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.
Four major targets for prevention:
- • Surgical site infections.
- • Venous thromboembolism.
- • Cardiac morbidity.
- • Respiratory morbidity.
Surgical Site Infection
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.
- • 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
- • Maintenance of peri-/postoperative normothermia.
Without appropriate prophylaxis, DVT is a complication in 20–50% of
major operations → pulmonary embolism
- • Recommended DVT prophylaxis ordered.
- • Appropriate DVT prophylaxis initiated within 24
hours before surgery to 24 hours after surgery.
Adverse Cardiac Events
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.
- • Perioperative β-blocker administration
if previously required (eg, for angina, hypertension, arrhythmias).
Patients on respirator with mechanical ventilation are at increased
risk of ventilator-associated pneumonia (10–30%),
stress ulcer disease, and GI bleeding.
Suggested (but not yet approved) measures:
- • Elevation of head of bed.
- • Provision of stress ulcer disease prophylaxis.
- • Use of ventilator weaning protocols to reduce
duration of mechanical ventilation.
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).
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.
- • < 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 ...