Influence of Adhesive Incise Drape Use on Surgical Site Infection Rates in Contaminated and Dirty Abdominal Operations

BACKGROUND

Surgical Site Infection (SSI) remains the most common cause of Healthcare-Associated Infections (HCAIs). In particular, contaminated and dirty abdominal wounds are attended by a high rate of SSI which in turn is associated with a huge burden on patients, caregivers and the entire health care system.

OBJECTIVE

To compare SSI rates following the use of iodine-impregnated adhesive incise drapes (Ioban) with routine conventional drapes in contaminated and dirty abdominal surgical wounds in a Nigerian tertiary hospital.

METHODOLOGY

Consecutive, consenting adult patients who underwent laparotomy for cases classified as contaminated and dirty were prospectively enrolled in the study. Patients in the investigation arm had in addition to conventional drapes, iodine-impregnated adhesive incise drapes (Ioban) applied on the skin of the abdomen through which incisions were made, while patients in the control arm only had routine conventional drapes applied. All patients were followed up to 30 days after the operation. Surgical site infection rates were compared between the two groups.

RESULTS

Sixty-two consecutive patients were enrolled into this study, of which 55 completed the 30-day follow-up. The mean ages of patients in the two groups were 37.96 ± 19.59 years and 36.74 ± 16.93 years (p=0.81). Males were 36 (65.5%) and females were 19 (34.5%). Overall, 30 (54.5%) patients had surgical site infection (SSI) in this study. Thirteen (46.4%) patients had SSI in iodine iodine-impregnated adhesive incise drape group while 17 (63%) patients had SSI in the conventional drape group, a difference that was not statistically significant (p=0.22). The most commonly isolated organism from infected wounds was Klebsiella species.

CONCLUSION

The use of iodine-impregnated surgical incise drapes was associated with a lower, though non-statistically significant SSI rates compared to the use of conventional drapes. This marginal benefit will require a larger population study to examine its potential cost-effectiveness in our setting.

Effectiveness of iodine-impregnated incise drapes for preventing surgical site infection in patients with clean or clean contaminated wounds: A systematic literature review and cost-consequence analysis

BACKGROUND

Surgical site infection is a serious complication associated with significant morbidity, mortality and health care expenditure.

AIMS

To determine the clinical effectiveness and economic impact of using iodine-impregnated incise drapes for preventing surgical site infection.

METHODS

MEDLINE, Embase, Cochrane Library and CINAHL databases were systematically searched. Critical appraisal and synthesis of clinical evidence informed a decision analytical cost-consequence model.

FINDINGS

Nine studies were included in the systematic literature review. Evidence from cardiac surgery patients was considered appropriate to inform the cost analysis. The economic model evaluation estimated cost savings of £549 per patient with the iodophor-impregnated drape in the deterministic analysis and a mean cost saving per patient of £554,172 per 1000 in the probabilistic analysis.

CONCLUSION

Using iodine-impregnated drapes in cardiac surgery patients may effectively reduce infections and provide cost-savings, but further research is required.

Are iodophor-impregnated drapes associated with lower intraoperative contamination compared to no adhesive drape?: A protocol for systematic review and meta analysis

BACKGROUND

Surgical site infection (SSI) is one of the most frightening complications after surgery. Adhesive drapes (AD) are widely used as an infection prevention tool. They can be non-impregnated or iodophor-impregnated, although non-impregnated are less used as they might be related to higher number of infections. One of the most common ways to study their efficacy is by analyzing the intraoperative contamination, which is a useful primary endpoint as it does not need follow-up and it has been strongly associated with infections. Therefore, we believe a systematic review (SR) and meta-analysis is needed to determine which is the literature available about this topic and to explore their results.

METHODS

All randomized controlled trials (RCT) published since 1984 through to January 15, 2023 will be included. Non-human and experimental studies will be excluded. We will only include studies written in English. We will conduct searches in the following electronic databases: MEDLINE (via PubMed), SCOPUS and Web Of Science. The protocol of the SR was registered in PROSPERO under the number CRD42023391651 and was written according to the Preferred Reporting Items for Systematic Reviews and Meta-Analysis Protocol guidelines.

DISCUSSION

The evidence regarding the benefits of using iodophor-impregnated adhesive drapes (IIAD) is scarce. Therefore, this SR and meta-analysis is required to determine if they are related with a lower intraoperative contamination incidence, compared to no AD.

Do Adhesive Drapes Have an Effect on Infection Rates in Orthopaedic Surgery? A Systematic Review and Meta-Analysis

BACKGROUND

Adhesive surgical drapes are purported to reduce the rates of surgical site infection. Despite that, international surgical guidelines generally recommend against the use of such drapes; however, this is primarily based on nonorthopaedic evidence.

QUESTIONS/PURPOSES

(1) Does the use of adhesive drapes decrease the risk of wound contamination? (2) Does intraoperative drape peeling (intentional or inadvertent) increase the risk of wound contamination? (3) Does the use of adhesive drapes decrease the risk of surgical site infection?

METHODS

A systematic review of the MEDLINE and Embase databases was performed according to the Cochrane Handbook methods for randomized controlled trials (RCTs) published since 2000 and comparing adhesive drapes with controls. All databases were searched from inception to March 1, 2021. A pooled meta-analysis was performed, where possible. The Cochrane Risk of Bias Assessment Tool was used to assess risk of bias among the included studies. From among 417 search results, five eligible RCTs were identified and included, all of which were published between 2018 and 2020. There were a total of 2266 patients, with 1129 (49.8%) in the adhesive drape groups, and 1137 (50.2%) in the control groups. The studies included hip and knee surgery trials (n = 3 trials; 1020 patients in intervention groups and 1032 patients in control groups) as well as trials on shoulder arthroscopy (n = 1 trial; 65 patients in the intervention group and 61 patients in the control group) and lumbar spine surgery (n = 1 trial; 44 patients in each group). The data for all three outcomes (wound contamination, impact of intraoperative peeling, and surgical site infection) revealed low heterogeneity based on random-effects models (I2 = 14%, 0%, and 0%, respectively).

RESULTS

Based on data from pooled wound swab culture results from four studies, a reduction in wound contamination was associated with the use of adhesive drapes (odds ratio 0.49 [95% CI 0.34 to 0.72]; p < 0.001). The available evidence was inconclusive to determine whether intraoperative drape peeling (intentional or inadvertent) influenced the risk of wound contamination. Three studies did not report on this outcome, one study found an increased infection rate with drape peel back, and another study found a reduced treatment effect of adhesive drapes when peel back occurred in a subgroup analysis. The two studies that analyzed surgical site infections reported no infections in either arm; therefore, we could not answer the question of whether adhesive drapes affect risk of surgical site infection.

CONCLUSION

The findings of this review suggest that adhesive drapes, including those with antimicrobial properties, decrease the risk of wound contamination during orthopaedic procedures. In circumstances where drape adhesion is compromised and peel back occurs at the wound edge, there is an increased risk of wound contamination with the use of adhesive drapes. The best currently available evidence is indeterminate as to the effect of adhesive drapes on the risk of surgical site infections; however, if used, care should be taken to avoid or minimize drape peel back.

LEVEL OF EVIDENCE

Level I, therapeutic study.

Preventing Operating Room Fires: Impact of Surgical Drapes on Oxygen Contamination of the Operative Field

OBJECTIVE

The aim of the study was to measure underdrape oxygen pooling, surgical site oxygen contamination, and time to restoration of 21% oxygen concentration after cessation of oxygen delivery by measuring oxygen concentration under simulated clinical conditions with various drapes.

METHODS

In a 2-part study, oxygen permeability of four differing surgical drapes was measured (Part A) and a mannequin was used to measure underdrape oxygen pooling and surgical site oxygen contamination (Part B). In Part A, a container of high concentration oxygen was sealed with a surgical drape. Oxygen concentrations on both sides of the drape were then measured over time to quantify drape oxygen permeability. Part B included a mannequin model draped for a hypothetical surgical site with oxygen administered by face mask. Oxygen concentration was measured at both the surgical site and under the drape nearest the surgical site.

RESULTS

Oxygen permeability varied significantly between drapes tested. The surgical site oxygen concentration ranged from 20% to 58% (P = 0.0001). The commonly used woven 100% cotton operating room (OR) towel was highly permeable. The plastic occlusive drape created an impermeable barrier, which did not allow for any oxygen contamination but created the longest time to return to 21% oxygen concentration at the underdrape site after cessation of oxygen delivery.

CONCLUSIONS

Surgical drapes have varying oxygen permeability and can lead to high concentration underdrape oxygen pooling. Oxygen contamination of the surgical site varies widely based on drape material and may reach dangerously high levels, especially with the cotton OR towel. Surgical drape selection may impact OR fire risk.

Negative Pressure Assisted Microenvironment Surgical Hood: A Novel Cost-Effective Device to Minimize Aerosol Contamination During Neurosurgical Procedures in Times of COVID-19

Objective

Present guidelines on reducing aerosol generation during neurosurgical procedures are futile. The aim of this article was to describe a novel device to contain aerosol within a small localized environment around the operative field—the negative pressure assisted microenvironment surgical hood (NEPA-MESH).

Methods

This device can be assembled using easily available materials—steel wires, image intensifier cover, surgical drape, and three-dimensional–printed self-locking copolyester double hoops. Large-bore pipes in continuity with a high-volume suction apparatus create a constant negative pressure microenvironment around the operative field. The CEM DT-9880 particle counter was used to estimate particle concentration inside the NEPA-MESH during various stages of a neurosurgical procedure as well as outside. The NEPA-MESH was tested in different craniotomies and endoscopic procedures.

Results

Mean particle concentration inside the NEPA-MESH and outside during drilling in various procedures was calculated and compared using unpaired t test. Significant reduction in particle concentrations was recorded for particles sized 0.3 μm (t = 17.55, P < 0.0001), 0.5 μm (t = 11.39, P < 0.0001), 1 μm (t = 6.36, P = 0.0002), 2.5 μm (t = 2.04, P = 0.074), 5.0 μm (t = 7.026, P = 0.0008), and 10 μm (t = 4.39, P = 0.0023).

Conclusions

As definitive evidence demonstrating the presence of coronavirus disease 2019 (COVID-19) in aerosol particles is awaited, we describe a cost-effective strategy to reduce aerosol contamination. Significant reduction in particle concentrations was seen outside the NEPA-MESH compared with inside it during various stages of neurosurgical procedures.

C-arm Drape Perforation During Primary Anterior Hip Arthroplasty

Violation of the sterile field due to tears or perforations in the C-arm drape during primary anterior hip arthroplasty could lead to an increased risk of infection. Deep prosthetic infection is a catastrophic complication of hip arthroplasty. The incidence of C-arm drape perforation during primary anterior hip arthroplasty is unknown. We sought to determine the incidence of C-arm drape perforation during primary anterior hip arthroplasty. The integrity of the C-arm drape was checked with a novel leak test after 36 primary anterior hip arthroplasties. One or more C-arm drape perforations were found intraoperatively or during testing of drapes used for four of thirty-six (11%) procedures. An additional drape leaked at its end seam and ruptured at this seam during testing. Quality testing of this seam may need further evaluation. No infections or wound complications were found at an average follow-up of 9 months. (Journal of Surgical Orthopaedic Advances 30(3):173-175, 2021).

Skin preparation for preventing infection following caesarean section

BACKGROUND

The risk of maternal mortality and morbidity is higher after caesarean section than for vaginal birth. With increasing rates of caesarean section, it is important to minimise risks to the mother as much as possible. This review focused on different skin preparations to prevent infection. This is an update of a review last published in 2018.

OBJECTIVES

To compare the effects of different antiseptic agents, different methods of application, or different forms of antiseptic used for preoperative skin preparation for preventing postcaesarean infection.

SEARCH METHODS

For this update, we searched Cochrane Pregnancy and Childbirth's Trials Register, ClinicalTrials.gov, the WHO International Clinical Trials Registry Platform (ICTRP) (9 July 2019), and reference lists of retrieved studies.

SELECTION CRITERIA

Randomised and quasi-randomised trials, evaluating any type of preoperative skin preparation (agents, methods or forms). We included studies presented only as abstracts, if there was enough information to assess risk of bias. Comparisons of interest in this review were between: different antiseptic agents (e.g. alcohol, povidone iodine), different methods of antiseptic application (e.g. scrub, paint, drape), different forms of antiseptic (e.g. powder, liquid), and also between different packages of skin preparation including a mix of agents and methods, such as a plastic incisional drape, which may or may not be impregnated with antiseptic agents. We mainly focused on the comparison between different agents, with and without the use of drapes. Only studies involving the preparation of the incision area were included. This review did not cover studies of preoperative handwashing by the surgical team or preoperative bathing.

DATA COLLECTION AND ANALYSIS

Three review authors independently assessed all potential studies for inclusion, assessed risk of bias, extracted the data and checked data for accuracy. We assessed the certainty of the evidence using the GRADE approach.

MAIN RESULTS

We included 13 individually-randomised controlled trials (RCTs), with a total of 6938 women who were undergoing caesarean section. Twelve trials (6916 women) contributed data to this review. The trial dates ranged from 1983 to 2016. Six trials were conducted in the USA, and the remainder in India, Egypt, Nigeria, South Africa, France, Denmark, and Indonesia. The included studies were broadly at low risk of bias for most domains, although high risk of detection bias raised some specific concerns in a number of studies. Length of stay was only reported in one comparison. Antiseptic agents Parachlorometaxylenol with iodine versus iodine alone We are uncertain whether parachlorometaxylenol with iodine made any difference to the incidence of surgical site infection (risk ratio (RR) 0.33, 95% confidence interval (CI) 0.04 to 2.99; 1 trial, 50 women), or endometritis (RR 0.88, 95% CI 0.56 to 1.38; 1 trial, 50 women) when compared with iodine alone, because the certainty of the evidence was very low. Adverse events (maternal or neonatal) were not reported. Chlorhexidine gluconate versus povidone iodine Moderate-certainty evidence suggested that chlorhexidine gluconate, when compared with povidone iodine, probably slightly reduces the incidence of surgical site infection (RR 0.72, 95% CI 0.58 to 0.91; 8 trials, 4323 women). This effect was still present in a sensitivity analysis after removing four trials at high risk of bias for outcome assessment (RR 0.87, 95% CI 0.62 to 1.23; 4 trials, 2037 women). Low-certainty evidence indicated that chlorhexidine gluconate, when compared with povidone iodine, may make little or no difference to the incidence of endometritis (RR 0.95, 95% CI 0.49 to 1.86; 3 trials, 2484 women). It is uncertain whether chlorhexidine gluconate reduces maternal skin irritation or allergic skin reaction (RR 0.64, 95% CI 0.28 to 1.46; 3 trials, 1926 women; very low certainty evidence). One small study (60 women) reported reduced bacterial growth at 18 hours after caesarean section for women who had chlorhexidine gluconate preparation compared with women who had povidone iodine preparation (RR 0.23, 95% CI 0.07 to 0.70). Methods Drape versus no drape This comparison investigated the use of drape versus no drape, following preparation of the skin with antiseptics. Low-certainty evidence suggested that using a drape before surgery compared with no drape, may make little or no difference to the incidence of surgical site infection (RR 1.29, 95% confidence interval (CI) 0.97 to 1.71; 3 trials, 1373 women), and probably makes little or no difference to the length of stay in the hospital (mean difference (MD) 0.10 days, 95% CI -0.27 to 0.46; 1 trial, 603 women; moderate-certainty evidence). One trial compared an alcohol scrub and iodophor drape with a five-minute iodophor scrub only, and reported no surgical site infection in either group (79 women, very-low certainty evidence). We were uncertain whether the combination of a one-minute alcohol scrub and a drape reduced the incidence of metritis when compared with a five-minute scrub, because the certainty of the evidence was very low (RR 1.62, 95% CI 0.29 to 9.16; 1 trial, 79 women). The studies did not report on adverse events (maternal or neonatal).

AUTHORS' CONCLUSIONS

Moderate-certainty evidence suggests that preparing the skin with chlorhexidine gluconate before caesarean section is probably slightly more effective at reducing the incidence of surgical site infection in comparison to povidone iodine. For other outcomes examined there was insufficient evidence available from the included RCTs. Most of the evidence in this review was deemed to be very low or low certainty. This means that for most findings, our confidence in any evidence of an intervention effect is limited, and indicates the need for more high-quality research. Therefore, it is not yet clear what sort of skin preparation may be most effective for preventing postcaesarean surgical site infection, or for reducing other undesirable outcomes for mother and baby. Well-designed RCTs, with larger sample sizes are needed. High-priority questions include comparing types of antiseptic (especially iodine versus chlorhexidine), and application methods (scrubbing, swabbing, or draping). We found two studies that are ongoing; we will incorporate the results of these studies in future updates of this review.

A Proactive Approach to Quantification of Blood Loss in the Perinatal Setting

OBJECTIVE

To educate nurses and physicians on changing practice from visual estimation of blood loss to quantification of blood loss (QBL) and to replace estimation of blood loss with QBL for at least 85% of vaginal births during a 3-month period.

DESIGN

Quality improvement project.

SETTING/LOCAL PROBLEM

A midwestern U.S. urban community hospital with 1,200 annual births, where postpartum blood loss was being measured by using visual estimation.

PARTICIPANTS

A convenience sample of 43 intrapartum nurses and 17 physicians.

INTERVENTION/MEASUREMENTS

A goal was set to use the QBL method for at least 85% of vaginal births for 3 consecutive months. Study participants were surveyed at baseline to assess their knowledge of the QBL method; they then received a 10-minute educational presentation by the clinical nurse specialist (CNS) on QBL. The CNS attended births on both 12-hour shifts to give support, evaluate correct use of the new drapes, and answer questions. Midway through the project, a brief survey was distributed to participants for their feedback. The CNS conducted a chart audit to determine the compliance rate for the QBL process.

RESULTS

Data analysis indicated an average 89% compliance rate with the QBL process for the time period studied.

CONCLUSION

Education on the QBL method increased nurses' and physicians' awareness of the importance of using this method as the new standard of care for assessment of postpartum blood loss. Accuracy of postpartum blood loss measurement is critical to help prevent maternal morbidity and mortality. Nurses play a key role in the development and implementation of practice changes to use QBL measurement.

Skin preparation for preventing infection following caesarean section

BACKGROUND

The risk of maternal mortality and morbidity (particularly postoperative infection) is higher for caesarean section (CS) than for vaginal birth. With the increasing rate of CS, it is important to minimise the risks to the mother as much as possible. This review focused on different forms and methods of preoperative skin preparation to prevent infection. This review is an update of a review that was first published in 2012, and updated in 2014.

OBJECTIVES

To compare the effects of different antiseptic agents, different methods of application, or different forms of antiseptic used for preoperative skin preparation for preventing postcaesarean infection.

SEARCH METHODS

For this update, we searched Cochrane Pregnancy and Childbirth's Trials Register, ClinicalTrials.gov, the WHO International Clinical Trials Registry Platform (ICTRP) (27 November 2017), and reference lists of retrieved studies.

SELECTION CRITERIA

Randomised and quasi-randomised trials, evaluating any type of preoperative skin preparation agents, forms, and methods of application for caesarean section.Comparisons of interest in this review were between different antiseptic agents used for CS skin preparation (e.g. alcohol, povidone iodine), different methods of antiseptic application (e.g. scrub, paint, drape), different forms of antiseptic (e.g. powder, liquid), and also between different skin preparations, such as a plastic incisional drape, which may or may not be impregnated with antiseptic agents.Only studies involving the preparation of the incision area were included. This review did not cover studies of preoperative handwashing by the surgical team or preoperative bathing.

DATA COLLECTION AND ANALYSIS

Three review authors independently assessed all potential studies for inclusion, assessed risk of bias, and extracted the data using a predesigned form. We checked data for accuracy. We assessed the quality of the evidence using the GRADE approach.

MAIN RESULTS

For this update, we included 11 randomised controlled trials (RCTs), with a total of 6237 women who were undergoing CS. Ten trials (6215 women) contributed data to this review. All included studies were individual RCTs. We did not identify any quasi- or cluster-RCTs. The trial dates ranged from 1983 to 2016. Six trials were conducted in the USA, and the remainder in Nigeria, South Africa, France, Denmark, and Indonesia.The included studies were broadly methodologically sound, but raised some specific concerns regarding risk of bias in a number of cases.Drape versus no drapeThis comparison investigated the use of a non-impregnated drape versus no drape, following preparation of the skin with antiseptics. For women undergoing CS, low-quality evidence suggested that using a drape before surgery compared with no drape, may make little or no difference to the incidence of surgical site infection (risk ratio (RR) 1.29, 95% confidence interval (CI) 0.97 to 1.71; 2 trials, 1294 women), or length of stay in the hospital (mean difference (MD) 0.10 day, 95% CI -0.27 to 0.46 1 trial, 603 women).One-minute alcohol scrub with iodophor drape versus five-minute iodophor scrub without drapeOne trial compared an alcohol scrub and iodophor drape with a five-minute iodophor scrub only, and reported no surgical site infection in either group (79 women, very-low quality evidence). We were uncertain whether the combination of a one-minute alcohol scrub and a drape reduced the incidence of endomyometritis when compared with a five-minute scrub, because the quality of the evidence was very low (RR 1.62, 95% CI 0.29 to 9.16; 1 trial, 79 women).Parachlorometaxylenol with iodine versus iodine aloneWe were uncertain whether parachlorometaxylenol with iodine before CS made any difference to the incidence of surgical site infection (RR 0.33, 95% CI 0.04 to 2.99; 1 trial, 50 women), or endometritis (RR 0.88, 95% CI 0.56 to 1.38; 1 trial, 50 women) when compared with iodine alone, because the quality of the evidence was very low.Chlorhexidine gluconate versus povidone iodineLow-quality evidence suggested that chlorhexidine gluconate before CS, when compared with povidone iodine, may make little or no difference to the incidence of surgical site infection (RR 0.80, 95% CI 0.62 to 1.02; 6 trials, 3607 women). However, surgical site infection appeared to be slightly reduced for women for whom chlorhexidine gluconate was used compared with povidone iodine after we removed four trials at high risk of bias for outcome assessment, in a sensitivity analysis (RR 0.59, 95% CI 0.37 to 0.95; 2 trials, 1321 women).Low-quality evidence indicated that chlorhexidine gluconate before CS, when compared with povidone iodine, may make little or no difference to the incidence of endometritis (RR 1.01, 95% CI 0.51 to 2.01; 2 trials, 2079 women), or to reducing maternal skin irritation or allergic skin reaction (RR 0.60, 95% CI 0.22 to 1.63; 2 trials, 1521 women).One small study (60 women) reported reduced bacterial growth at 18 hours after CS for women who had chlorhexidine gluconate preparation compared with women who had povidone iodine preparation (RR 0.23, 95% CI 0.07 to 0.70).None of the included trials reported on maternal mortality or repeat surgery.Chlorhexidine 0.5% versus 70% alcohol plus drapeOne trial, which was only available as an abstract, investigated the effect of skin preparation on neonatal adverse events, and found cord blood iodine concentration to be higher in the iodine group.

AUTHORS' CONCLUSIONS

There was insufficient evidence available from the included RCTs to fully evaluate different agents and methods of skin preparation for preventing infection following caesarean section. Therefore, it is not yet clear what sort of skin preparation may be most effective for preventing postcaesarean surgical site infection, or for reducing other undesirable outcomes for mother and baby.Most of the evidence in this review was deemed to be very low or low quality. This means that for most findings, our confidence in any evidence of an intervention effect is limited, and indicates the need for more high-quality research.This field needs high quality, well designed RCTs, with larger sample sizes. High priority questions include comparing types of antiseptic (especially iodine versus chlorhexidine), and application methods (scrubbing, swabbing, or draping). We found four studies that were ongoing; we will incorporate the results of these studies in future updates of this review.

Methods for blood loss estimation after vaginal birth

BACKGROUND

Almost 358,000 women die each year in childbirth, mainly in low-income countries. More than half of all maternal deaths occur within 24 hours of giving birth; severe bleeding in the postpartum period is the single most important cause. Depending on the rate of blood loss and other factors, such as pre-existing anaemia, untreated postpartum haemorrhage (PPH) can lead to hypovolaemic shock, multi-organ dysfunction, and maternal death, within two to six hours.This review investigated different methods for estimating blood loss. The most common method of measuring blood loss during the third stage of labour is visual estimation, during which the birth attendant makes a quantitative or semi-quantitative estimate of the amount of blood lost. In direct blood collection, all blood lost during the third stage of labour (except for the placenta and membranes) is contained in a disposable, funnelled, plastic collector bag, which is attached to a plastic sheet, and placed under the woman's buttocks. When the bleeding stops, there are two options: the bag can be weighed (also called gravimetric technique), or the bag can be calibrated, allowing for a direct measurement. A more precise measurement of blood loss is haemoglobin concentration (Hb) in venous blood sampling and spectrophotometry. With the dye dilution technique, a known quantity of dye is injected into the vein and its plasmatic concentration is monitored after the uterus stops bleeding. Using nuclear medicine, a radioactive tracer is injected, and its concentration is monitored after the uterus stops bleeding. Although hypothetically, these advanced methods could provide a better quantification of blood loss, they are difficult to perform and are not accessible in most settings.

OBJECTIVES

To evaluate the effect of alternative methods to estimate blood loss during the third stage of labour, to help healthcare providers reduce the adverse consequences of postpartum haemorrhage after vaginal birth.

SEARCH METHODS

We searched Cochrane Pregnancy and Childbirth's Trials Register (2 February 2018), ClinicalTrials.gov and the WHO International Clinical Trials Registry Platform (ICTRP; 21 March 2018), and reference lists of retrieved studies.

SELECTION CRITERIA

All randomised trials, including cluster-randomised trials, evaluating methods for estimating blood loss after vaginal birth.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed trials for inclusion and risk of bias, extracted data, and checked them for accuracy.

MAIN RESULTS

The search retrieved 62 reports in total. Of these, we assessed 12 reports in full, corresponding to six trials. We included three trials and excluded one; two trials are ongoing.The included trials were conducted in hospital settings. Two trials were conducted in India; the third trial was a large cluster-randomised trial, which took place in 13 European countries. Overall, we judged the included trials to be at a low risk of bias. One study evaluated the use of calibrated drapes versus visual estimation, another evaluated the use of calibrated drapes versus the gravimetric technique (weight of blood-soaked materials), therefore, we were unable to pool the data from the two studies. The third study did not measure any of the outcomes of interest, so did not contribute data to the analyses.Direct measurement using calibrated drapes versus visual estimationOne cluster-randomised controlled trial in 13 western European countries, with over 25,000 women, examined this comparison.The trial did not report on postpartum anaemia (defined as Hb lower than 9 mg/dL), blood loss greater than 500 mL, or maternal infection.Moderate-quality evidence suggests there is probably little or no difference between groups in: severe morbidity (coagulopathy, organ failure, intensive care unit admission; adjusted risk ratio (RR) 0.82, 95% confidence interval (CI) 0.48 to 1.39); the risk of blood transfusion (adjusted RR 0.82, 95% CI 0.46 to 1.46); the use of plasma expanders (adjusted RR 0.77, 95% CI 0.42 to 1.42); and the use of therapeutic uterotonics (adjusted RR 0.87, 95% CI 0.42 to 1.76).Direct measurement using calibrated drapes (Excellent BRASSS-V Drape™) versus gravimetric techniqueOne randomised controlled trial in India, with 900 women, examined this comparison.The trial did not report on postpartum anaemia (defined as Hb lower than 9 mg/dL), severe morbidity, or maternal infection.High-quality evidence showed that using calibrated drapes improved the detection of blood loss greater than 500 mL when compared with the gravimetric technique (RR 1.86, 95% CI 1.11 to 3.11). Low-quality evidence suggests there may be little or no difference in the risk of blood transfusion between the two groups (RR 1.00, 95% CI 0.06 to 15.94), or in the use of plasma expanders, reported as intravenous fluids given for PPH treatment (RR 0.67; 95% CI 0.19 to 2.35). High-quality evidence showed little or no difference in the use of therapeutic uterotonics (RR 1.01, 95% CI 0.90 to 1.13), but the use of therapeutic uterotonics was extremely high in both arms of the study (57% and 56%).

AUTHORS' CONCLUSIONS

Overall, the evidence in this review is insufficient to support the use of one method over another for blood loss estimation after vaginal birth. In general, the quality of evidence for our predefined outcomes ranged from low to high quality, with downgrading decisions due to imprecision. The included trials did not report on many of our primary and secondary outcomes.In trials that evaluate methods for estimating blood loss during vaginal birth, we believe it is important to measure their impact on clinical maternal and neonatal outcomes, along with their diagnostic accuracy. This body of knowledge needs further, well designed, appropriately powered, randomised controlled trials that correlate blood loss with relevant clinical outcomes, such as those listed in this review.

Staff radiation dose during percutaneous coronary procedures: Role of adjunctive protective drapes

BACKGROUND

The use of adjunctive protective drapes placed on the patient protects the operating physician from scatter radiation during percutaneous coronary procedures (PCP). No data are available on the effect of these drapes for staff members' radio-protection.

PURPOSE

To evaluate staff radiation exposure during PCP and the effect of adjunctive protective drapes on dose reduction.

METHODS

The RADIANT study (NCT01974453) is a prospective, observational study evaluating operator radiation exposure during PCP using electronic dosimeter. In a sub-group of procedures all the staff members (II operator, nurse circulator and technologist) were also equipped with a dedicated electronic dosimeter.

RESULTS

From a total of 2028 procedures included in the RADIANT study, staff members' doses were available for 122 procedures (67 coronarography and 55 percutaneous coronary interventions). Median fluoroscopy time was 306 s (Interquartile range 155-526 s) and the dose area product (DAP) was 18.0 Gy*cm² (10-35.5 Gy*cm²). The radiation exposure was highest for the operating physician (6.7 μSv) and progressively lower for the nurse circulator (1.8 μSv), the II operator (1 μSv) and the technologist (0.7 μSv, p < 0.001). Protective pelvic drapes were used in 43 procedures and associated with a lower radiation exposure for all staff members (14 μSv vs 2.2 μSv for operating physician, p < 0.001, 1.7 μSv vs 0.49 μSv for II operator, p < 0.001, 2.16 μSv vs 0.93 μSv for nurse circulator, p = 0.02 and 0.85 μSv vs 0.39 μSv for technologist, p = 0.01).

CONCLUSIONS

The use of adjunctive protective drapes is effective in reducing radiation protection for all staff members during PCP.

[Determination of postoperative hemoglobin levels and their correlation with the weight of the transoperative textiles]

OBJECTIVE

To determine postsurgical hemoglobin levels and the correlation with trans-surgical textile weight.

MATERIALS AND METHODS

A cross-sectional study, including 120 patients who underwent gynecological surgery, was performed in the HGR 1 in Cd. Obregon Sonora, from June to July 2015; the account of textile weight blood loss estimation was carried out and subsequently became an association of hemoglobin levels in the postoperative period, performing the conversion of a gram to one milliliter. There was expected to be an association between blood loss with low levels of hemoglobin; for each lost 500 ml, the hemoglobin decreased by 1 g.

RESULTS

120 patients were evaluated; the average age was 48.65 years. The surgical events were divided in abdominal in 76.67%, breast surgery 19.17%, and vaginal 9.17%. There was a decrease in hemoglobin of 0.74 mg/dl and hematocrit of 1.93%. We found significant association between blood loss and the decrease in hemoglobin with relative risk of 3.01 (95% CI: 1.69-5.36).

CONCLUSIONS

The main conclusion of this study is to establish that a loss > 500 ml has a direct association with > 1.1 g postoperative hemoglobin decrease and hematocrit reduction > 6%.

Evaluation of measured postpartum blood loss after vaginal delivery using a collector bag in relation to postpartum hemorrhage management strategies: a prospective observational study

AIM

To evaluate the incidence of postpartum hemorrhage (PPH) and severe PPH via routine use of a pelvic drape to objectively measure blood loss after vaginal delivery in connection with PPH management.

METHODS

This prospective observational study was undertaken at the obstetrical department of the Charité University Hospital from December 2011 to May 2013 and evaluated an unselected cohort of planned vaginal deliveries (n=1019 live singletons at term). A calibrated collecting drape was used to meassure blood loss in the third stage of labor. PPH and severe PPH were defined as blood loss ≥500 mL and ≥1000 mL, respectively. Maternal hemoglobin content was evaluated at admission to delivery and at the first day after childbirth.

RESULTS

During the study period, 809 vaginal deliveries were analysed. Direct measurement revealed a median blood loss of 250 mL. The incidences of PPH and severe PPH were 15% and 3%, respectively. Mean maternal hemoglobin content at admission was 11.9±1.1 g/dL, with a mean decrease of 1.0±1.1 g/dL. Blood loss measured after vaginal delivery correlated significantly with maternal hemoglobin decrease.

CONCLUSIONS

This study suggests that PPH incidence may be higher than indicated by population-based data. Underbuttocks drapes are simple, objective bedside tools to diagnose PPH. Blood loss should be quantified systematically if PPH is suspected.

Impact of wound edge protection devices on surgical site infection after laparotomy: multicentre randomised controlled trial (ROSSINI Trial)

OBJECTIVE

To determine the clinical effectiveness of wound edge protection devices in reducing surgical site infection after abdominal surgery.

DESIGN

Multicentre observer blinded randomised controlled trial.

PARTICIPANTS

Patients undergoing laparotomy at 21 UK hospitals.

INTERVENTIONS

Standard care or the use of a wound edge protection device during surgery.

MAIN OUTCOME MEASURES

Surgical site infection within 30 days of surgery, assessed by blinded clinicians at seven and 30 days and by patient's self report for the intervening period. Secondary outcomes included quality of life, duration of stay in hospital, and the effect of characteristics of the patient and operation on the efficacy of the device.

RESULTS

760 patients were enrolled with 382 patients assigned to the device group and 378 to the control group. Six patients in the device group and five in the control group did not undergo laparotomy. Fourteen patients, seven in each group, were lost to follow-up. A total of 184 patients experienced surgical site infection within 30 days of surgery, 91/369 (24.7%) in the device group and 93/366 (25.4%) in the control group (odds ratio 0.97, 95% confidence interval 0.69 to 1.36; P=0.85). This lack of benefit was consistent across wound assessments performed by clinicians and those reported by patients and across all secondary outcomes. In the secondary analyses no subgroup could be identified in which there was evidence of clinical benefit associated with use of the device.

CONCLUSIONS

Wound edge protection devices do not reduce the rate of surgical site infection in patients undergoing laparotomy, and therefore their routine use for this role cannot be recommended.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN 40402832.

Reduction in operator radiation exposure during transradial catheterization and intervention using a simple lead drape

BACKGROUND

Transradial access for cardiac catheterization and intervention is a recognized method for reducing complications and improving patient comfort. However, there are concerns over possible increased operator radiation exposure. We tested the hypothesis that a simple lead drape would reduce operator exposure in transradial procedures.

METHODS

Patients undergoing either diagnostic or interventional procedures using transradial access were assigned in an alternating manner to the use of a 0.5-mm lead apron across the patient's abdomen in addition to standard operator protection. Patients were divided into 4 groups: (left enhanced shielding vs left standard shielding; right enhanced shielding vs right standard shielding). Dosimeters were taped to the primary and secondary operators' left wrist and outside the thyroid guard. The operator exposure was measured for each site on every case in centigray.

RESULTS

In standard shielded patients, there was no increase in operator exposure between the left and right approach patients at any measurement site. Measured exposure was reduced with enhanced shielding at all dosimeter sites except the secondary operator's collar (both left and right) and the primary operator's collar from the right. There was no significant difference in fluoroscopy, air kerma, or dose area product between standard and enhanced shielded patients.

CONCLUSIONS

The use of a lead drape reduces the rate of operator radiation exposure at multiple measurement sites. Use of the left radial approach was not associated with an increase in operator exposure compared with the right radial approach.

Surgical site infection prevention: the operating room environment

Surgical site infections can complicate orthopaedic procedures and contribute to morbidity, mortality, and health care costs. Extensive literature has been published on this topic; however, the quality of data using standards of evidence-based medicine is variable with a lack of well-controlled studies. A review of the literature concerning measures to prevent surgical site infections in the operating room environment may be helpful in preventing such infections.