Gentamicin

Use of tissue glue in circumcision

Pediatric Surgery International

October 2004

Circumcision is a common surgical procedure that involves surgical removal of the foreskin that covers the tip of the penis. Techniques for circumcision vary from excision without suturing to wound approximation with sutures and the use of tissue glue. The purpose of this prospective randomized study was to evaluate the advantages of glue versus sutures for circumcision in children. (1)

One hundred fifty-two boys scheduled for circumcision were randomly assigned to one of two groups. For participants in the suture group (n = 72), the mucosal cuff and the outer skin were approximated with interrupted sutures. For participants in the glue group (n = 80), similar approximation was achieved with single circumferential application of tissue glue. The time to approximation was recorded. Postoperatively, wound healing and comesis, scab formation, pain, and comfort level were assessed weekly by an independent observer and at two weeks after the surgery by the respective surgeon. Statistical procedures, including chi square and t tests, were used to analyze differences between the groups.

Findings. The mean time to wound approximation was significantly shorter for participants in the glue group (0.54 minutes; range 0.2-4.56) compared to participants in the suture group (3.34 minutes; range 2-11.5, P < .001). Additionally, pain duration and pain scores, as reported by the patients' parents, were significantly lower for participants in the glue group (P < .001). There were no allergic reactions to the tissue glue.

Clinical implications. This study revealed that operating time was significantly reduced when glue was used as opposed to sutures during circumcision, and patients experienced less pain. Use of tissue glue for circumcision most likely will increase. Perioperative nurses should be prepared to stock adequate supplies and assist surgeons using this technique.

Gentamicin-collagen implants

Journal of Hospital Injection

February 2005

Sternal wound infection after cardiac surgery continues to be one of the most serious postoperative complications because it invariably results in increased morbidity and mortality, prolonged hospital stay, and increased health care costs. The purpose of this randomized, controlled study was to determine the effects of locally administered gentamicin in preventing sternal wound infections after coronary artery bypass grafting (CABG) surgical procedures. (2)

During a 14-month period, 542 patients undergoing elective CABG procedures at a university hospital in Finland were randomly assigned to one of two groups. Participants in the study group (n = 272) received a 10 cm by 10 cm gentamicin-collagen implant containing 130 mg gentamicin and 280 mg collagen beneath the sternum before the incision was closed. For participants in the control group (n = 270), the incision was closed in a routine manner with steel wires and without a gentamicin-collagen implant. All patients received routine IV antimicrobial prophylaxis with cefuroxime. Patients who were hospitalized for three or more days before the surgical procedure received vancomycin in addition to antimicrobial prophylaxis with cefuroxime.

Patient characteristics, including age, gender, body mass index, underlying disease, duration of surgery, number of bypasses, and aortic cross-clamp time, were recorded. Patients were monitored daily for fever, wound discharge, and other evidence of sternal wound infection during their hospital stay and at three months after discharge. Diagnosis of sternal wound infection was established using criteria from the Centers for Disease Control and Prevention. Common statistical techniques, including logistic analysis techniques, were used to analyze differences between the groups.

Findings. Patient characteristics were comparable between the two groups. The sternal wound infection rate was not significantly different in the two groups (P = .470). Eleven patients (4%) who had the gentamicin-collagen implant and 16 patients (5.9%) in the control group developed sternal wound infections. No side effects related to the gentamicin-collagen implant were reported.

Clinical implications. This study suggests that gentamicin-collagen implants are safe, easy to use, and may be effective in preventing surgical site infections. The sternal wound infection rate was reduced slightly in patients who received the gentamicin-collagen implant compared to patients in the control group.

The authors note that this is the first study on the use of a gentamicin-collagen implant as prophylaxis in cardiac surgery and that additional studies with larger populations are warranted before conclusions can be drawn. Consequently, perioperative nurses should be prepared to assist in evaluating the use of gentamicin-collagen implants for preventing sternal wound infections after cardiac surgery.

Gentamicin prophytaxis in cardiac surgery

The Annals of Thoracic Surgery

January 2005

The administration of IV antimicrobial prophylaxis before incision has documented efficacy in reducing the potential for the development of surgical site infections after cardiac surgery. Antimicrobial prophylaxis generally is accomplished using cephalosporin or penicillin; however, coagulase-negative staphylococci, which are resistant to these antimicrobial agents, are emerging as the most common pathogen in surgical wound infections. Alternative approaches to preventing surgical wound infections, therefore, must be considered. The objective of this randomized, prospective, double-blinded study was to determine whether locally administered gentamicin in addition to routine IV prophylaxis with isoxazolyl penicillin could reduce the incidence of postoperative surgical wound infections after cardiac surgery. (3)

From October 2000 through August 2002, patients undergoing cardiac surgery through median sternotomy at two cardiothoracic centers in Sweden were randomly assigned to one of two groups. Participants in the treatment group (n = 983) received IV prophylaxis with isoxazolyl penicillin and sternal application of a 10 cm by 10 cm by 0.5 cm gentamicin-collagen sponge that contained 130 mg gentamicin and 280 mg collagen beneath the sternum before the incision was closed. Participants in the control group (n = 967) received only IV prophylaxis with isoxazolyl penicillin. The incision was closed in a routine manner without the gentamicin-collagen sponge.

Postoperatively, patients were assessed daily for surgical wound infection and serum creatine levels. After discharge, patients were assessed for the development of surgical wound infections. They were contacted by telephone two months postoperatively and asked to answer a structured list of standardized questions. Any reported symptoms of impaired wound healing or possible wound infection resulted in a review of the medical records from all postoperative contacts with medical services. Common statistical techniques were used to analyze differences between the two groups.

Findings. One hundred twenty-nine surgical wound infections were recorded. Significantly fewer patients in the treatment group received antibiotics or needed surgical revision of the sternal wound during the follow-up. Patients in the control group were significantly more likely to develop surgical site infection (9% versus 4.3%, relative risk 0.47, 95% confidence interval 0.33-0.68, P < .001). Twenty-four of the 129 surgical wound infections (ie, 17 in the control group and seven in the treatment group) were diagnosed before the patients were discharged. There were no cases of verified or suspected allergic or adverse reactions to gentamicin or collagen.

Clinical implications. This study found that the use of a gentamicin-collagen sponge underneath the sternum before the incision was closed was safe and was associated with a significantly lower incidence of surgical wound infection after cardiac surgery. Perioperative nurses should assess patients for gentamicin and collagen allergies when gentamicin-collagen sponges are scheduled to be used before the incision is closed.

Smoking cessation in patients with coronary heart disease

European Heart Journal

December 2004

Smoking cessation has clear beneficial effects on cardiovascular health and has emerged as a major component of cardiac rehabilitation programs; however, smoking continues to be prevalent among patients with newly diagnosed coronary heart disease. The objective of this study was to assess the impact of smoking and smoking cessation measured by self-report and by serum cotinine levels on the risk of secondary cardiovascular disease events during one-year follow-up in patients with acute coronary syndrome or coronary artery revascularization (ie, coronary artery bypass grafting, coronary angioplasty, stent implantation). (4)

Patients aged 30 to 70 years who were newly diagnosed with a coronary heart disease event and were participating in an inpatient rehabilitation program in one of two participating clinics in Germany were enrolled in the study (N = 1,006). All the patients were asked to fill out a standardized questionnaire containing questions on sociodemographic factors, smoking history, and medical history. Smoking status was classified into four categories:

1) never smoked,

2) former smoker,

3) recent quitter, and

4) continued smoker.

Additionally, before they were discharged from the clinic, a blood sample was drawn to determine cardiovascular risk factors, including total cholesterol and cotinine levels. Patients who had a cotinine level of [greater than or equal to] 15 ng/mL were classified as smokers. Follow-up assessment was conducted one year after discharge from the rehabilitation clinic using a standardized questionnaire that was mailed to patients. A similar standardized questionnaire was mailed to the patients' primary physicians to document physician-diagnosed cardiovascular disease events and treatments after discharge from the inpatient rehabilitation clinic. Common statistical techniques were used to analyze the data.

Findings. The analysis was completed on 967 patients. Subsequent cardiovascular disease events were observed in 139 of the patients (14.3%). A small number of patients (4.3%) self-reported as continued smokers at the beginning of rehabilitation. The occurrence of secondary cardiovascular disease events was strongly associated with smoking status (P value for trend = .002). According to the cotinine level at the end of rehabilitation, substantially more patients (13.4%) were classified as smokers. When only cotinine level was used as a marker of smoking status, the odds ratio for cardiovascular disease events was 0.59 (95% confidence interval 0.36-0.97), indicating a 40% risk reduction for patients who were nonsmokers compared to patients who were smokers.

Clinical implications. The results of this study clearly demonstrate the benefits of not smoking and smoking cessation in patients with coronary heart disease. Perioperative nurses can use these findings in their educational efforts when preparing patients for all types of surgical procedures.

NOTES

(1.) R Subramaniam, A S Jacobsen, "Sutureless circumcision: A prospective randomized controlled stud);" Pediatric Surgery International 20 (October 2004) 783-785.

(2.) A M Eklund, M Valtonen, W A Werkkala, "Prophylaxis of sternal wound infections with gentamicin-collagen implant: Randomized controlled study in cardiac surgery," Journal of Hospital Infection 59 (February 2005) 108-112.

(3.) O Friberg et al, "Local gentamicin reduces sternal wound infections after cardiac surgery: A randomized controlled trial," The Annals of Thoracic Surgery 79 (January 2005) 153-162.

(4.) D Twardella et al, "Short-term benefit of smoking cessation in patients with coronary heart disease: Estimates based on self-reported smoking data and serum cotinine measurements," European Heart Journal 25 (December 2004) 2101-2108.

GEORGE ALLEN

RN, PHD, CNOR, CIC

DIRECTOR OF INFECTION CONTROL

DOWNSTATE MEDICAL CENTER

BROOKLYN, NY

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