Key point

• Do not ignore universal precautions in emergency situations.

TRAUMA

Traumatized tissues are often contaminated and resulting loss of vitality means that sepsis may develop.

1. Before operation on a patient with an injury, carefully

assess and investigate the injuries to soft tissue, skin, bones and joints, blood vessels and nerves and the
presence of foreign bodies. This allows you to plan your strategy ahead and to order any equipment and
back-up that you will need.

2. Every surgical operation is traumatic. Do not compound it by handling the tissues roughly. Injured tissues
have increased susceptibility to infection as a result of contamination.
3. Under suitable anaesthetic induction, open and explore the wound one layer at a time. Gently remove all
dead tissue, ensuring that all remaining tissue is clean and viable. Viable muscle should bleed when cut,
contract when pinched. Dead muscle appears pale and homogeneous, is friable and does not contract when
pinched. Seek and remove all fragments.
4. Make use of lavage with sterile physiological saline to wash out fragments of foreign material.
5. It is particularly dangerous to introduce, or fail to remove, microorganisms that require little or no oxygen
for their metabolism within damaged, dead or ischaemic tissues.
6. Battle injuries and traffic accidents cause risk of severe infections. Penetrating injuries allow organisms to
be carried deeply. High-velocity missiles, especially bullets fired from high-velocity rifles and shrapnel
scattered from an explosion, are particularly dangerous. They carry in clothing and other foreign material.
If the kinetic energy of the missile is rapidly dissipated in the tissues, it acts like an explosive, disrupting the
cells. Anaerobic organisms flourish in the resulting dead tissue. For this reason it is essential to remove all
dead tissue and foreign material, and expose the retained healthy tissue to the air.

PREOPERATIVE

1. We all have microorganisms constantly with us on our skin, in our noses, mouths, and gut and we may become infected as
a result of contact with other people or infected material, especially if we have exposed cuts or injuries or have diminished
resistance.

2. Many of the operations surgeons perform are for the treatment of existing infection. Patients submitting themselves to
operation often carry organisms that could be carried to the site of operation. Many organisms are harmless in one site, as in
the gut, but are harmful elsewhere.

3. Hospitals are reservoirs of nosocomial infection

(G nosos = sickness + komeien = to tend; hospital sickness) from organisms often resistant to antibiotics. Although they may
be harboured in instruments, dressings and bedding, many studies have demonstrated that transmission of the majority of
infections is by personal contact. This can occur between patients, or via nurses and doctors, especially if effective hand-
washing is neglected between encounters.

4. Consider the need for prophylactic or peroperative antibiotics, especially for someone at increased risk, including patients
with a prosthesis such as a heart valve replacement.

OPERATING ROUTINES
 1. Before ‘scrubbing up’, check your hands for cuts, abrasions and ulceration. If you find any, apply a
waterproof adhesive dressing.
2. During procedures placing you at risk, wear a long apron, an impervious gown, eye shields and double
gloves. If your gloves are damaged, change them.
3. Keep all sharp instruments in separate dishes. Never pass them by hand.
4. Avoid spilling blood as far as possible by sealing vessels before you divide them.
5. To reduce the risk of spreading infection on surgeons’ gloves during the operation, Sir Arbuthnot Lane
(1869–1943) successfully popularized ‘no touch’ techniques. All the procedures were carried out using
instruments. A modification of the technique is continued in minimal access procedures.
6. If you sustain a needle-stick injury, encourage bleeding, wash your hands, and put on fresh gloves as soon as
you can. Afterwards report it to the Occupational Health Officer.
7. As a routine, at the end of every operation check your hands for any injuries you may not have noticed
while concentrating on the procedure.

Key points

 Systemically administered antibiotics cannot reach dead or ischaemic tissues.

 Do not close a wound if you are uncertain if it is recent, healthy, with no foreign material and tension-free.
 In case of doubt employ delayed primary closure (see Ch. 6).

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Handling infection

Chapter
Key points

 ‘Universal precautions’ means employing safe routines as part of your automatic behaviour.
 I repeat, this is particularly true in emergency situations.
 Do not relax them, thinking, ‘It will be safe this time’.

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OPERATION
1. In the past the skin was assiduously shaved, washed and prepared with sterilizing applications before operation. Shaving is
now avoided because of the resultant damage to the skin; if necessary, the hairs are clipped short, using a clipper with a
disposable head.

2 Before making the incision, clean the skin with an antiseptic solution such as 2% iodine in 50% ethanol or 0.5%
chlorhexidine in 70% ethanol. Drape the area with sterile towels, usually proprietary disposable sheets, to isolate the
operation site. Some towels cover a wide area and have a central hole through which you make the approach. If you apply
several towels, fix them together with towel clips. Alternatively, or
in addition, you may apply a sterile, transparent, adhesive sheet through which you make the incision.

3. You may be operating to deal with an existing infection, or in an area where there are organisms present
that are harmless here but would be dangerous if they spread elsewhere. In both cases take every possible
precaution to avoid disseminating the organisms. Pack off tissues outside the immediate area of the
operation. Remove immediately, or isolate, contaminated material. Keep all the instruments used in the
contaminated area in a special container, to be discarded as soon as the ‘dirty’ part of the operation

is completed. If it is essential for you to handle contaminated or potentially contaminated material and
tissues to assess them, or as part of the procedure, discard your gloves and replace them with sterile ones
before completing the operation. Similarly discard and replace soiled drapes.

4. If you encounter infection, always take a specimen or swab for culture and tests of sensitivity to antibiotics.
5. At the end of the operation the whole area should be

clean and viable.

6. Should you close the wound?

7. Be willing to lightly pack the wound and wait until it

is clean, healthy, free of discharge and then close it, if

necessary by applying a skin graft.

8. If you have closed the wound, or if you are dealing

with a closed injury, frequently and carefully watch to exclude swelling and tissue tension. This may be most

obvious in a limb. If necessary carry out debridement (F = unbridle – the original meaning was to cut
away constricting bands; only later was it extended
to mean excision of dead tissue). Incise the skin and deep tissues longitudinally to release the tension. Lay in sterile gauze
and replace it at intervals until the wound is suitable for closure or grafting.

9. Mesothelial-lined cavities such as the peritoneal

space may be contaminated, as when large bowel is breached surgically, by trauma or disease, releasing
organisms within the peritoneum. It may be necessary to create an artificial opening of the colon onto the
abdominal wall – a colostomy. Remove every trace

of colonic content from the peritoneal cavity with warm, sterile, physiological saline. Once it is free of
contamination, the peritoneum is usually well able to resist infection. However, the superficial part of the
wound is much more susceptible. You should either drain the superficial layers or leave them open.

10. The precepts of Kocher, Halsted and Cushing of gentleness, haemostasis and perfect tissue apposition did
not specifically include oxygenation. Ischaemia (G ischein = to restrain + haima = blood) was well
recognized but tissue anoxia (G an = not + oxygen + ia = indicating a pathological condition) is not always
clinically detectable.

BLEEDING

Stagnant blood provides an ideal culture medium for micro- organisms. The incidence of wound infection is increased after
operations in which excessive bleeding has occurred. Make every effort to leave the operative field completely dry,
removing all spilled blood, and guard against continuing or recurring bleeding when the procedure is completed.
SURGICAL SITE INFECTION

The incidence of infection at the site of operation is related to bacterial factors, surgical technique and the patient.

1. Bacterial factors include the type: Staphylococcus aureus and Escherichia coli are commonly involved but other
organisms including fungi may be causative. Bacteria in one site may be harmless for example within the gut, but be
pathological elsewhere.

2. Surgical factors include whether the wound is clean or dirty, the perfection of operating technique, operating time,
presence of necrosis and the presence of foreign materials or prostheses.

3. The patient’s age, immune status and nutritional state affect resistance and this is reduced in obesity, diabetes,
malignancy, co-morbidity and as a result of smoking.

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