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Preventing Surgical Site Infections in the Diabetic Cardiac Surgical Patient. Paula Pintar BSN, RN Alverno College – MSN Student Tutorial Project Spring 2010. Navigation of Tutorial. This button will return you to the Tutorial menu screen. This button will return you to the previous slide.
Paula Pintar BSN, RN
Alverno College – MSN Student
Tutorial Project Spring 2010
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Stages of Surgical
What is it?
Why are Surgical
Site Infections a
Tying It All
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The Learner Will:
Identify criteria used for classifying a surgical site infection (SSI).
Identify why Surgical Site infections are a problem.
Review of Diabetes Mellitus and the genetic link of incidence.
Identify what risk factors can put Diabetic patients at a higher risk to developing a Surgical Site infection.
Review the three main stages of wound healing: Inflammation, Proliferation, Remodeling.
Be able to correlate the factors of Age, Inflammation, and the Generalized Stress Response in the diabetic patient; relate how these factors impact the stages of wound healing.
Review Best Practice Standards and Nursing interventions for a Surgical Site infection prevention plan.
Apply Nursing indicators to a case study.
Understand how applying “best practice guidelines” will support positive outcomes for the patient, family, staff, health system, and community.
Clinical and laboratory signs of infection at the surgical site within:
30 days of the surgery or
Within 1 year if an implant was used (heart valve/joint)
Criteria for Defining a Surgical Site Infection (SSI) Documented at various tissue levels:
Deep (soft tissue/muscle)
Deep/organ space (organ space)
Endogenous bacteria – patients’ own skin flora
Exogenous bacteria – environmental bacteria or surgical material
Higher cost related to longer stays
Decreased patient turnover translates into less income for healthcare facility
Healthcare facility develops a reputation of poor patient outcomes.
Decreased reimbursement by The Centers for Medicare and Medicaid (CMS) as of October 1, 2008 stopped reimbursement for hospital acquired infections
38% of all Healthcare Associated Infections are SSI’s.
the hospital stay by 5 to 7 days.
The Centers for Medicare and Medicaid (CMS)
as of October 1, 2008 started for
hospital acquired infections.
of infection rates for healthcare facilities.
Diabetes mellitus affects approximately 2.8 million people in the United States
The disease is a metabolic process that results from a lack of insulin secretion or action.
Insulin is a hormone that is secreted by the beta cells in the pancreas.
This hormone then allows the cells in our body to absorb the glucose and convert it into energy to maintain metabolic processes.
There are two main types of diabetes mellitus that the majority of diabetics are classified into.
This is characterized by an complete lack of insulin secretion and elevated blood sugar, related to destroyed pancreatic beta cells (6)
Usually occurs at an early age (childhood)
5 to 10% of the diabetic population have this type of diabetes (~ 1 million people) (6)
These individuals have been associated with an autoimmune link to the disease. (4)
This autoimmune response is the cause of beta cell destruction (4)
The other factor identified is an exposure to an environmental mediator, such as having an infection. (6)
Source: 4, 6
Type 2 :
This is characterized by having insulin resistance
Approximately 90 to 95% of diabetics present with this type (~19 million people)
18 -20% of persons 65 and older have diabetes
40% have the disease or precursor to disease
Obesity and older individuals is commonly associated with Type 2
There is multiple hypothesis as to the causal agents of this form.
Due to the variability of the causal agents, it is difficult to predict or identify specific factors that lead to disease.
It is known that autoimmune destruction of the beta cells, as in Type 1 does not occur.
C reactive protein
Finger stick glucose
There are 3 main stages of wound healing
Within each stage there is a complex system of cellular functions that occur. (5)
Factors that can impede good wound healing are:
Poor diet/uncontrolled blood sugars
Compromised blood flow
Disruption of inflammatory response
Effects of age (14)
Stage 1 Inflammatory (acute)
Incision – initial vasoconstriction followed by platelet aggregation to damaged endothelium (14)
Followed by a dilation of capillaries
Around 24 hours macrophages enter the area and remain there to clean up cellular debris and stimulate the healing process (5)
Stage 2 – Proliferation
24-48 hours after wound occurrence the fibroblast and vascular endothelial cells begin formation (5)
This is a fragile period for the wound due to new capillary growth (14)
Then formation of new dermal layers begins (14)
Stage 3 – Remodeling
Occurs post wound by about week 3
Formation of a scar develops
During this process the healing wound experiences a decrease in vascularization with the continuing development of scar tissue.
Stages of Wound Healing
New capillary growth
Click on stage definition
Stages of Wound Healing
Stages of Wound Healing
each object in order
Blood Glucose is the
Liver releases glucose
Release of fatty acid
from the fat cells
Stops insulin release
from beta cells
of glycogen stores
The Diabetic patient experiencing stress will have added risk to SSI development
Sporadic, transient increases of cortisol can affect blood sugar control
There is an increased secretion of cortisolin response to stress, (it can cause damage to brain neurons over time) if the levels become too high.
This is a Positive feedback system – an example of this is when an elderly person secretes cortisol in response to stress. Repeated exposure to the neurons causes the damaged. Therefore the neurons can no longer sense the level and the hypothalamus continues to secrete the hormone.
To view graphic of Positive Feedback
System, click HERE
Positive Feedback System
There is a 20% decrease in the dermal layer
This translates into less strength and elasticity
Blood vessels supplying the dermis are also more fragile
These conditions translate into a decrease of vascular circulation with a decrease in oxygen delivery to the wound site.
Elderly persons have stiffer arteries and narrower capillaries which will accentuate the effects of diabetes
Stages of Wound Healing
Stages of Wound Healing
Lets apply this knowledge to a case study:
65 year old Caucasian, widowed female who is overweight (101 kg.) has a sedentary life style and lives alone.
She has had poor medical care due to lack of financial resources.
She thinks she recalls a doctor telling her in the past that she may have diabetes or “something.”
The patient is now in the Cardiovascular Surgical Intensive care unit following surgery of a 4 vessel myocardial revascularization.
Post operative day #1 Patient presents with the following:
Elevated blood glucose for the last 4 assessments: 190, 200,207,195
Fatigue and difficult to arouse
Low blood pressure :100/60
Sinus tachycardia: 120 bpm
Urine output: 25-30cc/hr
Low grade temperature: 99.1 blood temp
Slight elevated white blood cell count: 11,000
Elevated C-reactive protein (CRP) level: 2
Decreased bilateral pedal pulses: + 1
Cool bilateral lower leg extremities: new on assessment
Indicators that may lead to an SSI
Unstable blood sugars
Lack of family support
Low grade temperature
Decreased pedal pulses
Cool lower leg extremities
Decreased urine output
Click an indicators on the right to see what
Physiological system they belong to.
Strict adherence to hand hygiene www.cdc.gov/handhygiene/Patient_Admission_Video.html
Treat all remote infections to the elective surgical site prior surgery
Do not shave hair at surgical site, but use clippers. This will cause less microabraisions to the skin.
Control serum blood sugar levels, avoid hyperglycemic states.
Recommend stopping tobacco use
Antiseptic showers prior surgical procedure
Use appropriate surgical skin prep
Surgical team hand & forearm antisepsis
Administration of appropriate antimicrobial prophylaxis drug at the correct time, and dose prior surgical incision (30min.)
Pre-surgical baths have shown to decrease skin flora and multi-drug resistant bacteria (MDRO's) such as Methicillin resistant Staphaureus, vancomycin resistant Enterococci that may lead to surgical site infections.
Most SSI’s are caused by the patients own bacterial flora
20% Staphylococcus aureus
14% Coagulase negative staphylococcus
Glucose control intra-operative and postoperative (target less than 200 mg/dL)
Unstable blood sugars affect the neutrophils ability to provide adequately functioning phagocytes
Maintaining the postoperative dressing for 24-48 hours
This is a critical time period when wound site is gaining stability in cellular repair and revascularization.
Appropriate surgical antimicrobial prophylaxis given at:
The appropriate time – 30 minutes prior cut time
Provides a therapeutic blood & tissue level of antibiotic at time of surgery
Appropriate dosage – weight based. Repeat dose if surgery extends past the ½ life of the drug
Appropriate agent – for gram negative and gram positive organisms
Discontinue antibiotic 24 hours post surgery – assists in decreasing resistance. Doses past 24 hour time frame of wound closure have not proven beneficial.
Source: 1, 3
Clipping surgical site in place of shaving
Eliminates micro abrasions to the skin that provides an entry portal for microorganisms
Maintain normothermia (greater that 36.0 Celsius) pre, intra, and postoperatively
Decreases vasoconstriction in blood vessels.
Normothermia will promote the blood flow and oxygen delivery to the cells
Fosters immune function preservation
If normothermia maintained produces less overall stress to diabetic patient
Lets apply this knowledge to our case study:
Post operative surgical day #3 Assessment findings:
Blood Sugar range 185-220 over last 48hours
Temp. 99.1-100.9(oral ranges)
CRP level 3
Sternal incision warm, red, small opening at bottom draining creamy white fluid
Wound culture showing Moderate PMS’s & Moderate colonies of Staphylococcus aureus
Stable SBP, Sinus tachycardia (105-110bpm), U.O. 30cc/hr
Diabetes affect 2.8 million people in the United States. Identify three case study laboratory results that may be indicators of an SSI.
Temperature, WBC, CRP, U.O., Positive wound culture, Fatigue
What assessment finding is a response to activation of the Generalized Stress Response?
Increased Heart Rate, Warm draining wound, Positive wound culture
During cardiovascular revascularization surgery, what process causes a cytokine response?
The process of “bypass”, anesthesia, maintaining normothermia
In reference to question 3, what stage of wound healing is critical to a diabetic with uncontrolled blood sugars?
Inflammation, Proliferation, Remodeling
How is the proliferation stage of wound healing affected by diabetes?
Microcirculation, cellular regeneration , decrease in metabolic needs
What three nursing interventions can be initiated to help decrease the risk of patients developing an SSI?
Hand Hygiene, Blood glucose control, Maintaining normothermia, quick ventilator weaning, frequent turning of patient
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Engelic, G., Wright, D.G., Hartshorn, K.L. (2001). Acquired disorders of phagocyte function complicating medical and surgical illness. Clinical Infectious Diseases, 33, 2040-8.
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Microsoft clipart online.
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Thank you for your attention and participation!