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Proceedings of the International Consensus Meeting on Periprosthetic Joint Infection

Javad Parvizi MD, FRCS
Thorsten Gehrke MD


Title:
Operative Environment

Liaisons:
Pouya Alijanipour MD, Joseph Karam MD

Leaders:
Adolfo LlinĂ¡s MD (International), Kelly G Vince MD (International), Charalampos Zalavras MD (US)

Delegates:
Matthew Austin MD, Grant Garrigues MD, Snir Heller MD, James Huddleston MD, Brian Klatt MD, Viktor Krebs MD, Christoph Lohmann MD, Edward J McPherson MD, Robert Molloy MD, Ali Oliashirazi MD, Mitchell Schwaber MD, Eoin Sheehan MD, Eric Smith MD, Robert Sterling MD, Gregory Stocks MD, Shrinand Vaidya MD

Vol 1, Num S1, September 2014

 

   

Question 1: Do numbers of bacteria arriving in the surgical wound correlate directly with the probability of surgical site infection (SSI)?

Consensus: We recognize that the probability of SSI correlates directly with the quantity of bacteria that reach the wound. Accordingly we support strategies to lower particulate and bacterial counts at surgical wounds.

Delegate Vote: Agree: 97%, Disagree: 2%, Abstain: 1% (Strong Consensus)


Question 2: Do numbers of bacteria in the operating room (OR) environment correlate directly with the probability of SSI?

Consensus: We recognize that airborne particulate bacteria are a major source of contamination in the OR environment and that bacteria shed by personnel are the predominant source of these particles. The focus of our recommendations is to reduce the volume of bacteria in the OR with particular attention to airborne particles.

Delegate Vote: Agree: 93%, Disagree: 5%, Abstain: 2% (Strong Consensus)


Question 3: Should the OR in which an elective arthroplasty is performed be fitted with laminar air flow (LAF)?

Consensus: We believe that arthroplasty surgery may be performed in operating theaters without laminar flow. Laminar flow rooms and other strategies that may reduce particulates in operating rooms would be expected to reduce particulate load. Studies have not shown lower SSI in laminar flow rooms and some cases are associated with increased rates of SSI. These are complex technologies that must function in strict adherence to maintenance protocols. We recommend further investigation in this field.

Delegate Vote: Agree: 85%, Disagree: 7%, Abstain: 8% (Strong Consensus)


Question 4: Is there enough evidence to enforce the universal use of body exhaust suits during total joint arthroplasty (TJA)?

Consensus: There is currently no conclusive evidence to support the routine use of space suits in performing TJA.

Delegate Vote: Agree: 84%, Disagree: 11%, Abstain: 5% (Strong Consensus)


Question 5: What strategies should be implemented regarding OR traffic?

Consensus: We recommend that OR traffic should be kept to a minimum.

Delegate Vote: Agree: 100%, Disagree: 0%, Abstain: 0% (Unanimous Consensus)


Question 6: Should operating lights be controlled with a foot pedal as opposed to reaching above eye level?

Consensus: We recommend a general awareness that light handles can be a source of contamination and to minimize handling of lights as much as possible. Other strategies for light control need to be developed in the future to minimize contamination.

Delegate Vote: Agree: 91%, Disagree: 4%, Abstain: 5% (Strong Consensus)


Question 7: Is there a role for ultraviolet (UV) light use in the prevention of infection after TJA?

Consensus: We agree that UV light environments can lower infection rates, but recognize that this can pose a risk to OR personnel. We recognize that the benefit of UV might be the inhibition of operating traffic.

Delegate Vote: Agree: 74%, Disagree: 13%, Abstain: 13% (Strong Consensus)


Question 8: Do UV decontamination/sterilization lights or portable units in unoccupied ORs (nights and weekends) make a difference in the sterility of the OR environment?

Consensus: UV would be expected to lower bacterial load in ORs, but the technology has not been studied in this application. It might be considered an adjunct but not a replacement for conventional cleaning. There are potential risks to staff by UV technology inadvertently left on at the start of the work day.

Delegate Vote: Agree: 84%, Disagree: 3%, Abstain: 13% (Strong Consensus)


Question 9: Should the patient and OR personnel wear a mask to avoid contamination of the OR air?

Consensus: Despite the absence of conclusive studies that show a reduction in SSI when surgical masks are worn properly and uniformly by all staff, we believe there is reason to expect particulate airborne bacteria counts to be reduced by disciplined use of surgical masks. Until evidence appears that shows an advantage to NOT wearing a mask, we believe that it is in the interest of patient safety that all personnel wear surgical masks at all time that they are in the OR. There is insufficient evidence to support the use of masks by patients that outweighs the benefit of airway access.

Delegate Vote: Agree: 85%, Disagree: 7%, Abstain: 8% (Strong Consensus)


Question 10: What garments are required for OR personnel?

Consensus: We recommend that all personnel wear clean theater attire including a disposable head covering, when entering an OR. Garments worn outside of the hospital should not be worn during TJA.

Delegate Vote: Agree: 98%, Disagree: 1%, Abstain: 1% (Strong Consensus)


Question 11: What restrictions should be placed on the use of portable electronic devices (such as mobile phones, laptops, tablets, or music devices) in the OR?

Consensus: We recognize that portable electronic devices may be contaminated with bacteria. We also recognize that increased levels of talking are associated with higher levels of bacteria in the OR environment. Accordingly we recommend that portable electronic device usage be limited to that which is necessary for patient care.

Delegate Vote: Agree: 84%, Disagree: 14%, Abstain: 2% (Strong Consensus)


Question 12: Does prolonged surgical time predispose to an increased risk of PJI?

Consensus: We recognize that SSI rates increase directly with the duration of surgery. We recognize that some surgeries present a marked and inescapable level of complexity that will require more time. We recognize that minimizing the duration of surgery is an important goal and a cooperative effort on the base of the entire surgical team as well as the institution. We recommend that a coordinated effort be made to minimize the duration of surgery without technical compromise of the procedure.

Delegate Vote: Agree: 96%, Disagree: 3%, Abstain: 1% (Strong Consensus)


Question 13: Should the scheduling of elective TJA be ordered so that clean cases are not preceded by known infected, dirty, or contaminated cases?

Consensus: We recognize the concern regarding risk of infection to a clean surgery following a contaminated surgery. We recognize that studies have not demonstrated increased infection rates in clean surgery performed subsequent to contaminated cases. We recommend thorough cleaning after contaminated surgery and before further surgery, as defined by local institutional standards.

Delegate Vote: Agree: 89%, Disagree: 8%, Abstain: 3% (Strong Consensus)


Question 14: Does patient normothermia have an essential role in preventing infectious complications?

Consensus: We recognize the significance of patient normothermia and the data from non-orthopaedic procedures. We support general recommendations from the general surgery literature and identify this as a field that requires further research.

Delegate Vote: Agree: 92%, Disagree: 1%, Abstain: 7% (Strong Consensus)


Question 15: Do FAW blankets increase the risk of SSI?

Consensus: We recognize the theoretical risk posed by FAW blankets and that no studies have shown an increase in SSI related to the use of these devices. We recommend further study but no change to current practice.

Delegate Vote: Agree: 89%, Disagree: 5%, Abstain: 6% (Strong Consensus)


Question 16: Should OR personnel be required to decontaminate their hands with at least an alcohol-based foam every time their hands have been in contact with inanimate objects (including medical equipment) located in the immediate vicinity of the patient?

Consensus: We support current recommendations for hand hygiene in patient care.

Delegate Vote: Agree: 86%, Disagree: 8%, Abstain: 6% (Strong Consensus)


Question 17: What are the guidelines for hand hygiene and glove use for personnel in contact with the patient for examination, manipulation, and placement on the OR table?

Consensus: We support current recommendations in patient care in accordance with the principles of Standard Precautions.

Delegate Vote: Agree: 92%, Disagree: 1%, Abstain: 7% (Strong Consensus)


Question 18: Should triple gloving be used to prevent contamination during TJA?

Consensus: We recommend double gloving and recognize the theoretical advantage of triple gloving.

Delegate Vote: Agree: 89%, Disagree: 7%, Abstain: 4% (Strong Consensus)


Question 19: How frequently should gloves be changed during surgery?

Consensus: We recognize the advantage of glove changes at least every 90 minutes or more frequently and the necessity of changing perforated gloves. Permeability appears to be compromised by the exposure to methacrylate cement and gloves should be changed after cementation.

Delegate Vote: Agree: 89%, Disagree: 6%, Abstain: 5% (Strong Consensus)


Question 20: When should instrument trays be opened?

Consensus: We recommend that the timing of opening trays should occur as close to the start of the surgical procedure as possible with the avoidance of any delays between tray opening and the start of surgery.

Delegate Vote: Agree: 98%, Disagree: 1%, Abstain: 1% (Strong Consensus)


Question 21: Should trays be covered with sterile drapes/towels when not in use?

Consensus: We recognize a theoretical advantage to covering trays when not in use for extended periods, and that larger covers may be disadvantageous, if they are moved from contaminated areas across the sterile field. We recommend further study of this question regarding timing and techniques.

Delegate Vote: Agree: 90%, Disagree: 4%, Abstain: 6% (Strong Consensus)


Question 22: After skin incision, should the knife blade be changed for deeper dissections?

Consensus: We recognize high contamination rates in studies of scalpel blades that have been used for the skin incision and recommend changes after skin incision.

Delegate Vote: Agree: 88%, Disagree: 8%, Abstain: 4% (Strong Consensus)


Question 23: Should electrocautery tips be changed during TJA? If so, how often?

Consensus: In the absence of evidence we recommend further study and no specific behavior.

Delegate Vote: Agree: 95%, Disagree: 0%, Abstain: 5% (Strong Consensus)


Question 24: Should suction tips be regularly changed during surgery? If so, how frequently? Should suction tips enter the femoral canal?

Consensus: We recommend changing suction tips every 60 minutes based on studies showing higher rates of contamination. Suction tips can be introduced into the femoral canal for the time necessary to evacuate fluid but should not be left in the canal, where they circulate large amounts of ambient air and particles that may contaminate the surgery.

Delegate Vote: Agree: 85%, Disagree: 8%, Abstain: 7% (Strong Consensus)


Question 25: Should splash basins be used, as they are known to be a source of contamination?

Consensus: We recommend against the use of fluid filled basins that sit open during the surgery.

Delegate Vote: Agree: 88%, Disagree: 3%, Abstain: 9% (Strong Consensus)


Question 26: Do disposable instruments and cutting guides reduce contamination and subsequent PJI?

Consensus: We recognize the possible theoretical advantages of disposable instrumentation but in the absence of data we can make no recommendations.

Delegate Vote: Agree: 95%, Disagree: 2%, Abstain: 3% (Strong Consensus)


Question 27: Is there a role for incise draping? What type of incise draping should be used (impregnated or clear)?

Consensus: We recognize the presence of studies that show iodine-impregnated skin incise drapes decreased skin bacterial counts but that no correlation has been established with SSI. We do not make any recommendations regarding the use of skin barriers but do recommend further study.

Delegate Vote: Agree: 89%, Disagree: 7%, Abstain: 4% (Strong Consensus)


Question 28: Does the application of towels or other sterile materials to wound edges and subcutaneous fat during an operation, clipped securely to the edges of the wound, diminish the chances of wound contamination and wound infection?

Consensus: We recognize the traditional practice of covering skin edges with sterile draping but there is wide variation in clinical practice and we make no recommendations.

Delegate Vote: Agree: 94%, Disagree: 2%, Abstain: 4% (Strong Consensus)


Question 29: What type of draping should be used (reusable or disposable)?

Consensus: We recognize that penetration of drapes by liquids is believed to be equivalent to contamination and recommend impervious drapes. In the absence of data on disposable versus cloth drapes, we make no recommendation except for further study.

Delegate Vote: Agree: 90%, Disagree: 6%, Abstain: 4% (Strong Consensus)


Question 30: Is there evidence that the use of sticky U drapes, applied before and after prepping, effectively seals the non-prepped area from the operative field?

Consensus: We recognize that adhesive U-drapes to isolate the perineum has been traditional practice but in the absence of data we make no recommendations.

Delegate Vote: Agree: 83%, Disagree: 11%, Abstain: 6% (Strong Consensus)


Question 31: Is irrigation useful? How should the delivery method for irrigation fluid be (high pulse, low pulse or bulb)?

Consensus: We recognize the theoretical basis for irrigation to dilute contamination and non-viable tissue and that a greater volume of irrigation would be expected to achieve greater dilution. We recognize advantages and disadvantages of different methods of delivering fluid but make no recommendations of one method over another.

Delegate Vote: Agree: 91%, Disagree: 4%, Abstain: 5% (Strong Consensus)


Question 32: What type of irrigation solution should be used? Should antibiotics be added to the irrigation solution?

Consensus: We recognize the mechanical advantage of irrigation as per question 31 but that conflicting evidence exists supporting the use of one agent over the other and make no recommendation regarding type of solution.

Delegate Vote: Agree: 90%, Disagree: 7%, Abstain: 3% (Strong Consensus)


Question 33: Is there a role for intraoperative application of autologous blood-derived products to the wound in preventing infection?

Consensus: In the absence of data we make no recommendation regarding autologous blood derived products to the wound to prevent infection.

Delegate Vote: Agree: 94%, Disagree: 2%, Abstain: 4% (Strong Consensus)


Question 34: Do staples or the type of suture have an effect on infectious events? If so, what is the best closure method to prevent infectious events?

Consensus: In the absence of conclusive data and the wide variability in surgical practice, we make no recommendation regarding specific sutures or staples to prevent infection.

Delegate Vote: Agree: 92%, Disagree: 3%, Abstain: 5% (Strong Consensus)


Question 35: Does the use of a surgical safety checklist and time-out affect the rate of SSI in arthroplasty patients?

Consensus: We support the surgical checklist protocol as beneficial to patient safety, and specifically as it applies to correct administration of prophylactic antibiotics.

Delegate Vote: Agree: 97%, Disagree: 1%, Abstain: 2% (Strong Consensus)