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Overview

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Initiative sponsored by several organizations to improve the surgical care and reduce preventable surgical complications (morbidity and mortality). Linked to pay-for-performance quality parameters.

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Four major targets for prevention:

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  • • Surgical site infections.
  • • Venous thromboembolism.
  • • Cardiac morbidity.
  • • Respiratory morbidity.

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Prevention of Surgical Site Infection

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Surgical site infection is responsible for 15% of all nosocomial infections: 2–5% of clean extra-abdominal cases and up to 20% of intra-abdominal cases.

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Measures:

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  • • Appropriate selection of prophylactic antibiotics: eg, cephalosporin + metronidazole, ertanpenem, fluorochinolone + metronidazole. Betalactam allergy: fluoroquinolone + metronidazole, clindamycin + fluoroquinolone, clindamycin + aztreonam, etc.
  • • Prophylactic antibiotics received within 1 hour before surgical incision.
  • • Prophylactic antibiotics limited to 24 hours (longer duration okay for therapeutic indication).
  • • Appropriate hair removal for surgical field preparation (clipper, no razor).
  • • Monitoring and correction of peri-postoperative glucose levels.
  • • Maintenance of peri-/postoperative normothermia.

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Prevention of Venous Thromboembolism

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Without appropriate prophylaxis, DVT is a complication in 20–50% of major operations → pulmonary embolism in 10–30%.

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Measures:

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  • • Recommended DVT prophylaxis ordered.
  • • Appropriate DVT prophylaxis initiated within 24 hours before surgery to 24 hours after surgery.

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Prevention of Adverse Cardiac Events

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Adverse cardiac events (eg, myocardial infarction, sudden cardiac death, congestive heart failure) complicate 2–5% of noncardiac surgeries overall, causing increased mortality rate, length of stay, cost.

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Measures:

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  • • Perioperative β-blocker administration if previously required (eg, for angina, hypertension, arrhythmias).

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Prevention of Respiratory Complications

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Patients on respirator with mechanical ventilation are at increased risk of ventilator-associated pneumonia (10–30%), stress ulcer disease, and GI bleeding.

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Suggested (but not yet approved) measures:

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  • • Elevation of head of bed.
  • • Provision of stress ulcer disease prophylaxis.
  • • Use of ventilator weaning protocols to reduce duration of mechanical ventilation.

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Cross-Reference

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Overview

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Colorectal surgery encompasses an enormously broad spectrum of diseases and conditions through all age and risk groups. Treatment equally varies in a wide range of approaches and is delivered in several different settings (office, OR, endoscopy suite, outpatient/inpatient).

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Hence, management is not “one-size-fits-all.” Nonetheless, a few principles have evolved that should be considered in the perioperative management of a patient undergoing an abdominal procedure.

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Risk Assessment

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  • • < 40 years, no risk factors/symptoms → no specific workup needed.
  • • > 40 years, no risk factors → ECG, chest x-ray, basic set of lab work.
  • • Any age, specific risk factors/symptoms → ECG, chest x-ray, basic set of ...

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