Ramos Velasquez Fredy

HERIDA Es toda solucin de continuidad en la cubierta cutnea, en la que con frecuencia se produce una simultanea o diferida perdida de sustancias, por accin de diversos agentes causantes y que puede extenderse a los tejidos y rganos subyacentes
Victoria Valer Tito. Heridas y cicatrizacin. Ciruga general - UNMSM

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

ETIOLOGA

Agentes perforantes Agentes cortantes Agentes perforo-cortantes Agentes contundentes Proyectiles de armas de fuego

Victoria Valer Tito. Heridas y cicatrizacin. Ciruga general - UNMSM

MECANISMO

Friccin Percusin Compresin Traccin Accin combinada

Victoria Valer Tito. Heridas y cicatrizacin. Ciruga general - UNMSM

Formas clnicas

Excoriacin Heridas punzantes Heridas incisas Heridas contusas Heridas por proyectiles Heridas venenosas Heridas por mordedura Herida penetrante Herida transfixiante Heridas por asta de toro Herida por arrancamiento

Victoria Valer Tito. Heridas y cicatrizacin. Ciruga general - UNMSM

Objetivo: ayudar a predecir la probabilidad de infeccin de las heridas con base al grado de contaminacin bacteriana transoperatoria.

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

Victoria Valer Tito. Heridas y cicatrizacin. Ciruga general - UNMSM

 Intervencin quirrgica (heridas no traumticas) donde se conserva bien la tcnica asptica. La incisin no penetra en el tracto respiratorio, digestivo genitourinario o cavidad abdominal ni a tejidos infectados Ciruga electiva Tasa de infeccin 2 % Ejemplos: revascularizacin de arterias coronarias, laparotoma exploratoria sin apertura de vsceras, injertos de piel. No profilaxis antibitica.

Victoria Valer Tito. Heridas y cicatrizacin. Ciruga general - UNMSM

Rodolfo E. Quirs. INFECCION DE HERIDA QUIRURGICA . Actualizacin 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 patients 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

 Intervencin quirrgica en la que se penetra el tracto respiratorio, digestivo o genitourinario bajo condiciones controladas y sin contaminacin inusual. Tasa de infeccin 5% Ejemplos: cesrea, laringotoma, nefrectoma, tracto genitourinario si infeccin urinaria, apendicetoma sin perforacin, colecistoma sin inflamacin. Profilaxis antibitica.

Victoria Valer Tito. Heridas y cicatrizacin. Ciruga general - UNMSM

Rodolfo E. Quirs. INFECCION DE HERIDA QUIRURGICA . Actualizacin julio 2003

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.

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

 Se incluyen heridas traumticas recientes ( 4 horas) y quirrgicas en las cuales ha habido una transgresin importante de la tcnica asptica, gran contaminacin a partir del tubo digestivo o ingreso en las vas genitourinarias, inflamacin aguda no purulenta. Tasa de infeccin 10-20 % Ejemplos: histerectoma abdominal con derrame de secrecin vaginal, cesrea con derrame de liquido amnitico, colecistoma con derrame macroscpico. Profilaxis antibitica.

Victoria Valer Tito. Heridas y cicatrizacin. Ciruga general - UNMSM

Rodolfo E. Quirs. INFECCION DE HERIDA QUIRURGICA . Actualizacin julio 2003

CONTAMINATED CASES

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 issue24 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.

Abdominal procedures. In colorectal procedures, antibiotics active against both aerobes and

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

 Incluye heridas traumticas sucias o con tratamiento retardado, con contaminacin fecal, cuerpos extraos, una vscera desvitalizada o liquido purulento visible de cualquier origen. Tasa de infeccin > 40 % Ejemplos: reseccin intestinal con presencia de infeccin, apendicetoma con perforacin y peritonitis, lobectoma con presencia de infeccin. Tratamiento antibitico.

Victoria Valer Tito. Heridas y cicatrizacin. Ciruga general - UNMSM

Rodolfo E. Quirs. INFECCION DE HERIDA QUIRURGICA . Actualizacin julio 2003

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 dbridement. 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.

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

Gua para la prevencin de la Infeccin de herida quirrgica y post-quirrgica. Noviembre, 2008

GUIDELINE FOR PREVENTION OF SURGICAL SITE INFECTION, 1999

Gua para la prevencin de la Infeccin de herida quirrgica y post-quirrgica. Noviembre, 2008

Gua para la prevencin de la Infeccin de herida quirrgica y post-quirrgica. Noviembre, 2008

Gua para la prevencin de la Infeccin de herida quirrgica y post-quirrgica. Noviembre, 2008

Gua para la prevencin de la Infeccin de herida quirrgica y post-quirrgica. Noviembre, 2008

Recomendaciones par prevenir infecciones del sitio quirrgico 2007

Ramos-Luces, Molina-Guilln, Pillkahn-Daz, Moreno-Rodrguez, Vieira-Rodrguez, Gmez-Len. Infeccin de heridas quirrgicas en ciruga general. Cir Cir 2011;79:349-355

El Center of Disease Control (CDC) de Atlanta determin el uso de puntajes para definir el riesgo de infeccin conforme a tres factores, agrupados por The National Nosocomial Infection Surveillance (NNIS): 1. Clasificacin ASA (estado fsico previo del paciente) . 2. Procedimiento quirrgico clasificado como contaminado. 3. Ciruga mayor de 2 horas. Estos factores definen un puntaje de 0 a 3, que est directamente relacionado con el riesgo de infeccin, as: 0 corresponde al 1% 1 corresponde al 3% 2 corresponde al 7% 3 corresponde al 15% El SENIC (Study Efficacy of Nosocomial Infection Control), realiz un estudio que es tambin predictor del riesgo de infeccin teniendo en cuenta cuatro parmetros: 1. Ciruga de ms de 2 horas. 2. Procedimiento contaminado. 3. Procedimiento abdominal. 4. Tres o ms diagnsticos clnicos. Para este caso se da un puntaje de 0 a 4, cuya relacin con el riesgo de infeccin es la siguiente: 0 corresponde al 1% 1 corresponde al 3% 2 corresponde al 9% 3 corresponde al 18% 4 corresponde al 27%

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