Thursday, January 14, 2016

Can patients shower immediately after surgery?

Here’s what a recent paper published ahead of print in Annals of Surgery says:

Between May 2013 and March 2014, 222 patients were randomized to the group allowed remove their dressings and shower at 48 hours and 222 to the group permitted to shower only after the original dressing and the sutures were removed in clinic. There were 4 (1.8%) superficial surgical site infections in the early shower group and 6 (2.7%) in the late shower group, an insignificant difference with p = 0.751.

The authors concluded that clean and clean-contaminated wounds can be safely showered 48 hours after surgery, and early postoperative showering may increase patient satisfaction.

I have always been an advocate of early showering after surgery. Wounds properly closed will be bridged by epithelium within 48 hours. Tap water is relatively sterile or we couldn't drink it. Many studies have shown that even irrigating open wounds with tap water instead of sterile saline does not lead to more infections. [Links here and here.]

Much as I would like to believe the Annals study, I can’t because it is probably underpowered to show a difference between the two groups.

Here is a nice definition of statistical power from a website called

“In plain English, statistical power is the likelihood that a study will detect an effect when there is an effect there to be detected. If statistical power is high, the probability of making a Type II error, or concluding there is no effect when, in fact, there is one, goes down.”

To their credit, the authors did try to estimate the sample sizes they would need by doing a power calculation. They knew that the wound infection rate for the cases they intended to enroll was about 1%. The problem is they estimated that showering at 48 hours would result in a wound infection rate of 5%. That seems very high to me for the types of cases included in their investigation—thyroid, lung, inguinal hernia and skin tumors.

If they had hypothesized that early showering would merely triple the rate of wound infections from 1% to 3%, they would have needed at least 1536 patients in each arm of the study. Then if there was no difference, one could conclude that early showering truly does not cause more wound infections.

Even if the known incidence of wound infection was much larger, say 5%, and the rate of infection with showering was presumed to be doubled (10%), to have enough power a study would need 434 patients in each arm.

Many websites provide calculators for determining the appropriate sample sizes to detect with a reasonable degree of certainty whether one intervention is better than another. Anyone thinking about doing a prospective randomized trial should realistically estimate the expected difference and calculate the power.

Whenever you read a negative study, the first question to ask is, “Was the study adequately powered to avoid a type II error?”


Anonymous said...

No question - wounds are waterproof within 48 hours of a procedure. We tell our breast implant patients they can shower without concern for implant contamination 48 hours after surgery.

Skeptical Scalpel said...

I agree.

Unknown said...

There are so many articles today which there are conclusions that are absurd even without statistical analysis. the majority of articles appear to be statistically underpowered but published anyway. Look at Medscape on a daily basis if you do not think this. Many years ago the Army tried to find out if they could show that their surgeons had unacceptable negative appendectomy rates. They discovered the following: if a surgeon and a rate of 50% negative appendixes and it took 30 cases to prove this; 45% negative appendixes required around 3000 cases; to show rate of 40% or less they would never be enough cases in the suit's practice to document this statistically. since when do statistics become the final arbiter?

What happened to carefully reading articles for quality, acceptable presentation of data and for determination of whether or not there was a plausible reason for a statistical relationship?

Skeptical Scalpel said...

I agree there are a lot of bad papers out there, some of which I wrote myself. Publish or perish, you know--especially if you're running a residency program. Think "scholarly activity" of faculty and residents. I am like a reformed smoker now.

Anonymous said...

Thanks skeptical; never knew tap water was so sterile! @ Charles; I totally agree, Medscape has taken to "attention grabbing headlines" and some of their articles use such small samples that I have to read the study they cite before I believe any of it.

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