Selected bibliography supporting the ten essential objectives for safe surgery
6. The team will consistently use methods known to minimize risk of surgical site infection.
Astagneau, P., C. Rioux, et al. (2001). "Morbidity and mortality associated with surgical site infections: results from the 1997-1999 INCISO surveillance." J Hosp Infect 48(4): 267-74.
- Since 1997, a surgical-site infections (SSI) surveillance network (INCISO) has been implemented in volunteer general surgical units in Northern France. For three months each year, all patients who undergo a surgical procedure are consecutively reviewed for their peri-operative condition and traced for outcome with a 30-day follow-up. Of the 38973 surgical patients included over a three-year period, 1344 (3.4%) developed SSI and 568 died (1.5%) including 78 with an SSI. Organ-space and deep incisional SSI were associated with a higher mortality and required re-operation more frequently than did superficial incisional SSI. SSI incidence and mortality varied according to the surgical procedure. SSI was a significant predictor of mortality, independently of NNIS risk index and other survival predictors. Thirty-eight percent of deaths in SSI patients were attributable to infection. Hence, the significant impact of SSI on mortality and morbidity in surgical patients is now an additional reason to reinforce compliance of surgical staff with preventive measures and hygiene practices.
Bratzler, D. W. and P. M. Houck (2004). "Antimicrobial prophylaxis for surgery: an advisory statement from the National Surgical Infection Prevention Project." Clin Infect Dis 38(12): 1706-15.
- In January 2003, leadership of the Medicare National Surgical Infection Prevention Project hosted the Surgical Infection Prevention Guideline Writers Workgroup (SIPGWW) meeting. The objectives were to review areas of agreement among the most-recently published guidelines for surgical antimicrobial prophylaxis, to address inconsistencies, and to discuss issues not currently addressed. The participants included authors from most of the groups that have published North American guidelines for antimicrobial prophylaxis, as well as authors from several specialty colleges. Nominal group process was used to draft a consensus paper that was widely circulated for comment. The consensus positions of SIPGWW include that infusion of the first antimicrobial dose should begin within 60 min before surgical incision and that prophylactic antimicrobials should be discontinued within 24 h after the end of surgery. This advisory statement provides an overview of other issues related to antimicrobial prophylaxis, including specific suggestions regarding antimicrobial selection.
Bratzler, D. W., P. M. Houck, et al. (2005). "Use of antimicrobial prophylaxis for major surgery: baseline results from the national surgical infection prevention project." Arch Surg 140(2): 174-82.
- HYPOTHESIS: Surgical site infections (SSIs) are a major contributor to patient injury, mortality, and health care costs. Despite evidence of effectiveness of antimicrobials to prevent SSIs, previous studies have demonstrated inappropriate timing, selection, and excess duration of administration of antimicrobial prophylaxis. We herein describe the use of antimicrobial prophylaxis for Medicare patients undergoing major surgery.
- DESIGN: National retrospective cohort study with medical record review.
- SETTING: Two thousand nine hundred sixty-five acute-care US hospitals.
- PATIENTS: A systematic random sample of 34,133 Medicare inpatients undergoing coronary artery bypass grafting; other open-chest cardiac surgery (excluding transplantation); vascular surgery, including aneurysm repair, thromboendarterectomy, and vein bypass operations; general abdominal colorectal surgery; hip and knee total joint arthroplasty (excluding revision surgery); and abdominal and vaginal hysterectomy from January 1 through November 30, 2001.
- MAIN OUTCOME MEASURES: The proportion of patients who had parenteral antimicrobial prophylaxis initiated within 1 hour before the surgical incision; the proportion of patients who were given a prophylactic antimicrobial agent that was consistent with currently published guidelines; and the proportion of patients whose antimicrobial prophylaxis was discontinued within 24 hours after surgery.
- RESULTS: An antimicrobial dose was administered to 55.7% (95% confidence interval [CI], 54.8%-56.6%) of patients within 1 hour before incision. Antimicrobial agents consistent with published guidelines were administered to 92.6% (95% CI, 92.3%-92.8%) of the patients. Antimicrobial prophylaxis was discontinued within 24 hours of surgery end time for only 40.7% (95% CI, 40.2%-41.2%) of patients.
- CONCLUSION: Substantial opportunities exist to improve the use of prophylactic antimicrobials for patients undergoing major surgery.
Classen, D. C., R. S. Evans, et al. (1992). "The timing of prophylactic administration of antibiotics and the risk of surgical-wound infection." N Engl J Med 326(5): 281-6.
- BACKGROUND. Randomized, controlled trials have shown that prophylactic antibiotics are effective in preventing surgical-wound infections. However, it is uncertain how the timing of antibiotic administration affects the risk of surgical-wound infection in actual clinical practice.
- METHODS. We prospectively monitored the timing of antibiotic prophylaxis and studied the occurrence of surgical-wound infections in 2847 patients undergoing elective clean or "clean-contaminated" surgical procedures at a large community hospital. The administration of antibiotics 2 to 24 hours before the surgical incision was defined as early; that during the 2 hours before the incision, as preoperative; that during the 3 hours after the incision, as perioperative; and that more than 3 but less than 24 hours after the incision, as postoperative.
- RESULTS. Of the 1708 patients who received the prophylactic antibiotics preoperatively, 10 (0.6 percent) subsequently had surgical-wound infections. Of the 282 patients who received the antibiotics perioperatively, 4 (1.4 percent) had such infections (P = 0.12; relative risk as compared with the preoperatively treated group, 2.4; 95 percent confidence interval, 0.9 to 7.9). Of 488 patients who received the antibiotics postoperatively, 16 (3.3 percent) had wound infections (P less than 0.0001; relative risk, 5.8; 95 percent confidence interval, 2.6 to 12.3). Finally, of 369 patients who had antibiotics administered early, 14 (3.8 percent) had wound infections (P less than 0.0001; relative risk, 6.7; 95 percent confidence interval, 2.9 to 14.7). Stepwise logistic-regression analysis confirmed that the administration of antibiotics in the preoperative period was associated with the lowest risk of surgical-wound infection.
- CONCLUSIONS. We conclude that in surgical practice there is considerable variation in the timing of prophylactic administration of antibiotics and that administration in the two hours before surgery reduces the risk of wound infection.
Dellinger, E. (1997). Surgical infections and choice of antibiotics. Textbook of surgery: the biological basis of modern surgical practice. D. Sabiston. Philadelphia, W.B. Saunders: 264-280.
Dellinger, E. (1999). Nosocomial infection. American College of Surgeons. Care of the surgical patient. D. Wilmore, M. Brennan, A. Harken, J. Holcroft and J. Meakins. New York, Scientific American.
Dellinger, E. P. (2007). "Prophylactic antibiotics: administration and timing before operation are more important than administration after operation." Clin Infect Dis 44(7): 928-30.
Dellinger, E. P., P. A. Gross, et al. (1994). "Quality standard for antimicrobial prophylaxis in surgical procedures. The Infectious Diseases Society of America." Infect Control Hosp Epidemiol 15(3): 182-8.
- OBJECTIVE: The objectives of this quality standard are 1) to provide an implementation mechanism that will facilitate the reliable administration of prophylactic antimicrobial agents to patients undergoing operative procedures in which such a practice is judged to be beneficial and 2) to provide a guideline that will help local hospital committees formulate policies and set up mechanisms for their implementation. Although standards in the medical literature spell out recommendations for specific procedures, agents, schedules, and doses, other reports document that these standards frequently are not followed in practice.
- OPTIONS: We have specified the procedures in which the administration of prophylactic antimicrobial agents has been shown to be beneficial, those in which this practice is widely thought to be beneficial but in which compelling evidence is lacking, and those in which this practice is controversial. We have examined the evidence regarding the optimal timing of drug administration, the optimal dose, and the optimal duration of prophylaxis.
- OUTCOMES: The intended outcome is more uniform and reliable administration of prophylactic antibiotics in those circumstances where their value has been demonstrated or their use has been judged by the local practicing medical community to be desirable. The result should be a reduction in rates of postoperative wound infection with a limitation on the quantities of antimicrobial agents used in circumstances where they are not likely to help.
- EVIDENCE: Many prospective, randomized, controlled trials comparing placebo with antibiotic and comparing one antibiotic with another have been conducted. In addition, some trials have compared the efficacy of different doses or methods of administration. Other papers have reported on the apparent efficacy of administration at different times and on actual practice in specific communities. Only a small group of relevant articles found through 1993 are cited herein. When authoritative reviews are available, these--rather than an exhaustive list of original references--are cited.
- VALUES: We assumed that reducing rates of postoperative infection was valuable but that reducing the total amount of antimicrobial agents employed was also worthwhile. The cost of and morbidity attributable to postoperative wound infections should be weighed against the cost and potential morbidity associated with excessive use of antimicrobial agents.
- BENEFITS, HARMS, AND COSTS: More reliable administration of antimicrobial agents according to recognized guidelines should prevent some postoperative wound infections while lowering the total quantity of these drugs used. No harms are anticipated. The costs involved are those of the efforts needed on a local basis to design and implement the mechanism that supports uniform and reliable administration of prophylactic antibiotics.
- RECOMMENDATIONS: All patients for whom prophylactic antimicrobial agents are recommended should receive them. The agents given should be appropriate in light of published guidelines. A short duration of prophylaxis (usually < 24 hours) is recommended.
- VALIDATION: More than 50 experts in infectious disease and 10 experts in surgical infectious disease and surgical subspecialties reviewed the standard. In addition, the methods for its implementation were reviewed by the American Society of Hospital Pharmacists.
- SPONSORS: The Quality Standards Subcommittee of the Clinical Affairs Committee of the Infectious Disease Society of America (IDSA) developed the standard. The subcommittee was composed of representatives of the IDSA (Drs. Gross and McGowan), the Society for Hospital Epidemiology of America (Dr. Wenzel), the Surgical Infection Society (Dr. Dellinger), the Pediatric Infectious Disease Society (Dr. Krause), the Centers for Disease Control and Prevention (Dr. Martone), the Obstetrics and Gynecology Infectious Diseases Society (Dr. Sweet), and the Association of Practitioners of Infection Contr
Dellinger, E. P., S. M. Hausmann, et al. (2005). "Hospitals collaborate to decrease surgical site infections." Am J Surg 190(1): 9-15.
- BACKGROUND: Despite a large body of evidence describing care processes known to reduce the incidence of surgical site infections, many are underutilized in practice.
- METHODS: Fifty-six hospitals volunteered to redesign their systems as part of the National Surgical Infection Prevention Collaborative, a 1-year demonstration project sponsored by the Centers for Medicare & Medicaid Services. Each facility selected quality improvement objectives for a select group of surgical procedures and reported monthly clinical process measure data.
- RESULTS: Forty-four hospitals reported data on 35,543 surgical cases. Hospitals improved in measures related to appropriate antimicrobial agent selection, timing, and duration; normothermia; oxygenation; euglycemia; and appropriate hair removal. The infection rate decreased 27%, from 2.3% to 1.7% in the first versus last 3 months.
- CONCLUSIONS: The Collaborative demonstrated improvement in processes known to be associated with reduced risk of surgical site infections. Quality improvement organizations can be effective resources for quality improvement in the surgical arena.
Fry, D. (2003) Surgical site infection: Pathogenesis and prevention. Medscape Volume, DOI:
Fry, D. E. (1995). Surgical Infections. Boston, Little, Brown and Company.
Garibaldi, R. A., D. Skolnick, et al. (1988). "The impact of preoperative skin disinfection on preventing intraoperative wound contamination." Infect Control Hosp Epidemiol 9(3): 109-13.
- The efficacy of total body showering and incision site scrub with disinfectant agents was evaluated in a randomized, prospective study of 575 patients undergoing selected surgical procedures. Patients who showered twice with 4% chlorhexidine gluconate had lower mean colony counts of skin bacteria at the surgical incision site in the operating room prior to the final scrub than patients who showered twice with povidone-iodine solution or medicated bar soap. Patients in the chlorhexidine group had no growth on 43% of the incision site skin cultures compared with 16% in the povidone-iodine group and 6% in the soap and water group. Patients who showered and who were scrubbed with chlorhexidine also had lower rates of intraoperative wound contamination. Bacteria were recovered from the wounds of 4% of patients using this regimen compared with 9% for patients who used povidone-iodine and 15% for patients who showered with medicated soap and water and were scrubbed with povidone-iodine. We noted no difference in surgery-specific infection rates among patients in the three treatment groups; however, our sample sizes were too small to evaluate this outcome parameter adequately. These data suggest that preoperative showering and scrubbing with chlorhexidine is an effective regimen to reduce extrinsic intraoperative contamination of the surgical wound from skin bacteria. The efficacy of this regimen to prevent postoperative wound infection needs to be evaluated in a well-designed, carefully controlled prospective trial with adequate numbers of patients to achieve statistically valid conclusions.
Gaynes, R. P. (1998). Surveillance of nosocomial infections. Hospital Infections. J. V. Bennett and P. S. Brachman. Philadelphia, Lippincott-Raven Publishers: 65-84.
Horan, T. C., D. H. Culver, et al. (1993). "Nosocomial infections in surgical patients in the United States, January 1986-June 1992. National Nosocomial Infections Surveillance (NNIS) System." Infection Control and Hospital Epidemiology 14(2): 73-80.
- OBJECTIVES: To describe the distribution of nosocomial infections among surgical patients by site of infection for different types of operations, and to show how the risk of certain adverse outcomes associated with nosocomial infection varied by site, type of operation, and exposure to specific medical devices.
- DESIGN: Surveillance of surgical patients during January 1986-June 1992 using standard definitions and protocols for both comprehensive (all sites, all operations) and targeted (all sites, selected operations) infection detection.
- SETTING AND PATIENTS: Acute care US hospitals participating in the National Nosocomial Infection Surveillance (NNIS) System: 42,509 patients with 52,388 infections from 95 hospitals using comprehensive surveillance protocols and an additional 5,659 patients with 6,963 infections from 11 more hospitals using a targeted protocol.
- RESULTS: Surgical site infection was the most common nosocomial infection site (37%) when data were reported by hospitals using the comprehensive protocols. When infections reported from both types of protocols were stratified by type of operation, other sites were most frequent following certain operations (e.g., urinary tract infection after joint prosthesis surgery [52%]). Among the infected surgical patients who died, the probability that an infection was related to the patient's death varied significantly with the site of infection, from 22% for urinary tract infection to 89% for organ/space surgical site infection, but was independent of the type of operation performed. The probability of developing a secondary bloodstream infection also varied significantly with the primary site of infection, from 3.1% for incisional surgical site infection to 9.5% for organ/space surgical site infection (p < .001). For all infections except pneumonia, the risk of developing a secondary bloodstream infection also varied significantly with the type of operation performed (p < .001) and was generally highest for cardiac surgery and lowest for abdominal hysterectomy. Surgical patients who developed ventilator-associated pneumonia were more than twice as likely to develop a secondary bloodstream infection as nonventilated pneumonia patients (8.1% versus 3.3%, p < .001).
- CONCLUSIONS: For surgical patients with nosocomial infection, the distribution of nosocomial infections by site varies by type of operation, the frequency with which nosocomial infections contribute to patient mortality varies by site of infection but not by type of operation, and the risk of developing a secondary bloodstream infection varies by type of primary infection and, except for pneumonia, by type of operation.
Horan, T. C., R. P. Gaynes, et al. (1992). "CDC definitions of nosocomial surgical site infections, 1992: a modification of CDC definitions of surgical wound infections." Am J Infect Control 20: 271-274.
Kurz, A., D. I. Sessler, et al. (1996). "Perioperative normothermia to reduce the incidence of surgical-wound infection and shorten hospitalization. Study of Wound Infection and Temperature Group [see comments]." N Engl J Med 334(19): P 1209-15.
- BACKGROUND. Mild perioperative hypothermia, which is common during major surgery, may promote surgical-wound infection by triggering thermoregulatory vasoconstriction, which decreases subcutaneous oxygen tension. Reduced levels of oxygen in tissue impair oxidative killing by neutrophils and decrease the strength of the healing wound by reducing the deposition of collagen. Hypothermia also directly impairs immune function. We tested the hypothesis that hypothermia both increases susceptibility to surgical-wound infection and lengthens hospitalization.
- METHODS. Two hundred patients undergoing colorectal surgery were randomly assigned to routine intraoperative thermal care (the hypothermia group) or additional warming (the normothermia group). The patient's anesthetic care was standardized, and they were all given cefamandole and metronidazole. In a double-blind protocol, their wounds were evaluated daily until discharge from the hospital and in the clinic after two weeks; wounds containing culture-positive pus were considered infected. The patients' surgeons remained unaware of the patients' group assignments.
- RESULTS. The mean (+/- SD) final intraoperative core temperature was 34.7 +/- 0.6 degrees C in the hypothermia group and 36.6 +/- 0.5 degrees C in the normothermia group (P < 0.001) Surgical-wound infections were found in 18 of 96 patients assigned to hypothermia (19 percent) but in only 6 of 104 patients assigned to normothermia (6 percent, P = 0.009). The sutures were removed one day later in the patients assigned to hypothermia than in those assigned to normothermia (P = 0.002), and the duration of hospitalization was prolonged by 2.6 days (approximately 20 percent) in hypothermia group (P = 0.01).
- CONCLUSIONS. Hypothermia itself may delay healing and predispose patients to wound infections. Maintaining normothermia intraoperatively is likely to decrease the incidence of infectious complications in patients undergoing colorectal resection and to shorten their hospitalizations.
Moro, M. L., F. Morsillo, et al. (2005). "Rates of surgical-site infection: an international comparison." Infect Control Hosp Epidemiol 26(5): 442-8.
- OBJECTIVES: To quantify the occurrence of surgical-site infections (SSIs) in an Italian region and to estimate the proportion of potentially avoidable infections through benchmarking comparison.
- DESIGN: Prospective study during 1 month based on a convenience sample of surgical patients admitted to 31 public hospitals. All of the patients undergoing an intervention included among the 44 operative procedures of the National Nosocomial Infections Surveillance (NNIS) System were enrolled. Ninety-five percent of the patients were actively observed after discharge for up to 30 days for all of the operations and for up to 1 year for operations involving implantation.
- RESULTS: Among the 6,167 operative procedures studied, 290 infections were recorded (4.7 per 100 procedures), 206 (71%) of which were SSIs (3.3 per 100 procedures; 95% confidence interval, 2.9-3.9). One hundred thirty-five SSIs (65.5%) were superficial infections, 53 (25.7%) were deep infections, and 12 (5.8%) were organ-space infections; in 6 cases (2.9%), the type of SSI was not recorded. The frequency of SSIs observed in this study was significantly higher for several procedures than that expected when the NNIS System rates (standardized infection ratio [SIR] ranging from 1.77 to 6.42) or the Hungarian rates (SIR ranging from 1.28 to 3.04) were applied to the study population.
- CONCLUSIONS: The high intensity of postdischarge surveillance can in part explain the differences observed. To allow for meaningful benchmarking comparison, in addition to intrinsic patient risk, data on the intensity of postdischarge surveillance should be included in published reports.
Rioux, C., B. Grandbastien, et al. (2007). "Impact of a six-year control programme on surgical site infections in France: results of the INCISO surveillance." J Hosp Infect 66(3): 217-23.
- Surgical site infections (SSI) are a key target of nosocomial infection control policy. We evaluated the impact of a six-year surveillance system based on data from INCISO, a network of volunteer surgical wards from hospitals in Northern France. Each year surgical patients were enrolled consecutively and surveyed during their in- and out-hospital stay until 30 days following surgery. A standardised form was completed for each patient including SSI diagnosis according to standard criteria and several risk factors such as wound class, American Society of Anesthesiologists score, operation duration, elective/emergency, videoscopy and type of surgery. A dashboard was displayed at the end of each annual survey, so that participants could compare with other surgery adjusted for National Nosocomial Infections Surveillance system (NNIS) risk index and standardised incidence ratio (SIR). Over the six years, 3661 SSI were identified in 150 440 surgical patients (crude incidence: 2.4%) from 548 surgery wards. The crude SSI incidence decreased from 3.8 to 1.7% (P for trend <0.0001, relative reduction: -55%) and the NNIS-0 adjusted SSI incidence from 2.0 to 1% (P for trend <0.0001; relative reduction: -50%). An active surveillance system striving for benchmark through a network is an effective strategy to reduce SSI incidence. Sustaining control efforts have to be made to maintain low SSI level beyond the three primer years.
Smaill, F. and G. J. Hofmeyr (2002). "Antibiotic prophylaxis for cesarean section." Cochrane Database Syst Rev(3): CD000933.
- BACKGROUND: The single most important risk factor for postpartum maternal infection is cesarean delivery.
- OBJECTIVES: The objective of this review was to assess the effects of prophylactic antibiotic treatment on infectious complications in women undergoing cesarean delivery.
- SEARCH STRATEGY: We searched the Cochrane Pregnancy and Childbirth Group trials register (January 2002) and the Cochrane Controlled Trials Register (The Cochrane Library, Issue 4, 2001).
- SELECTION CRITERIA: Randomized trials comparing antibiotic prophylaxis or no treatment for both elective and non-elective cesarean section.
- DATA COLLECTION AND ANALYSIS: Two reviewers assessed trial quality and extracted data.
- MAIN RESULTS: Eighty-one trials were included. Use of prophylactic antibiotics in women undergoing cesarean section substantially reduced the incidence of episodes of fever, endometritis, wound infection, urinary tract infection and serious infection after cesarean section. The reduction in the risk of endometritis with antibiotics was similar across different patient groups: the relative risk (RR) for endometritis for elective cesarean section (number of women = 2037) was 0.38 (95% confidence interval (CI) 0.22 to 0.64); the RR for non-elective cesarean section (n = 2132) was 0.39 (95% CI 0.34 to 0.46); and the RR for all patients (n = 11,937) was 0.39 (95% CI 0.31 to 0.43). Wound infections were also reduced: for elective cesarean section (n = 2015) RR 0.73 (95% CI 0.53 to 0.99); for non-elective cesarean section (n = 2780) RR 0.36 95% CI 0.26 to 0.51]; and for all patients (n = 11,142) RR 0.41 (95% CI 0.29 to 0.43).
- REVIEWER'S CONCLUSIONS: The reduction of endometritis by two thirds to three quarters and a decrease in wound infections justifies a policy of recommending prophylactic antibiotics to women undergoing elective or non-elective cesarean section.
Stone, H. H., B. B. Haney, et al. (1979). "Prophylactic and preventive antibiotic therapy: timing, duration and economics." Ann Surg 189: 691-699.
Sullivan, S. A., T. Smith, et al. (2007). "Administration of cefazolin prior to skin incision is superior to cefazolin at cord clamping in preventing postcesarean infectious morbidity: a randomized, controlled trial." Am J Obstet Gynecol 196(5): 455 e1-5.
- OBJECTIVE: The objective of the study was to determine whether the administration of cefazolin prior to skin incision was superior to administration at the time of umbilical cord clamping for the prevention of postcesarean infectious morbidity.
- STUDY DESIGN: This was a prospective, randomized, double-blind, placebo-controlled trial. Study subjects received cefazolin 15-60 minutes prior to incision and controls received cefazolin at the time of cord clamping. The occurrence of endomyometritis, wound infection, total infectious morbidity, and neonatal complications were compared.
- RESULTS: There were 357 subjects enrolled. No demographic differences were observed between groups. There were decreased total infectious morbidity in the study group (relative risk [RR] = 0.4, 95% confidence interval [CI] 0.18 to 0.87), decreased endometritis (RR = 0.2, 95% CI 0.15 to 0.94). No increase in neonatal sepsis (P = .99), sepsis workups (P = .96), or length of stay (P = .17) was observed.
- CONCLUSION: Administration of prophylactic cefazolin prior to skin incision resulted in a decrease in both endomyometritis and total postcesarean infectious morbidity, compared with administration at the time of cord clamping. This dosing did not result in increased neonatal septic workups or complications.
van den Berghe, G., P. Wouters, et al. (2001). "Intensive insulin therapy in the critically ill patients.[see comment]." New England Journal of Medicine 345(19): 1359-67.
- BACKGROUND: Hyperglycemia and insulin resistance are common in critically ill patients, even if they have not previously had diabetes. Whether the normalization of blood glucose levels with insulin therapy improves the prognosis for such patients is not known.
- METHODS: We performed a prospective, randomized, controlled study involving adults admitted to our surgical intensive care unit who were receiving mechanical ventilation. On admission, patients were randomly assigned to receive intensive insulin therapy (maintenance of blood glucose at a level between 80 and 110 mg per deciliter [4.4 and 6.1 mmol per liter]) or conventional treatment (infusion of insulin only if the blood glucose level exceeded 215 mg per deciliter [11.9 mmol per liter] and maintenance of glucose at a level between 180 and 200 mg per deciliter [10.0 and 11.1 mmol per liter]).
- RESULTS: At 12 months, with a total of 1548 patients enrolled, intensive insulin therapy reduced mortality during intensive care from 8.0 percent with conventional treatment to 4.6 percent (P<0.04, with adjustment for sequential analyses). The benefit of intensive insulin therapy was attributable to its effect on mortality among patients who remained in the intensive care unit for more than five days (20.2 percent with conventional treatment, as compared with 10.6 percent with intensive insulin therapy, P=0.005). The greatest reduction in mortality involved deaths due to multiple-organ failure with a proven septic focus. Intensive insulin therapy also reduced overall in-hospital mortality by 34 percent, bloodstream infections by 46 percent, acute renal failure requiring dialysis or hemofiltration by 41 percent, the median number of red-cell transfusions by 50 percent, and critical-illness polyneuropathy by 44 percent, and patients receiving intensive therapy were less likely to require prolonged mechanical ventilation and intensive care.
- CONCLUSIONS: Intensive insulin therapy to maintain blood glucose at or below 110 mg per deciliter reduces morbidity and mortality among critically ill patients in the surgical intensive care unit.
Washington, J. A., 2nd, W. H. Dearing, et al. (1974). "Effect of preoperative antibiotic regimen on development of infection after intestinal surgery: Prospective, randomized, double-blind study." Ann Surg 180(4): 567-72.
Wilson, A. P., T. Treasure, et al. (1986). "A scoring method (ASEPSIS) for postoperative wound infections for use in clinical trials of antibiotic prophylaxis." Lancet 1(8476): 311-3.
- To compare antibiotic regimens for their effectiveness in preventing or treating wound sepsis, well-defined criteria for outcome are needed. A method of assessing wound healing has been devised that defines carefully the characteristics to be considered and how they are to be awarded points. Objective criteria are also included in the assessment. Points are given for the need for Additional treatment, the presence of Serous discharge, Erythema, Purulent exudate, and Separation of the deep tissues, the Isolation of bacteria, and the duration of inpatient Stay (ASEPSIS).