09 surgical infection
围手术期手术部位感染预防与控制措施
主要内容
u 手术部位感染概述
(基本概念、手术部位感染、手术切口的分类、发病率与危险因素)
u 围手术期手术部位感染的基本要求与防控措施
（围手术期SSl预防、手术前的预防 、手术中的预防、手术后的预防 ）
u 手术部位感染管理质量控制
概况
l 手术部位感染（Surgical Site Infection，SSI）是指患者术后30天内发生的 表浅切口、深部切口、器官（或腔隙）感染，有植入物的手术于手术后1年内 发生的与手术有关的器官或腔隙的感染。
l 肥胖因素：临床流行病学调查显示，肥胖者术后感染率大约为13.5%～16.5%，明显高于非肥胖患者， 也被视为手术部位感染的危险因素。肥胖感染机遇增大的原因可能与脂肪组织血供量少以及影响手 术暴露，延长手术时间，并难以完全避免脂肪层死腔形成有关。
发病率与危险因素
* 慢性疾病：患慢性肾脏疾病、糖尿病、粒细胞减少、血小板增多症、免疫缺陷、严 重营养不良、尿毒症、慢性肺疾患、术前低蛋白血症、手术部位放射治疗时等患者， 由于全身抵抗力下降对细菌的易感性增加，属高危人群。高血糖是SSI已知的独立 危险因素。Fumary和他的同事证明深部胸骨切口感染在术后实施持续胰岛素输注严 格控制血糖能显著改善疗效。如果有必要，术前、术中和术后都应优化控制血糖
物外溢、手术部位存在急性非化脓性炎症。 Ⅳ类：感染切口 infected incision * 手术部位已经存在感染（如有失活组织的陈旧性创伤手术，已有临床感染或脏器穿孔）
发病率与危险因素
发病率
* 外科手术部位感染（SSI）包括手术切口及手术脏器的感染，是常见的医院感染 * 非腹部清洁手术如胸部外科手术感染率约为2%～5%，整形外科手术和腹部手术感染率为20% * 造成手术部位感染的主要原因：系手术技术自身所决定，因为外科手术必然破坏了人体宿主抵抗力的第一道
SSI
满意度
满意度
汽车4S店的销售服务满意度，即SSI(Sales Satisfaction Index)，指经销商在售车过程中、客户购车过 程中，客户对经销商售车过程的满意程度，是根据新车用户的满意度调查得出的指数，主要是根据影响消费者满 意度的八项要素来做评估。以深圳优凯DMS对SSI标准的定义，总分100分，80分以上为合格，85~90分为客户满意， 95分以上为客户非常满意，满意度各品牌主机厂会定期(一般为1个月)进行调查，并针对这个调查结果对经销商 进行赏罚。SSI分数越高，表明对销售过程的满意度越高。这八项要素依重要性排列分别为：交车流程、销售负 责人、成交条件、交付时间、广告信息、保险装潢、销售体制及设施、书面手续。这项调查主要基于顾客在购买 新车的3至8个月期内的评价。
同步接口
同步接口
同步串行接口：Synchronous Serial Interface，是各类DSP处理器中的常见接口。工作在络模式下的SSI 端口在某些应用场合非常重要。
SSI接口通信协议是一种带有帧同步信号的串行数据协议； 全双工的串行接口，允许芯片与多种串行设备通信； 高精度绝对值角度编码器中较常用的接口方式 数据传输时序图SSI采用主机主动式读出方式，即在主控者发出的时钟脉冲的控制下，从最高有效位（MSB） 开始同步传输。其数据传输时序图如下：
影响因素
影响SSI的因素很多，大体可以分为患者因素与手术因素两大类。患者因素包括：1）年龄，2）免疫力系统 受损，3）糖尿病，4）非手术区域的感染灶，5）伤口分类，6）营养不良，7）吸烟，8）肥胖，9）术前住院天 数过长，和10）激素。手术因素则包括：1）预防性抗生素的使用，2）患者管理，3）手术时间过长，4）皮肤准 备，5）外科洗手，6）手术室环境（通风，消毒等状况，7）手术衣和铺巾，8）手术技术：止血、无菌技术、异 物，以及9）器械的灭菌监测。
外科感染英语
Obstruction
Trauma
Ischemia
Etiology：Systemic Factors
• Severe Trauma • DM • Cancer, Chemotherapy • Leukemia • AIDS • Immunodeficiency • Malnutrition
• Mixed infection
• Tuberculosis
• Systemic infection
• Tetanus, gas gangrene
• Opportunistic infection
• Fungi
Clinical Mancal infection
Most non-specific infection Tetanus Gas gangrene
Chronic infection (>2M)
Tuberculosis
Sub-acute infection (3w-2M)
Urine tract infection Fungal infection
Classifications：Others
Systemic phase • Bacteremia • Sepsis
Etiology of surgical infection
• Pathogenic microorgansim • Local factors • Systemic factors
Etiology：Pathogenic Microorgansim
Breast abscess
Physical Exam： Biopsy
• Being necessary for diagnosis sometimes
外科医生手术前消毒流程
外科医生手术前消毒流程英文回答：Surgical site infection (SSI) is a significant concern in the field of surgery, and proper disinfection procedures play a crucial role in preventing such infections. The preoperative disinfection process is a critical step that ensures the surgical site is clean and free from harmful microorganisms. This process involves several steps and should be followed meticulously to minimize the risk of infection.Firstly, the surgical team should thoroughly wash their hands with soap and water for at least 20 seconds. Hand hygiene is essential to prevent the transfer of bacteria from the hands to the surgical site. After washing, the hands should be dried using a sterile towel or a disposable paper towel.Next, the surgical team should put on sterile glovesand a surgical gown. These items create a barrier betweenthe surgical team and the patient, preventing the transferof microorganisms. It is important to ensure that thegloves and gown are sterile and free from any contamination.The next step involves preparing the surgical site. The area around the surgical site should be thoroughly cleaned with an antiseptic solution. The most commonly used antiseptic solution is chlorhexidine or povidone-iodine.The antiseptic solution should be applied using sterile gauze or swabs and should cover a sufficient area aroundthe surgical site. This process helps to eliminate bacteria on the patient's skin and reduces the risk of infection.In addition to the surgical site, other areas that may come into contact with the surgical instruments should also be disinfected. This includes the surgical table,instrument trays, and any other equipment that will be used during the procedure. Disinfection can be achieved by using an appropriate disinfectant solution or by autoclaving the instruments.After the disinfection process, the surgical team should maintain a sterile environment by using sterile drapes to cover the patient and the surrounding area. The drapes create a barrier that prevents microorganisms from contaminating the surgical site.Overall, the preoperative disinfection process is a vital step in ensuring the safety and success of surgical procedures. By following proper disinfection procedures, the surgical team can minimize the risk of surgical site infections and provide the best possible care to their patients.中文回答：手术前的消毒流程对于预防手术切口感染非常重要。
克氏外科学-外科感染及抗生素应用
SURGICAL INቤተ መጻሕፍቲ ባይዱECTIONS AND ANTIBIOTIC USE
Philip S. Barie
risk factors for infection infection control specific infections antibiotic use disease-, pathogen-, and antibiotic-specific considerations antibiotic toxicities important pathogens of critically ill patients fungal infections
Traditionally, surgical infections have been considered to be those that require surgical therapy (e.g., complicated intraabdominal infections [cIAIs] and skin or soft tissue infections [cSSTIs]). However, surgical patients are particularly vulnerable to nosocomial infections, so a more expansive definition includes any infection that affects surgical patients. Examples of infections that may complicate perioperative care include surgical site infections (SSIs), central line–associated bloodstream infections (CLABSIs), urinary tract infections (UTIs), and hospital- or ventilator-associated pneumonia (HAP, VAP). This chapter takes the more encompassing view, recognizing that the surgical patient is at particular risk for nosocomial infections for numerous reasons. Surgery’s inherent invasiveness creates portals of entry for pathogens to invade the host through natural epithelial barriers. Surgical illness is immunosuppressive (e.g., trauma, burns, malignant tumors), as is therapeutic immunosuppression following solid organ transplantation. General anesthesia almost always means a period of endotracheal intubation and mechanical ventilation, and a period of reduced consciousness during emergence that poses a risk of pulmonary aspiration of gastric contents; both increase the risk of pneumonia. Considering that the development of a postoperative infection has a negative impact on surgical outcomes, recognizing and minimizing risk and an aggressive approach to the diagnosis and treatment of these infections are crucial. Although morbid and costly, infection is preventable to some degree, and every physician who has patient contact must do his or her utmost to prevent infection. An ensemble of prevention methods is required, because no single method is universally effective. Infection control is paramount. Surgical incisions and traumatic wounds must be handled gently, inspected daily, and dressed if necessary using strict asepsis. 240
手术部位感染的预防精品PPT课件
防水的手术巾 脉冲冲洗 层流装置 穿封闭式排气手术衣
◆消灭已侵入的细菌
预防性抗生素应用
局部抗生素应用
假体表面改性
抗生素假体表面涂层
自我监测、自我诊断、自我治疗的智能型植入物
RNAIII抑制肽
层流装置可以滤过0.3um以上的颗粒 细菌通常为0.5um 每小时通常空气交换12～15次 垂直层流或水平层流
患者方面：患者的年龄、营养状况、免疫功能、 健康状况等等
创口污染的程度 微生物的毒力 组织的血供和活力 手术区域以外的感染 原有的疾病（糖尿病、免疫抑制或肥胖）
针对细菌的预防措施
◆减少侵入的细菌
治疗其他部位的感染：如泌尿系、口腔感染等
严格消毒病人 戴双层手套 预防性抗菌素应用 限制人员在手术间来回走动
手术切口的污染情况 机体的免疫力 细菌的毒力
血肿、组织缺血坏死、异物 →引发、加重感染
我们应该朝哪个 方向努力？
认识感染 预防感染
什么是SSI？
来自于皮肤，身体其他部位和周围环境中的微 生物进入手术切口，并在组织是繁殖就引发了 外科部位感染。
藏匿大量细菌的手术部位更容易发生术后感染， 如肠道。
SSI发生率 3.8% 0.6% 1.4% 3.3%
结论：抗生素应该在皮肤切开前半小时或麻醉 诱导尽量保持手术室正压勇气，环境表面清洁，最大限 度减少人员数量和流动。
保证使用的手术器械、器具及物品等达到灭菌水平。 手术中医务人员要严格遵循无菌技术原则和手卫生规范。 若手术时间超过3小时，或者手术时间长于所用抗菌药物半衰期的，或
感染：病人的免疫力，抗菌素的预防应用，切 口关闭······
外科手术切口的分类
外科手术部位感染分类
切口浅部组织感染
富血小板血浆局部多点注射治疗胫骨内侧应力综合征的疗效
富血小板血浆局部多点注射治疗胫骨内侧应力综合征的疗效施荣茂,陈志安,王令,吕晓雨,袁礼波,徐永清,谭洪波 （联勤保障部队第九二〇医院骨科，云南 昆明 650032）［摘要］ 目的 评估自体富血小板血浆（PRP ）局部多点注射治疗胫骨内侧应力综合征（MTSS ）的临床效果及安全性。
方法 纳入我院收治的60例单侧MTSS 患者，随机分为PRP 组（30例）和曲安奈德组（30例），分别予单次PRP 、曲安奈德局部多点注射治疗。
治疗后1周、4周及8周，评估患肢疼痛视觉模拟量表(VAS)评分、单足跳试验（hop test ）距离，统计重返训练的人数。
结果 2组患者局部注射后均未出现注射部位红肿、感染等并发症。
2组患者治疗后1周、4周及8周的VAS 评分和hop test 距离均较治疗前明显改善，差异具有统计学意义（P <0.01）。
2组患者治疗前、治疗后1周、治疗后4周、治疗后8周VAS 评分、hop test 距离比较，差异均无统计学意义（P >0.05）；2组患者治疗后4周、8周重返训练人数差异无统计学意义（P >0.05）。
结论 局部多点注射PRP 治疗MTSS 的近期疗效与曲安奈德相当，可缓解疼痛，改善患肢功能，且并发症少。
［关键词］ 军事训练伤；胫骨内侧应力综合征；富血小板血浆；皮质类固醇［中图分类号］ R874.5 ［文献标志码］ A ［收稿日期］ 2023-05-12Effect of local multi -point injection of platelet -rich plasm for the treatment of medial tibial stress syndrome SHI Rong -mao ，CHEN Zhi -an ，WANG Ling ，LYU Xiao -yu ，YUAN Li -bo ，XU Yong -qing ，TAN Hong -bo （Deparment ofOrthopedics ，the 920th Hospital of Joint Logistics Support Force ，Kunming Yunnan 650032，China ）Abstract: Objective To evaluate the clinical efficacy and safety of local multi -point injection of platelet -rich plasma （PRP ） for thetreatment of medial tibial stress syndrome （MTSS ）.Methods A total of 60 patients of unilateral MTSS in our hospital were enrolled ，and randomly divided into PRP group （30 cases ） and triamcinolone acetonide group （30 cases ）， which were given local multi -point injection of PRP and triamcinolone acetonide ， respectively. At 1 week ，4 weeks and 8 weeks post -injection ，the visual analogue scale （VAS ） score ，the distance of hop test of patients were evaluated ，and the number of patients who returned to training were counted.Results No complications such as injection site erythema and infection occurred in both groups after local injection.The VAS scores and distance of hop test of patients 1 week ， 4 weeks and 8 weeks after injection in both groups were significantly improved compared with those before injection ， the differences were statistically significant （P <0.01）.There was no significant difference in VAS score and distance of hop test at pre -injection or 1 week ，4 weeks and 8 weeks post -injection between the two groups （P >0.05）， and no significant difference in the number of patients who returned to training between the two groups at 4 and 8 weeks post -injection （P >0.05）.Conclusion Local multi -point injection of PRP for the treatment of MTSS has the same short -term efficacy as triamcinolone acetonide ，which can relieve the pain and improve the function of theaffected limb with fewer complications.Keywords: military training -related injuries ； medial tibial stress syndrome ； platelet -rich plasma ； cortical steroids军事训练是战斗力生成及维持的必要途径，军事训练伤则是影响军事训练效果的重要因素，其预防和治疗一直是部队的重点关注和研究领域。
手术部位感染的预防
100
100 40-80 40-80 30-70 30-50 20-60 25-35 5-55
Peptostreptococcus sp. 消化链球菌属
Peptococcus sp. 消化球菌属 Clostridium tetani 破伤风梭菌 Clostridium septicum 败血梭菌
?common
Bowel anaerobes
• Cefoxitin (头孢西丁) or cefotetan (头孢替坦） • Second generation cephalosporins • Broader coverage including anaerobic activity than the above agents • Some gram-negative bacilli such as E. coli have become resistant to cefoxitin • Reasonable alternatives include cefazolin plus metronidazole or monotherapy with ampicillin-sulbactam
observations
Common, occasionally pathogenic Infrequent, usually pathogenic Infrequent, occasionally pathogenic Infrequent, usually pathogenic Frequent, occasionally pathogenic Frequent, occasionally pathogenic Frequent, occasionally pathogenic Frequent, occasionally pathogenic Infrequent, occasionally pathogenic