Assists the surgeon and assistant during the surgical procedure by anticipating the required instruments, sponges, drains and other equipment. Even more compromises may have to be made to protect the patient from injury secondary to prolonged positioning. Respirations become shallow, the pulse is weak and thread and the pupils are widely dilated and no longer contract when exposed to light. However, these things may be avoided if the anesthetic is administered smoothly and quickly. The OIS is summarised below but should not be treated as an optimal sample size for any future research. Of the 77 comparisons providing evidence for the outcome of SSI, seven provided high or moderatecertainty evidence, 39 provided lowcertainty evidence and 31 very lowcertainty evidence. Further, we did not group the outcomes into followup of 30 days or less and followup of more than 30 days, as these time points were not recorded by the original reviews when the review authors did the metaanalysis. PDF 1945 Safely Positioning the Surgical Patient SSIs can result in delayed wound healing, increased hospital stays, increased use of antibiotics, unnecessary pain and, in extreme cases, death. For this review, where it is clear that antibiotics were given very soon before the incision, we consider this to be intraoperative, that is, prophylactic intravenous antibiotics administered less than 60 minutes before surgery; the postoperative phase as the time period from the end of the intraoperative phase to resolution of surgical procedure (which we acknowledge could take several, weeks or months for some patients). Where a review contained trials that variously delivered interventions at different starting phases, we aimed to extract and present data only for those trials relevant to the intraoperative phase (that is where the treatment started in the intraoperative phase). et al. and were the eligibility criteria appropriate for the review question?" Forearm oscillometry demonstrated better measurement performance than upper arm or lower leg oscillometry . We did not contact study authors for details of missing data, but rather assumed that review authors had done all they could to retrieve data. we did not differentiate between infectionrelated mortality and other mortality from other causes). However, previous publications have referred to the higherquality grading (high ROBIS score) in Cochrane Reviews due to the basic criteria necessary for publication at any stage (protocol or full review), suggesting that they may be the most reliable source of evidence (Pollock 2017). Surgical positioning, which is inextricably related to surgical site approach, may affect all three components of Virchow's triad. Silver L, Lu X, Yang Q, Zhu L, Liu L, Tang H, Deng J, Lu X. J Int Med Res. Gill Norman: my employment at the University of Manchester was funded by the National Institute for Health Research (NIHR) UK and focuses on high priority Cochrane Reviews in the prevention and treatment of wounds. All 32 included reviews scored well across the ROBIS assessment, likely due to the stringent reporting guidelines implemented by Cochrane prior to publication. Skilled perioperative nursing interventions afford patients safe and comfortable positioning during surgery, ensure optimal exposures of surgical sites, and prevent postoperative complications (e.g., pressure injuries, neuropathies, cardiovascular and respiratory compromises). Kao 2009 included five trials (743 participants in total). Circulating nurses coordinate the positioning of patients during , cardiovascular and respiratory compromises). POH rates were noteworthy for virtually all categories of operative procedures and POH and POPA were independent predictors of post-operative length of stay, and a study is needed to determine if modest reverse-Trendelenburg positioning during general anesthesia has a relationship with reduced POHand POPA rates. Of the 77 comparisons presenting SSI data, we judged 51% (39/77) as low certainty and 40% (31/77) as very low certainty. study identification, review authors' details; included populations, including types of surgery or procedure and depth of incision; all relevant comparisons and associated time points; concurrent intervention types that were the same for all intervention arms; outcomes reported and details of reported outcome values; method and results of risk of bias and evidence quality assessment; details of any subgroup and sensitivity analyses. It is uncertain whether intensive glycaemic control reduces SSI risk when compared with conventional glycaemic control (RR 0.71, 95% CI 0.22 to 2.26; very lowcertainty evidence; downgraded twice for imprecision and once for inconsistency assessed by overview authors). Where this was not possible we present original data. Vincent 2016 included three trials (2106 participants) that compared disposable face mask use with no mask in a single comparison. Cookson BD, Jenks PJ, Evaluation of operating room reverse Trendelenburg positioning and its effect on postoperative hypoxemia, aspiration, and length of stay: a retrospective study of consecutive patients. Results One patient out of 150 (incidence rate 0.7) developed an intra-operative Stage 1 PI. Surgical wound irrigation: a call for evidencebased standardization of practice, Chapter 22: Overviews of reviews. What is Patient Positioning? PI is soluble in both water and alcohol, and available preparations include aqueous iodophor scrub and paint, aqueous iodophor onestep preparation with polymer (3M), and alcoholic iodophor with water insoluble polymer (DuraPrep). Pulse rate is rapid and respirations are irregular. We present data according to the time points used in reviews (if reported). The evidence presented in the majority of comparisons (91%) was rated either low or very lowquality/certainty. However, many of the comparisons were supported by low or very lowcertainty evidence and so require further evidence to support future decision making. Of these, we categorised 22 included trials (3604 participants in total) as delivering interventions that started in the intraoperative phase. Louise OConnor: advised on the overview; and approved the final overview prior to submission. Cooper BS, The Surgical Patients' Pressure Injury Incidence (SPPII) study: a The effects of high perioperative inspiratory oxygen fraction for adult surgical patients, Cyanoacrylate microbial sealants for skin preparation prior to surgery. Performs sterilization of surgical instrumentation and . All trials reported peristomal infection as an outcome. As this overview only included Cochrane Reviews and relevance was considered as part of our screening and selection process, we did not assess relevance using the ROBIS tool (an optional first phase). 19 0. pre, intra or postoperative, or a combination of these) we extracted data on only trials where the intervention was started in the intraoperative phase. Clipboard, Search History, and several other advanced features are temporarily unavailable. 2017 Jan;105(1):92-99. doi: 10.1016/j.aorn.2016.10.018. AbdelAziz Salama MH. For transparency, we have reported review authors' GRADE decisions but these may not calibrate well with our assessments. Available trial evidence reports no clear difference in SSI risk following use of disposable face masks compared with no mask (lowcertainty evidence; downgraded for once for imprecision and once for inconsistency assessed by overview authors). Commonly used positions The basic patient positions for surgery are supine, prone, and lateral, with the head down (Trendelenburg position) ( Figure 243-1) or head up (reverse Trendelenburg). We summarised the characteristics of included reviews in the text and in additional tables. The views expressed in this publication are those of the author(s) and not necessarily those of the NHS, the National Institute for Health Research or the Department of Health. GRADE working group. as sensitivity analyses). Again, there were no key differences in findings reported for microbial sealant and blood glucose control. One trial (371 participants) showed no clear difference when applying strict intraoperative glycaemic control (using insulin infusion) with conventional glycaemic control (RR 0.86, 95% CI 0.30 to 2.52; lowcertainty evidence; downgraded twice for imprecision assessed by overview authors). Sanabria 2010 included 11 trials (1664 participants in total). Just a few interventions altered the surgical approach itself (e.g. Twentytwo trials (3604 participants) presented six comparisons of different antibiotic regimens or different routes of administration of antibiotic prophylaxis. Zhenmi Liu, Jo C Dumville, [], and Cochrane Wounds Group. Reviews focused solely on graft sites and wounds of the mouth and eye were excluded. Use of surgical drapes was also considered by both guidelines and our overview. National Institute for Health and Care Excellence (NICE). Intraoperative Fluid Management in Patients Undergoing Spine Surgery: A Wound class is assessed using the classification system adopted by the Centres for Disease Control and Prevention (HICPAC 1999). ALKhamis 2010 included 26 trials (2530 participants in total) and of these, 17 trials (1940 participants) reported SSI data. SSIs can also develop after people have left hospital. Gill Rizzello (Managing Editor): coordinated the editorial process; advised on content; edited the overview. Can occur in prone, supine and lateral positons. Whilst adverse events should be collected as part of a trial, additional data on mortality and other rare events might be better collected as part of observational, prospective studies perhaps using routinely collected data if possible. For the comparison of additional anaerobic coverage, we pooled data from four trials (1098 participants) and found that, with added anaerobic coverage, an antimicrobial prophylaxis regimen may slightly reduce SSI risk compared with no additional anaerobic coverage (RR 0.65, 95% CI 0.47 to 0.90; lowcertainty evidence; downgraded once for risk of bias and once for imprecision assessed by overview authors). Undertaking warming aims to maintain body temperature and prevent the development of perioperative hypothermia, which can lead to negative postoperative outcomes, which potentially include SSI. If there were no separate data for RCTs in a review of patientfocused interventions we did not include that review in analyses. Studies also need to have carefully considered sample size calculations and recruitment strategies to ensure that they are not underpowered. Surgeon - leader of the surgical team. Only 3 studies included (322 legs) were pooled into metaanalysis. Jo Dumville: I received research funding from the National Institute for Health Research (NIHR) UK for the production of systematic reviews focusing on high priority Cochrane Reviews in the prevention and treatment of wounds. Common but usually less serious complications relate to the skin. November 2016, www.who.int/gpsc/ssipreventionguidelines/en/. Iodophor has largely replaced iodine as the active ingredient in antiseptics. Hunt H, Typically, 10% PI formulations contain 1% available iodine (Larson 1995; Reichman 2009). The perioperative nurse involved in the intraoperative care of the obese patient is faced with numerous issues and challenges. Wilson P, The relationship between operating room table surfaces and skin integrity was examined and the overlay was more effective than the foam and gel or standard foam mattresses for preventing pressure sore formation. In: Higgins JP, Green S, editor(s). Additionally, intraoperative antibiotic prophylaxis, considered as part of this overview, were only considered as pre or postoperative interventions in the guidelines. Antibiotic prophylaxis for the prevention of methicillinresistant Staphylococcus aureus (MRSA) related complications in surgical patients. Circulating Nurse respond to request from the surgeon, anesthesiologist or anesthetist, obtain supplies, deliver supplies to the sterile field, and carry out the. 18.2). Shea B, Multistate pointprevalence survey of health careassociated infections. Carle Health hiring Surgical Tech - OR in Urbana, Illinois, United Positioning Pitfalls to Avoid - Association of periOperative Registered Richards C, Timing of intravenous prophylactic antibiotics for preventing postpartum infectious morbidity in women undergoing cesarean delivery. We also extracted contextual information to enable narrative descriptions of how data were pooled (or not) presented per comparison (e.g. To present an overview of Cochrane Reviews of the effectiveness and safety of interventions, delivered during the intraoperative period, aimed at preventing SSIs in all populations undergoing surgery in an operating theatre. Microbial sealants are liquids that are applied to the patient's skin before surgery and left to dry forming a protective film over the planned incision site. In terms of the overall 'Risk of bias' assessment, we judged 94% (30/32) of reviews to be at low risk of bias. Buchleitner AM, The WHO reviews are standard systematic reviews, more recent ones, in some cases, include observational as well as randomised controlled trial data and have review questions that, in some cases, differ in scope to corresponding Cochrane Reviews (as do related alibility criteria). It is important to present the quality or certainty of evidence from each review. Occurrence of postoperative SSI as defined by the CDC criteria (Horan 1992), or the study authors' definition of SSI. Fowler's position, also known as sitting position, is typically used for neurosurgery and shoulder surgeries. We planned to take a conservative approach and calculated an optimal information size (OIS) for the SSI outcome using conventional sample size calculation methods and assuming a relative risk reduction of between 20% and 30% (Guyatt 2011). Six trials (3294 participants in total) presented 11 comparisons of different prophylactic antibiotic regimens with each other, including pefloxacin, cefazolin, ertapenem, cefotetan, cefamendole, gentamycin, vancomycin, daptomycin, and cefuroxime. Perioperative antibiotics to prevent infection after firsttrimester abortion. Carle Health hiring Surgical Assistant in Urbana, Illinois, United Higgins JP, Wilson J, Drapes are used as a barrier between the incision and the patient's skin, which, although cleansed may harbour microorganisms, such as at deeper levels of the skin that cleansing cannot reach (, Use of electrosurgery for surgical incisions, In electrosurgery, an electric current is used to generate heat, which vaporises cellular material, cutting the skin in place of a scalpel. Circulating nurses coordinate the positioning of patients during intraoperative periods of care. We present all data in tabular, metaanalysis or narrative formats. For the comparisons of the different routes of administration of antibiotics from one trial (72 participants), it is uncertain whether oral antibiotics reduce SSI risk compared with intravenous routes (RR 2.11, 95% CI 0.20 to 22.29; very lowcertainty evidence, downgraded once for risk of bias and twice for imprecision assessed by overview authors). woven (material) or disposable (paper) drapes). Antibiotic prophylaxis for the prevention of methicillinresistant Staphylococcus aureus (MRSA)related complications in surgical patients. One trial (180 participants) compared longduration antibiotics with shortduration antibiotics; however there were no events in either arm in this trial (very lowcertainty evidence; downgraded once for risk of bias, once for imprecision and once for publication bias assessed by review authors). It will also be a useful resource for guideline developers, especially for the key NICE guidelines, which have not been fully updated for several years (NICE 2008). Theintraoperative phaseextends from the time the client is admitted to the operating room, to the time of anesthesia administration, performance of the surgical procedure and until the client is transported to the recovery room or postanesthesia care unit (PACU). Ensure that supplies and materials are available for use during surgical procedures. December 2016. PMC They may be applied to the skin before the injection of a local anesthetic that works to numb the area more deeply, in order to avoid the pain of the needle or the drug itself (penicillin, for example, causes pain upon injection). Communicates accurate and timely information to the Registered Nurse or Physician regarding patients in their care. We did not consider nonCochrane reviews. Medications may be administered to help the patient relax or sleep. 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