Percutaneous endoscopic gastrostomy; surgical errors; hepatitis B vaccination; feasibility of sharpless surgery

AORN Journal,  Jan, 2007  by George Allen

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Antimicrobial prophylaxis for percutaneous endoscopic gastrostomy

Cochrane Database of Systematic Reviews

October 2006

Percutaneous endoscopic gastrostomy (PEG) involves surgically placing a feeding tube through the anterior abdominal wall to the stomach using an endoscopic technique. The tube serves as a clean or sterile delivery system through which a liquid diet or medication is delivered. Patients undergoing PEG placement are often vulnerable to infection as a result of factors including advanced age; compromised nutritional intake; immunosuppression; and underlying diseases, such as malignancy and diabetes mellitus. Infections associated with PEG placement, including surgical site infections (SSIs), account for many of the minor, major, and fatal complications seen in these patients. Superficial SSIs (ie, peristomal infections) that occur after PEG placement are associated with a mortality rate of approximately 2%. Such SSIs involve skin or subcutaneous tissue presenting with at least one of the following: pus, pain, localized swelling, or redness and heat. Such SSIs also may be identified through diagnosis by a clinician.

A systematic review and metaanalysis (ie, the most credible form of evidence for applying evidence-based clinical practice) published in 2000 supported the use of prophylactic antibiotics for PEG placement. Prophylactic antibiotic use involves giving the patient a very brief course of an antimicrobial agent, which is initiated before the initial incision is made and may continue for a set period of time postoperatively. There is debate, however, concerning the merits of antibiotic prophylaxis, and the systematic review conducted in 2000 was found to have methodological weaknesses, including that the review was limited to published studies and no attempts were made to retrieve unpublished data. The objective of this study was to determine whether prophylactic use of systemic antimicrobial medications reduce the risk of peristomal infection in patients undergoing PEG placement. (1)

The researchers searched the following databases for randomized, controlled trials evaluating antimicrobial prophylaxis in people undergoing PEG placement:

* the Cochrane Wounds Group Specialized Register, compiled through searches of major health databases including Medline, CINAHL, and EMBASE and

* the Cochrane Central Register of

Controlled Trials (ie, CENTRAL). Additionally, wound care journals, relevant conference proceedings, and the bibliographies of all retrieved and relevant publications were searched, and manufacturers and distributors of PEG products, relevant government bodies, and professional organizations were contacted for details on unpublished and ongoing studies. Outcome measures included

* diagnosis of peristomal site infection up to 30 days after PEG placement;

* identification of bacteria causing infection;

* peritonitis;

* adverse effects, such as antibiotic-associated diarrhea or anaphylaxis;

* mortality;

* removal of the PEG tube because of infection; and

* length of hospital stay. Common statistical procedures, including odds ratios and a fixed effect model, were used to analyze the data.

Findings. Ten randomized clinical trials evaluating prophylactic antimicrobials in 1,100 patients met the inclusion criteria, with use of prophylactic antibiotics compared to placebo or no intervention. No unpublished trials were found, and three authors responded to requests for information. Broad-spectrum antibiotics were used in all the trials, with the method of delivery being W by bolus or infusion. In nine of the trials, antibiotics were administered approximately 30 minutes before PEG placement, and in one trial, antibiotics were administered immediately before PEG placement. All the trials reported peristomal infections as an outcome, and the pooled analysis resulted in a statistically significant reduction in the incidence of peristomal infection with prophylactic antibiotics (pooled odds ratio 0.31, 95% confidence interval [CI] 0.22-0.44).

Clinical implications. The results of this review show that the use of systemic, broad-spectrum antibiotic prophylaxis is effective at preventing peristomal infection after PEG placement. Perioperative nurses should facilitate the routine administration of antibiotic prophylaxis to patients undergoing PEG placement. Additionally, they must understand that the timing of prophylactic antibiotic administration is of critical importance; the antibiotics must be administered in sufficient time to establish a bactericidal concentration in the tissues before PEG placement.

Surgical error analysis using malpractice claims

Surgery

July 2006

Patient safety and the consequent reduction in the incidence and cost of medical errors have become a national priority. It is estimated that one-half to two-thirds of inpatient adverse events are attributable to surgical errors, and more than half of these are believed to be preventable. Several factors have been linked to poor surgical outcomes, including