棉签探查可减少手术后伤口感染

潮水

http://www.sciencedaily.com/releases/2011/06/110628113149.htm

Surgeon Shows Simple Cotton Swab Slashes Post-Surgical Wound Infections

ScienceDaily (June 27, 2011) — A simple item found in almost every medicine cabinet -- a cotton swab -- may be a key tool in the fight against post-surgical wound infections.
In a sentinel trial, Cedars-Sinai Medical Center surgeon Shirin Towfigh, MD, showed that painless and gentle probing of a wound with a dry cotton swab after surgery dramatically reduced infections in post-operative incision sites: only 3 percent of patients who had the daily probings contracted infections compared to 19 percent of those who didn't -- a rate more than six times higher than that of the study group.

"That a humble cotton swab could have such an impact in reducing the incidence of hospital-acquired infections is really quite remarkable," Towfigh said. "This study reminds us that scientists can still find effective treatments when we are willing to think outside of the 'technology box.' "

Surgical site infections most commonly occur when patients have "dirty" or contaminated wounds, such as after a trauma, bowel surgery, or perforated appendicitis. Until now, no preventative treatment at the contaminated wound site -- including topical antibiotics, under-the-skin wound drains or delayed closure of the wound -- has proven to reliably decrease these infections. More than 500,000 such infections occur in the U.S each year, accounting for nearly one-quarter of hospital-acquired infections and a major source of illness and cause of death in patients.

The exact mechanism by which the technique prevents surgical site infection is unclear, though Towfigh and colleagues surmise that wound probing allows contaminated fluid trapped within soft tissues to drain, reducing the bacterial burden while maintaining a moist environment needed for successful wound healing.

Besides greatly reducing incision infections, painless probing with the cotton swab resulted in less post-operative pain for patients and significantly shorter hospital stays (five vs. seven days). Patients also had better cosmetic healing of their incisions and -- unsurprisingly -- higher satisfaction with their outcomes.

As reported in the Archives of Surgery, all study participants had undergone an appendectomy for a perforated appendicitis. Half of the 76 patients in the prospective, randomized trial had their incisions loosely closed with staples, then swabbed daily with iodine (the control group). The study group had their incisions loosely closed. Then, their wounds were probed gently between surgical staples with a dry, sterile cotton tip applicator each day.

"This practice was introduced to me as a surgical resident 15 years ago," Towfigh says. "I've used it routinely since then. While I thought all surgeons were aware of this treatment approach, I learned otherwise when I began my professional career. Since it was evident to me that probing certain wounds after surgery resulted in far fewer infections, I developed this clinical trial so that my colleagues across the country could learn about -- and confidently adopt -- the practice."

Towfigh, part of the Cedars-Sinai's Center for Minimally Invasive Surgery and the Department of Surgery, has taught her wound probing technique to the medical and nursing staff throughout Cedars-Sinai Medical Center. The team of colorectal surgeons at Cedars-Sinai has not only adopted the practice but has begun a clinical study in their own patient population.

As a surgical educator at Cedars-Sinai, Towfigh teaches the probing technique to her medical students, residents and fellows with the expectation they will educate others as they fan out to hospitals nationwide.

Towfigh is a faculty member in the medical center's division of General Surgery.  

科学日报（2011年6月27日）---一种几乎在每个医药箱中都会有的简单物件，棉签，可能成为战胜手术后伤口感染的关键工具。
在一个定点试验中，美国洛杉矶雪松西奈山医疗中心外科医生Shirin Towfigh博士展示了手术后无痛、轻轻的用干棉签探查伤口可以大大减少手术后切口位置的感染：每天探查伤口的患者中只有3%的患者发生手术后感染，而不这样做的患者中却有19%发生感染，这个比率是使用干棉签的试验组的6倍多。

“这小小的棉签能够对减少医院获得性感染方面产生这么大的影响，实在令人惊奇，”Towfigh说。“这个试验提醒当我们愿意从“技术盒”之外的角度去考虑时科学家仍然能够找到有效的处理方法。”

手术切口感染常发生于患者的切口比较“脏”或者受到污染的情形，比如创伤、肠部手术或者穿孔性阑尾炎。在此之前污染手术切口的保守治疗方法，包括局部给予抗生素、皮下创口引流或者延迟闭合创口等都未能有效的减少这些窗口感染。美国每年有超过50万例这类感染，约占医院获得性感染的近四分之一，是患者感染疾病和发生死亡的一种主要原因。

这种技术预防手术切口感染的确切机制尚不清楚，Towfigh及其同事推测可能是因为伤口探查可以使污染的液体被软组织吸收后排除出去，因而减少细菌载量同时维护创口成功修护所需的湿性环境。

除了大大减少切口感染，用棉签进行的无痛探查还能减少患者手术后的疼痛，并显著缩短住院时间（5天vs 7天）。而且患者手术切口的外观也更加美观，不令人惊奇的是，患者对结果的满意度也相应增加。

如同Archives of Surgery杂志中的报道，所有的参与人员都因为穿孔性阑尾炎接受了阑尾切除术，这项前瞻性随机临床试验中76位参与人员中有一半的手术切口采用手术缝合器宽松缝合，然后每天采用碘酒擦拭切口（对照组）。其他的参与人员（试验组）手术切口经宽松缝合后，每天采用一个干的无菌棉签轻轻探查手术切口。

“15年前当我还是个住院医生时我就采用这种方法了，”Towfigh说。“从那以后我就将其作为处理创口的常规方法。我过去认为所有的外科医生都已了解这种处理方法，我在开始我的职业生涯时时了解到这点的。对我来说，很明显手术后进行一定的探查可以大大减少手术后感染发生，我进行了这次临床试验，希望全国的同时能学习并信任的采用这种操作方法。”

Towfigh作为雪松西奈山医疗中心微创手术中心以及外科的一员，已经将他的这种手术伤口探查技术教授给整个雪松西奈山医疗中心的医护人员。雪松西奈山医疗中心结直肠外科的团队不仅采用了这种技术并且在他们自己的患者中开展了一项临床试验。

作为雪松西奈山医疗中心的外科教育人员，Towfigh还将他的伤口探查技术教授给医学系的学生、住院医生以及研究院，希望当他们奔向全国各地的医院时，也能将这种技术教授给其他人。

Towfigh是雪松西奈山医疗中心普外科的教职人员。

潮水

“这种技术预防手术切口感染的确切机制尚不清楚，Towfigh及其同事推测可能是因为伤口探查可以使污染的液体被软组织吸收后排除出去，因而减少细菌载量同时维护创口成功修护所需的湿性环境。”

wzxiaomin

请问老师：用棉签探查，具体还要做哪些事情？探查伤口的愈合情况，之后要做什么呢？探查之后还用常规消毒或者换药吗？

hongmei

我认为，伤口探查后仍需要消毒和换药，而且操作医务人员要注意手卫生和无菌技术

lemoncherry

不懂 观摩学习ing  {:5_617:}

绿衫狐

老师能否告知具体的操作方法？

550364678

我也非常想知道棉签如何探查伤口的具体步骤。

550364678

请教潮水老师，胫骨骨髓炎做培养取样时如何取样？

回忆

很想知道用棉签探查手术切口的具体操作方法

gaoxd5

能否提供全文，具体研究方法，否则很难判断文章的科学性

茉莉花开

回复 1# 潮水
真的是有一种很什么什么的感觉，我院以前的外科病人医生使用手去探查伤口，按压之类的！后来因为手卫生依从性不够，我建议他们使用棉签探查伤口，但是没有调查也没有数据支持！

鬼才

回复 10# gaoxd5
这本身就是一个新闻报道，怎样会有学术论文的全文呢？

潮水

回复 10# gaoxd5

http://www.ncbi.nlm.nih.gov/pubmed/21502454
Archives of Surgery, 2011; 146 (4): 448
Significant Reduction of Wound Infections With Daily Probing of Contaminated Wounds
A Prospective Randomized Clinical Trial

Shirin Towfigh, MD; Tatyan Clarke, MD; Wael Yacoub, MD; Aydin H. Pooli, MD; Rodney J. Mason, MD, PhD; Namir Katkhouda, MD; Thomas V. Berne, MD


Arch Surg. 2011;146(4):448-452. doi:10.1001/archsurg.2011.61

Hypothesis  Local wound management using a simple wound-probing protocol (WPP) reduces surgical site infection (SSI) in contaminated wounds, with less postoperative pain, shorter hospital stay, and improved patient satisfaction.

Design  Prospective randomized clinical trial.

Setting  Academic medical center.

Patients  Adult patients undergoing open appendectomy for perforated appendicitis were enrolled from January 1, 2007, through December 31, 2009.

Interventions  Study patients were randomized to the control arm (loose wound closure with staples every 2 cm) or the WPP arm (loosely stapled closure with daily probing between staples with a cotton-tipped applicator until the wound is impenetrable). Intravenous antibiotic therapy was initiated preoperatively and continued until resolution of fever and normalization of the white blood cell count. Follow-up was at 2 weeks and at 3 months.

Outcome Measures  Wound pain, SSI, length of hospital stay, other complications, and patient satisfaction.

Results  Seventy-six patients were enrolled (38 in the WPP arm and 38 in the control arm), and 49 (64%) completed the 3-month follow-up. The patients in the WPP arm had a significantly lower SSI rate (3% vs 19%; P = .03) and shorter hospital stays (5 vs 7 days; P = .049) with no increase in pain (P = .63). Other complications were similar (P = .63). On regression analysis, only WPP significantly affected SSI rates (P = .02). Age, wound length, body mass index, abdominal circumference, and diabetes mellitus had no effect on SSI. Patient satisfaction at 3 months was similar (P = .69).

Conclusions  Surgical site infection in contaminated wounds can be dramatically reduced by a simple daily WPP. This technique is not painful and can shorten the hospital stay. Its positive effect is independent of age, diabetes, body mass index, abdominal girth, and wound length. We recommend wound probing for management of contaminated abdominal wounds.


Author Affiliations: Departments of Surgery, Cedars-Sinai Medical Center, Los Angeles, California (Drs Towfigh and Pooli), University of Southern California, Los Angeles (Drs Clarke, Mason, Katkhouda, and Berne), and Washington University, St Louis, Missouri (Dr Yacoub).

潮水

Archives of Surgery
期刊译名：外科学文献（美）
原版刊号：644B0005
ISSN号：0004-0010
出版社：(查)AMA(美)
语 种：英文
全年期数：12
期刊状态：可用
内容介绍：
1925年创刊，由美国American Medical Association编辑出版。1998年开始征订，月刊。此刊为国际心血管学会和美国西部外科学会的机关刊物。主要刊载有关外科的基础理论、临床和手术等方面的文章，并针对外科临床实践和临床研究，发表外科学应用方面的论文。
也有译为《外科学档案》或《外科学索引杂志》或《外科学文献》

潮水

回复 11# 茉莉花开
是啊！创新其实就是一个小细节加坚持。

清丽幽妙

我也很想了解具体操作，这种简单的办法是很值得推广！

小敏鱼飞

方法都很简单,棉签也很平凡,只是看我们的医师是否有意识,是否有无菌观念.

姬国晴

有点看不懂，具体怎么操作？

论坛好老师

很想了解一下具体的操作方法和原理，能否讲的具体点？

safihu

我们的外科医生 ，没有一点无菌操作意识，如果是在无菌操作很规范的基础上来做这个探查工作，可能会有好的效果！