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Revista de la Facultad de Medicina Humana
versión impresa ISSN 1814-5469versión On-line ISSN 2308-0531
Rev. Fac. Med. Hum. vol.23 no.3 Lima jul./set. 2023 Epub 21-Sep-2023
http://dx.doi.org/10.25176/rfmh.v23i3.5906
Original Article
Antiseptics solutions in the prevention of surgical wound infection on patients operated by complicated acute appendicitis
1Health Education and Research Directorate, High Specialty Medical Unit, Hospital de Especialidades de Puebla, “Gral. de Div. Manuel Ávila Camacho” National Medical Center, Instituto Mexicano del Seguro Social, Puebla, Mexico.
2General Surgery, Hospital General de Zona No 20, Delegation Puebla, Instituto Mexicano del Seguro Social, Puebla, Mexico.
3Medical-Surgical Emergency Department, Hospital General de Zona No 20, Delegation Puebla, Instituto Mexicano del Seguro Social, Puebla, Mexico.
4Division of Special Health Projects, Instituto Mexicano del Seguro Social, Ciudad de México, Mexico.
Objective:
The objective was to compare Dakin and Superoxidative solutions in preventing surgical wound infections in patients with complicated acute appendicitis.
Methods:
Comparative, cross-sectional study of 104 patients with complicated acute appendicitis (Average age: 36.29 years, 69 (66.43%) men). Group-1: 52 patients, with surgical wound wash using modified Dakin's solution. Group-2: 52 patients with superoxidative solution (Microdacyn®). Ceftriaxone 1 gr was administered before surgery, conventional appendectomy was performed, and the wall was closed with Vicryl-1 and Nylon-2/0. The surgical wound was evaluated 7 days after the operation, noting the presence of pus, edema, erythema, and local heat. Chi-squared (X2) and Student's t-tests were used.
Results:
Surgical wound infection occurred in 11 (10.6%) patients; 3 (5.8%) patients from Group-1 and 8 (15.4%) from Group-2 (p=0.1).
Conclusion:
Both solutions are useful in preventing surgical wound infections in patients with complicated acute appendicitis.
Keywords: Appendicitis; Infections; Surgical Wound; Local Antiseptics; Sterilizing Agents
INTRODUCTION
Appendectomy is the most common emergency surgical procedure worldwide; delayed diagnosis increases its complications, which range from seromas, wound dehiscence, intra-abdominal abscesses, surgical wound infection (SWI), peritonitis, to septicemia and/or death1-4.
SWIs are the second leading cause of healthcare-associated infections in hospitalized patients, accounting for up to 20% of all such infections4. They occur in 4% of clean wounds and in 35% of contaminated wounds5.
SWI following appendectomy impacts the patient's disease progression5and is associated with increased mortality4. Phase IV of acute appendicitis, compared to non-complicated phases of acute appendicitis, has a higher risk of presenting SWI6.
The type of surgical approach does not reduce the frequency of SWI; the open approach has a higher frequency of parietal SWI, and the laparoscopic approach of organ and/or space infection7,8.
Prevention of SWI includes various techniques such as the use of antimicrobials, skin asepsis and antisepsis, to solutions for irrigation with or without antiseptics9.
Antiseptic solutions are used to reduce the frequency of SWIs. Broad-spectrum antimicrobial solutions and so-called superoxidative solutions are alternatives to saline solution and/or iodine solutions (iodine, iodopovidone, which can cause irritation or allergy)10-14. The Dakin solution has variable results when compared with other antiseptics15.
The aim was to compare the results of using modified Dakin solution vs superoxidative solution in preventing SWI in patients undergoing conventional surgery for phase IV acute appendicitis.
MATERIALS AND METHODS
Design and Study Area
A comparative and cross-sectional clinical study conducted in a Secondary Level Medical Care Hospital in Puebla, Mexico.
Population and Sample
Through non-probabilistic convenience sampling, all patients with complicated acute appendicitis - Phase IV operated on by conventional surgery, over 18 years of age, with complete clinical follow-up, were included if they agreed to participate in the study by filling out and signing an informed consent. Phase IV of acute appendicitis is understood to be when the intraoperative finding was appendicular necrosis-perforation with local abscess, generalized peritonitis, or multiple intraperitoneal abscesses6.
Inclusion and exclusion criteria Patients with concomitant immunosuppressive pathologies such as diabetes mellitus, rheumatic diseases, etc., were excluded. Those who chose to leave the study or did not complete the information for any other reason were eliminated.
Procedures
The assignment of the antiseptic solution was done using a table of random numbers, balanced every 10 patients.
Group 1 consisted of patients treated with Dakin solution.
Group 2 consisted of patients treated with superoxidative solution.
The physical appearance of both solutions is the same, so during the application, the surgical team was unaware of which solution was being applied.
Surgical Technique
All patients underwent a right paramedian approach (Jalaguier-Battle). Once access to the abdominal cavity was achieved, the cecal appendix was located, the mesoappendix was ligated with vicryl 2-0, appendectomy was performed by ligating the base of the cecal appendix with free silk 2-0, and the base was invaginated with a purse string suture using chromic catgut 2-0. The purulent material found was aspirated and subsequently washed with saline solution. It was aspirated and dried with gauze. A Penrose-type drain was then placed, brought out through a counter-opening, and the abdominal wall was closed in layers until the aponeurosis (standard technique,16-18). Once the aponeurosis was closed, the wound was irrigated with either Dakin or superoxidative solution. The wound was dried, and the subcutaneous tissue was sutured with separate stitches using vicryl 2-0 and the skin with simple Sarnoff-type stitches.
Antiseptic Solutions
The superoxidative solution contains hypochlorite (35.7 mg/L), hypochlorous acid (25.2 mg/L), sodium chloride (110.6 mg/L), and hydrogen peroxide (999.8 g/L). It has a pH of 6.2-7.8 and an osmolarity of 13 mOsm/kg. It is processed by electrolysis, allowing it to form reactive species of oxygen and chlorine. It does not induce cytotoxicity in fibroblasts and, therefore, does not interfere with the healing process19,20.
The modified Dakin solution (MDS) contains 0.025% to 0.25% sodium hypochlorite mixed with 5% sodium bicarbonate in equal parts. Concentrations below 0.025% lose their bactericidal effect, and concentrations above 0.25% are toxic to tissues. The solution also promotes wound healing by increasing the strength in epithelial junctions without damaging tissues21-22. The Modified Dakin Solution was used at 0.05%, prepared with 5 milliliters of 6% sodium hypochlorite (commercial bleach), one liter of 0.9% saline solution, and one ampule of bicarbonate.
Pharmacological Management
All patients in both groups received antimicrobial prophylaxis with 1g intravenous ceftriaxone 30 minutes before surgery, according to the current Clinical Practice Guide for acute appendicitis16. From the immediate postoperative period, the antibiotic regimen was continued with ceftriaxone 1g IV every 12 hours and metronidazole 500 mg IV every 8 hours. In cases of suspected generalized peritonitis, amikacin 500 mg IV every 12 hours was added. This regimen was maintained for 5 days, and at the end, patients were discharged to continue outpatient care with oral ciprofloxacin 500 mg every 12 hours, with follow-up in outpatient consultation. For analgesia, 30 mg of Ketorolac was used, diluted in 100 ml of 0.9% saline solution every 6 hours, and if the pain persisted, 1g of metamizole in 100 ml of 0.9% saline solution was administered every 8 hours. This analgesic regimen was maintained until hospital discharge. The wound's progress was monitored for pus discharge, edema, erythema, and heat 7 days after surgery. Surgical wound infection (SWI) was considered with the presence of at least one of these signs or symptoms.
Statistical Analysis
Descriptive statistics, Chi-square (X2), and Student's t-test for independent samples were used. A p-value of ≤0.05 was considered statistically significant.
Ethical Aspects
This study was approved by the Local Research Committee of the participating medical unit of the Instituto Mexicano del Seguro Social, with the registration number: R-2019-2106-023. Patients signed an informed consent form, and the anonymity of the participants was preserved at all times.
RESULTS
104 patients were recruited; the average age was 36.29 (18 to 70) ± 12.56 years; the age group of 21 to 30 years predominated with 46 (44.23%) patients; 69 (66.43%) patients were men, and 35 (33.65%) were women. In 11 (10.6%) patients, surgical wound infection occurred. (See table No. 1)
Group 1: Thirty-six (69.23%) patients were men and 16 (30.77%) women. The average age was 43 (18 to 66) ± 12.17 years. In 3 (5.8%) patients, surgical wound infection occurred, manifested by purulent discharge in all, edema in 2 (66%), erythema in 1 (33%), and local heat in 1 (33%).
Group 2: Thirty-three (63.46%) patients were men and 19 (36.54%) women. The average age was 47.5 (21 to 70) ± 12.11 years. In 8 (15%) patients, surgical wound infection occurred. All had purulent discharge, 3 (37.5%) had edema, 3 (37.5%) had erythema, and 5 (62.5%) had local heat.
The presence of surgical wound infection by group, as well as the sociodemographic data, signs, and symptoms evaluated in the SWI, are shown in table I. There was no statistically significant difference in the presentation of SWI for any of these signs and symptoms in both groups. The difference in the presentation of surgical wound infection by patient group is shown in table II, which was representative, but in reference to the presence of infection in both cases, there was no statistically significant difference between both groups, p=0.1.
Table 1. Comparison of patient groups, sociodemographic data, and clinical manifestations evaluated in surgical wound infection.
| Sociodemographic data and clinical manifestations | Group 1 SWI | Group 2 SWI | ||
| Data and clinic | + | - | + | - |
| Male p = 0.18 | 2 | 34 | 5 | 28 |
| Female p = 0.37 | 1 | 15 | 3 | 16 |
| Purulent discharge p = 0.11 | 3 | 49 | 8 | 44 |
| Edema p = 0.64 | 2 | 50 | 3 | 49 |
| Erythema p = 0.30 | 1 | 51 | 3 | 49 |
| Local heat p = 0.09 | 1 | 51 | 5 | 47 |
| Abbreviations: SWI = surgical wound infection, + = present, - = absent p = statistical significance | ||||
DISCUSSION
Acute appendicitis phase IV, compared to uncomplicated acute appendicitis, has a higher likelihood of complications. These complications include the presence of seroma, wound dehiscence, intra-abdominal abscesses, peritonitis, and even septicemia; the most frequent is surgical wound infection (SWI). SWI occurs in up to 20% of hospitalized patients, 35% in contaminated wounds, which hinders patient recovery. There are various mechanisms to prevent these infections, including the use of antibiotics administered before, during, and after surgery, proper hand hygiene of personnel involved in patient care, implementing an appropriate surgical protocol, and rinsing the surgical wound with antiseptic solutions such as chlorhexidine, povidone-iodine, superoxidative solutions, and Modified Dakin's Solution. In this study, which included 104 patients, an average age of 36 ±12 years for the presentation of acute appendicitis phase IV was obtained. This data agrees with what is reported in global literature, where the presentation age for acute appendicitis is 18 to 35 years2. The percentage of patients by gender with acute appendicitis phase IV was 66.34% in men and 33.65% in women. This data also matches what is reported in global literature, which states that the incidence is higher in men compared to women at a 2:1 ratio2,3. Regarding SWI occurrence, 10.6% of patients suffered it. This percentage is lower compared to the global literature, in patients without the application of antiseptic solutions, which indicates that SWI occurs in up to 35% of wounds5. It is likely that the use of antiseptic solutions contributes to this decrease in SWI. On the other hand, regarding the clinical data evaluated in SWI, the most frequent was pus discharge, which occurred in all SWIs, followed by local heat and swelling, which occurred in 54.54% and 45.45% respectively of the infected wounds. This matches literature where SWI manifests with the presence of pus, swelling, erythema, and local heat5. Although it was searched in the literature, we did not find the frequency of each of these manifestations in patients. SWI occurred in 5.8% and 15.4% of patients in group 1 and 2 respectively, without statistically significant differences (p≥0.05) between both groups, implying that both solutions offer good outcomes for surgical wound management in patients undergoing appendectomy for complicated acute appendicitis or phase IV. With these results, it is suggested to conduct comparative studies with populations that are not washed with any of these solutions to further define their importance. Therefore, not having made this comparison can be considered a weakness of this study.
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8Article published by the Journal of the faculty of Human Medicine of the Ricardo Palma University. It is an open access article, distributed under the terms of the Creatvie Commons license: Creative Commons Attribution 4.0 International, CC BY 4.0 (https://creativecommons.org/licenses/by/1.0/), that allows non-commercial use, distribution and reproduction in any medium, provided that the original work is duly cited. For commercial use, please contact revista.medicina@urp.edu.pe.
Received: March 08, 2022; Accepted: June 02, 2022
Este es un artículo publicado en acceso abierto bajo una licencia Creative Commons
