-
The Cochrane Database of Systematic... Jun 2020The risk of maternal mortality and morbidity is higher after caesarean section than for vaginal birth. With increasing rates of caesarean section, it is important to... (Meta-Analysis)
Meta-Analysis
BACKGROUND
The risk of maternal mortality and morbidity is higher after caesarean section than for vaginal birth. With increasing rates of caesarean section, it is important to minimise risks to the mother as much as possible. This review focused on different skin preparations to prevent infection. This is an update of a review last published in 2018.
OBJECTIVES
To compare the effects of different antiseptic agents, different methods of application, or different forms of antiseptic used for preoperative skin preparation for preventing postcaesarean infection.
SEARCH METHODS
For this update, we searched Cochrane Pregnancy and Childbirth's Trials Register, ClinicalTrials.gov, the WHO International Clinical Trials Registry Platform (ICTRP) (9 July 2019), and reference lists of retrieved studies.
SELECTION CRITERIA
Randomised and quasi-randomised trials, evaluating any type of preoperative skin preparation (agents, methods or forms). We included studies presented only as abstracts, if there was enough information to assess risk of bias. Comparisons of interest in this review were between: different antiseptic agents (e.g. alcohol, povidone iodine), different methods of antiseptic application (e.g. scrub, paint, drape), different forms of antiseptic (e.g. powder, liquid), and also between different packages of skin preparation including a mix of agents and methods, such as a plastic incisional drape, which may or may not be impregnated with antiseptic agents. We mainly focused on the comparison between different agents, with and without the use of drapes. Only studies involving the preparation of the incision area were included. This review did not cover studies of preoperative handwashing by the surgical team or preoperative bathing.
DATA COLLECTION AND ANALYSIS
Three review authors independently assessed all potential studies for inclusion, assessed risk of bias, extracted the data and checked data for accuracy. We assessed the certainty of the evidence using the GRADE approach.
MAIN RESULTS
We included 13 individually-randomised controlled trials (RCTs), with a total of 6938 women who were undergoing caesarean section. Twelve trials (6916 women) contributed data to this review. The trial dates ranged from 1983 to 2016. Six trials were conducted in the USA, and the remainder in India, Egypt, Nigeria, South Africa, France, Denmark, and Indonesia. The included studies were broadly at low risk of bias for most domains, although high risk of detection bias raised some specific concerns in a number of studies. Length of stay was only reported in one comparison. Antiseptic agents Parachlorometaxylenol with iodine versus iodine alone We are uncertain whether parachlorometaxylenol with iodine made any difference to the incidence of surgical site infection (risk ratio (RR) 0.33, 95% confidence interval (CI) 0.04 to 2.99; 1 trial, 50 women), or endometritis (RR 0.88, 95% CI 0.56 to 1.38; 1 trial, 50 women) when compared with iodine alone, because the certainty of the evidence was very low. Adverse events (maternal or neonatal) were not reported. Chlorhexidine gluconate versus povidone iodine Moderate-certainty evidence suggested that chlorhexidine gluconate, when compared with povidone iodine, probably slightly reduces the incidence of surgical site infection (RR 0.72, 95% CI 0.58 to 0.91; 8 trials, 4323 women). This effect was still present in a sensitivity analysis after removing four trials at high risk of bias for outcome assessment (RR 0.87, 95% CI 0.62 to 1.23; 4 trials, 2037 women). Low-certainty evidence indicated that chlorhexidine gluconate, when compared with povidone iodine, may make little or no difference to the incidence of endometritis (RR 0.95, 95% CI 0.49 to 1.86; 3 trials, 2484 women). It is uncertain whether chlorhexidine gluconate reduces maternal skin irritation or allergic skin reaction (RR 0.64, 95% CI 0.28 to 1.46; 3 trials, 1926 women; very low certainty evidence). One small study (60 women) reported reduced bacterial growth at 18 hours after caesarean section for women who had chlorhexidine gluconate preparation compared with women who had povidone iodine preparation (RR 0.23, 95% CI 0.07 to 0.70). Methods Drape versus no drape This comparison investigated the use of drape versus no drape, following preparation of the skin with antiseptics. Low-certainty evidence suggested that using a drape before surgery compared with no drape, may make little or no difference to the incidence of surgical site infection (RR 1.29, 95% confidence interval (CI) 0.97 to 1.71; 3 trials, 1373 women), and probably makes little or no difference to the length of stay in the hospital (mean difference (MD) 0.10 days, 95% CI -0.27 to 0.46; 1 trial, 603 women; moderate-certainty evidence). One trial compared an alcohol scrub and iodophor drape with a five-minute iodophor scrub only, and reported no surgical site infection in either group (79 women, very-low certainty evidence). We were uncertain whether the combination of a one-minute alcohol scrub and a drape reduced the incidence of metritis when compared with a five-minute scrub, because the certainty of the evidence was very low (RR 1.62, 95% CI 0.29 to 9.16; 1 trial, 79 women). The studies did not report on adverse events (maternal or neonatal).
AUTHORS' CONCLUSIONS
Moderate-certainty evidence suggests that preparing the skin with chlorhexidine gluconate before caesarean section is probably slightly more effective at reducing the incidence of surgical site infection in comparison to povidone iodine. For other outcomes examined there was insufficient evidence available from the included RCTs. Most of the evidence in this review was deemed to be very low or low certainty. This means that for most findings, our confidence in any evidence of an intervention effect is limited, and indicates the need for more high-quality research. Therefore, it is not yet clear what sort of skin preparation may be most effective for preventing postcaesarean surgical site infection, or for reducing other undesirable outcomes for mother and baby. Well-designed RCTs, with larger sample sizes are needed. High-priority questions include comparing types of antiseptic (especially iodine versus chlorhexidine), and application methods (scrubbing, swabbing, or draping). We found two studies that are ongoing; we will incorporate the results of these studies in future updates of this review.
Topics: Adult; Anti-Infective Agents, Local; Bandages; Cesarean Section; Chlorhexidine; Endometritis; Ethanol; Female; Humans; Iodine; Iodophors; Length of Stay; Povidone-Iodine; Pregnancy; Preoperative Care; Randomized Controlled Trials as Topic; Surgical Drapes; Surgical Wound Infection; Xylenes
PubMed: 32580252
DOI: 10.1002/14651858.CD007462.pub5 -
Anesthesiology Jan 2021Disease severity in coronavirus disease 2019 (COVID-19) may be associated with inoculation dose. This has triggered interest in intubation barrier devices to block...
BACKGROUND
Disease severity in coronavirus disease 2019 (COVID-19) may be associated with inoculation dose. This has triggered interest in intubation barrier devices to block droplet exposure; however, aerosol protection with these devices is not known. This study hypothesized that barrier devices reduce aerosol outside of the barrier.
METHODS
Aerosol containment in closed, semiclosed, semiopen, and open barrier devices was investigated: (1) "glove box" sealed with gloves and caudal drape, (2) "drape tent" with a drape placed over a frame, (3) "slit box" with armholes and caudal end covered by vinyl slit diaphragms, (4) original "aerosol box," (5) collapsible "interlocking box," (6) "simple drape" over the patient, and (7) "no barrier." Containment was investigated by (1) vapor instillation at manikin's right arm with video-assisted visual evaluation and (2) submicrometer ammonium sulfate aerosol particles ejected through the manikin's mouth with ventilation and coughs. Samples were taken from standardized locations inside and around the barriers using a particle counter and a mass spectrometer. Aerosol evacuation from the devices was measured using standard hospital suction, a surgical smoke evacuator, and a Shop-Vac.
RESULTS
Vapor experiments demonstrated leakage via arm holes and edges. Only closed and semiclosed devices and the aerosol box reduced aerosol particle counts (median [25th, 75th percentile]) at the operator's mouth compared to no barrier (combined median 29 [-11, 56], n = 5 vs. 157 [151, 166], n = 5). The other barrier devices provided less reduction in particle counts (133 [128, 137], n = 5). Aerosol evacuation to baseline required 15 min with standard suction and the Shop-Vac and 5 min with a smoke evacuator.
CONCLUSIONS
Barrier devices may reduce exposure to droplets and aerosol. With meticulous tucking, the glove box and drape tent can retain aerosol during airway management. Devices that are not fully enclosed may direct aerosol toward the laryngoscopist. Aerosol evacuation reduces aerosol content inside fully enclosed devices. Barrier devices must be used in conjunction with body-worn personal protective equipment.
Topics: Aerosols; COVID-19; Cough; Health Personnel; Humans; Intubation, Intratracheal; Occupational Exposure; Personal Protective Equipment
PubMed: 33125457
DOI: 10.1097/ALN.0000000000003597 -
Operative Techniques in... Jun 2022In this article, we aim to summarize the impacts of COVID-19 on the practice of otologic surgery. Cadaveric studies have indicated COVID-19 viral particles are present...
In this article, we aim to summarize the impacts of COVID-19 on the practice of otologic surgery. Cadaveric studies have indicated COVID-19 viral particles are present in the middle ear mucosa of infected hosts. Otologic procedures can generate significant amounts of droplets due to reliance on high-speed drills. Multiple guidelines have been developed to improve patient and provider safety peri-operatively. Particle dispersion can be mitigated during microscopic mastoidectomy by utilizing barrier drape techniques. The barrier drape may similarly be applied to the surgical exoscope. Endoscopic techniques have theoretical improved safety benefits by minimizing the need for drilling. The discoveries and innovations borne of the COVID-19 pandemic will lay the groundwork for the practice of otology amidst future pandemics.
PubMed: 35502269
DOI: 10.1016/j.otot.2022.04.004 -
Asian Journal of Andrology 2020Inflatable penile prostheses are an important tool in the treatment of medically refractory erectile dysfunction. One of the major complications associated with these... (Review)
Review
Inflatable penile prostheses are an important tool in the treatment of medically refractory erectile dysfunction. One of the major complications associated with these prostheses is infections, which ultimately require device explanation and placement of a new device. Over the past several decades, significant work has been done to reduce infection rates and optimize treatment strategies to reduce patient morbidity. This article reviews the current state of knowledge surrounding penile prosthesis infections, with attention to the evidence for methods to prevent infection and best practices for device reimplantation.
Topics: Anti-Bacterial Agents; Anti-Infective Agents, Local; Antibiotic Prophylaxis; Bandages; Carrier State; Chlorhexidine; Coated Materials, Biocompatible; Device Removal; Diabetes Mellitus; Erectile Dysfunction; Gram-Negative Bacterial Infections; Hair Removal; Humans; Immunocompromised Host; Male; Penile Implantation; Penile Prosthesis; Preoperative Care; Prosthesis-Related Infections; Reoperation; Risk Factors; Spinal Cord Injuries; Staphylococcal Infections; Staphylococcus aureus; Staphylococcus epidermidis; Surgical Drapes; Surgical Instruments; Surgical Wound Infection
PubMed: 31489848
DOI: 10.4103/aja.aja_84_19 -
Colorectal Disease : the Official... Jun 2020The rapid spread of the COVID-19 pandemic has created unprecedented challenges for the medical and surgical healthcare systems. With the ongoing need for urgent and...
AIM
The rapid spread of the COVID-19 pandemic has created unprecedented challenges for the medical and surgical healthcare systems. With the ongoing need for urgent and emergency colorectal surgery, including surgery for colorectal cancer, several questions pertaining to operating room (OR) utilization and techniques needed to be rapidly addressed.
METHOD
This manuscript discusses knowledge related to the critical considerations of patient and caregiver safety relating to personal protective equipment (PPE) and the operating room environment.
RESULTS
During the COVID-19 pandemic, additional personal protective equipment (PPE) may be required contingent upon local availability of COVID-19 testing and the incidence of known COVID-19 infection in the respective community. In addition to standard COVID-19 PPE precautions, a negative-pressure environment, including an OR, has been recommended, especially for the performance of aerosol-generating procedures (AGPs). Hospital spaces ranging from patient wards to ORs to endoscopy rooms have been successfully converted from standard positive-pressure to negative-pressure spaces. Another important consideration is the method of surgical access; specifically, minimally invasive surgery with pneumoperitoneum is an AGP and thus must be carefully considered. Current debate centres around whether it should be avoided in patients known to be infected with SARS-CoV-2 or whether it can be performed under precautions with safety measures in place to minimize exposure to aerosolized virus particles. Several important lessons learned from pressurized intraperitoneal aerosolized chemotherapy procedures are demonstrated to help improve our understanding and management.
CONCLUSION
This paper evaluates the issues surrounding these challenges including the OR environment and AGPs which are germane to surgical practices around the world. Although there is no single universally agreed upon set of answers, we have presented what we think is a balanced cogent description of logical safe approaches to colorectal surgery during the COVID-19 pandemic.
Topics: Air Filters; Betacoronavirus; COVID-19; Colorectal Surgery; Coronavirus Infections; Digestive System Surgical Procedures; Humans; Infection Control; Infectious Disease Transmission, Patient-to-Professional; Laparoscopy; Operating Rooms; Pandemics; Personal Protective Equipment; Pneumonia, Viral; Pneumoperitoneum, Artificial; SARS-CoV-2; Surgical Drapes
PubMed: 32359223
DOI: 10.1111/codi.15112 -
Cureus Oct 2021Our objective is to analyze the risk of particle spread through mastoidectomy during the COVID-19 pandemic with an aim to assess the tools used to mitigate the... (Review)
Review
Our objective is to analyze the risk of particle spread through mastoidectomy during the COVID-19 pandemic with an aim to assess the tools used to mitigate the spread. A systematic review was conducted using PRISMA guidelines. Our search terms included: MASTOIDECTOMY + COVID-19 or MASTOIDECTOMY + SAR- CoV-2 or MASTOIDECTOMY + CORONAVIRUS. Studies consistent with the inclusion and exclusion criteria were included in the review. Of the 20 articles identified in the initial search, six met the inclusion criteria. The included articles were all experimental studies, with five studies using cadaver subjects and one study using live human subjects. Three studies measured droplet spread and three studies measured aerosolized particle spread. The maximum distance of particle spread ranged from 30 cm to 208 cm. Four studies assessed the use of a barrier system, with two using the OtoTent and two using a barrier drape. Two studies defined the microscope alone as a possible mitigatory tool. One study compared burr type and size to determine the effects on particle spread. During the coronavirus disease 2019 (COVID-19) pandemic, evaluation of tools to mitigate particle spread is imperative for the safety of the surgical team and the healthcare system at large. Barrier drapes, OtoTents and microscopes all have proven to mitigate particle spread; however, further research needs to be performed to compare their efficacy and develop a standard of safety.
PubMed: 34853757
DOI: 10.7759/cureus.19040 -
Plastic and Reconstructive Surgery.... Jun 2022Planning a combined procedure requires ensuring an optimal fill of the reduced breast skin envelope, which in turn requires a system to quantify skin excess to ensure...
UNLABELLED
Planning a combined procedure requires ensuring an optimal fill of the reduced breast skin envelope, which in turn requires a system to quantify skin excess to ensure that the selected implant achieves that optimal fill. This has led us to develop a five-step approach that a surgical team can use to assess patients scheduled to undergo an augmentation mastopexy and arrive at an optimal surgical strategy.
METHODS
This retrospective study included 50 consecutive cases where layered mastopexies combined with augmentation mammaplasties were performed. Step 1 entailed a preoperative examination and evaluation of the breasts. In step 2, the breast volume was assessed. The pocket plane was determined in step 3. The choice of which surgical technique to use was done in step 4, and in step 5, the horizontal skin excess was assessed.
RESULTS
The average implant size was 300 cm (range: 170-350 cm). The overall revision rate was 4%: on average, revision surgeries were performed 24 months after the first surgery. The average implant size was 300 cm (range: 170-350 cm).
CONCLUSIONS
Early results of single-stage augmentation with mastopexy have shown that the design of this systematic five-step approach demonstrates a great potential for producing reliable results with minimal risk. Using this five-step approach will improve patient and surgeon satisfaction and help to replace the old concept of "fill and re-drape" with a new one of "plan, reduce, fill, and re-drape."
PubMed: 35720197
DOI: 10.1097/GOX.0000000000004349 -
Journal of the American Association For... Sep 2022Surgical procedures are commonly performed using mice but can have major effects on their core body temperature, including development of hypothermia. In this study, we...
Surgical procedures are commonly performed using mice but can have major effects on their core body temperature, including development of hypothermia. In this study, we evaluated active perioperative warming with and without surgical draping with adherent plastic wrap to refine practices, improve animal welfare, and optimize research experiments. Mice were randomized into treatment groups ( = 6; 8 CD1 mice per group). Treatments included placement within a small-animal forced-air incubator at 38 ° C for 30 min before surgery (Pre), after surgery (Post), or before and after surgery (Both). To explore the effect of surgical draping, one group received incubator warming before and after surgery in addition to surgical draping (Both/ Drape), whereas another group received surgical draping only without incubator warming (Control/Drape). The final group of mice received neither warming nor draping (Control). Subcutaneous temperature transponders were placed in all mice. Approximately 5 d after transponder placement, mice were anesthetized with ketamine-xylazine and underwent laparotomy. Subcutaneous body temperatures were collected perioperatively from transponders, and rectal temperatures were taken every minute during surgery. For recovery from anesthesia, mice were placed either in a standard cage on a warm water blanket set to 38 °C (100.4 °F) or in the incubator. Subcutaneous body temperatures were significantly higher in mice prewarmed for 30 min (Pre, Both, Both/Drape) as compared with mice that were not prewarmed. Anesthetic recovery times were significantly longer for mice placed in the incubator (Pre, Post, Both, Both/Drape) than for those that did not receive incubator warming (Control, Control/Drape). Mean intraoperative rectal temperatures of Both/Drape mice tended to be greater than those of mice in the Both group, suggesting a warming benefit of surgical draping. Using a forced air incubator and adherent plastic draping mitigated body temperature loss in mice during both surgery and postoperative recovery.
Topics: Animals; Body Temperature; Hypothermia; Ketamine; Mice; Plastics; Water; Xylazine
PubMed: 36045004
DOI: 10.30802/AALAS-JAALAS-21-000036