Le Catherine, Guppy Kern H, Axelrod Yekaterina V, Hawk Mark W, Silverthorn James, Inacio Maria C, Akins Paul T
University of California Los Angeles, Neurocritical Care Department, Los Angeles, USA.
Kaiser Sacramento Neurosurgery Department, 2025 Morse Avenue, Sacramento, 95825, USA.
Clin Neurol Neurosurg. 2014 May;120:41-4. doi: 10.1016/j.clineuro.2014.02.009. Epub 2014 Feb 25.
The overall benefits of craniectomy must include procedural risks from cranioplasty. Cranioplasty carries a high risk of surgical site infections (SSI) particularly with antibiotic resistant bacteria. The goal of this study was to measure the effect of a cranioplasty bundle on peri-operative complications.
The authors queried a prospective, inpatient neurosurgery database at Kaiser Sacramento Medical Center for craniectomy and cranioplasty over a 7 year period. 57 patients who underwent cranioplasties were identified. A retrospective chart review was completed for complications, including surgical complications such as SSI, wound dehiscence, and re-do cranioplasty. We measured cranioplasty complication rates before and after implementation of a peri-operative bundle, which consisted of peri-operative vancomycin (4 doses), a barrier dressing through post-operative day (POD) 3, and de-colonization of the surgical incision using topical chlorhexidine from POD 4 to 7.
The rate of MRSA colonization in cranioplasty patients is three times higher than the average seen on ICU admission screening (19% vs. 6%). The cranioplasty surgical complication rate was 22.8% and SSI rate was 10.5%. The concurrent SSI rate for craniectomy was 1.9%. Organisms isolated were methicillin-resistant Staphylococcus aureus (4), methicillin-sensitive S. aureus (1), Propionibacterium acnes (1), and Escherichia coli (1). Factors associated with SSI were peri-operative vancomycin (68.6% vs. 16.7%, p=0.0217). Complication rates without (n=21) and with (n=36) the bundle were: SSI (23.8% vs. 2.8%, p=0.0217) and redo cranioplasty (19% vs. 0%, p=0.0152). Bundle use did not affect rates for superficial wound dehiscence, seizures, or hydrocephalus.
The cranioplasty bundle was associated with reduced SSI rates and the need for re-do cranioplasties.
颅骨切除术的总体益处必须包括颅骨修补术带来的手术风险。颅骨修补术存在手术部位感染（SSI）的高风险，尤其是感染耐抗生素细菌。本研究的目的是评估颅骨修补术综合措施对围手术期并发症的影响。
作者查询了凯撒萨克拉门托医疗中心一个前瞻性的住院神经外科数据库，该数据库涵盖了7年期间的颅骨切除术和颅骨修补术。确定了57例行颅骨修补术的患者。对并发症进行了回顾性病历审查，包括手术并发症，如手术部位感染、伤口裂开和再次颅骨修补术。我们测量了围手术期综合措施实施前后的颅骨修补术并发症发生率，该综合措施包括围手术期万古霉素（4剂）、术后第3天前使用屏障敷料，以及术后第4天至第7天使用局部洗必泰对手术切口进行去定植。
颅骨修补术患者中耐甲氧西林金黄色葡萄球菌（MRSA）定植率比重症监护病房（ICU）入院筛查时的平均定植率高3倍（19%对6%）。颅骨修补术的手术并发症发生率为22.8%，手术部位感染率为10.5%。颅骨切除术的同期手术部位感染率为1.9%。分离出的病原体有耐甲氧西林金黄色葡萄球菌（4株）、甲氧西林敏感金黄色葡萄球菌（1株）、痤疮丙酸杆菌（1株）和大肠杆菌（1株）。与手术部位感染相关的因素是围手术期万古霉素（68.6%对16.7%，p=0.0217）。未使用（n=21）和使用（n=36）综合措施时的并发症发生率分别为：手术部位感染（23.8%对2.8%，p=0.0217）和再次颅骨修补术（19%对0%，p=0.0152）。使用综合措施对浅表伤口裂开、癫痫发作或脑积水的发生率没有影响。
颅骨修补术综合措施与手术部位感染率降低以及再次颅骨修补术需求减少相关。
