HERIDAS QUIRÚRGICAS

HERIDAS QUIRÚRGICAS

Ramos Velasquez Fredy

INTRODUCCIÓN HERIDA

Es toda solución de continuidad en la cubierta cutánea, en la que con frecuencia se produce una simultanea o diferida perdida de sustancias, por acción de diversos agentes causantes y que puede

extenderse a los tejidos y órganos subyacentes

Salem Z, Pérez P,Henning L, Uherek P, Schultz O,Butte B y González F. Heridas. Conceptos generales. ARTÍCULO DOCENTE. Cuad. Cir. 2000; 14: 90-99

Victoria Valer Tito. Heridas y cicatrización. Cirugía general - UNMSM

ETIOLOGÍA

Agentes perforantesAgentes cortantesAgentes perforo-cortantesAgentes contundentesProyectiles de armas de fuego


INTRODUCCIÓN

MECANISMO

FricciónPercusiónCompresiónTracciónAcción combinada

INTRODUCCIÓN


Formas clínicas

INTRODUCCIÓN

ExcoriaciónHeridas punzantesHeridas incisasHeridas contusasHeridas por proyectilesHeridas venenosasHeridas por mordeduraHerida penetranteHerida transfixianteHeridas por asta de toroHerida por arrancamiento


Clasificación de las heridas quirúrgicas (National Research Council, Ad Hoc Commitee Trauma, 1964)

Objetivo: ayudar a predecir la probabilidad de infección de las heridas con base al grado de contaminación bacteriana

transoperatoria.

Herida limpia (tipo I)Herida limpia – contaminada (tipo II)Herida contaminada (tipo III)Herida sucia o infectada (tipo IV)


Herida limpia (tipo I) Intervención quirúrgica (heridas no

traumáticas) donde se conserva bien la técnica aséptica.

La incisión no penetra en el tracto respiratorio, digestivo genitourinario o cavidad abdominal ni a tejidos infectados

Cirugía electiva Tasa de infección ≤ 2 % Ejemplos: revascularización de arterias

coronarias, laparotomía exploratoria sin apertura de vísceras, injertos de piel.

No profilaxis antibiótica.


Rodolfo E. Quirós. INFECCION DE HERIDA QUIRURGICA . Actualización julio 2003

CLEAN CASES

Prophylactic antibiotics are not indicated in clean operations if the patient has no host risk factors or if the operation does not involve placement of prosthetic materials. Open heart operation and operations involving the aorta of the vessels in the groin require prophylaxis. Patients in whom host factors suggest the need for prophylaxis include those who have more than three concomitant diagnoses, those whose operations are expected to last longer than 2 hours, and those whose operations are abdominal. A patient who meets any two of these criteria is highly likely to benefit from prophylaxis. When host factors suggest that the probability of a surgical site infection (SSI) is significant, administration of cefazolin at induction of anesthesia is appropriate prophylaxis. Vancomycin should be substituted in patients who are allergic to cephalosporins or who are susceptible to major immediate hypersensitivity reactions to penicillin. When certain prostheses (e.g., heart valves, vascular grafts, and orthopedic hardware) are used, prophylaxis is justified when viewed in the light of the cost of an SSI to the patient’s health. Prophylaxis with either cefazolin or vancomycin is appropriate for cardiac, vascular, or orthopedic patients who receive prostheses. Catheters for dialysis or nutrition, pacemakers, and shunts of various sorts are prone to infection mostly for technical reasons, and prophylaxis is not usually required. Meta-analysis indicates, however, that antimicrobial prophylaxis reduces the infection rate in cerebrospinal fluid shunts by 50%. The placement of such foreign bodies is a clean operation, and the use of antibiotics should be based on local experience. A recent meta-analysis indicates that antibiotic prophylaxis (cefazolin) prevents SSI in breast surgery.

1 Prevention of Postoperative Infection Mamta Swaroop, MD, FACS, and Carla M. Pugh, MD, PhD, FACS

Herida limpia – contaminada (tipo II)

Intervención quirúrgica en la que se penetra el tracto respiratorio, digestivo o genitourinario bajo condiciones controladas y sin contaminación inusual.

Tasa de infección ≤ 5% Ejemplos: cesárea, laringotomía,

nefrectomía, tracto genitourinario si infección urinaria, apendicetomía sin perforación, colecistomía sin inflamación.

Profilaxis antibiótica.


CLEAN-CONTAMINATED CASES Abdominal procedures. In biliary tract procedures (open or laparoscopic), prophylaxis is required only for patients at high risk: those whose common bile duct is likely to be explored (because of jaundice, bile duct obstruction, stones in the common bile duct, or a reoperative biliary procedure); those with acute cholecystitis; and those older than 70 years. A single dose of cefazolin is adequate. In hepatobiliary and pancreatic procedures, antibiotic prophylaxis is always warranted because these operations are clean-contaminated, because they are long, and because they are abdominal. Prophylaxis is also warranted for therapeutic endoscopic retrograde cholangiopancreatography. In gastroduodenal procedures, patients whose gastric acidity is normal or high and in whom bleeding, cancer, gastric ulcer, and obstruction are absent are at low risk for infection and require no prophylaxis; all other patients are at high risk and require prophylaxis. Patients undergoing operation for morbid obesity should receive double the usual prophylactic dose; cefazolin is an effective agent. Operations on the head and neck (including the esophagus). Patients whose operation is of significance (i.e., involves entry into the oral cavity, the pharynx, or the esophagus) require prophylaxis. Gynecologic procedures. Patients whose operation is either high-risk cesarean section, abortion, or vaginal or abdominal hysterectomy will benefit from cefazolin. Aqueous penicillin G or doxycycline may be preferable for first-trimester abortions in patients with a history of pelvic inflammatory disease. In patients with cephalosporin allergy, doxycycline is effective for those having hysterectomies and metronidazole for those having cesarean sections. Women delivering by cesarean section should be given the antibiotic immediately after cord clamping. Urologic procedures. In principle, antibiotics are not required in patients with sterile urine. Patients with positive cultures should be treated. If an operative procedure is performed, a single dose of the appropriate antibiotic will suffice.


Herida contaminada (tipo III) Se incluyen heridas traumáticas recientes (‹ 4

horas) y quirúrgicas en las cuales ha habido una transgresión importante de la técnica aséptica, gran contaminación a partir del tubo digestivo o ingreso en las vías genitourinarias, inflamación aguda no purulenta.

Tasa de infección 10-20 % Ejemplos: histerectomía abdominal con derrame

de secreción vaginal, cesárea con derrame de liquido amniótico, colecistomía con derrame macroscópico.

Profilaxis antibiótica.


CONTAMINATED CASES Abdominal procedures. In colorectal procedures, antibiotics active against both aerobes and anaerobes are recommended. In appendectomy, SSI prophylaxis requires an agent or combination of agents against both aerobes and anaerobes; a single dose of cefoxitin, 2 g IV, or, in patients who are allergic to b-lactam antibiotics, metronidazole, 500 mg IV, is effective. A combination of an aminoglycoside and clindamycin is effective if the appendix is perforated; a therapeutic course of 3 to 5 days is appropriate but does not seem warranted unless the patient is particularly ill. A laparotomy without a precise diagnosis is usually an emergency procedure and demands preoperative prophylaxis. If the preoperative diagnosis is a ruptured viscus (e.g., the colon or the small bowel), both an agent active against aerobes and an agent active against anaerobes are required. Trauma. The proper duration of antibiotic prophylaxis for trauma patients is a confusing issue—24 hours or less of prophylaxis is probably adequate, and more than 48 hours is certainly unwarranted. When laparotomy is performed for nonpenetrating injuries, prophylaxis should be administered. Coverage of both aerobes and anaerobes is mandatory. The duration of prophylaxis should be less than 24 hours. In cases of penetrating abdominal injury, prophylaxis with either cefoxitin or a combination of agents active against anaerobic and aerobic organisms is required. The duration of prophylaxis should be less than 24 hours, and in many cases, perioperative doses will be adequate. For open fractures, management should proceed as if a therapeutic course were required. For grade I or II injuries, a first-generation cephalosporin will suffice, whereas for grade III injuries, combination therapy is warranted; the duration may vary. For operative repair of fractures, a single dose of cefazolin may be given preoperatively, with a second dose added if the procedure is long. Patients with major soft tissue injury with a danger of spreading infection will benefit from cefazolin, 1 g IV every 8 hours for 1 to 3 days.


Herida sucia o infectada (tipo IV)

Incluye heridas traumáticas sucias o con tratamiento retardado, con contaminación fecal, cuerpos extraños, una víscera desvitalizada o liquido purulento visible de cualquier origen.

Tasa de infección > 40 % Ejemplos: resección intestinal con presencia

de infección, apendicetomía con perforación y peritonitis, lobectomía con presencia de infección.

Tratamiento antibiótico.


DIRTY OR INFECTED CASES

Infected cases require therapeutic courses of antibiotics; prophylaxis is not appropriate in this context. In dirty cases, particularly those resulting from trauma, contamination and tissue destruction are usually so extensive that the wounds must be left open for delayed primary or secondary closure. Appropriate timing of wound closure is judged at the time of débridement. Antibiotics should be administered as part of resuscitation. Administration of antibiotics for 24 hours is probably adequate if infection is absent at the outset. However, a therapeutic course of antibiotics is warranted if infection is present from the outset or if more than 6 hours elapsed before treatment of the wounds was initiated.


Guía para la prevención de la Infección de herida quirúrgica y post-quirúrgica. Noviembre, 2008

GUIDELINE FOR PREVENTION OF SURGICAL SITE INFECTION, 1999

Guía para la prevención de la Infección de herida quirúrgica y post-quirúrgica. Noviembre, 2008

Recomendaciones par prevenir infecciones del sitio quirúrgico 2007

Ramos-Luces, Molina-Guillén, Pillkahn-Díaz, Moreno-Rodríguez, Vieira-Rodríguez, Gómez-León. Infección de heridas quirúrgicas en cirugía general. Cir Cir 2011;79:349-355

El Center of Disease Control (CDC) de Atlanta determinó el uso de puntajes para definir el riesgo de infección conforme a tres factores, agrupados por The National Nosocomial Infection Surveillance (NNIS):1. Clasificación ASA (estado físico previo del paciente) .2. Procedimiento quirúrgico clasificado como contaminado.3. Cirugía mayor de 2 horas.Estos factores definen un puntaje de 0 a 3, que está directamente relacionado con el riesgo de infección, así:• 0 corresponde al 1%• 1 corresponde al 3%• 2 corresponde al 7%• 3 corresponde al 15% El SENIC (Study Efficacy of Nosocomial Infection Control), realizó un estudio que es también predictor del riesgo de infección teniendo en cuenta cuatro parámetros:1. Cirugía de más de 2 horas.2. Procedimiento contaminado.3. Procedimiento abdominal.4. Tres o más diagnósticos clínicos.Para este caso se da un puntaje de 0 a 4, cuya relación con el riesgo de infección es la siguiente:• 0 corresponde al 1%• 1 corresponde al 3%• 2 corresponde al 9%• 3 corresponde al 18%• 4 corresponde al 27%

HERIDAS QUIRÚRGICAS

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