Wound infection: a nurse's perspective

There is clinical uncertainty about the involvement of bacteria in open wounds. Frequently asked questions are: Is this wound infected? Should I culture the wound? How should I clean the wound? Do I need to use sterile technique when I perform local wound care? Using available science and common sense, a practical approach is proposed to answer these questions.     

Wound infection: a prospective study of 7519 operations

Wound infection was prospectively studied in 7,519 consecutive operations after preoperative classification as clean, clean-contaminated, and infected. The overall infection rate was 3.9 per cent. Clean, 3.2 per cent; clean-contaminated, 4.4 per cent; contaminated, 12.4 per cent; infected, 16.2 per cent. Wound infection was not seasonally related or dependent on changes in house staff. In clean cases, the predominant role of Staphylococcus aureus (37%) has been superceded by enterococci (44%). In clean-contaminated cases, enterococci (43.5%) were the most common, followed by Escherichia coli (40.0%). In contaminated wounds, E. coli was most common (40.0%). The infected case category grew mixed flora (E. coli, 82 per cent; enterococci, 54 per cent, and Pseudomonas aeruginosa, 43 per cent). Nosocomial organisms were important only in the contaminated (14%) and infected (43%) categories. Antibiotic therapy before cultures are available should include agents with activity against enterococci as well as S aureus, and E. coli in clean cases.     

Wound infection following cesarean section

To investigate a high incidence of wound infections occurring in patients following cesarean section at a 650 bed charity hospital in Louisiana, a bacteriologic investigation was carried out. In this study, cultures were made at multiple sites prior to operation. An attempt was made to identify those bacteria that were predominately responsible for wound infection and their source, whether from the patient herself or from a nosocomial origin. The patients were divided into three groups depending on the degree of postoperative morbidity that followed. The bacterial flora in each group was relatively the same. Other factors were more significant in predicting those patients in whom postoperative morbidity occurred.     

Wound infection following arterial surgery in the pelvis-leg region

In a series of 581 reconstructions of the aorta to the leg arteries, 28 cases (4.8%) developed wound infection with positive microbiological identification. There were 24 monoinfections with significant prevalence of Staphylococcus aureus and S. epidermis. Thirteen patients with prosthetic implants and one patient with autologous saphenous vein bypass showed graft infection, which occurred in 13 patients as a complication of reoperation for bleeding or graft occlusion in the early postoperative period. The incidence of vascular infection in patients without reoperation was 0.4%. The risk of wound infection could not be lowered by the use of prophylactic broad spectrum antibiotics. Five (33%) patients with graft infection died because of sepsis and/or rupture of anastomosis. In the group of 9 survivors there were 3 patients with excision of the graft and limb preservation without reconstruction, and 3 patients with partial or total excision of the graft and successful simultaneous axillofemoral or obturator bypass. From this study it is assumed that improvement of indication and operative technique in reconstructive procedures is more promising in preventing wound infection than the extended administration of prophylactic antibiotic drugs. In case of vascular infection the excision of the graft is very urgent and consequent "extraanatomic" reconstruction can prevent loss of limb and life.     

Wound healing and complementary therapies: a review

A series of five innovative experiments conducted by Wirth et al. which examined the effect of various complementary healing interventions on the reepithelialization rate of full thickness human dermal wounds was assessed as to specific methodological and related factors. The treatment interventions utilized in the series included experimental derivatives of the Therapeutic Touch (TT), Reiki, LeShan, and Intercessory Prayer techniques. The results of the series indicated statistical significance for the initial two experiments and nonsignificance or reverse significance for the remaining three studies. This review article examines the methodological designs of the series of studies, along with the TT practitioners' phenomenologically based journal reports, to provide potential contributing correlative factors for the differential results obtained. These factors include: (1) methodological design restrictions, (2) a transference/inhibitory effect (3) the influence of experimental assistants, (4) healer visualization /imagery techniques, (5) variations in subject populations, and (6) a potential cancellation effect. While the placebo controlled double-blind methodological designs used in the series were as stringent as those used in other fields of scientific inquiry, the overall results of the experiments were inconclusive in establishing the efficacy of the treatment interventions for accelerating the rate of reepithelialization of full thickness dermal wounds.     

Behavior modification: a perspective

Behavior modification is an approach for changing behavior based on a preliminary study of the individual. Behavior change is attempted once the individual's learning characteristics and the identification of the optimal learning conditions for the learner have been analyzed. The ability to analyze systematically and to develop behavior-environment relationships also brings a responsibility to the user to understand and master the principles and procedures of behavior modification. This article basically ignores the issue of selecting broad treatment goals and the authority of clinicians or teachers to work actively toward achieving these goals. The principal focus is to provide a perspective on the evaluation and use of behavior modification programs based on their conceptual and procedural foundations. Criticisms and the misuse of behavior modification programs are included as well as a set of guidelines for evaluating and developing effective ones.     

Carotid endarterectomy: a perspective

Carotid endarterectomies have been performed for over a decade now. To review the knowledge derived from this surgical experience, i studied 18 reports on the subject, giving attention to four specific phases of patient care: the diagnostic, preoperative, intraoperative, and postoperative periods. Emphasis was placed on studying the causes of postoperative morbidity and mortality and how they are approached through radiologic, surgical, and medical technics.     

Rationing: a transatlantic perspective

Despite the differing mechanisms of health care delivery and financing in the United Kingdom and the United States many of the issues faced by the two countries are similar, most notably the increasing financial pressures. In both countries there have been recent changes in the allocation of resources and the mechanisms of decision making. Different criteria for determining resource allocation have been tried in the two health care systems. These developments change long traditions of rationing decisions at the individual patient level in the US, and of centralised government decision making in the UK.