11 phòng ngừa nhiễm trùng sau gãy hở

STRATEGIES TO PREVENT INFECTION
FOLLOWING OPEN FRACTURES

Le Ngoc Quyen, MD. PhD


Definition

Open fractures imply
communication between
the external environment
and the fracture

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Definition
• Four components :
- Fractures
- Soft tissue damage
- Neurovascular
compromise
- Contamination

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Open
fracture
classification
Gustilo – Anderson

classification



Importance of Infection Prevention
• High Infection Risk: Open frx expose the internal environment of the body
to external contaminants, making them highly susceptible to infections.

• Potential Complications: Infections can lead to severe complications, such
as delayed wound healing, septic nonunion and osteomyelitis

• Early Intervention: Early and effective infection prevention measures can
significantly reduce the risk of complications and improve the overall
prognosis for the patient.


Risk Factors for Infection Following Open Fractures
1. Severity of soft-tissue injury
2. Extent and type of contamination
3. Timing of treatment
4. Antibiotic prophylaxis
5. Surgical treatment
6. Patient factors

Modifiable risk factors


Stages of care
Initial assessment
Primary operations

Secondary operations

Rehabilitation
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Transport: It's crucial to transport the patient to
a healthcare facility within this timeframe to
minimize the risk of infection.

Immediate
Care: The
Golden
Hour

Wound Coverage: Covering the open wound
with a sterile dressing as soon as possible helps
prevent contamination and the introduction of
pathogens.
Splinting: Immobilizing the fractured limb with
a splint or other stabilizing device is essential to
minimize movement, which can further damage
soft tissues and exacerbate the injury.


ER management
8 components

Antibiotics
Tetanus prophylaxis

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• History and mechanism of injury
• Vascular and neurological status
• Size of the skin wound
• Muscle crush or loss
• Periosteal stripping or bone necrosis
• Fracture pattern, fragmentation,
and/or bone loss
• Contamination
• Compartment syndrome


Pre-op IV Antibiotics
• The selection of antibiotics depends on factors such as the severity of

the fracture and potential pathogens. Broad-spectrum antibiotics are
often initiated initially until culture results are available.
➢ Grade 1 – 2: Cefazolin 1-2 grams/8 hours
➢ Grade 3: + Aminoglycoside (gentamycin 80 mg/8-12 h).
➢ “barnyard” contamination: + high-dose IV penicillin (5M-10M UI/24 h).

• Timing: asap, ideally within 3h


Surgical Management

Debridement

Fixation

Wound
closure


Time of surgical debridement
- 6-hour rule… timelines are controversial

- The patient should not be taken to the OR until medically
stabilized.

- If possible, the patient should be taken to the OR within
24 hours of injury.

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Debridement
• is the most important part of treating an open fracture

• must be complete, thorough and aggressive.
• irrigated during debridement to reduce the bacterial
population.

• In cases with significant amounts of dead, or possibly
ischemic, tissue, reoperation for additional debridement may
be necessary.


Take an organized approach that precedes in orderly steps through

tissue levels:
• enlarge the wound for adequate exposure.
• Only minimal non-viable wound margin need be excised.

• Define the depths of the wound, and examine it thoroughly.
• All dead or significantly injured tissue is excised systematically

according to tissue layer: subcutaneous tissues, fascia, muscle, bone


Irrigation
• Reduce the bacterial load
• Normal saline

• No advantage in adding antiseptic solutions or antibiotics

• high-pressure irrigation causes more adverse events.
• minimum volume : 3 L for type I, 6 L for type II, and 9L for
type III injuries.
• 2nd or 3rd debridement after 24–48 hours if in doubt
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Fracture stabilization
• The selection of the method of fixation remains controversial
• Internal fixation (plates and intramedullary nails)
- Good tissue envelope (upper limb or femoral fractures)
- Soft tissue cover within 48-72 hours
• External fixation
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Wound coverage
• primary wound closure
ongoing research
• open wound should be left
open (unless articular)
• But, early closure if
possible
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V.A.C : Vacuum-assisted wound closure

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Open Wound Care
Ongoing wound care and appropriate dressing play a pivotal role in
infection prevention
•Regular Wound Irrigation: Regular irrigation of
• Avoid contamination

the wound with sterile saline solution helps
• Avoid dessication
remove contaminants and reduce bacterial
load.
• Consider special dressing
• Antibiotic bead pouch
• Vacuum-assisted closure

• Close promptly

•Sterile Dressings: Dressings must be sterile
and changed regularly to maintain a clean
environment around the wound.


Patient factor
• Smoking
• Obsesity
• Diabetic
• Significant alcohol use (>14 units per week)
• Low albumin (<36g/L)
• Poor nutrition