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Table of contents :
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| clean |
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| clean-contaminated |
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| contaminated |
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| dirty |
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and hypothermia
=> vasoconstriction => local hypoxia
(suspend corticosteroids before surgery)
: only normoglycemic patients can be operated
and antiplatelet drugs-induced
fever are other differential diagnoses
(compare lower limbs, expecially calves)
prophylaxis to reduce bacterial load (not sterilization) thanks to adequate
concentration in operatory field blood and reducing pathogenic microflora
of the targeted organs. Number of administrations depends on duration of
surgery and drug half-life. Antibiotic should be present in the target
tissues at the time of incision and when contamination occurs. The duration
of such treatment is commonly 3 to 5 days. The optimum timing for prophylaxis
by parenteral administration is at the time of induction of anaesthesia.
The infection rate increases if antibiotics are given > 2 hours preoperatively
or are delayed until after the start of the operation. For the majority
of procedures lasting for 2 hours or less, a single dose of prophylactic
antibiotic is sufficient : ecessively long courses of ‘prophylactic’ antibiotic,
whether before or after surgery, select for resistant organisms and may
increase the risk of infection and the practice of continuing antibiotics
until such time as surgical drains have been removed is unproven and not
recommended. For procedures lasting > 2 hours, or when there is massive
blood loss producing antibiotic ‘wash-out’, 1 or 2 further doses may be
required. The antibiotics chosen for prophylaxis should have spectra of
activity that include those organisms most likely to cause infection following
the procedure. It is not necessary for the chosen agent to ‘cover’ all
the likely contaminants. The benefits of prophylaxis should outweigh the
risks, e.g. the antibiotic should be safe and should not contribute to
the emergence of antibiotic-resistant bacteria. Since antibiotic prophylaxis
accounts for at least 33% of all antibiotics used in hospital practice,
the issues of antibiotic costs and cost-effective prophylaxis are becoming
increasingly important. Prophylactic antibiotics are only one factor that
determines the risk of infection. Other factors of equal or even greater
importance are surgical technique, the duration of surgery, the duration
of preoperative stay, shaving the operation site (if this must be done,
shave immediately preoperatively), repeat surgical procedure, obesity,
immune compromise and a variety of other host factors.|
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| clean surgery (prostheses and other) | Staphylococcus
aureus,
coagulase-negative
staphylococci (CNS),
Enterobacteriaceae
(aorto-coronary bypass surgery, prosthetic vascular surgery with inguinal
and lower limbs involvement) |
||
head and neck surgery (clean-contaminated/contaminated).
Antibiotic prophylaxis is not recommended in:
|
anaerobic bacteria of oral cavity, aerobic gram-negative bacteria (Enterobacteriaceae
and others) |
||
| eye surgery : local policy makers may identify exceptions in cataract surgery | Staphylococcus
aureus,
coagulase-negative
staphylococci (CNS),
streptococci, enteric Gram-negative bacilli |
topical drops (parenteral antibiotics do not penetrate the aqueous
or vitreous humour adequately) + cefazoline
100mg subconjunctivally at end of operation |
|
| neurosurgery : | |||
| election cholecystectomy (videolaparoscopy) | Enterobacteriaceae
(Escherichia coli,
Klebsiella
spp.,
Enterobacter
spp.,
Proteus
spp.)
Enterococcus spp.
Clostridium spp.
Bacterioides fragilis |
ureidopenicillins :
amoxicillin/clavulanate
(clavamox)
first-generation cephalosporins : second-generation cephalosporins : |
i.v. (bolus or small infusion) |
| election cholecystectomy (abdominal route) | Enterobacteriaceae
(Escherichia coli,
Klebsiella
spp.,
Enterobacter
spp.,
Proteus
spp.)
Enterococcus spp.
Clostridium spp.
Bacterioides fragilis |
ureidopenicillins :
amoxicillin/clavulanate
(clavamox)
first-generation cephalosporins : second-generation cephalosporins : |
i.v. (bolus or small infusion) |
| complicated cholecystectomy (pregressed cholecystitis/empyema) | Enterobacteriaceae
(Escherichia coli,
Klebsiella
spp.,
Enterobacter
spp.,
Proteus
spp.)
Enterococcus spp.
Clostridium spp.
Bacterioides fragilis |
ureidopenicillins :
amoxicillin/clavulanate
(clavamox)
first-generation cephalosporins : second-generation cephalosporins : |
i.v. (bolus or small infusion) |
| choledocholithiasis
without jaundice |
Enterobacteriaceae
(Escherichia coli,
Klebsiella
spp.,
Enterobacter
spp.,
Proteus
spp.)
Enterococcus spp.
Clostridium spp.
Bacterioides fragilis |
ureidopenicillins :
amoxicillin/clavulanate
(clavamox)
first-generation cephalosporins : second-generation cephalosporins : |
i.v. (bolus or small infusion) |
| obstruction
jaundice |
Enterobacteriaceae
(Escherichia coli,
Klebsiella
spp.,
Enterobacter
spp.,
Proteus
spp.)
Enterococcus spp.
Clostridium spp.
Bacterioides fragilis |
ureidopenicillins :
amoxicillin/clavulanate
(clavamox)
first-generation cephalosporins : second-generation cephalosporins : |
i.v. (bolus or small infusion) |
| external biliary drainage | Enterobacteriaceae
(Escherichia coli,
Klebsiella
spp.,
Enterobacter
spp.,
Proteus
spp.)
Enterococcus spp.
Clostridium spp.
Bacterioides fragilis |
ureidopenicillins :
amoxicillin/clavulanate
(clavamox)
first-generation cephalosporins : second-generation cephalosporins : |
i.v. (bolus or small infusion) |
| election operations on stomach, duodenum and small bowel | Staphylococcus spp.
Streptococcus spp.
Enterococcus spp.
Escherichia coli
Proteus spp.
gram-positive and gram-negative anaerobes (Peptostreptococcus spp. ,
Bacteroides spp. ) |
ureidopenicillins :
amoxicillin/clavulanate
(clavamox)
first-generation cephalosporins : second-generation cephalosporins : |
i.v. (bolus or small infusion) |
| operations on colon (total colectomy, hemicolectomy, transversectomy, segmentary resection, etc.) | Bacteroides spp.
Escherichia coli
Enterobacteriaceae
(Escherichia coli,
Klebsiella
spp.,
Enterobacter
spp.,
Proteus
spp.) |
ureidopenicillins :
amoxicillin/clavulanate
(clavamox)
second-generation cephalosporins : clindamycin
+ gentamycin |
i.v. (bolus or small infusion) |
| ano-rectal surgery | Staphylococcus spp.
Streptococcus spp.
Enterobacteriaceae
(Escherichia coli,
Klebsiella
spp.,
Enterobacter
spp.,
Proteus
spp.)
anaerobes |
amoxicillin/clavulanate
(clavamox)
first-generation cephalosporins : vancomycin
and teicoplanin
if MRSA
> 50% |
i.v. (bolus or small infusion) |
| election appendicectomy | i.v. (bolus or small infusion) | ||
| diverticulosis |
i.v. (bolus or small infusion) | ||
obstetric-gynecological surgery : antibiotic
prophylaxis is recommended but local policy makers may identify exceptions
in:
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Enterobacteriaceae,
Bacteroides
spp.
(including Bacterioides
fragilis),
Enterococcus
spp. |
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urology :
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vascular surgery : antibiotic prophylaxis
is recommended in:
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general surgery
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orthopaedic surgery
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Staphylococcus
aureus,
coagulase-negative
staphylococci (CNS)
Less commonly enteric Gram- negative bacilli and Clostridium |
cephazolin 1g iv or
cefamandole 2g iv or cefuroxime 1.5g iv or vancomycin 1g iv (where MRSA infections are common or patient is allergic to ß-lactam antibiotics) |
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| major lacerations, > 4 hours and untreated | S. aureus
Streptococci Gram-negative bacilli |
Amoxycillin/clavulanic acid 1.2g iv
then 500mg orally q6-8h or cefoxitin 1g iv q6-8h |
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| extensive soft tissue injury, penetrating wounds or crush injuries | anaerobes | cefotetan 1g iv q12h | |
| animal or human bites | as above plus :
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as above | |
| ruptured, perforated or gangrenous viscus | as for colorectal surgery | as for colorectal surgery but treat for at least 3 days |
may result in functional menomation, e.g. :
and hemodialysis
occurs in 25% of election surgery (severe ARF in 0.4-7.5% of cardiosurgery
(cardiopathy, arterial hypotension, and hemolysis secondary to extracorporeal
circulation), 0.6% of general surgery; higher in surgery for obstructive
jaundice (due to increased intestinal endotoxin resorption) and abdominal
aortic aneurysm (renal ischemia during supraaortic clamping)). Mortality
= 60% when requiring hemodialysis. Patients with renovascular disease (<5%)
don't recover function.
or thoracoscope,
transanal, tranesophageal, and transgastric surgery) and high-definition
microcamera (which allow better vision of operatory field than open surgery!),
thereby reducing pain, blood loss, wound complications (hernias) hospital
stay (faster recovery of respiratory and intestinal functions), infections
and overall cost of an operation.
assisted surgery (LAP)
,
sexile polyps, early-stage carcinomas. Colorectal end-to-end anastomosis
via endorectal route with mechanical circular stapler
assisted surgeryref
and wound repair
and coagulopathies
and dysmetabolism
in the surgical patient
of the surgical patient.
It without the use of drugs in patients with congestive heart failure
and atrial fibrillation significantly improve cardiac function, symptoms,
exercise capacity, and quality of liferef.
Based on the success of surgical approaches to AF, several catheter ablation
strategies have been designed to produce similar effectsref1,
ref2,
ref3.
Ablation strategies limited to the RA produce marginal improvementref,
whereas linear ablation in the LA has been more successful. The recognition
that foci triggering AF often originate within the pulmonary veins has
led to ablation strategies that target this zone or electrically isolate
the pulmonary vein from the LA. Other sites of arrhythmogenic foci have
been found in the superior vena cava, the RA and LA, and the coronary sinus.
Ablation of these foci eliminates or reduces the frequency of recurrent
AF in more than 60% of patients, but the risk of recurrent AF after a focal
ablation procedure is still 30% to 50% over the first year and even higher
when more than 1 pulmonary vein is involved. Thus, many patients continue
to require antiarrhythmic drug therapy after ablative therapy of AFref.
Potential complications of catheter ablation for AF include systemic embolism,
pulmonary vein stenosis, pericardial effusion, cardiac tamponade, and phrenic
nerve paralysis. Thus, although these procedures have produced promising
results, they have not yet been widely applied. Atrial flutter can develop
not only as a distinct arrhythmia but also during antiarrhythmic drug therapy
of AF, especially with type IC agents. Catheter ablation is more effective
than antiarrhythmic drugs for treatment of atrial flutter, reducing the
recurrence rate from 93% to 5% when used as first-line therapyref.
In addition, the risk of developing AF might also be lower after catheter
ablation of atrial flutter than with pharmacological therapy (29% vs 60%
over the first year).,
removal of the tumor alone by direct incision of the tumor capsule; of
diagnostic value only since it leaves some gross tumor intact.,
removal of the entire anatomic compartment containing the tumor, as well
as the origins and insertions of all muscles, bones, and joints contained
in the compartment; frequently it involves the amputation of a limb.
rejection or anthracycline-induced cardiotoxicity, and sometimes in diagnosing
myocarditis, cardiomyopathy, or infiltrative diseases. Side effects : damage
of tricuspid valve
stained film
for haemosiderin| Indications |
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| investigation of unexplained microcytic
anemia
: misdiagnosis of anaemia of chronic disease as iron deficiency is common
and it is not infrequent for such patients to be subjected to an extensive
search for a source of blood loss without a firmly based diagnosis of iron
deficiency. If results of biochemical assays are equivocal it is important
to perform a bone marrow aspirate to ensure an accurate diagnosis before
embarking on other investigations. |
only if myelodysplastic syndrome
is suspected |
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| investigation of unexplained megaloblastic
anemia
: it is acceptable to omit bone marrow examination if the peripheral blood
features are totally typical and if assays of vitamin B12 and
folic acid are suggestive of a deficiency state. Otherwise, bone marrow
aspiration is still indicated. If the diagnosis does not appear straightforward,
or if the patient requires urgent treatment and haematinic assays are not
available, bone marrow aspiration is indicated. |
only if myelodysplastic syndrome
is suspected |
deoxyuridine suppression test may be useful but is mainly a research technique |
| investigation of unexplained anaemia |
usually | cytogenetic analysis if MDS is suspected; ultrastructural examination if congenital dyserythropoietic anaemia is suspected |
| investigation of unexplained thrombocytopenia |
only if myelodysplastic syndrome
is suspected |
|
| investigation of pancytopenia
(including suspected aplastic anaemia) |
yes | cytogenetic analysis if MDS is suspected; appropriate culture if mycobacterial infection or leishmaniasis is suspected; bone marrow is a useful source of DNA if investigation for Pearson's syndrome is required; cytogenetic analysis if a haemophagocytic syndrome is suspected (because EBV-related haemophagocytic syndrome may be associated with a clonal proliferation of neoplastic T cells) |
| investigation of a leucoerythroblastic blood film and suspected bone marrow infiltration | yes | cytogenetic analysis if a haematological neoplasm is suspected; if an abnormal infiltrate is found, immunophenotyping and cytogenetic analysis may be useful; cytogenetic analysis is indicated if a small cell tumour of childhood is suspected because the demonstration of certain specific cytogenetic abnormalities can confirm the diagnosis |
| investigation of suspected acute leukaemia : although it is often possible to establish a diagnosis of acute leukaemia from peripheral blood examination, bone marrow aspiration should nevertheless be carried out. This is both because the likelihood of successful cytogenetic analysis is higher if bone marrow cells are used and because a baseline is needed for comparison with bone marrow aspirates performed during treatment. In addition, bone marrow aspiration permits the assessment of trilineage dysplasia, which may be of prognostic relevance. | no (unless there is difficulty obtaining a good aspirate) | cytogenetic and possibly molecular genetic analysis; immunophenotypic analysis unless cells are clearly myeloid |
| assessment of remission status after treatment of acute leukaemia | no (unless there is difficulty obtaining a good aspirate) | follow up cytogenetic analysis is only occasionally useful; molecular genetic analysis may be indicated for assessment of minimal residual disease |
| investigation of suspected myelodysplastic
syndromes/
myeloproliferative
disorders |
yes | cytogenetic analysis; investigation of colony forming units if juvenile myelomonocytic leukaemia is suspected |
| investigation of suspected chronic
myeloid leukaemia
: usually offers little diagnostically useful information beyond that which
can be gleaned from a careful examination of the peripheral blood. However,
as for the acute leukaemias, cytogenetic analysis is more often
successful when performed on the bone marrow and aspiration is therefore
indicated for this purpose |
no (unless there is difficulty obtaining a good aspirate or if the accelerated phase of the disease or blast transformation is suspected) | cytogenetic analysis; molecular genetic analysis is not indicated because it can be performed, when necessary, on peripheral blood cells |
| follow up of chronic
myeloid leukaemia |
no | cytogenetic analysis |
| investigation of suspected myeloproliferative
disorders
(polycythaemia rubra vera, essential thrombocythaemia, idiopathic myelofibrosis,
or systemic mastocytosis) |
yes | cytogenetic analysis; investigation of colony forming units (erythropoietin independent burst forming units) may be useful but in most centres is not a routine diagnostic test |
| investigation of chronic lymphocytic
leukaemia
: the diagnosis of chronic lymphocytic leukaemia can usually be made without
difficulty from the peripheral blood features and the immunophenotype.
A bone marrow aspirate is therefore not essential in patients with early
stage disease, particularly in elderly patients in whom treatment may never
become necessary. Bone marrow assessment is indicated before treatment
is undertaken |
yes because the bone marrow aspirate gives very little information beyond that already available from examination of the blood, while BMTB permits an accurate assessment of the extent of infiltration and gives information of prognostic importance. During follow up of intensive treatment of CLL there is little point in performing a bone marrow aspirate alone because there may be residual disease detectable only by trephine biopsy. | immunophenotyping is not indicated because it can be performed easily on the peripheral blood |
| investigation of suspected non-Hodgkin's
lymphoma
: diagnosis of non-Hodgkin's lymphoma is usually based on a lymph node
biopsy. However, in patients with bone marrow involvement, diagnosis can
be reliably based on cytology, immunophenotyping, and the pattern of bone
marrow infiltration. When there are circulating lymphoma cells, immunophenotyping
can be performed on the peripheral blood and the bone marrow aspirate is
of little importance. The trephine biopsy is much more important because
it permits an assessment of the pattern and extent of infiltration, which
is of both diagnostic and prognostic relevance, and may demonstrate lymphoma
when no abnormal cells have been detected in the blood or the bone marrow
aspirate. However, if circulating lymphoma cells are not present, the detailed
immunophenotyping that is possible on cells in a bone marrow aspirate can
help in both diagnosis and classification of NHL |
yes | if an abnormal infiltrate is present, immunophenotyping, molecular analysis and cytogenetic analysis may be needed |
| diagnosis and follow up of hairy
cell leukaemia |
yes | immunophenotyping, unless there are sufficient circulating cells for it to be performed on peripheral blood cells; tartrate resistant acid phosphatase stain if detailed immunophenotyping is not available |
| staging of low grade non-Hodgkin's
lymphoma
(if the results of investigation will alter management) |
yes. A bone marrow biopsy performed in patients with low grade lymphoma sometimes shows unexpected high grade transformation, which necessitates a different therapeutic approach. | immunophenotyping, unless there are sufficient circulating cells for this to be done on blood cells; cytogenetic and molecular genetic analyses are sometimes useful if the specific type of NHL has not already been determined |
| staging of high grade non-Hodgkin's
lymphoma
(in those cases where results of the investigation will alter management) |
yes | |
| investigation of
(indicated)
(controversial). If such patients are referred to a haematologist then
a bone marrow aspirate is often performed. However, it should be remembered
that at least 1% of patients over the age of 60 years have a paraprotein
and over the age of 70 years the figure rises to 3%. Furthermore, investigation
of serum immunoglobulins is often performed without a clear clinical indication.
It seems reasonable not to perform a bone marrow examination if a low concentration
paraprotein has been detected almost incidentally in a patient who does
not have anaemia, bone pain, hypercalcaemia, or other relevant clinical
features. A crush preparation of bone marrow fragments is useful |
generally indicated. Because infiltration is often focal, it is sometimes essential for a diagnosis. In other patients it provides a baseline for comparison with follow up biopsies | cytogenetic analysis may be useful because demonstration of poor prognosis abnormalities may influence management; immunophenotyping is only needed if cytology of the aspirate is not diagnostic and if it is not certain whether or not a monoclonal plasma cell population is present |
| investigations of suspected storage
disease |
not essential | |
| investigation of fever
of unknown origin (FUO) |
yes | cultures for mycobacteria and also, if there is a possibility of previous exposure, for Leishmania and Histoplasma |
| in suspected chromosomal disorders in neonates when rapid confirmation is required | no | cytogenetic analysis (may produce results in 1 day cf. several days if cultured peripheral blood lymphocytes are used) |
| confirmation of normal bone marrow if bone marrow is being aspirated
for allogeneic HSCT |
no | |
| autoimmune
thrombocytopenic purpura (AITP)
: some controversy surrounds the role of bone marrow aspiration in suspected
AITP. In children, the American Society of Haematology (ASH) guidelines
suggest that bone marrow aspiration is not usually neededref.
The guidelines of the British Paediatric Haematology Group recommend bone
marrow examination for children whose disease does not remit within 2-3
weeks or if treatment, especially with corticosteroids, is plannedref.
The consensus has swung against BMAB provided the history and the clinical
picture is entirely typical of acute onset ITP and the peripheral blood
is entirely normal apart from profound and isolated thrombocytopenia. However,
the threshold for marrow examination should be low if there is the slightest
clinical doubtref.
is suspected, a trephine biopsy is also needed. American practice appears
to differ somewhat from that in the UK, with the ASH guidelines suggesting
bone marrow aspiration only in patients above the age of 60 yearsref. |
—because
the guard cannot slip during the procedure. A needle with a guard secured
by a side screw—for example a
Salah
needle—is
less satisfactory because the guard can slip, allowing the needle to penetrate
further than was intended. Occasionally, in a very obese patient, it is
necessary to use a needle-cannula for anesthesia and a trephine biopsy
needle, which is generally longer than an aspiration needle, to obtain
an aspirate from the iliac crest.
and in elderly patients who may have osteoporosis;
inadvertent penetration through the sternum is more likely in these patients
if the needle guard is not set correctly or if a needle with an insecure
guard is used