ASSESSMENT

Assessment

Assessment

Introduction

The combined use of a tourniquet and exsanguinator is common practice in orthopedic surgery. Infection following total knee arthroplasty is an infrequent but serious complication, with a reported incidence of 1-2% (Leone and Hanssen 2005). Deep infection complicating knee arthroscopy and anterior cruciate ligament reconstruction is also infrequent, with rates of 1% and 2%, respectively (Armstrong et al 1992, Schollin-Borg et al 2003). Known risk factors associated with deep infection in these procedures include rheumatoid arthritis, intraarticular and oral steroids, ulcers of the skin, previous surgery, recurrent urinary tract infections, and prolonged operating times (Wilson et al. 1990, Papavasiliou et al. 2006).

Highly infectious pathogens including methicillin-resistant Staphylococcus aureus (MRSA) have not only been cultured from the skin and nasopharynx of healthcare workers and patients but also from many surfaces of the healthcare environment—including pens, keyboards, stethoscopes, doctors' white coats, privacy curtains, venepuncture tourniquets, and blood pressure cuffs (Banerjee et al. 1999, Bures et al. 2000, Loh et al. 2000, Rourke et al. 2001, Das et al. 2002, Guinto et al. 2002, Walker et al. 2006, Kaminski et al. 2007). There is, however, a relative lack of data on the use of limb tourniquets and exsanguinators in the operating theater and their possible role in surgical site infection (SSI). In addition to this lack of data regarding the colonization rates and type of colonization, there is also an absence of guidelines on proper and effective maintenance of these devices. With this in mind, our objective was to examine these devices for colonization by microorganisms in order to determine the extent to which they may play a role in surgical site infection. Having ascertained that they can be contaminated, we examined the efficacies of different sterilization methods.

Literature Review

Orthopedic surgical site infection prolongs hospital stay by a median of 2 weeks per patient, doubles re-hospitalization rates, and can increase healthcare costs by 300% (Whitehouse et al. 2002). Risk factors for surgical site infection may be divided into those related to the patient, to the type of operation, or to the environment. The main factors in orthopedic patients include age, American Society of Anesthesiologists (ASA) grade, co-morbidities, obesity, additional nosocomial infections, long preoperative stay, and corticosteroid therapy (de Boer et al. 1999, 2001, Evaillard et al. 2001, Ercole and Chianca 2002). Prevalence studies have shown that the SSI rate is higher in patients with a history of trauma, emergency surgery, and contaminated wounds (Sohn et al. 2002). Our results show a substantial difference in the mean number of colony forming units per swab when comparing the elective orthopedic hospital with both trauma hospitals. This is not surprising, given the higher throughput and the greater number of infected and open cases in the trauma setting. However, it may reflect better cleaning practices in the elective unit and does raise the possibility that high bacterial loads on these devices may contribute to higher infection rates in acute hospitals.

The tourniquets in use in hospital B showed evidence of wear. It was not common practice for the tourniquets ...