN SEVERITY CATEGORIZATION AND MANAGEMENT

CATEGORY REMARKS MANAGEMENT
• Superficial burns
• Partial-thickness burns involving less than 15% ofTBSA in
• Can be managed
adults or 10% ofTBSA in children younger than 10 years or
safely in the
Minor burns adults older than 50 years
outpatient
• Full-thickness burns involving less than 2% ofTBSA that do not
setting
present a serious threat of functional or cosmetic risk to eyes,
ears, face, hands, feet, or perineum

• Partial-thickness burns of 15-25% ofTBSA in adults or 10-20%

ofTBSA in children younger than 10 years or adults older than
• Should be
50 years
hospitalized
• Full-thickness burns involving 2-10% ofTBSA that do not
Moderate for their initial
present serious threat of functional or cosmetic impairment of
burns care but not
the eyes, ears, face, hands, feet, or perineum
necessarily at a
• Excludes high-voltage electrical injury, all burns complicated
burn center
by inhalation injury or other trauma, and burns sustained by
high-risk patients

• Best managed
• Partial-thickness burns involving more than 25% ofTBSA in
in a specialized
adults or 20% ofTBSA in children younger than 10 years or
burn center
adults older than 50 years
staffed by
• Full-thickness burns involving more than 10% ofTBSA
a team of
• Burns involving the face, eyes, ears, hands, feet, or perineum that
professionals
Major burns may result in functional or cosmetic impairment
with expertise
• Burns caused by caustic chemical agents
in the care of
• High-voltage electrical injury
burn patients,
• Burns complicated by inhalation injury or major trauma
including both
• Burns sustained by high-risk patients (those with underlying
acute care and
debilitating diseases)
rehabilitation
Source: American Burn Association. BullAm Coli Surg; 1984.
VI. INITIAL EMERGENCY ROOM MANAGEMENT
A. Overview of Emergency Room Management
• Application ofATLS principles (identify any immediate threat to life, burn is treated secondary)
• Primary survey and Concurrent Resuscitation:
• A: Airway
• 8: Breathing
• C: Circulation
• D: Disability
• E: Environment control and exposure
• F: Fluid resuscitation
• Secondary survey (burn·specific):
• History
• Detection of the mechanism of injury
• Time of injury
• Consideration of abuse

• Height and weight

• Possibility of carbon monoxide intoxication
• Facial burns
• Tetanus immune status

Definitive Care:

• Cool wound with tap water

• Tetanus prophylaxis
• Wound care, debridement of dead tissue, proper analgesics
Minor burns
• Apply bland ointment and nonstick porous gauze
• Systemic prophylactic antibiotics not required
• May be sent home with proper follow-up
• Use sterile gloves when handling patients
• Suspect inhalational injury if with burn to fuce, sooty phlegm, singed
nostril hairs, hoarseness, stridor, history of burn in enclosed space, or
circumferential chest burn
• Intubate patient if burns is greater than or equal to 50% BSA, suspected
Moderate and inhalatonal injury, or with smoke inhalation
major or critical • Fluid resuscitation
burns • Insert foley catheter, NGT

• Get baseline weight (or estimate)

• Tetanus prophylaxis, H2-blockers

• Escharotomy: done o n emergent basis for patients with circumferential

burns around the extremities or chest associated with absent pulses or

limited chest excursion, respectively
 B. Fluid Resuscitation
• Most common cause of mortality in the 1st 48 hours following a burn injury is inadequate fluid
resuscitation
• Patients with moderate and major burns will require fluid resuscitation via intravenous route (those
with minor burns are encouraged to increase oral intake)
• The calculated fluid requirement should only serve as a general guideline to the amount of fluid
needed, and end-points of resuscitation need to be monitored (sensorium, temperature, urine output,
pulse, blood pressure, base deficit)

1. Most common formula used: Parkland or Baxter formula (for initial 24 hours):

IVF requirement = TBSA burned (%) x Weight (kg) x 4 mLjkg

• IV fluid required is 4 mL/kg per % TBSA burned (Lactated Ringer's)

o Half given during the first 8 hours after burn

o Remaining halfover subsequent 16 hours

• Calculate fluid loss from the time of injury, and take into account the fluid administered by
prehospital personnel for fluid replacement

Example case: A 75 kg adult sustains a 20% body surface area bum. Thefluid replacement will be
delivered asfollows:

IVF requirement = 20 (%) x 75 (kg) x 4 mL/kg

= 6,000 mL (or cc)

• First half is delivered within 8 hours

• Remaining is delivered in the next 16 hours

2. For children, use the Galveston formula (for initial 24 hours):

• 5,000 mL per BSA (m2) per %TBSA burned + 2,000 mL per BSA (m2) D5% Lactated Ringer's
• Halfgiven during the first 8 hours after burn
• Remaining half over subsequent 16 hours
• Add dextrose to the resuscitation fluid in children to prevent hypoglycemia, because children have
smaller glycogen stores than adults
• The standard Parkland formula commonly underestimates fluid requirements in a burned child

3. Fluid needs for the Second 24 hours Postburn:

• After the capillary leak has reversed itself, colloids (5% albumin in Ringer's lactate or fresh frozen
plasma O.SmL/Kg/% TBSA burned/day) are administered in the second 24 hours following burn
• Colloid volume is subtracted from the calculated crystalloid rate
• Amount of crystalloids (DS Water for adults, DS 1h or 1/.o Normal Saline for children) depends on
the maintenance requirements plus the amount of transcutaneous evaporative losses from burn
wounds (1 mljkg/% TBSA/day)
• Amount is titrated to maintain normal urine output and mean arterial pressure (MAP)
• Optimal MAP (for adequate end-organ perfusion) = 60 mmHg
• Urine output goals:
o Adults: 0.5 mL/kg/hr

o Children: 1·1.5 mL/kg/hour

C. Wound Dressing
• Performed in a sterile area
• Give patient a
full body bath using warm water & soap
• Debride the burned areas, removing dead skin and unroofing blisters
• Wash the burn areas with betadine soap and rinse with sterile water
• Dress wounds with a topical antibacterial or another dressing modality

1nn
VII. TOPICAL ANTIMICROBIAL AGENTS USED IN BURN CARE

ANTIMICROBIAL DISADVANTAGES OR
AGENT ADVANTAGES
COVERAGE PRECAUTIONS
• Soothes and
• Gram-positive moisturizes; good • Not appropriate for deeper
Bacitracin
antibacterial for facial care and wounds
epithelializing wounds

• Broad-spectrum • Penetrates eschar well; • Painful on application

Mafenide antibacterial; available as solution or • Causes metabolic acidosis via
• Anticlostridial cream carbonic anhydrase inhibition

• Narrow (poor gram-negative)

Mupirocin • Anti-MRSA • Effective against MRSA
antimicrobial coverage

• Provides fungal
• Antifungal • May interfere with activity of
Nystatin prophylaxis with swish
(Candida) mafenide
and-swallow solution

• Effective for both • Penetrates eschar poorly;

• Broad-spectrum prophylaxis and causes hyponatremia; stains
Silver nitrate
antibacterial treatment of wound linen and dressings;
infection • Induces methemoglobinemia

• Broad-spectrum
Silver • Soothes on application • Penetrates eschar poorly
antibacterial;
sufadiazine and causes no pain • Causes leukopenia
• Antipseudomonal

Daikin
solution
• Broad-spectrum
(Preparation:
antibacteria
15 ml of • Chlorine compounds may
(effective against • Inexpensive topical
sodium cause skin redness, irritation,
MRSA, VRE, antimicrobial
hypochlorite and swelling
viruses, molds,
solution
fungi and yeast)
(Zonrox) + 985
ml ofpNSS)

Source: Modifiedfrom ACS Surgery: Principles and Practice, 2007.

VIII. BURN CENTER REFERRAL CRITERIA

• Partial thickness burns greater than 10% total body surface area (TBSA)
• Burns that involve the face, hands, feet, genitalia, perineum, or major joints
• Third degree burns in any age group
• Electrical burns, including lightning injury
• Chemical burns
• Inhalation injury
• Burn injury in patients with preexisting medical disorders that could complicate management,
prolong recovery, or affect mortality
• Any patient with burns and concomitant trauma (such as fractures) in which burn injury poses the
greatest risk of morbidity or mortality. In such cases, if the trauma poses the greater immediate risk,
the patient may be initially stabilized in a trauma center before being transferred to a burn unit.
Physician judgment will be necessary in such situations and should be in concert with the regional
medical control plan and triage protocols
• Burned children in hospitals without qualified personnel or equipment for the care of children
• Burn injury in patients who will require special social, emotional. or rehabilitative intervention

Source: Modifiedfrom Guidelinesfor the Operation ofBurn Centers. American College o{Swyeons,· 2006.

11';7
 IX. DEFINITIVE MANAGEMENT
• Priority in the management of burns in the 1st 48 hours is to maintain the intravascular volume
• Once this problem is hurdled, attention is now turned to the definitive management of the patient's
burn wounds

A. Components of Definitive Management

• Present trend: early (within 7 days postburn) excision of the burn wound, followed by skin grafting
• Attention to nutrition
• Pain control: meperidine, nalbuphine
• Rehabilitation
• Management of complications

B. Common Complications in Burn Patients

• Most common cause of death in burns
• Manifestations: fever, hypotension, conversion from partial to full
Burn wound
thickness burns, persistence ofecthyma gangrenosum in burn wound
sepsis
• The practice of early burn wound excision has significantly decreased the
incidence of burn wound sepsis and improved survival

Acute respiratory • Occurs in electrical or inhalational or pulmonary injury

distress syndrome • Presents as progressive hypoxemia unresponsive to increasing Fi02

• Can be caused by massive resuscitation

• Characterized by:
" Increased airway pressures + hypoventilation
Abdominal o Decreased urine output
compartment o Hemodynamic comrpomise
syndrome
• Standard of care: decompressive laparotomy
• Adjunctive measures: minimizing fluid, torso escharotomy; decreasing
tidal volume, chemical paralysis

Deep vein • Can cause fatal pulmonary embolus

thrombosis • Heparin prophylaxis may be considered (if no contraindication)
• Stress ulcer prophylaxis is needed in those patients who are not taking oral
Stress ulcers
diet or enteral feeds or in patients with previous history of PUD
[Curling ulcers)
• Histamine receptor blockers, sucralfate, and protein pump inhibitors

C. Criteria for Discharge

• No existing complications of thermal injury such as inhalational injury
• Fluid resuscitation completed
• Adequate pain tolerance
• Adequate nutritional intake
• No anticipated septic complications

REFERENCES

• Arrz CP; MoncriefJA. The Treatment of Burns, Philadelphia, WB Saunders Company; 1969.
• Brunicardi FC. Andersen DK. Billiar TR, et al. Schwartz's Principles ofSurgery lOth edition. New York, NY: McGraw Hill
Professional: 201S.
• Committee on Trauma of the American College of Surgeons. Guidelines for the Operation of Burn Centers: Resources for
Optimal Care of the Injured Patient; American College of Surgeons; 2006 .
• Consultants and Residents of the Alfredo T. Ramirez Memorial Burn Center at the University of the Philippines­

Philippine General Hospital (UP-PGH). Burn Notes ofUP-PGH Department of Surgery; 2015.
• Eastman /1., Rosenbaum D, Thai E. Parkland Memorial Hospital: Parkland Trauma Handbook 3rd ed. Mosby, Inc; 2009.

• Hettiaratchy, S. Papini, R. "ABC ofburns: Initial management of a major burn: 11-assessment and resusciation".
t BMJ.
2004;329 (7457): 101-103.
• Kirkpatrick AW, Roberts DJ, De Waele J, Jaeschke R, Malbrain ML. De Keulenaer B, et al. Intra-abdominal hypertension
and the abdominal compartment syndrome: updated consensus definitions and clinical practice guidelines from the
World Society of the Abdominal Compartment Syndrome, Intensive Care Med 2013;39:1190-1206.
• Lund, C., Browder. N.C.Estimation ofarea of burns. Surgery, Gynaecology and Obstetrics 1944;79: 352-358.

• Mattox KL. Moore EE, Feliciano DV (Editors). Trauma, 7th Ed.. The McGraw-Hill Companies, Inc; 2013.

• Meredith W, Rutledge R, Fakhry SM, Emery S, Kromhout-Schiro S. The conundrum ofthe Glasgow Coma Scale in

intubated patients: a linear regression prediction of the Glasgow verbal score from the Glasgow eye and motor scores, J
Trauma. 1998 May:44(5):839·44.
• Souba WW, Fink MP, Jurkovich Gf, Kaiser LR, Pearce WH, Pemberton JH, et al (Editors). ACS Surgery: Principles and

Practice. American College ofSurgeons; 2007.

• Thorne CH, Chung KC, Gosain AK, Gurtner GC, Mehrara BJ, Rubin JP, et al. Grabb and Smith's Plastic Surgery, 6th Edition.
Walters Kluwer; Lippincott Williams & Williams; 2007.
168
 P A R T F O U R

SURGICAL SITE INFECTION

I. SURGICAL SITE INFECTION (SSI) CRITERIA
TYPE OF SSI CRITERIA

• Infection occurs within 30 days after an operative procedure

• Involves only skin and subcutaneous tissue of the incision
• Patient has at least one of the following:
o Purulent drainage from superficial incision
S up erfici al o Organisms isolated from an aseptically obtained culture of fluid or tissue from
incisional SSI superficial incision
o At least one of the following: pain, tenderness, localized swelling, redness, or
heat, and superficial incision is deliberately opened by surgeon, unless incision
is culture-negative
o Diagnosis of a superficial incisional SSI by the surgeon

• Infection occurs within 30 days after operation if no implant is left in place or

within 1 year if implant is in place
• Involves deep soft tissues of the incision (e.g., fascial and muscle layers)
• Patient has at least one of the following:
o Purulent drainage from the deep incision

o Deep incision that spontaneously dehisces or is deliberately opened by a

Deep incisional
surgeon and is culture-positive (or not cultured) and patient has at least one
SSI
of the following signs or symptoms: fever, pain or tenderness (culture-negative
finding does not meet this criterion)
o An abscess or other evidence of infection involving the deep incision that is
found on direct examination, during invasive procedure, or by histopathologic
examination or imaging test.
o Diagnosis of a deep incisional SSI by a surgeon or attending physician

• Infection occurs within 3 0 days after the operation if no implant is left in place or
within 1 year if implant is in place
• Infection involves any part of the anatomy (e.g., organs or spaces) other than the
incision, which was opened or manipulated during an operation and at least one
of the following:
Organ or space o Purulent drainage from a drain that is placed into the organ or space

SSJ o Organisms isolated from an aseptically obtained culture of fluid or tissue in the

organ or space
o An abscess or other evidence of infection involving the organ or space that is

found on direct examination, during invasive procedure, or by histopathologic

examination, or imaging test
o Diagnosis of an organ or space SSI by a surgeon or attending physician

Source: Modifiedfrom CDC Guidelinesfor Prevention o[Surgiclll Site Infection; 201 7.

• 1) Procedure time >75th percentile

• 2) Class-Ill (contaminated) or IV (dirty) wound
• 3) American Society ofAnesthesiologists (ASA) Class 111-V
• 1.5%
• 2.9%
• 6.8%
• 13%
Source: Modifiedfrom Ercole FF, eta/. Bmzj Infect Dis; 2007.

AA
III. CHARACTERISTICS THAT INFLUENCE RISK OF SSI

• Comorbid illness:
o
Diabetes
o
Peripheral vascular disease
o Presence of ascites

' Hypocholesterolemia
, Anemia
Patient factors
o Chronic inflammatory disease

o Skin disease in area of infection

• Nutritional state: malnutrition, obesity

• Avoidable factors: preoperative shaving, extended preoperative admission
• Others: co-existent remote infection, on steroids, recent operation, hypoxemia,
prior irradiation

Environmental
• Inadequate sterilization, inadequate disinfection or skin antisepsis
factors

• Emergency procedure, failure to obliterate dead space, hypothermia,

Treatment factors inadequate antibiotic prophylaxis,surgical drains, poor hemostasis, tissue
trauma, prolonged operative time

Source: Modifiedfrom Cameron], et a/. Cameron's Current Surgical Therapy, 11th ed.: 2014.

IV. PREVENTION OF SSI

ASPECT RECOMMENDATIONS

• Give preoperative antibiotics onlywhen indicated based on clinical practice

Parenteral guidelines and timed such that a bactericidal concentration of the agents is
antimicrobial established in the serum and tissues when the incision is made (see table below)
prophylaxis • For clean and clean-contaminated procedures: no need to administer additional
prophylactic antimicrobial agent doses after surgical incision is closed in the
operating room, even in the presence of a drain

Nonparenteral • Do not apply antimicrobial agents (e.g., ointments, solutions, or powders) to the
antimicrobial surgical incision for the prevention ofSSl
prophylaxis • Consider the use of tr iclosan-coated sutures for the prevention of SSI.

• Perioperative glycemic control: target glucose level <200 mg/dL in patients with
Glycemic control
and without diabetes

• Advise patients to shower or bathe (full body) with soap or an antiseptic agent
on at least the night before the operative day.
Antiseptic • Perform intraoperative skin preparation with an alcohol-based antiseptic agent
prophylaxis unless contraindicated
• The use of plastic adhesive drapes (e.g., sterile incise drapes) with or without

antimicrobial properties is not necessary for the prevention of SSI

Source: Centersfor Disease Control and Prevention Guidelinefor the Prevention ofSurgical Site Infection; 2017.

V. PARENTERAL ANTIBIOTICS RECOMMENDED FOR SURGICAL PROPHYLAXIS

• Preoperative dose timing for administration is:
o Within 60 minutes before incision

o Within 120 minutes for vancomycin

• Most cases can be treated with a single dose

• Redosing: if duration of the surgery exceeds 2 half-lives of the antimicrobial or there is excessive
blood loss, intraoperative redosing is needed to ensure adequate concentrations of the antimicrobial
• Vancomycin is not recommended as a preferred choice for any procedure, unless advised by the
hospital's infectious disease section
 A. Recommendations for Surgical Antimicrobial Prophylaxis
ALTERNATIVE
SURGICAL
RECOMMENDED AGENT(S) (For patients w1th beta·lactam
PROCEDURE allergy)

Cardiac • Cefazolin
• Clindamycin or vancomycin
(CABG, pacemaker insertion) • Cefuroxime

Thoracic
• Ccfazolin
(lobectomy, pneumonectomy, lung • Clindamycin, vancomycin
• Ampicillin-sulbactam
resection, thoracotomy, VATS)

Gastroduodenal • Clindamycin or vancomycin +

(bariatric, vagotomy, antircflux, • Cefazolin aminoglycoside or aztreonam or
pancreaticoduodenectomy) fluoroquinolone

• Cefazolin • Clindamycin or vancomycin +

• Cefoxitin aminoglycoside or aztreonam or
Biliary tract
• Cefotetan fluoroquinolone
(open procedure)
• Ceftriaxone • Metronidazole + aminoglycoside or
• Ampic illin-sulbactam fluoroquinolone

Low risk laparoscopic procedure • None • None

High risk Japaroscopic procedure • Cefazolin • Clindamycin or vancomycin +

(emergency procedure, OM, long • Cefoxitin aminoglycoside or aztreonam or
procedure du�tion, age >70 years, • Cefotetan fluoroquinolonc
pregnancy, immunosuppression. • Ceftriaxone • Metronidazole + aminoglycoside or
prosthetic device) • Ampidllin·sulbactam fluoroquinolone

• Clindamycin or vancomycin +
• Cefoxitin aminoglycoside or aztreonam or
Appendectomy
• Ccfotetan fluoroquinolone
(uncomplicated appendicitis)
• Cefazolin + metronidazole • Metronidazole+ aminoglycoside or
nuoroquinolone

• Nonobstructed: clindamycin +
• Nonobstructed: Cefazolin
aminoglycoside or aztreon<tm or
• Obstructed: Cefazolin +
Small intestine nuoroquinolone
metronidazole, cefoxittn,
• Obstructed: metronidazole +
cefotetan
aminoglycoside or nuoroquinolone

Hernia repair
• Cefazolin • Clindamycin, vancomycin
(hernioplasty and herniorrhaphy)

• Cefazolin + metronidazole
• Cefoxilin • Clindamycin + aminoglycoside or
• Cefotetan aztreonam or nuoroquinolone
Colorectal
• Ampicillin-sulbactam • Metronidazole + aminoglycoside or
• Ceftriaxone + metronidazole nuoroquinolone
• Ertapenem

Neurosurgery
(elective craniotomy, CSF·shunting • Cefazolin • Clindarnycin or vanco111ycin
procedure)

Ortho pedic
(total joint replacement, spinal • Clindamycin or vancomycin
procedures, hip fracture repair, • Cefazolin
implantation of internal fixation
devices)

Urologic • Fluoroquinulonc
• Aminoglycosidc with or without
(lower tract instrumentation, • TMP-SMX
clindamycin
transrectal prostate biopsy) • Ccfazolin

• Clindamycin or vancomycin +
Plastic Surgery • Cefazolin aminoglycoside or aztreonam or
nuoroquinolone

Source: Bratzler OW el ol. Guidelinesfor antimicrobial propJrylox1s in surgery; 2013.

46
B. Recommended Doses and Redosing Intervals for Common Antimicrobials for Surgical Prophylaxis

RECOMMENDED DOSE RECOMMENDED

HALF-LIFE IN REDOSING
DRUG HOURS INTERVAL IN
(m Adults with Normal HOURS
ADULT CHILDREN Renal Function) (from lnotiatoon of
Preoperative Dose)

I
3g 50 mg/kg of
Ampicil lin-
(Ampicillin 2g + ampicillin 0.8-1.3 2
Sulbactam
Sulbactam lg) component

Ampicillin 2g 50 mg/kg 1-1.9 2

Aztreonam 2g 30 mg/kg 1.3-2.4 4

2g
Cefazolin 3 0 mg/kg 4
(3glf > 120 kll)
1.2-2.2

Cefuroxime I.Sg 50 mg/kg 1-2 4

Ccfotaxime lg SO mg/kg 0.9-1.7 3

ceroxitin 2g 40 mg/kg 0.7-1.1 2

Cefotetan 2g 40 mg/kg 2.8-4.6 6

Ceftriaxone 2g 50-7S mg/kg 5.4-10.9 N/A

Ciprofloxacin 400mg 1 0 mg/kg 3-7 N/A

Clindamycin 900 mg 10 mg/kg 2-4 6

Ertapenem 1g J S mg/kg 3-5 N/A

Fluconazole 400 mg 6 mgfkg 30 N/A

5 mg/kg 2.S mg/kg

Gentamicin based on based on 2-3 N/A
dosing weight dosingweight

lcvofloxacin (smgle dose) 10 mgfkg 6-8 N/A

Metronidazole SOO mg IS mg/kg 6-8 N/A

Moxifloxacin 400 mg 10 mg/kg 8-IS N/A

Children
Piperacillin- >9 mons: 100
3.37S g 0.7-1.2 2
tazobactam mg/kgof
pipcracillin

Vancomycin IS mg/kg IS mg/kg 4-8 N/A

Source: Modtfiedfrom Brotzler DWeta/. Guidelmesfor antimicrobial propl1ylaxis in surgery; 2013.

C. Oral Antibiotics for Colorectal Surgery Prophylaxis•

RECOMMENDED DOSE RECOMMENDED

HALF-LIFE IN
REDOSING
DRUG HOURS
(In Adults with Normal INTERVAL IN HOURS
ADULT CHILDREN (from lnillatoon of
Renal Function)
Preoperative Dose)

Erythromycin
lg 20 mg/kg 0.8-3 N/A
base

Metronidazole lg IS mg/kg 6-10 N/A

Neomycin lg IS mg/kg 2-3 N/A

•used m COIIJUIIclion wah mechcmical bowel preparat1or1

Source: Modified from Bratzler OW eta/. Gwdelmcsfor at�tumcrobinl prophylaxis 111 surgery: 2013.
d7
 P A R T F I V E

HEMOSTASIS, COAGULOPATHY, TRANSFUSION

AND PERIOPERATIVE BLEEDING
I. HEMOSTASIS
• Hemostasis is a cascade of events whose primary goal is to limit blood loss from an injured vessel
• Major hemostatic events include the following:

MAJOR
REMARKS
HEMOSTATIC EVENT
• Initial response to vessel injury
Vascular constriction
• Involves thromboxane A2, endothelin, serotonin, fibrinopeptides
• Platelets adhere to form a plug thataids in cessation of bleeding
Platelet plug formation
• Involves deep soft tissues of the incision (e.g., fascial & muscle layers)
• Production of fibrin by two classical pathways
Fibrin formation • Intrinsic or contact activation pathway

• Extrinsic or tissue factor pathway

• Fibrin clot breakdown to allow restoration of blood Oow during the

Fibrinolysis
reparative process

II. COAGULOPATHY OF TRAUMA

• Hemostatic failure with shock and tissue injury are key initiating events
• Thrombomodulin activation serves a central role
• Formation of thrombin or thrombomodulin complexes, which induce an anticoagulant state

III. SURGERY IN PATIENTS RECEIVING ANTICOAGULANTS

• Preoperative use of anticoagulants is often associated with bleeding
• Meticulous surgical technique and close postoperative monitoring are mandatory
• Surgery generally should not be performed in patients with ongoing use of anticoagulation especially
when even minor bleeding can cause significant morbidity (e.g., intracranial or extensive eye surgery)
A. Elective Surgical Operations in Patients on Anticoagulation or Antiplatelets

ANTICOAGULANT
OR MANAGEMENT REMARKS
ANTI PLATELETS
• PT-JNR is used to monitor effect of warfarin
• Discontinuation for several
• Before discontinuing warfarin, transition to IV
days
heparin infusion (which should be held 4-6 hours
Warfarin • Recheck prothrombin (PT)
prior to surgery and restarted within 12-24 hours
concentration (if available), a
post-op) is indicated for patients with mechanical
level >SO% is considered safe
heart valves or recent Ml, stroke or PE

• IV (unfractionated) heparin
• Reversal may not be necessary when the aPTT is
Heparin drip is usually held 4·6 hours
less than 1.3 times control
prior to OR

• Prior to discontinuation, consider consultation

• Discontinue 48·72 hours
Oabigatran, Apixaban,
prior to high bleeding risk
Rivaroxaban
procedure or surgery
with ;m internist regarding the risks of
discontinuation during the perioperativc period
• Time interval may be longer in those with renal

dysfunction

• Aspirin: discontinue 7·10

days berore surgery (resume
• The discontinuation orsuch antiplatelet therapy
Antiplatelets 24 hours post-op, if possible]
must be discussed among physicians
(Aspirin, Clopidogrel, • Clopidogrel and ticagrelor:
• Caution in discontinuing antiplatelet therapy in
Ticagrelor. Prasugrel, discontinue 5 days berorc
patients with a recent history of MI. stroke or
Cilostazol) surgery
patients with coronary stents
• Prasugrel: discontinue 7 days

before surgery

48
B. Emergency Operations in Patients on Anticoagulation

ANTICOAGULANT MANAGEMENT REMARKS

• Immediate discontinuation of
• Reversal may not be necessary
heparin
Heparin when the aPTI is less than 1.3 times
• Use of protamine sulfate for
control
more rapid reversal

• Transfusion of plasma
• Reversal may not be necessary
Warfarin or prothrombin complex
when the IN R is less than 1.5
concentrates

IV. LOCAL HEMOSTASIS

MODE OF
EXAMPLES
HEMOSTASIS
• Direct digital pressure (at the site or proximal to the site of bleeding)
• Pringle maneuver for liver bleeding
Mechanical procedures • Use of ligatures or transfixion suture
• Packing with gauze or laparotomy pads
• Caution with extremity tourniquet

Thermal agents • Electrocautery

Topical hemostatic • Gelatin foams, oxidized cellulose, microfibrillar collagen, biologic agents
agents (topical thrombin. fibrin sealants, platelet sealants)

V. RATIONAL USE OF BLOOD AND BLOOD PRODUCTS

A. General Indications for Blood Transfusion
• Improvement of oxygen-carrying capacity
• Treatment of anemia
• Volume replacement

B. Preoperative Blood Transfusion

• All undergoing elective surgery should be assessed pre-op to identity & treat anemia medically

• There is no single hemoglobin value that will dictate need for PRBC transfusion. more important is

the clinical situation

• In acute blood loss. RBC transfusion should not be used to expand vascular volume when the oxygen
carrying capacity is adequate
• Prcdonation of autologous blood should be considered for patients who will undergo surgery with
substantial risk for blood transfusion

C. Transfusion Reactions

ACUTE REACTIONS DELAYED REACTIONS

• Mild: mild allergic or urticarial reactions • Transfusion-transmitted infections

• Moderately severe: moderate-to-severe urticarial • Delayed hemolytic reactions
eruptions. febrile nonhemolytic reactions, • Posttransfusion purpura
possible bacterial contamination • Graft-versus-host disease
• Life-threatening: acute intravascular hemolysis, • Iron overload in repeated transfusions
bacterial contamination and septic shock, nuid
overload, anaphylactic reactions, transfusion­
associated acute lung injury (TRALI)
D. Blood Components
COMPONENT DESCRIPTION INDICATIONS

• Should generally be discouraged

• Possible indications:
• Provides RBC, plasma, and platelets
• Massive blood loss (loss ofl-1.5
• Should be of same ABO and Rh(D) type
times the whole blood volume within
as the patient whenever possible:
Fresh whole blood a 24-hr period; loss ofSO% blood
o If ABO group cannot be determined:
(FWB) volume; blood loss of150 mL/min]
use group 0 red cells
., Trauma patients with massive
• lf Rh(D) group cannot be determined:
transfusion requirements
use Rh(D) negative red cells
o Hemorrhagic shock when specific

blood products are not available

• Contains concentrated red cells • Preferred in patients with acute blood

• Transfusion of 1 unit PRBC increases loss >2L or a 40% loss ofblood volume
hemoglobin of 1 gjdl. and hematocrit • Preoperative transfusion
Packed red blood cells by3% o Liberal strategy: maintaining

(PRBC) • Response is determined 15 minutes hemoglobin levels between 7-9 gfdL

post-transfusion had no adverse effect on mortality
• Should be of same ABO and Rh(D) type (when compared with previous cut-off
as the patient whenever possible of10gjdL)

• Ongoing massive bleeding to maintain

platelet count >SO x 1 O'/L (if with CNS
trauma or bleeding. maintain counts
• Derived from whole blood within B
>100 X 109/L)
hours of blood donation
• Patients with massive blood
Random donor platelet • Transfusion of 1 unit RDP increases
transfusion and platelets <20 x 109
(RDP) platelet count by 7,000-10,000fmm1
(usual dictum:for every 6 RBCs &
• RDP should be ABO and Rh(D) type
plasma, give 6 packs RDP)
compatible with the recipient
• Patients with qualitative platelet
dysfunction with bleeding or will be
undergoing surgical intervention

• Multiple coagulation factor

deficiencies associated with severe
bleeding or DIC with bleeding
• Severe bleeding due to warfarin
or patients taking warfarin who
• Frozen noncellular blood component will undergo emergency surgical
Fresh frozen plasma
• Must be ABO-compatible with the procedures
(FFP)
recipient's red cells • Open-heart surgery with more than 6
units PRBC transfused
• Trauma casualties with 30% or more

blood loss and who will be requiring

massive transfusion (usual dictum:for
every 6 PRB( give 6 FFP)

• Fibrinogen deficiency with clinical

bleeding or trauma or patients with
• Contained concentrated levels of
Cryoprecipit"dte fibrinogen, factor VII:C, factor Vlll:vWF. fibrinogen deficiency who will undergo
invasive procedure
factor XIII and fibronectin
• DIC with bleeding
• Patients with massive transfusion

• Supernate plasma removed during

preparation of cryoprecipitate
• Rapid temporary reversal in patients
Cryosupernate • Contains most clotting factors as FFP
requiring emergency surgery
but deficient in factor VIII, fibrinogen,
vWF, factor XIII and fibronectin