Antibiotic prophylaxis; anti-adhesion membrane use in pediatric patients; postoperative oxygen; supplemental oxygen

AORN Journal, Feb, 2006 by George Allen

Effective antibiotic prophylaxis in arthroplastic surgery The Journal of Bone and Joint Surgery September 2005

Infection after total hip arthroplasty is a serious complication that may result in removal of the prosthesis. Such infections can occur through hematogenous seeding but more commonly, they occur from bacteria entering the wound at the time of the surgical procedure. Antibiotic prophylaxis has been identified as an effective method to address this problem when the antibiotics are administered in a time frame that would establish therapeutic levels in the bloodstream before the incision is made. For antibiotic prophylaxis to be effective, however, the antibiotics must be active against the pathogens most likely to contaminate the surgical wound. Most postoperative prosthetic hip infections are caused by gram-positive bacteria, predominately staphylococci. Beta-lactam-resistant staphylococci have become increasingly common, resulting in decreased effectiveness of antibiotic prophylaxis using pencillins or cephalosporins, including cefuroxime. The purpose of this study was to identify the contaminating bacteria after hip arthroplasty and to establish the bacteria's sensitivity to prophylactic antibiotics in current use. (1)

During the course of 50 total hip arthroplasty procedures performed at a university hospital in England, the gloved hands of the surgeon, first assistant, and scrub nurse were cultured. Immediately after gloves were either changed or discarded, impressions of the staff member's right and left hands were obtained on the same blood agar plate. Gloves were changed after draping and at 20-minute intervals, immediately before using cement, and whenever a visible puncture was detected. All isolates were identified by gram stain and were tested for sensitivity to floxacillin, a recognized indicator of sensitivity to cefuroxime. Gram-positive isolates also were tested against gentamicin, fusidic acid, and linezolid. Escherichia coli (E coli) isolates were tested against gentamicin, cefuroxime, and amoxicillin, and Pseudomonas species were tested against gentamicin, ceftazidime, piperacillin, and tazobactum. Common statistical procedures were used to analyze the data.

Findings. Six hundred twenty-seven pairs of gloved hands were cultured. Fifty-seven (ie, 9%) were found to be contaminated. Of the 106 isolates recovered, coagulase-negative staphylococcus accounted for 69.9%, micrococcus accounted for 12.3%, diphtheriods accounted for 9.3%, Staphylococcus aureus accounted for 6.6%, Pseudomonas accounted for 1.9%, and E coli accounted for 0.9%.

All the gram-positive isolates (ie, 103) were sensitive to linezolid. Although 89.4% of the coagulase-negative staphylococcus isolates were sensitive to fusidic acid and 95.5% were sensitive to gentamicin, only 52.1% were sensitive to cefuroxime. For Staphylococcus aureus, 71.4% were sensitive to cefuroxime, whereas 85.7% were sensitive to fusidic acid and gentamicin.

Clinical implications. The results of this study revealed that staphylococci represented 75% of the contaminating isolates, and almost half of the isolates (ie, 47.9%) were resistant to cefuroxime. This raises the question of whether cefuroxime is the most appropriate medication of choice for antibiotic prophylaxis in total hip arthroplasty. Perioperative nurses should bring these findings to surgeons.

Anti-adhesion membrane use in surgery

Journal of Pediatric Surgery August 2005

Adhesions generally may occur after laparotomy and may result in serious complications, such as intestinal obstruction, chronic abdominal pain, or infertility. Secondary laparotomies for lysis of adhesions increase the risk of intestinal and mesenteric injury. In addition, numerous pediatric conditions, such as imperforate anus, necrotizing enterocolitis, and biliary atresia, involve surgical procedures that require serial laparotomies. Consequently, pediatric surgeons are eager to identify new methodologies that could prevent the occurrence of postoperative adhesions in children.

In 1996, a sodium hyaluronate and carboxymethyl cellulose anti-adhesion membrane, which serves as a temporary bioresorbable barrier separating apposing tissue surfaces, became clinically available for use in abdominal surgery. Subsequently, data from animal studies and studies in adult humans showed that the anti-adhesion membrane safely reduced the formation of postoperative adhesions. The purpose of this prospective, randomized study was to evaluate the safety and effectiveness of the anti-adhesion membrane in pediatric patients. (2)

Pediatric patients who underwent laparotomy (n = 122) at a university hospital in Japan between December 1998 and November 2002 were randomly assigned to one of two groups. Study participants in group I (ie, the control group) did not receive the anti-adhesion membrane before the abdomen was closed. Participants in group II received the anti-adhesion membrane before abdominal closure. Diagnoses included duodenal atresia or stenosis, neuroblastoma, small intestinal atresia or stenosis, congenital diaphragmatic hernia, ulcerative colitis, ovarian tumor, gastric perforation, choledochal cyst, intussusception, imperforate anus, Hirschsprung's disease, gastroschisis or omphalocele, and histoblastoma.