What are the strategies to prevent surgical site hematomas and infection after below-knee amputation (BKA)?

From the Guidelines

To prevent surgical site hematomas and infection after below knee amputation, meticulous hemostasis during surgery, proper wound closure techniques, and postoperative care are essential, including the administration of prophylactic antibiotics, such as cefazolin 1-2g IV within 60 minutes before incision, as recommended by recent guidelines 1.

Key Considerations

• Meticulous hemostasis during surgery is crucial to prevent hematoma formation, and this can be achieved by carefully ligating all major vessels, using electrocautery for smaller bleeding points, and considering topical hemostatic agents when needed.
• Proper wound closure techniques, including the use of monofilament suture for closure of the subcuticular layer, can help avoid superficial postoperative cellulitis.
• Postoperative care should include the application of a compressive dressing to the residual limb, with consideration of rigid dressings or immediate post-operative prosthetics to provide uniform compression, as well as elevation of the residual limb above heart level for the first 24-48 hours to reduce edema and prevent hematoma formation.
• Prophylactic antibiotics should be administered, typically cefazolin 1-2g IV within 60 minutes before incision and continued for 24 hours after surgery, with alternative options such as vancomycin 15mg/kg IV for patients with MRSA risk or penicillin allergy.
• Proper wound care includes keeping the surgical site clean and dry, changing dressings as directed, and monitoring for signs of infection such as increasing pain, redness, warmth, drainage, or fever.

Additional Measures

• Early mobilization with physical therapy should begin within 24-48 hours after surgery to improve circulation and prevent complications.
• Blood glucose control for diabetic patients (maintaining levels below 180 mg/dL) and smoking cessation are crucial as they significantly impact wound healing and infection risk.
• The use of care bundles that include topical intranasal therapies, depilation protocols, and appropriate timing and stewardship of perioperative prophylactic antibiotics, combined with smoking cessation, adequate glycemic control, and promotion of postoperative normothermia during recovery, can help reduce surgical site infections, as suggested by moderate-quality meta-analysis 1.

From the Research

Preventing Surgical Site Hematomas and Infection after Below Knee Amputation

To prevent surgical site hematomas and infection after below knee amputation, several strategies can be employed:

• Antibiotic Prophylaxis: The use of appropriate antibiotic prophylaxis is crucial in preventing surgical site infections (SSIs) 2, 3, 4. Cefazolin and vancomycin are common choices for antimicrobial prophylaxis, with cefazolin being typically first-line due to its lower toxicity profile and specificity for gram-positives such as skin commensals.
• Hair Removal: Avoiding razors for hair removal and instead using clippers can reduce the risk of SSIs 5.
• Decolonization: Decolonization with intranasal antistaphylococcal agents and antistaphylococcal skin antiseptics can reduce the risk of SSIs, especially for high-risk procedures 5.
• Skin Preparation: Using chlorhexidine gluconate and alcohol-based skin preparation can reduce the risk of SSIs 5.
• Normothermia: Maintaining normothermia with active warming can reduce the risk of SSIs 5.
• Glycemic Control: Controlling perioperative glucose concentrations can reduce the risk of SSIs 5.
• Negative Pressure Wound Therapy: Using negative pressure wound therapy can reduce the risk of SSIs 5.
• Timing and Duration of Antibiotic Prophylaxis: Ensuring adequate, weight-adjusted dosing and early, preoperative delivery of prophylactic antibiotics may reduce the risk of SSIs, whereas the duration of prophylaxis beyond 24 hours is unnecessary 4.

Reducing the Risk of Surgical Site Infections

Several factors can reduce the risk of SSIs, including:

• Correct weight-adjusted dose of antibiotic prophylaxis 4
• Commencing preoperative cephalosporin within 60 minutes or longer prior to skin incision 4
• Avoiding non-cephalosporin antibiotics preoperatively 4
• Avoiding changing cephalosporin dose 4

Institutional Protocols

Institutions should consider their own investigations into local antibiograms, SSI rates, and choice of prophylaxis to develop effective protocols for preventing SSIs 2, 3. A uniform institutional protocol that employs the use of intravenous vancomycin and cefazolin as prophylactic agents may be effective in reducing revision procedures performed for SSI 3.