O impacto de mudanças nas medidas de prevenção e no tratamento de infecções incisionais em cirurgia de revascularização do miocárdio

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Abstract

OBJETIVO: Avaliar o impacto de novas medidas de prevenção e tratamento para infecções incisionais em cirurgia de revascularização do miocárdio (RM). MÉTODO: Estudo retrospectivo incluindo 468 pacientes submetidos a RM com circulação extracorpórea, distribuídos em Grupo A (n=224) e Grupo B (n=244), de pacientes operados antes e após a adoção do novo protocolo, respectivamente. Análise comparativa entre os grupos procurou detectar a incidência de infecções superficiais e profundas na incisão para esternotomia, de recorrências e reinternações. RESULTADOS: Quanto aos fatores de risco relacionados a hábitos e doenças dos pacientes, aspectos cirúrgicos e hospitalares, ocorreram diferenças entre os grupos quanto a maior utilização da artéria mamária (p=0,003) e menor tempo de intubação orotraqueal (p=0,001) no Grupo B. Infecções incisionais - no Grupo A foram 44 (19,6%) casos, sendo 33 (14,7%) superficiais e 11 (4,9%) profundas; no Grupo B foram 13 (5,3%) casos com 10 (4,1%) superficiais e três (1,2%) profundas, sendo significativa a diferença quanto ao número total de infecções incisionais (p<0,001), superficiais (p<0,001) e profundas (p=0,037). As recorrências foram de 36,3% e 7,7%, respectivamente para os Grupos A e B (p=0,102). Ocorreram 21 reinternações relacionadas à infecção incisional no Grupo A e 3, no Grupo B (p<0,001). CONCLUSÃO: Para este grupo de pacientes, as mudanças adotadas resultaram em redução nas infecções incisionais e também diminuíram as reinternações relacionadas a este aspecto.

Translated abstract

OBJECTIVE: To assess the impact of new preventive measures of surgical site infections after coronary artery bypass graft (CABG) surgery. METHOD: A retrospective study of 468 patients who underwent CABG surgery with cardiopulmonary bypass was performed. These patients were distributed into two groups: Group A (n=224) and Group B (n=244), respectively before and after a new protocol. The two groups were compared by statistical analysis to determine differences in risk factors, the incidence of sternotomy surgical site infections (superficial and deep), recurrent infections and hospital readmission. RESULTS: There was a greater use of internal thoracic artery grafts (p=0.003) and a shorter time of mechanical ventilation (p=0.001) in Group B. Surgical site infections occurred in 44 patients of Group A (19.6%); 33 superficial (14.7%) and 11 deep (4.9%) while in Group B only 13 patients had this complication (5.3%); 10 superficial (4.1%) and three deep (1.2%) surgical site infections. Significant improvements were seen in the total number of surgical site infections (p<0.001), of superficial infections (p<0.001) and of deep infections (p=0.037). There were 36.3% and 7.7% of recurrent infections in Groups A and B, respectively (p=0.102). Hospital readmissions due to surgical site infections were 21 in Group A and three in Group B (p<0.001). CONCLUSION: The new preventive measures and treatment for surgical site infections after CABG surgery in this series of patients, significantly reduced the incidence of sternotomy surgical site infections and hospital readmissions related to this complication.

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Cost of surgical site infections following coronary artery bypass surgery.

Salvy P Russo, D Spelman, A Jenney … (2001)

Little information is available on the financial impact of surgical site infections (SSI) after major surgery. In order to calculate the cost of SSI following coronary artery bypass graft surgery (CABGs), a 2-year retrospective case-control study was undertaken at Alfred Hospital, a university-affiliated tertiary referral centre. One hundred and eight patients with SSI (cases) after CABGs and 108 patients without SSI (controls) were matched for gender, age, risk index (Centers of Disease Control and Prevention, National Nosocomial Infection Surveillance (NNIS) System) and number of principal comorbidities. The patient's postoperative length of stay (LOS), in both the intensive care unit (ICU) and the non-ICU (general) ward, was obtained from the medical records and the cost of a day in each was provided by the hospital's finance department. The cost of antibiotics prescribed for SSI was provided by the hospital's pharmacy department. Postoperatively the cases were in ICU for a total of 313 days whereas the controls spent 165 days in ICU, a mean of 2.89 versus 1.53 days, respectively (P = 0.035). In general wards, cases were inpatients for a total of 1651 days and controls for 589 days. This is a mean of 10.8 days for cases and 4.7 days for controls (P = 0.0001). The extra LOS for 108 cases (compared to the controls) was costed at $1 299 082, a mean cost of $12 028 per patient. The total cost of antibiotics prescribed for these SSI was $42 270 (a cost per case of $391). The total excess cost related to increased LOS and antibiotic treatment was $12 419 per patient. In the subgroup analysis for deep sternal site infections the mean excess cost was $31 597 per patient. Postoperative SSI result in significant patient morbidity and consume considerable resources. In the present study, patients with SSI following CABGs had significant prolongation of hospitalization (both in ICU and general wards). The present study illustrates the potential cost savings of introducing interventions to reduce SSI rates. This is the first time such a study has been undertaken in Australia.

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Glove punctures and postoperative skin flora of hands in cardiac surgery.

Anne Eklund, Juhani Ojajärvi, Kirsi Laitinen … (2002)

Surgical gloves are frequently perforated during operations, including heart operations. This infection risk factor is inadequately studied. After preoperative hand disinfection and at the end of 116 heart operations, bacterial samples from hands of surgeons, altogether 800 samples, were taken. Glove punctures were examined with water test. Surgeons changed 70 gloves because of breakage during operations. Additionally, 154 of 400 (39%) gloves had holes in postoperative testing. The breakage rate of gloves increased from 30% in operations shorter than 3 hours to 65% when operations were longer than 5 hours. High bacterial counts of the hands were also more common after prolonged operations. Glove puncture rates and bacterial counts of hands increase with increasing operation time. We recommend changing of both gloves when a puncture is detected. Before donning new gloves, hands should be disinfected.