Gentamicin-loaded sponges; multimodal rehabilitation; nocardial endophthalmitis; acute-onset endophthalmitis

AORN Journal,  Nov, 2005  by George Allen

• E-mail
• Print
• Link

Gentamicin-loaded sponges in infected total hip arthroplasty

Acta Orthopaedica February 2005

Although prosthesis removal may be recommended for postoperative infection after total hip arthroplasty, several other treatment strategies are available. For early-onset postoperative deep hip prosthesis infection, a combination of debridement, suction-irrigation drainage, and the administration of high-dose antibiotics generally is effective if the treatment is started within 24 to 36 hours of the onset of signs of infection. Treatment involving surgical debridement, irrigation, retention of the prosthesis, and application of several gentamicin-loaded sponges also has been used for acute postoperative total hip arthroplasty infection. Aminoglycosides, including gentamicin, however, have a narrow therapeutic range, and gentamicin is known to produce systemic adverse effects, including ototoxicity, nephrotoxicity, and worsening of neuromuscular disorders. The purpose of this prospective study was to assess whether local application of gentamicin has a significant systemic effect. (1)

Twelve patients aged 54 to 83 years at a hospital in the Netherlands who presented with an acutely infected primary total hip arthroplasty and in whom it was believed that the prosthesis could be retained were evaluated systematically. A surgical debridement was performed, and cultures were collected. Pulse lavage was performed, and several 10-cm by 10-cm by 0.5-cm sponges containing approximately 130 mg gentamicin were introduced into the wound before it was closed. The manufacturer recommends that a maximum of five sponges be used in cases of osseous infections. Serum gentamicin levels were measured on the first postoperative day and on each consecutive day until gentamicin levels no longer were measurable. Additionally, creatinine clearance was calculated. Common statistical procedures were used to analyze the findings.

Findings. Eight women (mean age 72 years) and four men (mean age 68 years) participated in the study. Two-thirds of the patients were classified as American Society of Anesthesiologists physical status category two, and the remaining third was classified as category three. Four or five gentamicin sponges were used in 11 patients (92%), six sponges were used in one patient. Serum levels of gentamicin no longer could be measured after a mean of two days (range 2 to 10 days). Toxic levels of gentamicin (range 2 mg/L to 13 mg/L) were found in seven of the 12 patients (58%) one to 10 days after surgery. Additionally, three patients experienced a significant, persistent drop in renal clearance of more than two standard deviations from the baseline 1 mL per minute preoperative level in each patient.

Clinical implications. The findings of this study revealed that the local use of gentamicin sponges resulted in toxic serum gentamicin levels. Perioperative nurses should understand that gentamicin is excreted via the kidneys; consequently, patients with impaired renal function are at risk for adverse effects. Additionally, nurses should be familiar with the manufacturer's recommendation regarding the number of sponges that can safely be used and ensure that information is readily communicated to the surgeon and other members of the surgical team.

Multimodal rehabititation after colonic resection

Acute Pain May 2005

After abdominal surgical procedures, pain and ileus may contribute to morbidity, prolong hospital stay, and retard convalescence. Indeed, it is assumed that postoperative pain extends the period of ileus, resulting in an increased hospital stay. Epidural analgesia combined with local anesthetics and opioids attenuates ileus and is known to be an effective analgesic method after abdominal surgery. Its effect on postoperative morbidity and hospital length of stay, however, remains controversial.

It has been demonstrated that a multimodal rehabilitation program, including thoracic epidural analgesia, early mobilization and oral nutrition, and a planned 48-hour postoperative stay is feasible during a median hospital stay of two days after elective colonic surgery. The purpose of this prospective study was to evaluate initial postoperative pain intensity and the association with recovery of gastrointestinal function and length of stay in patients undergoing colonic resection and a standardized multimodal rehabilitation program. (2)

Researchers studied patients at a university hospital in Denmark undergoing elective open colonic resection under general anesthesia combined with thoracic epidural analgesia (N = 110). Postoperatively, epidural anesthesia was maintained for 48 hours with bupivacaine 2.5 mg/mL and morphine 50 mcg/mL at 4 mL per hour. Pain was assessed 24 and 48 hours after surgery using a categorical scale (ie, 0 = no pain, 1 = slight pain, 2 = moderate pain, 3 = severe pain). Additionally, time to first postoperative defecation and length of stay were documented. Common statistical techniques Including Chi square, Mann-Whitney U test, and analysis of variance were used to analyze the findings.