title: Lower complication rates for cranioplasty with peri-operative bundle.
abstract: BACKGROUND
  The overall benefits of craniectomy must include procedural risks from cranioplasty. Cranioplasty carries a high risk of surgical site infections (SSI) particularly with antibiotic resistant bacteria. The goal of this study was to measure the effect of a cranioplasty bundle on peri-operative complications.
  
  
  METHODS
  The authors queried a prospective, inpatient neurosurgery database at Kaiser Sacramento Medical Center for craniectomy and cranioplasty over a 7 year period. 57 patients who underwent cranioplasties were identified. A retrospective chart review was completed for complications, including surgical complications such as SSI, wound dehiscence, and re-do cranioplasty. We measured cranioplasty complication rates before and after implementation of a peri-operative bundle, which consisted of peri-operative vancomycin (4 doses), a barrier dressing through post-operative day (POD) 3, and de-colonization of the surgical incision using topical chlorhexidine from POD 4 to 7.
  
  
  RESULTS
  The rate of MRSA colonization in cranioplasty patients is three times higher than the average seen on ICU admission screening (19% vs. 6%). The cranioplasty surgical complication rate was 22.8% and SSI rate was 10.5%. The concurrent SSI rate for craniectomy was 1.9%. Organisms isolated were methicillin-resistant Staphylococcus aureus (4), methicillin-sensitive S. aureus (1), Propionibacterium acnes (1), and Escherichia coli (1). Factors associated with SSI were peri-operative vancomycin (68.6% vs. 16.7%, p=0.0217). Complication rates without (n=21) and with (n=36) the bundle were: SSI (23.8% vs. 2.8%, p=0.0217) and redo cranioplasty (19% vs. 0%, p=0.0152). Bundle use did not affect rates for superficial wound dehiscence, seizures, or hydrocephalus.
  
  
  CONCLUSIONS
  The cranioplasty bundle was associated with reduced SSI rates and the need for re-do cranioplasties.
authors.affiliation: University of California Los Angeles, Neurocritical Care Department, Los Angeles, USA.
authors.forename: Catherine
authors.initials: C
authors.lastname: Le
authors.affiliation: Kaiser Sacramento Neurosurgery Department, 2025 Morse Avenue, Sacramento, 95825, USA.
authors.forename: Kern H
authors.initials: KH
authors.lastname: Guppy
authors.affiliation: Kaiser Sacramento Neurosurgery Department, 2025 Morse Avenue, Sacramento, 95825, USA.
authors.forename: Yekaterina V
authors.initials: YV
authors.lastname: Axelrod
authors.affiliation: Kaiser Sacramento Neurosurgery Department, 2025 Morse Avenue, Sacramento, 95825, USA.
authors.forename: Mark W
authors.initials: MW
authors.lastname: Hawk
authors.affiliation: Kaiser Sacramento Neurosurgery Department, 2025 Morse Avenue, Sacramento, 95825, USA.
authors.forename: James
authors.initials: J
authors.lastname: Silverthorn
authors.affiliation: Kaiser Surgical Implant Registry, 8954 Rio San Diego Drive, Suite 406, San Diego, 92108, USA.
authors.forename: Maria C
authors.initials: MC
authors.lastname: Inacio
authors.affiliation: Kaiser Sacramento Neurosurgery Department, 2025 Morse Avenue, Sacramento, 95825, USA. Electronic address: paul.t.akins@kp.org.
authors.forename: Paul T
authors.initials: PT
authors.lastname: Akins
mesh_terms: D000328:Adult; D000900:Anti-Bacterial Agents / Q000008:administration & dosage*; D000891:Anti-Infective Agents, Local / Q000008:administration & dosage*; D019072:Antibiotic Prophylaxis / Q000379:methods*; D002710:Chlorhexidine / Q000008:administration & dosage*; D003399:Craniotomy / Q000009:adverse effects*; D005260:Female; D006801:Humans; D006849:Hydrocephalus / Q000209:etiology; D008297:Male; D008875:Middle Aged; D019990:Perioperative Care / Q000379:methods*; D011182:Postoperative Care / Q000379:methods; D012640:Seizures / Q000209:etiology; D013529:Surgical Wound Dehiscence / Q000209:etiology; D013530:Surgical Wound Infection / Q000382:microbiology / Q000517:prevention & control*; D014640:Vancomycin / Q000008:administration & dosage*
chemical_list: D000900:Anti-Bacterial Agents; D000891:Anti-Infective Agents, Local; D014640:Vancomycin; D002710:Chlorhexidine
keywords: Care bundles; Craniectomy; Cranioplasty; MRSA infection; Surgical site infection