PIAC Results: Case 01 - Anne | Pediatric Residency Program
UnityPoint Health - Des Moines

PIAC Case Series

ANSWERS
Case 01 - Anne, 22 years old 

  • Anne is a previously healthy 22 y/o who presents to the ER 5 days after appendectomy. She complains of lower abdominal pain, worsening over 48 hours, with fever and chills
  • Immediate postop course had been uncomplicated but perforation of the appendix was noted at surgery.
  • WBC = 15K

Questions

1) Name 3 health-care associated infections to consider.

Answers

  1. Surgical site infection (incisional vs. deep/organ space)
  2. C. difficile colitis
    Even brief peri-operative antibiotic use will increase risk of C diff. Risk of C diff is increased 7- to 10- fold while on antibiotics and for 1 month after discontinuation and by 3-fold for subsequent 2 months
  3. Urinary tract infection (especially if had Foley placed)

Questions

2) What are some risk factors for surgical site infection (SSI)?

  • Pre-operative risk factors - name 4
  • Intra-operative risk factors - name 2
  • Post-operative risk factors - name 1
  • Risk factors for surgical site infection

Answers

-Pre-operative

  • Malnutrition
  • Diabetes
  • Obesity
  • Immunosuppression/steroid use
  • Smoking
  • Active infection elsewhere
  • Colonization with MSSA or MRSA

-Operative

  • Preoperative shaving
  • Wound contaminated (ie perforation, traumatic)
  • Normothermia and adequate oxygenation not maintained
  • Poor hemostasis, dead space, tissue trauma

-Post-operative

  • Poorly controlled diabetes
  • Hematoma


Questions

3) What is the incidence of SSI after appendectomy?

Answers

Risk of SSI can be stratified based on wound classification and SSI is defined as superficial, deep or organ space. NHSN (National Healthcare Safety Network) reports overall SSI incidence with appendectomy: 1.4%

Incidence of SSI - as reported by NSQIP

  Superficial   deep  organ space
Clean    1.76%   0.54%   0.28%
 Clean Contaminated   3.94%   0.86%   1.87%
 Contaminated or Dirty   4.7-5.1%   1.3-2.1%   2.5-4.5%


Questions

4) What are the SCIP (Surgical Care Improvement Project) measures undertaken to prevent SSI? What are other measures that may decrease risk of SSI?

Answers

SCIP measures

  1. Optimal peri-op antibiotic use
    RIGHT antibiotic at the RIGHT time (< / = 1 hour before incision) and for the RIGHT duration (no longer than 24 hours postop except for sternotomy)
  2. Intra-op normothermia
  3. Post-op blood glucose control

Other measures to decrease risk
-Surgical site scrub using chlorhexidine/alcohol

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