Infections Prevention of Trauma Patients | CHAPTER 22 | Orthopedic Nursing

Infections Prevention of Trauma Patients – An orthopedic nurse is a nurse who specializes in treating patients with bone, limb, or musculoskeletal disorders. Nonetheless, because orthopedics and trauma typically follow one another, head injuries and infected wounds are frequently treated by orthopedic nurses.

Ensuring that patients receive the proper pre-and post-operative care following surgery is the responsibility of an orthopedic nurse. They play a critical role in the effort to return patients to baseline before admission. Early detection of complications following surgery, including sepsis, compartment syndrome, and site infections, falls under the purview of orthopedic nurses.

Infections Prevention of Trauma Patients

Basic concept of infection of traumatic and orthopedic patient :

The incidence of infection following injury approaches 25%. Although most trauma-related deaths occur within the first 24 hours after injury, from exsanguination or massive injury to the central nervous system, the leading cause of posttraumatic death after the initial 24 hours is infection, usually manifesting as the multiple organ dysfunction syndrome (MODS). The high risk of infection is due to the host immune response to injury and stress; inadequate attention to the principles of infection control under emergency conditions; direct inoculation of wounds by clothing, dirt, or debris; blood transfusions; and poor glycemic control. Appropriate antibiotic prophylaxis reduces the risk, but inappropriate prophylaxis may increase the risk of infection.

[Ref-Peitzman Trauma Manual, The: Trauma and Acute Care Surgery, 3rd Edition p-527]

Causes of infection of traumatic and orthopedic patient:

The high risk of infection of traumatic and orthopedic patients is due to:

• The host immune response to injury and stress;
• inadequate attention to the principles of infection control under emergency conditions;
• direct inoculation of wounds by clothing, dirt, or debris; blood transfusions; and poor glycemic control.
• Appropriate antibiotic prophylaxis reduces the risk, but inappropriate prophylaxis may increase the risk of infection.
• Inproper wound dressing.
• Properly not maintained aseptic technique by the health personnel.
• Using the unsterilized instrument or contaminated instruments.

[Ref- Trauma Manual, The: Trauma and Acute Care Surgery, 3rd Edition]

Pattern of injury of traumatic patient:

Infections following injury occur in the injured tissue, the surgical site (incision), or as a health care- associated (nosocomial) infection (HAI) such as pneumonia or catheter-related bloodstream infection (CR-BSI) (Table 57-1). Considered together, HAls are as common as infections of the injured tissues. The likelihood of infection is higher with increasing injury severity score (ISS), increasing number of abdominal organs injured.

traumatic brain injury, colon injury, shock, number of blood transfusions, and creation of an ostomy. Traumatic wounds are characterized by devitalized, ischemic tissue, with increased risk of infection if contaminated by enteric contents (e.g., penetrating abdominal trauma), fragments of clothing fabric (e.g., gunshot wounds), dirt or gravel (e.g., motor vehicle or farm injuries), or vegetation (e.g., fall from height into a tree). More wound contamination increases the risk of infection of injured tissue.

[Ref-Peitzman ‘s Trauma Manual, The: Trauma and Acute Care Surgery, 3rd Edition, p-528]

Risk factors of injury and infection of traumatic patient:

• The host is put at risk of invasion by microbial pathogens whenever a natural epithelial barrier (e.g., skin, respiratory tract mucosa, gastrointestinal mucosa) is breached.
• Colonization of the epithelial barriers occurs even in healthy hosts. However, invasion does not occur unless injury or some other mechanism of inoculation occurs.
• Injury, catheterization, or incision breach an epithelial barrier and create a portal for tissue invasion by pathogens.
• Potential pathogens are ubiquitous in the environment. Innate immunity provides continuous surveillance against invasion by foreign antigens, and stimulates a repair response (inflammation), which may result in counterproductive augmentation of the inflammatory response that is destructive to the host.
• Prolonged or severe inflammation (e.g., the systemic inflammatory response syndrome, SIRS) (Table 57-2) is associated with the multiple organ dysfunction syndrome (MODS).
• Injury severity: Severity of injury is directly related to the risk of infection.e.g: Shock and higher Injury Severity Score (ISS) increase the risk of infection globally. Thoracoabdominal
• penetrating injury is associated with a higher risk of infection than either abdominal or thoracic injury alone
• the Stress Response to Injury:

1. Activation of hypophyseal-pituitary-adrenal axis.
2. Peripheral insulin resistance.
3. Production of pro- and antiinflammatory cytokines.
4. Acute-phase changes of hepatic protein synthesis.
5. Recruitment and activation of neutrophils, monocyte/macrophages, and lymphocytes.
6. Upregulation of procoagulant activity.

• Immune dysfunction:

The immune response to injury is immediate and complex The consequences are immediate activation of: -Coagulation as a result of endothelial dysfunction and activation of platelets

-Mononuclear and polymorphonuclear leukocytes causing release of both pro- and antiinflammatory cytokines and activation of host defenses against microbial invasion

-Depression of humoral and cell-mediated immunity with predisposition to later HAI

• Medical comorbidity:

Both very young and elderly patients are at increased risk of infection (Table 57-6). Obesity, malnutrition, diabetes mellitus, hypocholesterolemia, hypothermia, and chronic renal insufficiency pose an increased risk of infection. Perioperative hypoxemia and male gender may be risk factors for infection, but the data are conflicting.

• During blood transfusion:

Trauma patients are more than fivefold more likely to develop infection if a blood transfusion is administered; red cell transfusion should be given only when necessary

• Conditions Known to Increase the Risk of Infection

1. Extremes of age
2. Malnutrition
3. Obesity
4. Diabetes
5. Prior site irradiation
6. Hypothermia
7. Hypoxemia
8. Remote infection
9. Corticosteroid therapy
10. Recent operation, especially of the chest or abdomen
11. Chronic inflammation
12. Hypocholesterolemia

• Hyperglycemia:

This was despite evidence that hyperglycemia (>200 mg/dL) was associated with an increased incidence of surgical site infection following cardiac or major general surgery.

[Ref- Peiman’s Trauma Manual, The: Trauma and Acute Care Surgery, 3rd Edition, p-529]

Prevention of Infection:

A) Principles: Infection is morbid, costly, and potentially a lethal complication in trauma patients. Infection can be prevented in part. However, no single method of prophylaxis is universally effective, and each patient presents a unique challenge; all available modalities must be utilized for every case. Infection control is paramount, but often underemphasized.

i Traumatic wounds must be cleansed thoroughly and debrided to remove devitalized tissue.

ii. Surgical incisions must be handled gently, inspected daily, and dressed if necessary using aseptic technique.

iii.Drains and catheters must be avoided if possible, and if utilized, removed as soon as possible

iv. Antibiotics should be used sparingly so as to minimize antibiotic selection pressure on the emergence of antibiotic-resistant pathogens.

B) Infection control

1) Infection control is an individual responsibility as well as a responsibility of the trauma team and trauma unit.

i. Hand hygiene is the single most effective means to reduce the spread of infection. Handwashing is studied, it is invariably found to be lacking. To be effective, hand cleansing with soap and water requires a minimum of 30 to 45 seconds.

ii.. Alcohol gel hand cleansers are equally effective as soap and water, and compliance is higher.

iii. Universal precautions (i.e., cap, mask, gown, gloves, and protective eyewear) must be observed whenever there is a risk of splashing of body fluids (at all times in the trauma bay, and commonly in the ICU).

2) The source of the bacteria causing infection are the patients’ endogenous flora, and skin surfaces, airways, gut lumen, wounds, catheters, and inanimate surfaces within the patient’s room (e.g., bed rails, and computer terminals do become colonized).

i. So any break in natural epithelial barriers (e.g., incisions, percutaneous catheters, airway or urinary catheters) provides a portal of entry for invasion of the host by pathogenic organisms.

ii. The fecal-oral route is the most common manner by which autoinfection develops, but health care workers can hasten the transmission of pathogens around a unit. цитрива

iii. Contact isolation is an important part of infection control, and should be used selectively to prevent the spread of pathogens such as methicillin-resistant Staphylococcus aureus and
vancomycin-resistant enterococci, or multi-drug-resistant gram-negative bacilli.

iv. However, contact isolation may decrease the amount of time that caregivers have direct patient contact, because donning protective garb is time-consuming. By guarding against this phenomenon, an appropriate balance can be struck between attention and protection.

3) Appropriate catheter care includes:

• Avoidance of insertion when nonessential.
• Appropriate skin cleansing and barrier protection during insertion.
• Selection of the proper catheter.
• Proper dressings while catheters are indwelling.
• Removal as soon as possible when no longer needed, or if inserted under less than ideal circumstances. The benefit of the information gained by catheterization must always be weighed against the risk of infection.
• Any indwelling catheter carries a risk of infection, but nontunnelled central venous catheters (and pulmonary artery catheters) pose the highest risk, including local site infections and bloodstream infections.
• Whenever possible, skin preparation should be with chlorhexidine solution, which is viricidal and fungicidal as well as bactericidal.

4) The choice of catheter may play a role in decreasing the risk of infection with endotracheal tubes, central venous catheters, and urinary catheters

• An endotracheal tube with an extra lumen is used that opens to the airway just above the balloon
• Antibiotic (e.g., minocycline/rifampin) or antiseptic-coated central venous catheters (e.g.. chlorhexidine/silver sulfadiazine) are effective in reducing the incidence of catheter-related
  bloodstream infection
• Urinary bladder catheters coated with ionic silver reduce the incidence of catheter-related bacterial cystitis.

5) Dressings: Dressing must be maintained clean, dry, and intact. Maintaining an intact dressing may be difficult when the patient is agitated or the body surface is irregular (e.g., the neck [internal jugular vein catheterization] as opposed to the chest wall [subclavian vein catheterization]), but its importance must be
emphasized.

• A simple gauze dressing is best. Occlusive transparent dressings can accumulate moisture beneath that is a usable growth medium for residual skin flora, which recolonize the skin anyway within a few hours.
• Mark the dressing clearly with the date and time of each change.
• Dressing carts or similar apparatus should not be brought from patient to patient; rather, sufficient supplies should be kept in each patient’s room. Be cognizant of the possibility for inanimate objects (e.g., stethoscopes, scissors) to be transmission vectors if not cleansed thoroughly after contact with each patient.

6) Every indwelling catheter must be evaluated daily for its continued utility; catheters must be removed as soon as possible

7) Antibiotic prophylaxis

• Some times antibiotic prophylaxis is useful to prevent infection of the patient with Shock, hypoperfusion, and hemorrhage

8) Nutrition:

• There is still much debate as to the ideal formula, route, and rate of feeding for injured patients. However, the effect of early enteral feeding to reduce the risk of infection following trauma or burn injury is well established.

[Ref- Trauma Manual, The: Trauma and Acute Care Surgery, 3rd Edition, p-529,30]

Catheter-related bloodstream infection:

• Trauma and hemodynamically unstable nontrauma ICU patients often require reliable large-bore intravenous access. Placed typically into central veins (e.g., femoral, internal jugular, or subclavian vein), these catheters are prone to local infection and bloodstream infection.
• Prevention by strict adherence to infection control and proper insertion technique is crucial because trauma patients are at particularly high risk for infection of central venous catheters (Table 57-1). When placed under elective (controlled) circumstances, proper insertion technique mandates that the operator prepare the operative field with chlorhexidine (not povidone-iodine solution), drape the entire bed into a sterile field, and don a cap, mask, and sterile gown and gloves.
• When sterile procedure or technique is breached, the risk of infection increases exponentially, and the catheter should be removed and replaced (if still needed) at a different site using strict sterile technique as soon as the patient’s condition permits (ideally within 24 hours).

1. Infection risk for femoral vein catheters is highest, and lowest for catheters placed via the subclavian route.
2. Peripheral vein catheters, peripherally placed central catheters (PICC), and tunneled central venous catheters (e.g., Hickman, Broviac), pose less risk of infection than percutaneous central venous catheters.
3. Information campaigns, educational initiatives, and strict adherence to insertion protocols are all effective to decrease the risk of CR-BSI.
4. Antibiotic and antiseptic-coated catheters are controversial, but may decrease the risk of infection.

• Catheter infection is diagnosed by isolation of >15 efu from a segment of catheter by the semi-quantitative roll-plate technique. The diagnosis of CR-BSI is confirmed when the isolates from blood and the cultured catheter are identical. The pathogens of CR-BSI are predominantly gram-positive cocci, most commonly MRSE, MRSA, and enterococci.

1. Unfortunately MRSE is not only the most common cause of CR-BSI, but also the most common cause of false-positive blood cultures because of contamination during the collection process. Isolation of MRSE from a single blood culture is likely a contaminant (do not treat), especially if the patient has no indwelling hardware that might become infected secondarily (e.g., prosthetic joint or heart valve).
2. Gram-negative bacillary pathogens are less common, and fungal CR-BSI are unusual in trauma patients.
3. Treatment is by removal of the catheter (for peripheral or percutaneous central venous catheters) with parenteral antibiotics, at least initially. Catheter-related bloodstream infections caused by MRSA require at least 2 weeks of therapy; some authorities argue for a longer course because of the risk of metastatic infection. Vancomycin or linezolid may be chosen for MRSA CR-BSI (or MRSE when treatment is indicated), with daptomycin as an alternative. Therapy for enterococcal or gram-negative CR-BSI is dictated by bacterial susceptibility, without clear consensus as to duration of therapy. Beyond removal of the catheter, treatment of fungal CR-BSI is controversial. Some authorities recommend removal of the catheter as sole therapy, others recommend at least 2 weeks of systemic antifungal therapy.

[Ref- Trauma Manual, The: Trauma and Acute Care Surgery, 3rd Edition]

Decubitus ulcer:

Infection from decubitus ulcer may be obvious or covert. Patients are at substantially increased risk with prolonged bed rest (>7 days), which may be mitigated by specialized bedding. Vasopressor therapy and poor nutrition may be additional risk factors, but any association is unsubstantiated. Morbid obesity is a clear risk factor, given that routine turning and positioning of such patients is a formidable undertaking. Most decubitus ulcers form in the pre-sacral area, but can form anywhere unremitting pressure is placed upon tissue.

For example, if the position of the endotracheal tube at the lips is not changed periodically, ulceration may occur at the corner of the mouth. Also, occipital decubitus ulceration results from ill-fitting cervical collars, when used for an obtunded patient or when “clearance” of the cervical spine is delayed. When evaluating a patient for occult infection, the skin must be inspected systematically for decubitus ulcers. Deep ulcers (Stage III, involving subcutaneous fat; Stage IV, involving fascia, muscle, or bone) may require debridement or systemic antibiotic therapy. In rare cases, a decubitus ulcer may transform into a life-threatening necrotizing soft-tissue infection.

[Ref- Trauma Manual, The: Trauma and Acute Care Surgery, 3rd Edition]

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