Preoperative Preparation

Nutrition

Extensive surgical procedures are followed by an obligate catabolic period, the length of which is influenced by the extent of the procedure, the natural history of the disease state, and the patient’s general health. Urgent and emergent conditions do not allow for the optimization of metabolic stores. But in elective cases, enteral supplementation, especially with protein-rich foods/supplements, or occasionally total parenteral nutrition (TPN) may be beneficial. The diets of patients with documented malnutrition (albumin of <3 g/dL or a recent 15% weight loss) should be supplemented. There is value in supplementation in elderly patients or in those with other chronic degenerative diseases or pulmonary insufficiency. Benefit is measurable in 5 to 7 days. Care should be taken to avoid overfeeding. Consultation with nutritional specialists can be extremely beneficial.

Hydration

Surgery is associated with intravascular volume depletion. This may include fluid losses such as bleeding and insensible losses because of exposure of surgical fields to the air, and hemodynamic changes because of anesthetic agents. Patients should be well hydrated preoperatively to account for potential losses. Additionally, patients may present with preexisting fluid deficits. Intra-abdominal infections and generalized sepsis are associated with sequestration of fluids or “third spacing.” Intravascular volume may be further depleted by vomiting, diarrhea, or anorexia before presentation. Correction of preexisting fluid deficits should be done before a surgical procedure. Fluid replacement therapy is covered more fully in Chapter 12, Chapter 17 . Follow fluid replacement therapy closely with adequate hemodynamic, urine output, and electrolyte monitoring. Care should be used when hydrating a patient with suspected congestive heart disease. A patient with sepsis will likely need preoperative, intraoperative, and postoperative resuscitation efforts.

Prophylactic Antibiotics

Prophylactic antibiotic treatment has documented efficacy in many, but not all, surgical procedures in decreasing the risk for surgical site infections (SSIs). Table 24.1 lists those instances in which the inherent costs of and risks for antibiotic therapy are outweighed by the potential costs and risks of infectious complications. Two good references are:

• Bratzler, D. W., Dellinger, E. P., Olsen, K. M., Perl, T. M., Auwaerter, P.G., Bolon, M. K., … Weinstein, R.A. (2013). Clinical practice guidelines for antimicrobial prophylaxis in surgery. American Journal of Health-System Pharmacy, 70 (3),195–283.

• Ban, K. A., Minei, J. P., Laronga, C., Harbrecht, B. G., Jensen, E. H., Fry, D. E., … Duane, T. M. (2016). American College of Surgeons and Surgical Infection Society: Surgical Site Infection Guidelines, 2016 Update. Journal of the American College of Surgeons, 224 (1), 59–74.

As always, stay up-to-date with continuously evolving guidelines and recommendations.

Keep in mind that other factors can and should be modified to decrease the risk of surgical site infection (SSI) including:

• Adequate glycemic control

• Preoperative smoking cessation (required counseling in clinic)

• Preoperative bathing/showering

The following guidelines pertain to the use of prophylactic antibiotics:

• 1.

  Antibiotic infusion should be started within 1 hour before the skin incision to ensure adequate tissue levels of the agent. Ideal location of antibiotic administration is in the operating room (OR) at time of induction of anesthesia.

• 2.

  Prophylactic antibiotics typically are not to be given for more than 24 hours after a surgical procedure. Any antibiotic use thereafter is defined as therapeutic and needs as specific indication for use toward a particular agent or disease process.

• 3.

  Determine before the administration if a patient has a specific allergy to the recommended agent.

• 4.

  Antibiotics should be re-administered intraoperatively if the case exceeds two half-lives of the antibiotic used or those in which there is excessive blood loss (>1500 mL).

  • Document use of prophylactic antibiotics and their indication in the medical record. Often, this is done in the operative note.

Attending surgeons often have their own preferences as to when antibiotics should be used and which agent is appropriate; for example, many physicians prefer the use of second-generation cephalosporins before bowel surgery. Many institutions also have published institution-specific guidelines based on the local antimicrobial resistance patterns. Check with your attending/consultant/senior surgeons or institution-specific guidelines. If an alternative regimen is used, it is advisable to provide justification in the medical record.

SSIs are a complex result of the interaction between patient factors, bacteria properties, and the surgical process. Surgical processes that can decrease the risk for SSIs include maintenance of perioperative glucose control (especially in diabetics), maintenance of perioperative normothermia, and normal oxygenation in the perioperative period. Hair removal, if necessary, should be done with clippers immediately before the incision. Razors should not be used for hair removal. A good reference is:

• World Health Organization. (2016). Global guidelines for the prevention of surgical site infection. Geneva: World Health Organization.