Abstract
Purpose
To highlight the role of anesthesiologists in the prophylaxis of surgical site infections (SSIs) and to recognize the central role they play in quality improvement initiatives for the prevention of SSIs.
Source
The medical literature was searched with a focus on three interventions affecting the risk of SSIs: preoperative antibiotic administration, perioperative normothermia, and perioperative hyperoxia. The literature was also searched for examples of initiatives in patient safety and quality improvement that highlight the role of anesthesiologists in preventing SSIs.
Principal findings
The timely administration of preoperative antibiotics and the maintenance of perioperative normothermia have been shown to reduce the risk of SSI significantly. Perioperative hyperoxia in the prevention of SSIs remains controversial but may improve outcomes in specific subsets of the surgical population. Initiatives in quality improvement show the challenges faced by many centres to improve upon these processes of care, but they also highlight the role of anesthesiologists as champions in the multidisciplinary efforts for the prevention of SSIs.
Conclusions
Anesthesiologists are responsible for many of the processes of care shown to impact the risk for SSIs, and they play an important role in the prevention of SSIs. Their leadership in the multidisciplinary efforts to improve the quality of the surgical patient is of critical importance.
Résumé
Objectif
Souligner le rôle des anesthésiologistes dans la prophylaxie des infections des cicatrices opératoires (ISS) et reconnaître leur rôle central dans les initiatives d’amélioration de la qualité pour la prévention des ISS.
Source
Des recherches ont été menées dans la documentation médicale en se concentrant sur trois interventions pouvant modifier le risque d’ISS : l’administration préopératoire d’antibiotiques, la normothermie periopératoire et l’hyperoxie périopératoire. Des exemples d’initiatives en matière de sécurité des patients et d’amélioration de la qualité soulignant le rôle des anesthésiologistes dans la prévention des ISS ont été également recherchés dans les publications.
Constatations principales
Il a été montré que l’administration d’antibiotiques préopératoires en temps opportun et le maintien d’une normothermie périopératoire diminuaient significativement le risque d’ISS. Le rôle de l’hyperoxie périopératoire pour la prévention des ISS reste controversé mais elle pourrait améliorer l’évolution dans des sous-groupes particuliers de patients chirurgicaux. Les initiatives en matière d’amélioration de la qualité montrent les nombreux défis auxquels sont confrontés beaucoup de centres pour améliorer ces processus de soins; cependant, elles mettent aussi en lumière le rôle primordial des anesthésiologistes dans les efforts multidisciplinaires de prévention des ISS.
Conclusions
Les anesthésiologistes sont responsables de nombreux processus de soins qui ont un impact démontré sur le risque d’ISS et ils jouent un important rôle dans la prévention de ces infections de la cicatrice opératoire. Leur leadership au sein d’efforts multidisciplinaires pour améliorer la qualité des soins pour les patients chirurgicaux revêt une importance essentielle.
Similar content being viewed by others
Perioperative infections place a significant burden on patients and on the healthcare system. Surgical site infections (SSIs) are the most common perioperative infection, accounting for 38% of all infections in surgical patients and 14-16% of all hospital-acquired infections.1 The Table provides the definition of SSI by location, as established by the Centers for Disease Control (CDC).2 In a population-based study of 1.2 million elective in-patient surgeries from Ontario, Canada, 13.5% of all patients developed a SSI.3 These patients were found to be at an increased risk of readmission to hospital (odds ratio [OR] 6.16; 95% confidence interval [CI] 5.98 to 6.35) and reoperation (OR 2.28; 95% CI 2.11 to 2.48). A matched cohort study found that SSIs were associated with an increased risk of death (relative risk [RR] 2.2; 95% CI 1.1 to 4.5), length of stay (mean 6.5 days; 95% CI 5 to 8),4 and increased hospital costs measured in the thousands of dollars per patient. The significance of infectious complications, such as SSIs, is not lost on the public, and there is increasing demand for hospitals and physicians to be held accountable. For example, mandatory public reporting of incident infections and the measures taken to prevent them is practice in Ontario, Canada.5 Among these reported measures includes the use of a Surgical Safety Checklist. Practices for the prevention of SSIs (the administration of antibiotic prophylaxis, glycemic control, use of warming devices) feature prominently among the elements in Ontario’s adaptation of the Checklist.
While SSI prevention is a multidisciplinary effort, most prophylactic measures begin and end in the operating room and are influenced directly by the anesthesiologist. Despite this, the role of the anesthesiologist is often understated. The medical literature identifies many areas where the anesthesiologist can affect a patient’s risk of infection, including the timing and selection of preoperative antibiotic administration, perioperative normothermia, hyperoxia and normoglycemia, regional anesthesia, smoking cessation, and hand washing. Given the breadth of topics, we selected three that are directly affected by anesthesiologists but also involve the broader multidisciplinary team. Lately, hand washing by anesthesiologists as it pertains to other perioperative infections has also been the subject of research, and we include a brief discussion on the topic. Finally, we highlight the role of anesthesiologists in a discussion on perioperative quality of care and patient safety initiatives.
Perioperative antibiotics
Surgical site infections are commonly the result of skin flora contamination of the wound, including Staphylococcus and Streptococcus species.6 Where surgery involves hollow viscera, such as the intestine, gram negative coliforms and anaerobes also become an important source of wound sepsis. The role of antibiotic prophylaxis for the prevention of SSIs was first shown in 1961.7 Since then, numerous studies have established the importance of timing antibiotic administration with skin incision. Published guidelines direct practitioners to administer antibiotics within 60 min of skin incision to minimize the risk of SSI.8 The risk of SSI has been shown to increase dramatically when antibiotics are given more than two hours before surgery (OR 6.7; 95% CI 2.9 to 14.7) or after the incision (OR 5.8; 95% CI 2.6 to 12.3).9 Despite this, population-based studies have shown that timing for antibiotic administration remains poor. Using data from the National Surgical Infection Prevention Project, Bratzler et al. 10 found as few as 55.7% of patients in participating hospitals across the United States were receiving preoperative antibiotics in a timely fashion.
The practice of administering antibiotics immediately before the induction of anesthesia can greatly improve antibiotic administration timing. In a recent quality improvement initiative focusing on major colorectal and hepatobiliary surgery, it was found that only five percent of patients were receiving prophylactic antibiotics in a timely fashion when they were administered in the patient holding unit prior to surgery. Delays in patient transfer and the time required for line insertion and patient positioning led to more than 50% of patients receiving their antibiotics more than two hours prior to surgery. Antibiotic timing improved when antibiotic administration was moved into the operating room, with 92.6% of patients receiving their antibiotics in a timely fashion.11 A similar study mirrored this experience. In a quality improvement study in patients undergoing major cardiac or vascular surgery, Kanter et al. 12 identified similar deficiencies in patient care, with only 11% of patients receiving antibiotics in a timely manner when administered in a preoperative holding area. While their changes in process underwent several iterations, it wasn’t until anesthesiologists were engaged and identified as the most influential party to improve practice that significant changes were seen. Having anesthesiologists assume responsibility for antibiotic administration, modifying computerized order entry forms, and adding prompts to anesthesiology records have led to a dramatic improvement in patient care. Sustained changes were found, and 97% of patients now receive antibiotics in a timely fashion. Consequently, rates of SSIs have fallen from 3.8% to 1.4%.
Anesthesiologists should also be involved in the selection of appropriate antibiotics. Recommended regimens vary with the type of surgery (cardiovascular, orthopedic, colorectal, etc.) and wound classification (clean, clean-contaminated). Recognizing patients who require modified antibiotic therapy, such as those with a documented penicillin allergy and patients colonized with methicillin resistant Staphylococcus aureus (MRSA), is an important part of perioperative care. Patients will often report symptoms attributed to penicillin use that do not represent true allergic reactions.8 A focused history can help to identify those patients with true allergies who require a modification to their antibiotic regimen. Where gram positive pathogens represent the most common infective agent, substitution of a cephalosporin with vancomycin or clindamycin is recommended.8 Modification is also required for patients known to be colonized with MRSA. Again, vancomycin is indicated in this case. This is especially true of patients with recent stays in hospital or other institutions, including long-term care.8,13 While the anesthesiologist may not be the prescriber of prophylactic antibiotics, their role in their administration at the time of surgery warrants their involvement and oversight in drug selection.
Perioperative normothermia
General anesthesia has a dramatic effect on core temperature. On induction of anesthesia, thermoregulatory mechanisms are impaired, and there is a redistribution of core body heat to the periphery.14 Core temperatures have been shown to fall as much as 1.6 (0.3)°C in the first hour of anesthesia alone. Hypothermia consequently leads to an impairment in immune function by affecting leukocyte migration, neutrophil phagocytosis, and cytokine production and increasing the risk of SSIs.15 Hypothermia has a myriad of effects on cellular metabolism, which has made it an attractive therapy in the setting of ischemia.16 Permissive hypothermia does offer significant neuroprotective effects and has become standard management of care for post-cardiac arrest resuscitation.17,18 Paradoxically, hypothermia may increase the risk of cardiac events in the first 24 hr after surgery.19 It also decreases platelet function, drug clearance, insulin secretion, and sensitivity to insulin, along with postoperative shivering and a sharply increased metabolic rate in the postanesthesia care unit.16
The prevention of perioperative hypothermia has been shown to reduce the incidence of SSIs significantly, perhaps to an even greater extent than antibiotic prophylaxis.20 A randomized controlled trial of 200 patients undergoing colorectal surgery with active warming strategies in place found the risk of SSI to be significantly less in the warmed group than in controls (RR 0.31; 95% CI 0.13 to 0.74).20 A similar effect was seen in patients being warmed while undergoing “clean surgery”. Melling et al. 21 found that perioperative warming in patients undergoing breast, hernia, or varicose vein surgery resulted in a significantly lower rate of SSIs than in controls (RR 0.42; 95% CI 0.19 to 0.93).
The anesthesiologist’s approach to perioperative warming is critical to patient safety. There are many warming solutions on the market today that have varying clinical effect. A recent systematic review of the literature examined the most common patient warming strategies used during abdominal surgery in North America.22 Level 1 evidence supports the use of both warmed intravenous fluid and forced-air devices for the prevention of perioperative hypothermia. After as little as 30-90 min of anesthesia, differences in core temperatures have been shown with the use of intravenous fluid warmers, differences that are sustained to the end of surgery.23,24 Heated forced-air has a similar effect when used in either the preoperative or intraoperative setting. In a randomized trial by Camus et al.,25 one hour of preoperative forced-air warming slowed the decrease in intraoperative core temperatures significantly compared with no warming after only 30 min. Intraoperative warming with forced air has similar sustained effects. Lindwall et al.26 randomized patients to receive either intraoperative forced-air warming vs warming with blankets. After only 30 min, patient core temperatures differed between the two groups; a difference that was sustained for up to an hour after discontinuing the warming strategy. Forced air has been found favourable to other active warming strategies as well. Leung et al.27 compared forced-air warming with electric blanket warming during laparotomy. Mean temperatures at the end of surgery were 36.2 (0.4)°C and 35.2 (1.0)°C, respectively (P < 0.01).
How the anesthesiologist chooses to monitor perioperative temperatures can also influence treatment. Level II evidence supports the use of esophageal thermometry to monitor intraoperative temperatures, given its accuracy and precision compared with the gold standard of pulmonary artery catheter thermometry.22 The same evidence discourages the use of infrared tympanic thermometry; while relatively easy to use, the accuracy of this device is questionable with as many as 50% of temperature measurements being more than 0.5°C from true core temperature.28,29 Inaccurate temperature measurement may lead the anesthesiologist or nurse in the recovery room to suspect normothermia is maintained, when in fact it is not. Standardization of the practices for perioperative normothermia has been shown to improve perioperative normothermia rates. A single-institution experience found that introducing a bundle of standardized practices, including raising room temperatures and employing forced-air devices and intravenous fluid warmers for all procedures longer than two hours, significantly maintained normothermia rates at the end of surgery.11
Hyperoxia
Oxygen therapy in the perioperative period is managed primarily by the anesthesiologist. The role of hyperoxia in the prevention of SSIs is controversial. In vitro studies have previously shown the effects of tissue oxygen tension on the oxidative killing effect of neutrophils.30 A number of prospective studies have also shown an association between low tissue oxygen tension and SSI. Hopf et al. 31 measured tissue oxygen tension for three days in patients undergoing major general surgery procedures determined to be of higher than average risk for SSI. Patients with SSI were found to have a significantly lower subcutaneous tissue oxygen tension than patients without SSI [72 (18) mmHg vs 59 (12) mmHg; P < 0.001]. There were no infections documented in patients with tissue oxygen tension levels > 90 mmHg. Another study using noninvasive techniques found lower tissue oxygen saturations in patients with SSIs than in those without SSIs32; however, this study found differences only when measuring saturation levels at locations remote from the operative site. No association was found between oxygen saturation at the surgical site and SSI.
Despite evidence supporting the theory that increased tissue oxygen levels reduce the risk of SSI, results from randomized controlled trials are conflicting, even showing harm in some cases. Greif et al.33 randomized 500 colorectal surgery patients to receive either 80% or 30% oxygen during surgery and for two hours after surgery. For each arm, the 15-day rate of SSI for positive wound culture was 5.2% vs 11.2%, respectively (P < 0.01). While not a primary end point of the ENIGMA study, the hyperoxia group did have a lower incidence of wound infections (adjusted OR 0.72; 95% CI 0.52 to 0.98; P = 0.036).34 Conversely, Pryor et al.35 randomized 165 abdominal surgery patients to receive either 80% or 35% inspired oxygen over a similar time period. This study actually found that the rates of SSI were increased in the hyperoxia group (25.0% vs 11.3%; P = 0.03). The authors suggest a number of cell-level mechanisms to explain this finding; nevertheless, the results have not since been replicated. Five other randomized trials have been reported in the literature,36-40 and all but one36 have shown equivalence.
Similarly, a meta-analysis of the seven trials yielded equivalent results.41 Pooling 2,728 patients (1,358 patients assigned to hyperoxia, 1,370 assigned to controls) failed to show a therapeutic advantage with hyperoxia (OR 0.85; 95% CI 0.52 to 1.38); however, subgroup analyses of patients undergoing colorectal surgery (OR 0.48; 95% CI 0.32 to 0.71) and patients undergoing general anesthesia (OR 0.66; 95% CI 0.46 to 0.93) did suggest that patients receiving hyperoxia were less likely to develop a SSI. The data would suggest then that specific populations may stand to benefit from hyperoxia as a method of SSI prophylaxis, although the role for all surgical patients remains equivocal. The anesthesiologist should weigh patient and procedural factors and consider hyperoxia as part of the perioperative strategy for SSI prevention where appropriate.
Hand washing and venous access infection
Central line-associated bloodstream infections are associated with both an increased length of hospital stay and mortality rates, and infections are most common in central lines inserted by anesthesiologists.42,43 Several interventions have been described to reduce the risk of central line infections (chlorhexidine skin prep, full barrier precautions, avoiding femoral access, and early removal of unnecessary catheters) and have been shown to reduce infectious complications significantly when bundled together.44 These efforts, however, do not address the potential for contamination after insertion when the device is being accessed. Stopcock contamination has been found to occur in as many as 11.5% of cases intraoperatively; in 47% of those contaminated cases, the source was found to be bacteria from anesthesia providers’ hands through biotyping of collected specimens.45 It has also been associated with a significant increase in 30-day mortality (OR 58.5; 95% CI 2.23 to 1477).46 In the latter study, several reservoirs were found for bacterial contamination in the operating room. The anesthesiologist remains an important vector for contamination, and both studies highlight the importance of hand washing and maintenance of sterile technique after line insertion.
Initiatives for patient safety and quality improvement
Prevention of SSIs is part of a broader initiative to maintain perioperative patient safety and improve quality of care, and it features prominently in such initiatives as the Surgical Safety Checklist. In an influential paper published in 2009, the World Health Organization (WHO) reported the results of an international pre- and post-intervention assessment of a 19-item perioperative checklist on patient outcomes.47 The intention of the WHO Checklist was to raise the awareness of healthcare providers to its components and to improve communication among operating room team members, thereby decreasing the risk of adverse events. There were 7,688 patients enrolled in the study. The post-intervention assessment showed a significant reduction in the rates of 30-day mortality compared with the pre-intervention assessment (1.5% vs 0.8%, respectively; P = 0.003) and a significant reduction in the number of postoperative complications (11.0% vs 7.0%, respectively; P < 0.001), including SSI (6.2% vs 3.4%, respectively; P < 0.001). Of relevance, the appropriate administration of preoperative antibiotics increased from 56.1-82.6% (P < 0.001). The Checklist engages all practitioners, including anesthesiologists, to become more aware of the potential for preventable errors (or omissions) that influence patient outcomes. As a result of this study, many jurisdictions around the world have implemented the Surgical Safety Checklist. Legislation in Ontario, Canada has made the use of the Surgical Safety Checklist mandatory for all patients having surgery, with hospitals required to report rates of compliance for public consumption.5 The impact of this effort on outcomes in Ontario has yet to be measured, but centres in other jurisdictions, including the United States and Europe, have shown a positive impact on patient outcomes with the implementation of a checklist.48,49
Voluntary reporting of performance as part of a collaborative effort between participating hospitals has been shown to have a positive impact on SSIs by improving relevant processes of care. Dellinger et al. 50 report the results from the National Surgical Infection Prevention Collaborative. Forty-four participating hospitals reported data on over 35,000 surgical procedures over a one-year period. The initiative included quarterly meetings of hospital “champions”, commonly surgeons or anesthesiologists, to share insights into barriers to change and successful measures to overcome them. At the end of the one-year project, the rate of SSIs fell 27% from the first to the fourth quarter (P = 0.0005). Similarly, tests of trend found continual improvements in all of the processes of care reported.50
A number of studies have shown the role of standardized practices for the prevention of SSIs. A pre- and post-intervention study by the authors of this review was conducted over a three-year period.11 A prospective needs assessment evaluated institutional performance on a number of measures in patients undergoing major abdominal surgery, including selection and timing of preoperative antibiotic administration and rates of perioperative normothermia. Multidisciplinary panels made up of relevant stakeholders, including surgeons, anesthesiologists, nurses, infectious disease specialists, residents, and patient safety specialists, were created. Each aspect of care was carefully scrutinized by the relevant panel, and new protocols were designed, tested for safety and feasibility, and subsequently implemented and put into practice. Changes were disseminated through educational sessions with staff; feedback was encouraged from those not directly involved with the stakeholder groups, and the responses were used to tailor the changes appropriately. A dramatic improvement resulted, with the number of patients receiving preoperative antibiotics within 60 min of incision increasing from 5.9-92.6% (RR 15.7; 95% CI 6.7 to 36.9), and the rate of normothermia at the end of surgery increased from 60.5-97.6% (RR 1.61; 95% CI 1.34 to 1.94).11
A similar study by Kanter et al.12 also shows the value of standardization and highlights the role of the anesthesiologist in the process in patients undergoing cardiac and vascular surgery. At the outset, anesthesiologists and surgeons collaborated to generate an institutional guideline for antibiotic selection and to review local practices. They identified the anesthesiologist as the practitioner most likely to have a positive impact on the timing of antibiotic administration. Practices were streamlined to facilitate the anesthesiologist’s role, including prompts on anesthesia records and reminders from nursing staff. An anesthesia “champion” for the process was identified early, and education regarding the process changes was disseminated at grand rounds and OR in-services for all staff. Antibiotic timing improved dramatically after implementation, with 91% of patients receiving antibiotics within 60 min of incision compared with 11% of patients before implementation. The changes have been sustained thanks to an ongoing audit and feedback loop that focuses on educating all practitioners rather than on isolating “bad apples”.12 Engaging all practitioners to change in a “bottom up” approach was a key factor in the success of both of these studies, and this approach should be encouraged as other centres strive to meet both internal and external standards for excellence.
An often unrecognized opportunity is the impact of professional societies on the practice patterns of their members. The current Canadian Anesthesiologists’ Society “CAS Guidelines to the Practice of Anesthesia” focus on the importance of having well-trained and qualified staff as well as standards for equipment and monitoring.51 We would ask the Society to consider including wording about the importance of equipping operating rooms with appropriate patient warming devices as well as articulating the expectation to maintain the patient’s temperature in a manner concordant with optimal patient outcome. Given the importance of anesthesiologists’ participation in antibiotic prophylaxis, it is time to consider knowledge in this area as a key competency for the specialty and an important construct to incorporate into anesthesia training programs.
Conclusions
Anesthesiology practice can affect a number of factors influencing the patient’s risk of infection, including the timing and selection of preoperative antibiotic administration, perioperative normothermia, hyperoxia and normoglycemia, regional anesthesia, smoking cessation, and hand washing.
While individual practice patterns are important, sustained improvement in care needs to include the entire perioperative team (anesthesiologists, surgeons, nurses, and other professionals) involved in the care of this patient population. Anesthesiologists have much to be proud of with respect to their leadership in this area. Ongoing participation and leadership in these activities is an important part of the anesthesiologist’s role as a perioperative physician.
Key points
-
The timely administration of preoperative antibiotics and the maintenance of perioperative normothermia significantly reduce the risk of surgical site infections (SSIs).
-
Perioperative hyperoxia in the prevention of SSIs remains controversial but may improve outcomes in specific subsets of the surgical population.
-
The importance of hand hygiene in minimizing transmission of infection should not be underestimated.
-
Quality improvement initiatives show the challenges that many centres face to improve upon these processes of care, but they also highlight the role of anesthesiologists as champions in the multidisciplinary efforts for the prevention of SSIs.
References
Mangram AJ, Horan TC, Pearson ML, Silver LC, Jarvis WR, Guideline for Prevention of Surgical Site Infection. Centers for Disease Control and Prevention (CDC) Hospital Infection Control Practices Advisory Committee. Am J Infect Control 1999; 27: 97-132. quiz 133-4; discussion 96.
Horan TC, Gaynes RP, Martone WJ, Jarvis WR, Emori TG. CDC definitions of nosocomial surgical site infections, 1992: a modification of CDC definitions of surgical wound infections. Am J Infect Control 1992; 20: 271-4.
Daneman N, Lu H, Redelmeier DA. Discharge after discharge: predicting surgical site infections after patients leave hospital. J Hosp Infect 2010; 75: 188-94.
Kirkland KB, Briggs JP, Trivette SL, Wilkinson WE, Sexton DJ. The impact of surgical-site infections in the 1990 s: attributable mortality, excess length of hospitalization, and extra costs. Infect Control Hosp Epidemiol 1999; 20: 725-30.
Ministry of Health and Long-Term Care. Patient Safety. 2011; Available from URL: http://www.health.gov.on.ca/en/public/programs/patient_safety/ (accessed August 2012).
Darouiche RO, Wall MJ Jr, Itani KM, et al. Chlorhexidine-alcohol versus povidone-iodine for surgical-site antisepsis. N Engl J Med 2010; 362: 18-26.
Burke JF. The effective period of preventive antibiotic action in experimental incisions and dermal lesions. Surgery 1961; 50: 161-8.
Bratzler DW, Houck PM, Surgical Infection Prevention Guidelines Writers Workgroup, et al. Antimicrobial prophylaxis for surgery: an advisory statement from the National Surgical Infection Prevention Project. Clin Infect Dis 2004; 38: 1706-15.
Classen DC, Evans RS, Pestotnik SL, Horn SD, Menlove RL, Burke JP. The timing of prophylactic administration of antibiotics and the risk of surgical-wound infection. N Engl J Med 1992; 326: 281-6.
Bratzler DW, Houck PM, Richards C, et al. Use of antimicrobial prophylaxis for major surgery: baseline results from the National Surgical Infection Prevention Project. Arch Surg 2005; 140: 174-82.
Forbes SS, Stephen WJ, Harper WL, et al. Implementation of evidence-based practices for surgical site infection prophylaxis: results of a pre- and postintervention study. J Am Coll Surg 2008; 207: 336-41.
Kanter G, Connelly NR, Fitzgerald J. A system and process redesign to improve perioperative antibiotic administration. Anesth Analg 2006; 103: 1517-21.
Jernigan JA, Pullen AL, Flowers L, Bell M, Jarvis WR. Prevalence of and risk factors for colonization with methicillin-resistant Staphylococus aureus at the time of hospital admission. Infect Control Hosp Epidemiol 2003; 24: 409-14.
Matsukawa T, Sessler DI, Sessler AM, et al. Heat flow and distribution during induction of general anesthesia. Anesthesiology 1995; 82: 662-73.
Kumar S, Wong PF, Melling AC, Leaper DJ. Effects of perioperative hypothermia and warming in surgical practice. Int Wound J 2005; 2: 193-204.
Polderman KH. Mechanisms of action, physiological effects, and complications of hypothermia. Crit Care Med 2009; 37(7 Suppl): S186-202.
Arrich J, Holzer M, Herkner H, Mullner M. Cochrane corner: hypothermia for neuroprotection in adults after cardiopulmonary resuscitation. Anesth Analg 2010; 110: 1239.
Schwartz BG, Kloner RA, Thomas JL, et al. Therapeutic hypothermia for acute myocardial infarction and cardiac arrest. Am J Cardiol 2012; 110: 461-6.
Frank SM, Fleisher LA, Breslow MJ, et al. Perioperative maintenance of normothermia reduced the incidence of morbid cardiac events. A randomized clinical trial. JAMA 1997; 277: 1127-34.
Kurz A, Sessler DI, Lenhardt R. Perioperative normothermia to reduce the incidence of surgical-wound infection and shorten hospitalization. Study of Wound Infection and Temperature Group. N Engl J Med 1996; 334: 1209-15.
Melling AC, Ali B, Scott EM, Leaper DJ. Effects of preoperative warming on the incidence of wound infection after clean surgery: a randomised controlled trial. 2001; 358: 876-80.
Forbes SS, Stephen WJ, Harper WL, et al. Implementation of evidence-based practices for surgical site infection prophylaxis: results of a pre- and postintervention study. J Am Coll Surg 2008; 207: 336-41.
Camus Y, Delva E, Cohen S, Lienhart A. The effects of warming intravenous fluids on intraoperative hypothermia and postoperative shivering during prolonged abdominal surgery. Acta Anaesthesiol Scand 1996; 40: 779-82.
Smith CE, Gerdes E, Sweda S, et al. Warming intravenous fluids reduces perioperative hypothermia in women undergoing ambulatory gynecological surgery. Anesth Analg 1998; 87: 37-41.
Camus Y, Delva E, Sessler DI, Lienhart A. Pre-induction skin-surface warming minimizes intraoperative core hypothermia. J Clin Anesth 1995; 7: 384-8.
Lindwall R, Svensson H, Soderstrom S, Blomqvist H. Forced air warming and intraoperative hypothermia. Eur J Surg 1998; 164: 13-6.
Leung KK, Lai A, Wu A. A randomised controlled trial of the electric heating pad vs forced-air warming for preventing hypothermia during laparotomy. Anaesthesia 2007; 62: 605-8.
Farnell S, Maxwell L, Tan S, Rhodes A, Philips B. Temperature measurement: comparison of non-invasive methods used in adult critical care. J Clin Nurs 2005; 14: 632-9.
Lawson L, Bridges EJ, Ballou I, et al. Accuracy and precision of noninvasive temperature measurement in adult intensive care patients. Am J Crit Care 2007; 16: 485-96.
Babior BM. Oxygen-dependent microbial killing by phagocytes (first of two parts). N Engl J Med 1978; 298: 659-68.
Hopf HW, Hunt TK, West JM, et al. Wound tissue oxygen tension predicts the risk of wound infection in surgical patients. Arch Surg 1997; 132: 997-1004.
Govinda R, Kasuya Y, Bala E, et al. Early postoperative subcutaneous tissue oxygen predicts surgical site infection. Anesth Analg 2010; 111: 946-52.
Greif R, Akca O, Horn EP, Kurz A, Outcomes Research Group. Supplemental perioperative oxygen to reduce the incidence of surgical-wound infection. N Engl J Med 2000; 342: 161-7.
Myles PS, Leslie K, Chan MT, ENIGMA Trial Group, et al. Avoidance of nitrous oxide for patients undergoing major surgery: a randomized controlled trial. Anesthesiology 2007; 107: 221-31.
Pryor KO, Fahey TJ III, Lien CA, Goldstein PA. Surgical site infection and the routine use of perioperative hyperoxia in a general surgical population: a randomized controlled trial. JAMA 2004; 291: 79-87.
Belda FJ, Aguilera L, Garcia de la Asuncion J, Spanish Reduccion de la Tasa de Infeccion Quirurgica Group, et al. Supplemental perioperative oxygen and the risk of surgical wound infection: a randomized controlled trial. JAMA 2005; 294: 2035-42.
Bickel A, Gurevits M, Vamos R, Ivry S, Eitan A. Perioperative hyperoxygenation and wound site infection following surgery for acute appendicitis: a randomized, prospective, controlled trial. Arch Surg 2011; 146: 464-70.
Gardella C, Goltra LB, Laschansky E, et al. High-concentration supplemental perioperative oxygen to reduce the incidence of postcesarean surgical site infection: a randomized controlled trial. Obstet Gynecol 2008; 112: 545-52.
Mayzler O, Weksler N, Domchik S, Klein M, Mizrahi S, Gurman GM. Does supplemental perioperative oxygen administration reduce the incidence of wound infection in elective colorectal surgery? Minerva Anestesiol 2005; 71: 21-5.
Meyhoff CS, Wetterslev J, Jorgensen LN, PROXI Trial Group, et al. Effect of high perioperative oxygen fraction on surgical site infection and pulmonary complications after abdominal surgery: the PROXI randomized clinical trial. JAMA 2009; 302: 1543-50.
Qadan M, Akca O, Mahid SS, Hornung CA, Polk HC Jr. Perioperative supplemental oxygen therapy and surgical site infection: a meta-analysis of randomized controlled trials. Arch Surg 2009; 44: 359-66.
Zingg W, Cartier-Fassler V, Walder B. Central venous catheter-associated infections. Best Pract Res Clin Anaesthesiol 2008; 22: 407-21.
Zingg W, Sax H, Inan C, et al. Hospital-wide surveillance of catheter-related bloodstream infection: from the expected to the unexpected. Journal of Hospital Infection 2009; 73: 41-6.
Pronovost P, Needham D, Berenholtz S, et al. An intervention to decrease catheter-related bloodstream infections in the ICU. N Engl J Med 2006; 355: 2725-32.
Loftus RW, Muffly MK, Brown JR, et al. Hand contamination of anesthesia providers is an important risk factor for intraoperative bacterial transmission. Anesth Analg 2011; 112: 98-105.
Loftus RW, Brown JR, Koff MD, et al. Multiple reservoirs contribute to intraoperative bacterial transmission. Anesth Analg 2012; 114: 1236-48.
Haynes AB, Weiser TG, Berry WR, Safe Surgery Saves Lives Study Group, et al. A surgical safety checklist to reduce morbidity and mortality in a global population. N Engl J Med 2009; 360: 491-9.
Neily J, Mills PD, Young-Xu Y, et al. Association between implementation of a medical team training program and surgical mortality. JAMA 2010; 304: 1693-700.
de Vries EN, Prins HA, Crolla RM, SURPASS Collaborative Group, et al. Effect of a comprehensive surgical safety system on patient outcomes. N Engl J Med 2010; 363: 1928-37.
Dellinger EP, Hausmann SM, Bratzler DW, et al. Hospitals collaborate to decrease surgical site infections. Am J Surg 2005; 190: 9-15.
Merchant R, Bosenberg C, Brown K, et al. Guidelines to the Practice of Anesthesia: Revised edition 2011. Can J Anesth 2011; 58: 74-107.
Competing interests
None declared.
Author information
Authors and Affiliations
Corresponding author
Rights and permissions
About this article
Cite this article
Forbes, S.S., McLean, R.F. Review article: The anesthesiologist’s role in the prevention of surgical site infections. Can J Anesth/J Can Anesth 60, 176–183 (2013). https://doi.org/10.1007/s12630-012-9858-6
Received:
Accepted:
Published:
Issue Date:
DOI: https://doi.org/10.1007/s12630-012-9858-6