Most of us read with a certain degree of disappointment the recent publication (Stulberg 2010) of outcomes using the SCIP (Surgical Care Improvement Project) measures. Adherence reported on individual SCIP measures was not associated with a significantly lower probability of infection, though adherence to the global all-or-none composite infection prevention score was associated with a lower incidence of SSIís (surgical site infections).
But some empirical observations have led to another possible approach for reducing SSIís: selection of anesthesia type. A new population-based study (Chang 2010) showed that patients having total hip or total knee replacement surgery done under general anesthesia are 2.21 times more likely to develop an SSI within 30 days of surgery compared to those done under epidural or spinal anesthesia.
The authors propose several potential biological explanations for the findings, all of which should be considered hypotheses at this time. Because this was a retrospective analysis and not a randomized controlled trial, one cannot be sure that there was not patient selection bias or some confounding variable that led to these results. Nevertheless, this empirical observation is striking and should lead to a randomized controlled trial.
The accompanying editorial (Sessler 2010) notes that the magnitude of difference here is similar to that seen with timely use of prophylactic antibiotics. He points out that other promising interventions, such as potential use of supplemental oxygen, did not hold up when assessed under the scrutiny of randomized controlled trials.
Stulberg JJ, Delaney CP, Neuhauser DV, et al. Adherence to
Surgical Care Improvement Project Measures and the Association With
JAMA 2010; 303: 2479-2485 June 23/30, 2010
Chang C-C, Lin H-C; Lin H-W, Lin H-C. Anesthetic Management and Surgical Site Infections in Total Hip or Knee Replacement: A Population-based Study. Anesthesiology 2010; 113(2): 279-284 August 2010
Sessler, DI. Neuraxial Anesthesia and Surgical Site Infection. Anesthesiology 2010; 113(2) :265-267† August 2010