1. General & Vascular Surgery Wound Class Review & Quiz Bruce Ryon, RN, MS, PhD KPSF NSQIP SCNR bruce.r.ryon@kp.org 415-833-0987

2. Bruce Ryon, RN, MS, PhD Wound Class Review Defined by the CDC -Largely related to bacteria presence & activity

3. Bruce Ryon, RN, MS, PhD Wound Class Review Defined by the CDC -Largely related to bacteria presence & activity #1 - Clean -Any incision thru non-infected material NOT in major tracts

4. Bruce Ryon, RN, MS, PhD Wound Class Review Defined by the CDC -Largely related to bacteria presence & activity #1 - Clean -Any incision thru non-infected material NOT in major tracts #2 - Clean, Contaminated -Baseline in GI, respiratory, reproductive, urinary tracts

5. Bruce Ryon, RN, MS, PhD Wound Class Review Defined by the CDC -Largely related to bacteria presence & activity #1 - Clean -Any incision thru non-infected material NOT in major tracts #2 - Clean, Contaminated - Baseline in GI, respiratory, reproductive, urinary tracts #3 - Contaminated -Presence of contained acute inflammation (not chronic) -Dry, but not wet and active gangrene -Example: inflamed, non-perforated appendix

6. Bruce Ryon, RN, MS, PhD Wound Class Review Defined by the CDC -Largely related to bacteria presence & activity #1 - Clean -Any incision thru non-infected material NOT in major tracts #2 - Clean, Contaminated - Baseline in GI, respiratory, reproductive, urinary tracts #3 - Contaminated -Presence of contained inflammation -Dry, but not wet and active gangrene -Example: inflamed, non-perforated appendix #4 – Dirty/Infected -Incision into infected material -Spilled purulence or fecal material, wet gangrene -Example: perforated and inflamed appendix with presence of purulence outside of appendix

7. Bruce Ryon, RN, MS, PhD Wound Class Review Defined by the CDC -Largely related to bacteria presence & activity #1 - Clean -Any incision thru non-infected material NOT in major tracts #2 - Clean, Contaminated - Baseline in GI, respiratory, reproductive, urinary tracts #3 - Contaminated -Presence of contained inflammation -Dry, but not wet and active gangrene -Example: inflamed, non-perforated appendix #4 – Dirty/Infected -Incision into infected material -Spilled purulence or fecal material, wet gangrene -Example: perforated and inflamed appendix with presence of purulence outside of appendix

8. Baseline Procedures & Wound Class Non-tracts Orthopedics – 1 Breast – 1 Vascular – 1 Cardiovascular – 1 Plastics – 1 Hernia - 1 Tracts Head & Neck – 2 Thoracic (lung) - 2 OB/GYN – 2 Colorectal – 2 Hepatobiliary – 2 Urology – 2 Bruce Ryon, RN, MS, PhD

9. Wound Class Quiz 1 st Slide – actual KPSF cases –Scenario explained with choices –Circulator recording marked by *asterisk –Think about the baseline of the procedure –Then think about anything that would change that baseline 2 nd Slide –Shows the answer in multiple asterisks –Note on key or important criteria Bruce Ryon, RN, MS, PhD

10. What is the wound class? A patient under went a Whipple for cancer. Surgery included a cholecystectomy. Gallbladder was documented as having changes consistent with chronic cholecystitis. 1.Clean 2.Clean/contaminated *3.Contaminated 4.Dirty/Infected

11. Bruce Ryon, RN, MS, PhD What is the wound class? A patient under went a Whipple for cancer. Surgery included a cholecystectomy. Gallbladder was documented as having changes consistent with chronic cholecystitis. 1.Clean ******* 2.Clean/contaminated ******* 3.Contaminated 4.Dirty/Infected Note: Chronic inflammation would not bump it to a 3

12. Bruce Ryon, RN, MS, PhD What is the wound class? An 18 year old patient with extensive Crohns disease underwent a total colectomy with a colostomy. 1.Clean 2.Clean/contaminated *3.Contaminated 4.Dirty/Infected

13. Bruce Ryon, RN, MS, PhD What is the wound class? An 18 year old patient with extensive Crohns disease underwent a total colectomy with a colostomy. 1.Clean ******* 2.Clean/contaminated ******* 3.Contaminated 4.Dirty/Infected Note: Chronic inflammation would keep it at a 2 and not bump it to a 3

14. Bruce Ryon, RN, MS, PhD What is the wound class? Patient underwent a breast biopsy. The operative report noted multiple areas of fatty necrosis on the large mass. There was also necrotic tissue around the mass. 1.Clean 2.Clean/contaminated 3.Contaminated *4.Dirty/Infected

15. Bruce Ryon, RN, MS, PhD What is the wound class? Patient underwent a breast biopsy. The operative report noted multiple areas of fatty necrosis on the large mass. There was also necrotic tissue around the mass. 1.Clean 2.Clean/contaminated ******* 3.Contaminated ******* 4.Dirty/Infected Note: Necrotic, ischemic dead tissue, without infection is a 3

16. Bruce Ryon, RN, MS, PhD What is the wound class? Patient underwent laparoscopic appendectomy. The pre op CT scan reported the appendix contained a fecalith. There was no mention of infection, rupture or inflammation on the operative report. 1.Clean 2.Clean/contaminated *3.Contaminated 4.Dirty/Infected

17. Bruce Ryon, RN, MS, PhD What is the wound class? Patient underwent laparoscopic appendectomy. The preop CT scan reported the appendix contained a fecalith. There was no mention of infection, rupture or inflammation on the operative report. 1.Clean ******* 2.Clean/contaminated ******* 3.Contaminated 4.Dirty/Infected Note: Fecalith contained within GI tract w/o infection, inflammation is a 2

18. Bruce Ryon, RN, MS, PhD What is the wound class? Patient underwent a laparoscopic appendectomy. The operative report states “inflamed appendix without perforation”. *1.Clean 2.Clean/contaminated 3.Contaminated 4.Dirty/Infected

19. Bruce Ryon, RN, MS, PhD What is the wound class? Patient underwent a laparoscopic appendectomy. The operative report states “inflamed appendix without perforation”. 1.Clean 2.Clean/contaminated ******* 3.Contaminated ******** 4.Dirty/Infected Note: Acute inflammation is a 3

20. Bruce Ryon, RN, MS, PhD What is the wound class? Patient underwent a laparoscopic appendectomy. The operative report states “inflamed appendix without perforation with exudates”. 1.Clean 2.Clean/contaminated 3.Contaminated *4.Dirty/Infected

21. Bruce Ryon, RN, MS, PhD What is the wound class? Patient underwent a laparoscopic appendectomy. The operative report states “injected appendix without perforation with exudates”. 1.Clean 2.Clean/contaminated ******* 3.Contaminated ******* 4.Dirty/Infected Note: Exudates outside of non-perforated injected appendix is a 3

22. Bruce Ryon, RN, MS, PhD What is the wound class? Patient underwent a laparoscopic appendectomy. The operative report states “acute appendix with perforation”. 1.Clean *2.Clean/contaminated 3.Contaminated 4.Dirty/Infected

23. Bruce Ryon, RN, MS, PhD What is the wound class? Patient underwent a laparoscopic appendectomy. The operative report states “acute appendix with perforation”. 1.Clean 2.Clean/contaminated 3.Contaminated ******* 4.Dirty/Infected ******* Note: Perforated appendix assumes contents have spilled into abdominal cavity

24. Bruce Ryon, RN, MS, PhD What is the wound class? Patient underwent an exploratory laparoscopic for possible small bowel obstruction. The procedure performed was terminal ileum resection. The operative report states “necrotic cecum and appendix”. 1.Clean 2.Clean/contaminated 3.Contaminated * 4.Dirty/Infected

25. Bruce Ryon, RN, MS, PhD What is the wound class? Patient underwent an exploratory laparoscopic for possible small bowel obstruction. The procedure performed was a terminal ileum resection. The operative report states surgeon found a “necrotic cecum and appendix”. 1.Clean 2.Clean/contaminated ******* 3.Contaminated ******* 4.Dirty/Infected Note: Necrosis, ischemic dead tissue, is generally not infected

26. Bruce Ryon, RN, MS, PhD What is the wound class? With a patient in significant abdominal pain, a preop CT scan indicated patient had SBO (small bowl obstruction). An ex-lap was performed and adhesion lysis freed up a SBO. 1.Clean *2.Clean/contaminated 3.Contaminated 4.Dirty/Infected

27. Bruce Ryon, RN, MS, PhD What is the wound class? With a patient in significant abdominal pain, a preop CT scan indicated patient had SBO (small bowl obstruction). An ex-lap was performed and adhesion lysis freed up a SBO. ******* 1.Clean ******* 2.Clean/contaminated 3.Contaminated 4.Dirty/Infected Note: Bowel was never incised, therefore surgery is on par with hernia repair

28. Bruce Ryon, RN, MS, PhD What is the wound class? Patient had necrotic foot d/t complications from peripheral ischemia r/t 150 pack years of smoking. Surgeon performed below knee amputation where the incision was clean without infection. 1.Clean 2.Clean/contaminated 3.Contaminated *4.Dirty/Infected

29. Bruce Ryon, RN, MS, PhD What is the wound class? Patient had necrotic foot d/t complications from peripheral ischemia r/t 150 pack years of smoking. Surgeon performed below knee amputation where the incision was clean without infection. ******* 1.Clean ******** 2.Clean/contaminated 3.Contaminated 4.Dirty/Infected Note: Incision was in a clean area, therefore on par with ortho baseline surgery

30. Bruce Ryon, RN, MS, PhD What is the wound class? Long term diabetic patient had infected gangrenous below-the-knee-amputation stump after vascular grafts failed to improve leg perfusion. Surgeon performed above the knee amputation where the initial incision expressed lymphatic pus. AKA surgery successful. 1.Clean 2.Clean/contaminated *3.Contaminated 4.Dirty/Infected

31. Bruce Ryon, RN, MS, PhD What is the wound class? Long term diabetic patient had infected gangrenous below-the-knee-amputation stump after vascular grafts failed to improve leg perfusion. Surgeon performed above the knee amputation where the initial incision expressed lymphatic pus. AKA surgery successful. 1.Clean 2.Clean/contaminated 3.Contaminated ******* 4.Dirty/Infected ******* Note: Incision cut into infected material

32. Bruce Ryon, RN, MS, PhD What is the wound class? Patient underwent a rectopexy procedure (rectal prolapse) where a portion of the rectum was resected. The anastamosis was checked for patency/leaks by rigid sigimoidoscopy. 1.Clean 2.Clean/contaminated 3.Contaminated *4.Dirty/Infected

33. Bruce Ryon, RN, MS, PhD What is the wound class? Patient underwent a rectopexy procedure (rectal prolapse) where a portion of the rectum was resected. The anastamosis was checked for patency/leaks by rigid sigimoidoscopy. 1.Clean ******* 2.Clean/contaminated ******* 3.Contaminated 4.Dirty/Infected Note: Anal & rectum procedures are 2, unless infection present, e.g. abscess/fistula