Infection prevention in breast implant surgery – A review of the surgical evidence, guidelines and a checklist

Barr SP, Topps AR, Barnes NL, Henderson J, Hignett S, Teasdale RL, McKenna A, Harvey JR, Kirwan CC; Northwest Breast Surgical Research Collaborative

"We have produced a perioperative "Theatre Implant Checklist" for SSI prevention in implant-based breast surgery, with a set of pragmatic up to date guidelines, which allows the reader to evaluate the evidence upon which our recommendations are based."

Active body surface warming systems for preventing complications caused by inadvertent perioperative hypothermia in adults

Madrid E, Urrútia G, Roqué i Figuls M, Pardo-Hernandez H, Campos JM, Paniagua P, Maestre L, Alonso-Coello P

"Forced-air warming seems to have a beneficial effect in terms of a lower rate of surgical site infection and complications, at least in those undergoing abdominal surgery, compared to not applying any active warming system. It also has a beneficial effect on major cardiovascular complications in people with substantial cardiovascular disease, although the evidence is limited to one study. It also improves patient's comfort, although we found high heterogeneity among trials. While the effect on blood loss is statistically significant, this difference does not translate to a significant reduction in transfusions. Again, we noted high heterogeneity among trials for this outcome. The clinical relevance of blood loss reduction is therefore questionable. The evidence for other types of ABSW is scant, although there is some evidence of a beneficial effect in the same direction on chills/shivering with electric or resistive-based heating systems. Some evidence suggests that extending systemic warming to the preoperative period could be more beneficial than limiting it only to during surgery. Nothing suggests that ABSW systems pose a significant risk to patients. The difficulty in observing a clinically-relevant beneficial effect with ABSW in outcomes other than temperature may be explained by the fact that many studies applied concomitant procedures that are routinely in place as co-interventions to prevent hypothermia, whether passive or active warming systems based in other physiological mechanisms (e.g. irrigation fluid or gas warming), as well as a stricter control of temperature in the context of the study compared with usual practice. These may have had a beneficial effect on the participants in the control group, leading to an underestimation of the net benefit of ABSW."

Effectiveness of a care bundle to reduce surgical site infections in patients having open colorectal surgery

Tanner J, Kiernan M, Hilliam R, Davey S, Collins E, Wood T, Ball J, Leaper D

"The [Department of Health] care bundle did not reduce SSIs after open colorectal surgery. Despite this, it is not possible to state that the bundle is ineffective as compliance rates before and after bundle implementation were similar. All studies evaluating the effectiveness of care bundles must include data for compliance with interventions both before and after implementation of the care bundle; poor compliance may be one of the reasons for the lower than expected reduction of SSIs."

The effects of local warming on surgical site infection

Whitney JD, Dellinger EP, Weber J, Swenson RE, Kent CD, Swanson PE, Harmon K, Perrin M

"Post-operative local warming compared with non-warming followed in this study, which included intra-operative warming to maintain normothermia and [fraction of inspired oxygen] level of 0.80, did not reduce SSI and had no effect on immune, endothelial cell presence, or collagen synthesis. [Tissue oxygen] increased significantly with warming, however, the increase was modest and less than expected or what has been observed in studies testing other interventions."

Infection control in the operating room

Cosgrove MS

"The use of antibiotics, attention to patient normothermia, and sound hand hygiene have been shown to decrease the rate of postoperative SSI. "

Infection control hazards associated with the use of forced-air warming in operating theatres

Wood AM, Moss C, Keenan A, Reed MR, Leaper DJ

"We conclude that FAW does contaminate ultra-clean air ventilation; however, there appears to be no definite link to an increased risk of SSI based on current research. Nevertheless, whereas this remains unproven, we recommend that surgeons should at least consider alternative patient-warming systems in areas where contamination of the operative field may be critical. Although this is not a systematic review of acceptable randomized controlled clinical trials, which do not exist, it does identify that there is a need for definitive research in this field. "

Defining intraoperative hypothermia in ventral hernia repair

Baucom RB, Phillips SE, Ehrenfeld JM, Holzman MD, Nealon WH, Sharp KW, Kaiser JL, Poulose BK

"Our results demonstrate no association between temperature and SSI in VHR. Efforts to reduce SSI should focus on factors such as smoking cessation, weight loss, and length of surgery. Our study suggests that maintenance of perioperative normothermia may only decrease SSIs in certain at-risk populations."

Forced-Air Warming Devices and the Risk of Surgical Site Infections

Kellam MD, Dieckmann LS, Austin PN

A literature examination investigates whether forced-air warming devices increase the risk of SSIs in patients undergoing general, vascular, or orthopedic surgical procedures. A review of 15 evidence sources did not conclusively suggest that the use of forced-air warmers increases the risk of SSIs.

Forced-air warming blowers: An evaluation of filtration adequacy and airborne contamination emissions in the operating room

Albrecht M, Gauthier RL, Belani K, Litchy M, Leaper D

An evaluation of 52 forced-air warming devices all with the model 200708C filter were sampled in their surgical environment of use from 11 hospitals and determined that the filter was inadequate for preventing the internal buildup and emission of microbial contaminants in the operating room.

Forced-air warming: a source of airborne contamination in the operating room?

Albrecht M, Gauthier R, Leaper D

A study evaluating 25 forced-air-warming (FAW) blowers in the operating room concluded that the design of FAW blowers was questionable for preventing the build-up of internal contamination and the emission of airborne contamination. Internally generated airborne contamination within the size range of free floating bacteria and fungi (<4 µm) could potentially be emitted from the FAW blowers and settle onto the surgical site.

Evidence-Based Guidelines for Prevention of Perioperative Hypothermia

Forbes SS, Eskicioglu C, Nathens AB, Fenech DS, Laflamme C, McLean RF, McLeod RS; Best Practice in General Surgery Committee, University of Toronto

A systematic review examined the most accurate tool for monitoring perioperative temperatures, whether warming devices help maintain core body temperature and whether there is direct evidence that preventing perioperative hypothermia reduces the risk of SSIs and morbid cardiac events. The literature search resulted in recommendations, including the use of IV fluid warmers for abdominal procedures of more than 1-hour duration and the use of warmed forced air both preoperatively and intraoperatively when procedures are expected to last more than 30 minutes.

Effect of prewarming on post-induction core temperature and the incidence of inadvertent perioperative hypothermia in patients undergoing general anaesthesia

Andrzejowski J, Hoyle J, Eapen G, Turnbull D

A randomized trial of 68 patients undergoing spinal surgery under general anesthesia found that preoperative warming for 60 minutes using a preoperative forced-air warming device resulted in smaller decreases in core temperature intraoperatively and less inadvertent perioperative hypothermia than patients in the non-prewarmed group.

Randomized clinical trial of perioperative systemic warming in major elective abdominal surgery

Wong PF, Kumar S, Bohra A, Whetter D, Leaper DJ

A randomized trial of 103 patients undergoing elective major abdominal surgery found that the group that had been warmed two hours before surgery, during surgery and two hours after surgery using a conductive carbon polymer mattress had lower blood loss and complication rates than the group that was warmed only during surgery.

Surgical Site Infection Following Bowel Surgery

Walz JM, Paterson CA, Seligowski JM, Heard SO

A retrospective analysis of 1,472 patients in a heterogeneous population undergoing bowel surgery demonstrated that patients with a lower intraoperative temperature nadir had a lower risk for SSI, although the difference is not clinically significant.

Perioperative hypothermia in the high-risk surgical patient

Leslie K, Sessler DI

The article reviews perioperative hypothermia, the risks associated with it and prevention methods. Proper thermal management may reduce complications and improve outcomes in high-risk surgical patients.

The Bair Hugger patient warming system in prolonged vascular surgery: an infection risk?

JKC Huang, EF Shah, N Vinodkumar, MA Hegarty, RA Greatorex

A study analyzing 16 patients undergoing abdominal vascular prosthetic graft insertion procedures using the Bair Hugger patient warming system determined that there was no increase in bacterial counts at the study sites; additionally, there was a decrease in air bacterial content around the patient and in the operating theatre after prolonged use of the warmer.

Effects of preoperative warming on the incidence of wound infection after clean surgery: a randomised controlled trial

Melling AC, Ali B, Scott EM, Leaper DJ

A randomized, controlled study of 416 patients undergoing clean (breast, varicose vein or hernia) surgery found that 14% of patients in the non-warmed group had a wound infection versus 5% in the group that received warming (local or systemic). Results suggest that warming patients before clean surgery aids in the prevention of postoperative wound infection.

Perioperative Normothermia to Reduce the Incidence of Surgical-Wound Infection and Shorten Hospitalization

Kurz A, Sessler DI, Lenhardt R; For the Study of Wound Infection and Temperature Group

A double-blind, randomized study of 200 patients undergoing colorectal surgery discovered that patients assigned to the routine intraoperative thermal care (hypothermia) group had a 19% surgical-wound infection rate versus a 6% infection rate in the additional warming (normothermia) group. Additionally, sutures were removed one day later and hospital stay was prolonged by 2.6 days in the hypothermia group.

Convective Warming Therapy Does Not Increase the Risk of Wound Contamination in the Operating Room

Zink RS, Iaizzo PA

A balanced cross-over study including eight healthy male volunteers was designed to determine if the use of convective warming therapy increased the risk of wound contamination in the operating room. It was concluded from observation of culture plates between study periods that the use of convective-based warming devices does not increase the risk for airborne bacterial wound contamination.