Pre-operative preparation for the patient

Pre-operative preparation is based on pre-operative shaving, shower with an antiseptic solution, skin preparation and antimicrobial prophylaxis

Wounds are divided into four classes

1. Clean

An uninfected operative wound in which no inflammation is encountered and the respiratory, alimentary, genital, or uninfected urinary tracts are not entered. In addition, clean wounds are primarily closed and, if necessary, drained with closed drainage. Operative incisional wounds that follow nonpenetrating (blunt) trauma should be included in this category if they meet the criteria.

2. Clean-Contaminated

Operative wounds in which the respiratory, alimentary, genital, or urinary tracts are entered under controlled conditions and without unusual contamination. Specifically, operations involving the biliary tract, appendix, vagina, and oropharynx are included in this category, provided no evidence of infection or major break in technique is encountered.

3. Contaminated

Open, fresh, accidental wounds. In addition, operations with major breaks in sterile technique (e.g., open cardiac massage) or gross spillage from the gastrointestinal tract, and incisions in which acute, nonpurulent inflammation is encountered including necrotic tissue without evidence of purulent drainage (e.g., dry gangrene) are included in this category.

4. Dirty or Infected

Includes old traumatic wounds with retained devitalized tissue and those that involve existing clinical infection or perforated viscera. This definition suggests that the organisms causing postoperative infection were present in the operative field before the operation.

Elimination of endogenous flora- Attention is given particularly to the following:

• Oral hygiene
• Skin
• Nail
• Perineal region
• ENT

Skin preparation

Skin preparation starts from clipping of the part. It is preferably done just before the surgery. If not done properly, it can cause injury to the skin leading to colonization and thereby increase the chance of surgical site infection.

Bathing

Antiseptic bath – Agents used are Chlorhexidine gluconate, Povidone-iodine and Triclosone medicated soap shower. Head to foot thorough scrub bath is given by warm water. The body is dried by a clean and laundered towel. The patient is given freshly laundered linen for the bed.

The patient is given a clean, ironed dress to wear. Scalp is covered with clean cap and legs are covered by clean leggings to prevent contamination by dirt. This is also part of Operation theatre discipline. Patient is wheeled to OT on a trolley which has clean linen over it.

Antibiotic prophylaxis as per the antibiotic policy.

Preoperative precautions

• Whenever possible identify and treat all infections remote to the surgical site before elective surgery. Postpone elective operations if there is a remote site infection until the infection has resolved.
• Do not remove hair preoperatively unless the hair on or around the incision site will interfere with the operation. Hairs are preferably removed just before the surgery.
• Patients who require shower bath with chlorhexidine 1% or with an antiseptic agent are given twice preoperatively or at least the night before the operative day.
• The blood sugar level in diabetic patients should be brought under control before surgery.
• Preferably, the pre-operative stay should be minimized as far as possible.

Post-operative precautions

• The operated site should be covered with sterile dressings and should not be disturbed at least up to 24 to 48 hrs.
• Strict hand hygiene to be followed before and after changing of wound dressing, and sterile technique should be followed.
• Patient’s attendant is educated as required regarding proper incision care and symptoms of surgical site infections and to report to the Doctor immediately.

Antibiotic prophylaxis: As per the Antibiotic Policy.

Incisional surgical site infection:

An incisional SSI must meet the following criterion:

Superficial incisional SSI

Must meet the following criteria:

• Date of event for infection occurs within 30 days after any NHSN(National Healthcare Safety Network) operative procedure (where day 1 = the procedure date)
• Infection occurs within 30 days after the operation if no implant is left in place or within one year if the implant is in place and the infection appears to be related to the operative procedure and involves deep soft tissues (e.g. fascia and muscles layers) of the incision and patient has at the surgical site

Deep incisional SSI

Must meet the following criteria:

• The date of event for infection occurs within 30 or 90 days after the NHSN operative procedure (where day 1 = the procedure date) according
• An abscess or other evidence of infection involving the deep incision is found on direct examination, during reoperation, or by histopathology or radiologic examination
• diagnosis of a deep incisional SSI by a surgeon or attending physician

Organ/Space Surgical site infection

Must meet the following criteria:

• Date of the event for infection occurs within 30 or 90 days
  An organ/space SSI involves any part of the body, excluding the skin incision, fascia, or muscle layers, that is opened or manipulated during the operative procedure limited to the following infections.
• Osteomyelitis
• Mediastinitis

An organ/space SSI must meet the following criteria on

• Infection occurs within 3 days after the operative procedure,
• if no implant is left in place or within one year,
• if implant is in place and the infection appears to be related to the operative procedure and infection involves any part of the body, excluding the skin incision, fascia, or muscle layers, that is opened or manipulated during the operative procedure and patient has at least one of the following:
• Purulent drainage from a drain that is placed through a stab wound into the organ/space
• Organisms isolated from an aseptically obtained culture or fluid or tissue in the organ/space
• An abscess or other evidence of infection involving the organ/space that is found on direct examination, during reoperation, or by histopathology or radiologic examination
• Diagnosis of an organ/space SSI by a surgeon or attending physician

Wound care – Surgical wounds

• After an elective surgery, the surgical wound is inspected on the third postoperative day or earlier if wound infection is suspected.
• All personnel doing dressings should perform hand hygiene before the procedure.
• Take off the dressings, wash hands again before applying a new dressing.
• Ideally, a two-member technique is followed. One to open the wound and one to do the dressings.
• A clean, dry wound may be left open without any dressing after inspection.
• If there is any evidence of wound infection or purulent discharge, then dressings are done daily, using Povidone-iodine to clean the wound and applying dry absorbent dressings.
• Preferably, disposable plastic aprons must be worn while changing the dressing.

Care of ulcers

• Dressings of ulcers, of whatever cause should be done at least daily, or more often, depending on the amount of discharge from the ulcer.
• Disposable plastic aprons must be worn while changing the dressing.
• The same technique for surgical wound dressing is used.
• After inspecting the dressing, all the devitalized tissue should be removed, using a scalpel or scissors if necessary.
• The wound should be cleaned with povidone-iodine. Other solutions that can be used include hydrogen peroxide and 1% sod. Hypochlorite solution.
• After debridement of the wound, a sterile absorbent dressing is applied. Bactigras dressings may also be applied if there is necrotic tissue in the ulcer.

Care of surgical wounds, Fistulae – Open surgical wounds and fistulae, discharge a lot of fluid, it should be tried to keep dry, using ostomy bags. The skin around the intestinal fistulae should be inspected daily for excoriation. If excoriation is present, either zinc oxide paste or aluminium paste is applied around the skin.