http://doi.org/10.33698/NRF0054 Sonali Banerjee, Jogindra Vati, Ramesh K. Sen, Pallab Ray
Experimental research is needed to create evidence based practice guidelines for pin site care to prevent pin site infection”.
Abstract: Evidence-based information is not available in literature regarding the success of various pin site care protocols due to inconsistencies in pin site care practices. The present study was undertaken with the objective to study the effect of two interventional protocol trails of pin site dressings among patients with external skeletal fixators admitted at Nehru Hospital, PGIMER, Chandigarh. Twenty seven patients with 184 pin site were studied during January- February 2006 and randomized into two experimental groups namely, experimental group I and experimental group II. Patients in experimental group I, comprised of 14 patients with 98 pin sites and were assigned type I protocol i.e. cleaning pin site with 3% hydrogen peroxide and dry gauze dressing. There were 13 patients with 86 pin sites and were assigned in experimental type II protocol i.e. cleaning pin site with betadin and betadin gauze dressing. Checketts and Otterburn’s definition was adopted to define pin site infection. On 7th day of interventions, 2(2.1%) pin sites had grade II infection when treated with type I protocol. Results with type II protocol revealed 38.4% pin sites had grade I infection, 7% had grade-II and 4.6% had grade- III infection. Acinetobacter anitratus was most predominant (40% in experimental group I and 33.7% in experimental group II ) causative organism for pin site infection. Comparison between both the groups in terms of prevention of pin site infection was found to be statistically significant. Cleaning pin site with 3% hydrogen peroxide and dry gauze dressing is highly effective.
Key words: Pin site infection, type I and type II pin site dressing protocol, prevention of infection.
Introduction
Fracture management has received increasing interest over the last 30 years due to the wide variety of fixator frames, larger and stronger pins, better metals and increased knowledge of techniques. When person sustains a fracture or has a surgery of a bone, external fixation is done. The implantation is done by a metallic device i.e. external skeletal fixator, by which pins and wires are inserted through the skin, the underlying tissue and the bone, above and below the fracture and surgery site. It secures fractured bone during healing process and allowing some degree of load bearing. Surgical implantation of external skeletal fixator pin represents a breach in the normal integumentary barrier and is a portal of entry for infection. Pin site infection is the most common complication. It is documented to be as high as 85% in the western countries and 71% 9including major and minor infection) in India. A common definition of pin site infection has not been accepted yet, which creates a problem in determining the prevalence of infection.
Checketts and Otterburn’s definition and classification is most commonly used to evaluate the pin site infection. According to this classification pin site infection is graded as shown in Table 1
Table 1: Checketts and Otterburn’s Grading System
| Grades of infection | Characteristics | Treatment |
| Grade-I | · Slight discharge
· Redness around the pins |
· Improved pin site care |
| Grade-II | · Redness of the surrounding skin
· Pain and tenderness in the soft tissue · Discharge of pus |
· Improved pin site care, oral antibiotics |
| Grade-III | · Similar to grade-II
· Fail to improve with intensive local treatment and antibiotics. |
· Affected pin or pins resited and external fixation can be continued |
| Grade-IV | · Severe soft tissues involvement
· Affecting more than one pin. · Associated loosening if the pin |
· External fixation must be abandoned |
| Grade-V | · Clinical appearance same as grade-IV
· Bone involvement · Radiographs show osteomyelitis |
· External fixation must be abandoned |
| Grade-VI | · Sequestrum formation within the bone
· A persistent sinus develops |
· Curettage of the pin tract |
Grade I-III = Minor infections, Grade IV-VII = Major infections
The common causative organisms of pin site infection are staphylococcus aureus, Staphylococcus epidermidis Escherichia coli, corynebacterium , Enterobacter aerogenes and Pseudomonas aeruginosa. In a study conducted by Sharma et al in 2005, result revealed that out of 101 infected pin sites; 25.74% were infected with Enterobacter aerogenes , 24.75% with Acinetobactors and 12.87% with pseudomonas aeruginosa.
Pin site infections are a major concern for the nurse managing the patient with a skeletal traction pin or an external fixator. Prevention of pin site infections is an important nursing responsibility. Pin site care is essential to avoid infection. Bernardo describes that pin site care involves inspecting the site for signs of infection (tenting, redness, tenderness, purulent discharge) and cleansing agent(s), removal of crusts, and use of dressings. Each point where the skeletal pins puncture the skin and soft tissue needs to be managed as an individual wound.
There are diverse opinions in the available reviewed literature related to the four aspects of pin site care namely frequency of care, the use of solutions, care given to pin-site crusts and the use of dressings. The frequency of care is an important aspect in pin site management. Trigueiro asserted that, “the more a pin site is handled, manipulated or prodded, the greater the possibility of irritation. Celeste advocated daily treatment, whereas sick, green and sproles have advocated twice daily treatment. In the early postoperative stages, pin sites should not be left undisturbed for long, as nursing observation of the skin around the pins is essential to ensure there is no vascular disturbance. Dressings left on for too long and allowed to dry will cause tissue damage when removed. On the other hand, excess exudates could macerate adjacent tissue, so it is important to remove excessive exudates. In a study conducted by W-Dahl results revealed that there was no difference between daily or weekly pin site care.
Review of literature reveals diversity in use of solutions for cleansing the pin site, such as hydrogen peroxide, Povidone iodine, normal saline alcohol and even soap and water. The most commonly recommended solution is hydrogen peroxide, either in half or full strength, and in some cases followed by a rinse of either saline solution or water.
Povidone-iodine is one of the most widely use antiseptics. Its antibiotic effect is however; reduced by contact with exudates. Iodine is also believed to have a corrosive effect on skeletal pins. Trigeuiro, in early as 1983, recommended the use of either dry kling dressing or impregnated with povidone, which is untouched for 24 hours. Review of literature consistently reveals that in external fixation, crusts should be removed to allowed free drainage. Massaging the area surrounding the pin is another aspect of pin site care, which is advocated by many authors.
The use of dressing has also been debated with a number of recommendations. The use of dressings to cover pin sites is advocated by Grant et al, while others support leaving pin sites uncovered. Trigueiro, sims advocate the use of dressings only if pin sited are draining. Advocates of using gauze dressings believe that dressings provide a protective barrier. Hile opponents believe that dressings could potentially block drainage of exudates, increasing risk of infection. According to Green the dressing needs to e bulky to try and reduce movement around pain. Iodine soaked gauze has been recommended. Few authors, Oppenheim, Livingston have recommended the use of the dry gauze dressing.
The combination of diverse nature of the research evidence and the weak designs used, lead the authors to conclude that there is sufficient evidence on which to recommended pin site care as beneficial and to make strong recommendations regarding any particular aspects of pin site care. Experimental research is needed to create evidence- based practice guidelines for pin site care to prevent pin tract infection. It is the need of the hour and recognized by the orthopedic department to test the most effective protocol of pin site are. Hence the investigator became keenly interested to find out the most effective protocol. This study is undertaken highlighting on prevention of pin site infection.
Objective
To study the effect of pin site dressings in terms of prevention of pin site infection among patients with external skeletal fixators.
Materials and methods
A quasi experimental study was undertaken in the selected wards of Nehru Hospital, PGIMER, Chandigarh during the months of January and February 2006. Written permission was sought from the head of orthopedics department. Target population comprised of 50 postoperative patients with external skeletal fixators. Thirty six patients met the inclusion criteria, 14 patients were excluded because of skin grafting along with external fixation or patients not willing to participate in the study for seven consecutive days. Out of the 36 enrolled patients, 9 patients were excluded from the study after randomization. Sample comprised of 27 postoperative patients with 184 pin sites. Randomization of the study sample was done for assigning the type of dressing protocol. Experimental group I consisted of 14 patients with 98 pin sites. for whom type I pin site dressing protocol was assigned. Experimental group II consisted of 13 patients with 86 pin sites, for whom type II pin site dressing protocol was assigned.
Conceptual framework of the study was adopted from the concepts of susceptible host and Betty Neuman’s 18 concept of nursing intervention i.e. primary and secondary prevention by interventions. Checketts and Otterburn’s1 definition and classification for grading pin site infection was adopted in the study. Interview schedule, assessment proforma and record proforma were prepared Validity of dressing protocols and tools was done by experts from the field of Clinical Nursing, Nursing Education, Orthopaedics and Microbiology Agreement percentage of 83% or more was established. Test-Retest method and inter rater reliability was also calculated and was found to be significant. Feasibility of the study was tested. Professional ethics were considered through out the study. After a short interview of the selected randomized patients, baseline assessment for presence of pin site infection was carried out after 24 hours of surgery. After the baseline assessment, pin site dressings were done once daily for seven days as assigned to experimental groups. Type I pin site dressing i.e. cleaning pin site with hydrogen peroxide (3%) followed by application of dry gauze dressing was done for subjects in experimental group I. Type II pin site dressing i.e. cleaning pin site with betadine followed by application of betadine soaked gauze dressing was done for subjects in experimental group II. The pin sites were assessed subsequently on 3rd, 5th, and 7th postoperative days for redness, pain, tenderness and discharge. In presence of increased or purulent discharge (continued for more than 24 hours), swabs for culture and sensitivity test were sent from the pin sites in order to confirm about the infection and Causative organisms. Test was repeated on in postoperative day. An X-ray was also done on 7th postoperative day for all the patients. Finding of culture sensitivity report and X ray were recorded.
Results
Thirty six patients who met the inclusion criteria were enrolled in the study, 9 patients were excluded after randomization. Of these 9 patients, 2 patients expired (one in each experimental group) and 7 patients could not continue with the seven days of intervention (2 patients from experimental group 1 and 5 patients from experimental group II). Ultimately, 27 patients with 184 pin sites patients were considered for analysis.
Majority of the study subjects i.e. 85.7% in experimental group 1 and 84.6% in experimental group II were males with mean age 34.14+ 13.83 years in experimental group I and 43.8+ 13.1 years in experimental group II. Majority of study subjects i.e. 35.7% in experimental group 1 and 69.2% in experimental group II were manual workers and resided in rural areas. Majority of study subjects 85.7% in experimental group I and 69.2% in experimental group II had compound fracture for whom external fixation was done. Majority of the study subjects had unilateral fixator in both the groups i.e. 9 (64.4%) in experimental group I and 11 (84.6%) in experimental group II. Both the experimental groups were homogenous in respect to age, gender, habitat and type of fracture. All the pins were non coated or plain type and were mostly inserted in the tibial bone for study subjects in both the groups. All the study subjects were on broad spectrum antibiotics during postoperative phase. All the pin sites were healthy before the trial of protocols in both the groups.
In experimental group I, i.e. dressing with hydrogen peroxide 3(3.1%) pin sites developed grade 1 infection on 3rd postoperative day which was increased to 5 (5.1%) pin sites by 5th post operative day, on 7th post operative day maximum 96 (97.7%) pin sites were not infected and 2 (2.1%) pin sites had grade II infection.
In experimental group II dressing with betadine, out of 86 non infected pin sites, 10 (11.6%) pin sites developed grade I infection and 2(2.3%) pin sites developed grade II infection on 3rd postoperative day. On 5th post operative day 27 (31.4%) pin sites developed grade 1 and 5 (5.8%) pin sites developed grade Il infection. By 7th postoperative day, only 43 (50 %) pins remained non infected, 33(38.4%) pin sites had grade 1 infection, 6(7.0%) had grade II and 4(4.6%) developed grade III infection. Two of the infected transfixion wires were removed and required reinsertion at healthy sites.
Table 2: Distribution of pin sites according to the grades of infection in both groups
N-184
| Pin site status Expt. Group-I (n=98)
Post operative days 3 5 7 f (%) f (%) f (%) |
Expt. Group-II (n=86)
Post operative days 3 5 7 f (%) f (%) f (%) |
| Not infected 95(96.9) 93(94.9) 96(97.9)
Infected Grade-I 3(3.1) 5(5.1) – Grade- II – – 2(2.1) Grade- III – – – |
74(86.1) 54(62.8) 43(50.0)
10 (11.6) 27 (31.4) 33 (38.4) 2 (2.3) 5 (5.8) 6 (7.0) – – 4(4.6) |
Figure 1 depicts the percentage of infected pin sites in both the groups during postoperative phase. The baseline status of the pin sites in both the groups were similar 1.e. no pin site was infected. In experimental group 1, the curve shows that on 3rd postoperative day, 3.1% pin sites were found to be infected, which increased to 5.1% on 5th postoperative day and there was decline to 2.1% on 7th postoperative day.
Whereas in experimental group II, there was a progressive incline in the curve showing the infection rate. On 3rd postoperative day it was 13.9% which increased to 37.2% by 5th postoperative day and further, increased to 50% by 7th postoperative day.
On the seventh postoperative day, five swabs were taken from the pin sites that were having discharge in experimental group I. Sixty percentage of the pin sites cultures were negative. Gram-negative bacilli Acineto anitratus was isolated from 2 (40%) pin sites.
In experimental group II, 18 pin sites that were having discharge, culture swabs were taken; of them 50% of the culture reports were sterile. From the positive cultures Gramnegative bacilli Acineto anitratus was isolated from 6 (33.3%) pin sites. Enterobacter aerogenes was isolated from 3 (16.7%) pin sites.
Table 3: Causative organisms isolated from pin sites with discharge on 7th postoperative day
| Culture & Sensitivity swabs Expt. Group-I Expt.Group-II |
| f (%) f (%)
Sterile 3 (60.0) 9 (50.0) Positive Gram negative bacilli Acineto antitratus 2 (40.0) 6 (33.3) Enterobacter aerogenes – 3 (16.7) |
| Total 5 (100.0) 18 (100.0) |
On seventh postoperative day, out of 98 pin sites maximum 96(97.9%) had no pin site infection, only 2 (2.1%) pin sites were infected in experimental group I. Where as in experimental group II, 43 (50%) out of 86 pin sites had no infection and equal number 43 (50%) developed pin site infection. Nonparametric Chi square test was applied to compare the findings. A significant statistical difference was found between two types of pin site dressings in terms of prevention of pin site infection. (x2,=57.02 at df = 1 and p< 0.01)
The calculated value of x, was more than the tabulated value at 5% level of significance on third, fifth and seventh postoperative day. The proposed null hypothesis (Ho) i.e. “There is no significant difference between two types of pin site dressings in terms of prevention of pin site infection”, was rejected.
Table 4: Comparison of pin status between the Experimental groups I and II
| Pin site status Expt. Group-I (n=98) Expt. Group-II (n=86) x2 Test
f (%) f (%) |
| 7th post-op day
Not Infected 96 (97.9) 43 (50.0) 57.02 Infected 2 (2.1) 43 (50.0) df=1 P < 0.01 |
No pin site infected on first postoperative day
Discussion
Results revealed 2.1% pin sites had grade – I infection when cleansed with 3% hydrogen peroxide and dry gauze dressing.
A study conducted by Egol et al23 reported 23/120 (28%) patients had pin site infection and no significant difference was observed between three types of regimes of pin site care i.e. i) daily dry dressing without pin care ii) daily pin care with half strength hydrogen peroxide iii) weekly dressing with chlorhexidine impregnated discs. Though the second regime undertaken by Egol et al was same as type I protocol of present study, but the findings could not be compared as no details of infection rate was available related to the three separate regimes.
In a study conducted by Sharma et al in the same setting i.e. PGIMER, Chandigarh results revealed that 2/17 (11.7%) pin sites had infection when cleansed with 3% hydrogen peroxide, where as 105 / 284 (36.9%) pin sites had infection when cleansed with betadine. 24 Though the first protocol was recommended but the findings were statistically insignificant. This can be justified with the understanding that the samples were not randomized and each group had varied number of pin sites.
There are no evidences from the studies supporting the outcomes of the type 1 pin site dressing protocol. But review of literature reveals that hydrogen peroxide is the most recommended cleansing agent, when hydrogen peroxide is applied to a wound it combines with catalase produced in the tissues and decomposes into oxygen and water, producing effervescence. It helps to loosen exudates that might hinder wound E recovery and enables them to be washed off more readily. Six percent w/v hydrogen peroxide liberates twenty times its volume of oxygen upon decomposition. The release of oxygen also kills some anaerobic bacteria. It is likely that the low infection rate i.e. 2.1% with 3% hydrogen peroxide cleaning and dry gauze dressing was due to above mentioned facts.
Type I dressing protocol was highly recommended in USA .Oppenheim et al also found daily pin site care with hydrogen peroxide for 2 weeks ‘was a successful protocol to prevent the pin site infection in patient with external fixators. In a descriptive survey conducted by Walton PJ, it was reported that more than 91% of the orthopaedic nurses were using hydrogen peroxide than any other product for pin site care.
Findings of the present study reveals that pin site infection was found to be 50% on 7th post operative day after giving daily pin site care using betadine and betadine soaked gauze dressing in the present study. There was progressive increase of pin site infection on 3rd, 5th and 7th postoperative days. This high infection rate with betadine cleaning had also been reported by Camilo & Bongiovanni29 in a controlled randomized trial. Infection rate of 66.7 % was reported with the use of 10% Polyvinyl Pyrolidine iodine for pin site care on a group of 15 randomized patients, whereas the infection rate was 46.7 % when physiological saline was used for pin site dressing on same number of patients. Patients with circular fixators and followed up as outpatients were exclusively included in the study. In the present study patients with all types of fixators admitted in the wards were included. Hence it can be concluded that infection rate was evidently higher when pin sites were cleaned with betadine, irrespective of the type of fixators used or different research settings. From review of literature, it is evident that the antibiotic effect of betadine is reduced by contact with wound exudates (Morgan 1990). Iodine is also believed to have corrosive effect on skeletal pins (Rutecki and Seligson).
Studies conducted by Henry, Dahl et al, Coppola et al reported that Staphylococcus aureus was the commonest causative organism for pin site infection in foreign settings. Sharma et al 8 reported in their study that one of the commonest causative organisms for pin site infection was Acinetobacter anitratus (24.75%). This fact was further reaffirmed by the findings of the present study. The reports of culture swabs sent on 7th post operative day revealed that gram negative bacilli Acinetobacter anitratus was the commonest organism found in both the experimental groups. In experimental group I, out of 5 pin site swabs sent, 2(40%) were positive cultures and the organism isolated was A. anitratus. In experimental group II, out of 18 pin site swabs sent for culture, the organisms were isolated in 9 (50%) pin sites. The most common organism isolated was gram negative Acineto anitratus in 6 (33.3%) pin sites and Enterobacter organism in 3 (16.7%) pin sites (Table 3). Hence conclusion can be derived that in the present research setting, Acinetobacter anitratus is the most predominant causative organism for hospital acquired pin site infection.
The results showed that the Type I pin site dressing protocol i.e. cleaning pin sites with 3% hydrogen peroxide, and dry gauze application, was fairly effective than Type II pin site dressing protocol i.e. cleaning with betadine and betadine gauze application (Table 4). This difference in prevention of infection had statistical significance.
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