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Table 6.5 Guidelines for hospital interventions (adapted from Ban [10], Allegranzi [11], and
Berrios-Torres [12])
Guideline
(Organization) Recommendation
Perioperative
glucose control
(CDC; ACS/SIS;
WHO)
Hair removal (CDC;
ACS/SIS; WHO)
Preoperative skin
preparation (CDC;
ACS/SIS; WHO)
Surgical hand scrub
(CDC; ACS/SIS;
WHO)
Surgical attire
(CDC; ACS/SIS;
WHO)
Prophylactic
antibiotics (CDC;
ACS/SIS; WHO)
Perioperative
oxygenation (CDC;
ACS/SIS; WHO)
Maintaining
normothermia
(CDC; ACS/SIS;
WHO)
Maintaining
normovolemia
(WHO)
Perioperative hyperglycemia increases the risk of SSI in both diabetics
and nondiabetics. As such, implementation of perioperative glycemic
control protocols is strongly recommended, with blood glucose target
levels less than 200mg/dL in patients with and without diabetes
There is no evidence to recommend an optimal hemoglobin A1C target
level for the prevention of SSI
Hair removal should be avoided unless hair interferes with surgery. If
hair removal is necessary, clippers should be used instead of a razor
The use of prophylactic antibiotics is strongly recommended with the
choice of prophylactic:
Alcohol-containing preparations are more effective in reducing SSI than
aqueous preparations and should be used unless contraindications exist.
When comparing chlorhexidine- to iodine-based alcohol solutions, there
is no clear superior agent to reduce SSI.In the absence of alcohol,
chlorhexidine gluconate may be superior to povidone-iodine
Use of a waterless chlorhexidine scrub is as effective as traditional water
scrub and requires less time, but there is no superior agent if used
according to manufacturer’s instructions
In the operating room, wear a surgical mask that fully covers the mouth
and nose, and use a skull cap if minimal hair is exposed
Remove or cover all jewelry on the head and neck, and professional
attire when outside the operating room (no scrubs or clean scrubs
covered with a white coat)
The use of prophylactic antibiotics is strongly recommended with the
choice of prophylactic antibiotic dictated by the type of the surgical
procedure and pathogens most likely to cause SSI
Administration of antibiotics should be completed within 1h prior to
incision (2h for vancomycin or uoroquinolone)
Antibiotics should be redosed based on agent half-life or for every
1500mL blood loss
There is no evidence that prophylactic antibiotic administration after
incision closure decreases SSI risk
The presence of a wound drain does not require prophylactic antibiotic
Adult patients with normal pulmonary function undergoing general
anesthesia with endotracheal intubation for surgical procedures should
receive 80% fraction of inspired oxygen intraoperatively and, if feasible,
in the immediate postoperative period for 2–6h. There is no evidence to
recommend an optimal oxygen delivery method or a target oxygenation
level
Perioperative maintenance of normothermia is strongly recommended.
There is no evidence to recommend optimal strategies to achieve and
maintain normothermia, the lower limit of normothermia, or the optimal
timing and duration of normothermia for the prevention of SSI
Intraoperative goal-directed uid therapy is suggested for preventing
SSI
K. M. F. Itani and G. Kristo
6 Reducing Surgical Site Infections
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Table 6.5 (continued)
Guideline
(Organization) Recommendation
Wound protectors
(ACS/SIS; WHO)
Antibiotic sutures
(CDC; ACS/SIS;
WHO)
Gloves/Instruments
(ACS/SIS)
Adhesive drapes
(CDC; ACS/SIS;
WHO)
Incisional wound
irrigation (CDC;
WHO)
Operating room
ventilation (CDC;
WHO)
Wound care (CDC;
ACS/SIS; WHO)
CDC Centers for Disease Control and Prevention, ACS/SIS American College of Surgeons and the
Surgical Infection Society, WHO World Health Organization
Use of an impervious plastic wound protector can prevent SSI in open
abdominal surgery. Evidence is strongest for elective colorectal and
biliary tract procedures
Triclosan antibacterial suture use is recommended for wound closure in
any type of surgery when available
The use of double gloves is recommended
Changing gloves before closure in colorectal cases is recommended;
however, rescrubbing before closure in colorectal cases is not
recommended
The use of new instruments for closure in colorectal cases is
recommended
Plastic adhesive incise drapes with or without antimicrobial properties
are not necessary for the prevention of SSI and should not be used.
Application of microbial sealant immediately after skin preparation is
not needed
Consider the use of irrigation of the incisional wound with an aqueous
povidone-iodine solution before closure, particularly in clean and
clean-contaminated wounds
Intraperitoneal lavage with aqueous iodophor solution in contaminated
or dirty abdominal procedures is not necessary
Antibiotic incisional wound irrigation before closure should not be used
Maintain positive pressure ventilation in the operating room and
adjoining spaces
Laminar airow ventilation systems should not be used for patients
undergoing total arthroplasty surgery
No type of advanced dressing should be used over a standard dressing
on primarily closed surgical wounds
Use of wound vacuum therapy over stapled skin can reduce SSI in open
colorectal (abdominal incision) and vascular (groin incision) cases
Mupirocin topic antibiotic application can decrease SSI compared with
a standard dressing
While close incisions are usually covered with a sterile dressing for
24–48h postoperatively, there is no evidence in the literature that timing
of dressing removal increases SSI risk
Early showering (12h postoperative) does not increase the risk of SSI
Daily wound probing can decrease SSI in contaminated wounds
95
Perioperative Glucose Control
Perioperative hyperglycemia increases the risk of SSI in both diabetics and nondiabetics [24–26]. As such, implementation of perioperative glycemic control protocols is strongly recommended, [10–12] with blood glucose target levels less than
200mg/dL in patients with and without diabetes. There is no evidence to recommend an optimal hemoglobin A1C target levels for the prevention of SSI.Furthermore,
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short-term glucose control can be more impactful in decreasing SSIs than long-term
control of hemoglobin A1C [10].
Close monitoring of blood glucose levels is very important, as hypoglycemia can
occur with perioperative glycemic control protocols.
K. M. F. Itani and G. Kristo
Hair Removal
Hair removal should be avoided unless hair interferes with surgery. If hair removal
is necessary, clippers should be used instead of a razor [10, 12].
Preoperative Skin Preparation
The use of alcohol-based skin scrubs is strongly recommended and has been shown
to be more effective in reducing SSI than aqueous preparations and should be used
unless contraindications exist [10, 12]. When comparing chlorhexidine- to iodinebased alcohol solutions, there is no clear superior agent to reduce SSI [10, 12]. In
the absence of alcohol, chlorhexidine gluconate may be superior to
povidone-iodine.
Surgical Hand Scrub
Use of a waterless chlorhexidine scrub is as effective as traditional water scrub and
requires less time, but there is no superior agent if used according to manufacturer’s
recommendations [10, 12]. Water-based scrub for rst cases is recommended. Hand
hygiene with soap and water is also recommended prior to waterless scrub for subsequent cases.
Surgical Attire
In the operating room, surgical mask that fully covers the mouth and nose should be
worn. All scalp and facial hair should be properly covered [10, 12]. Skull cap is now
accepted in addition to the bouffant cap.
All jewelry on the head and neck should be removed. Operating room scrubs
should not be worn outside the sterile area, or should be properly covered when
leaving the operating room areas [10].
Prophylactic Antibiotics
The use of prophylactic antibiotics is strongly recommended, with the choice of
prophylactic antibiotic dictated by the type of the surgical procedure and pathogens
6 Reducing Surgical Site Infections
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most likely to cause SSI.To achieve bactericidal concentration at time of the surgical incision, administration of weight-adjusted antibiotics should be completed
within 1h prior to incision (2h for vancomycin or uoroquinolone) [10–12]. To
maintain adequate tissue levels, antibiotics should be redosed based on agent halflife or for every 1500mL blood loss [10].
There is no evidence that prophylactic antibiotic administration after incision
closure decreases SSI risk. As such, in clean and clean-contaminated procedures,
additional prophylactic antibiotics should not be administered after incision closure,
even in the presence of a drain (possible exceptions include implant-based breast
reconstruction, joint arthroplasty, and cardiac procedures where optimal duration of
antibiotic therapy remains unknown) [10–12].
Although there is no evidence to recommend an optimal time for removal of
wound drains, they should be removed as soon as clinically indicated [10–12].
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Perioperative Supplemental Oxygenation
Adequate surgical-site tissue oxygenation is thought to have a role in preventing
SSIs. Infected tissue has a lower oxygen tension than non-infected tissue [27].
Administration of high-concentration oxygen (80% FiO2) provides more adequate
oxygenation at the surgical incision and might enhance oxidative killing by neutrophils [28].
Adult patients with normal pulmonary function undergoing general anesthesia
with endotracheal intubation for surgical procedures should receive 80% fraction of
inspired oxygen intraoperatively [10–12] and, if feasible, in the immediate postoperative period for 2–6h [10, 11].There is no evidence to recommend an optimal
oxygen delivery method or a target oxygenation level.
Maintaining Normothermia
Hypothermia (core temperature<36°C) commonly occurs during and after surgical procedures because of the impairment of thermoregulation by anesthetic agents
and the exposure to a cold operating room environment. Given evidence that hypothermia is associated with an increased risk of SSI [29], perioperative maintenance
of normothermia is strongly recommended [10–12]. There is insufcient evidence
to recommend specic strategies to achieve and maintain normothermia, the lower
limit of normothermia, or the optimal timing and duration of normothermia for the
prevention of SSI.
Maintaining Euvolemia
Fluid imbalance (hypovolemia and hypervolemia) can affect tissue perfusion, leading to decreased tissue oxygenation that might increase the risk of SSI [30]. As
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such, intraoperative goal-directed uid therapy is suggested for preventing SSI [11].
There is no evidence to suggest the optimal type of uid to be administered.
K. M. F. Itani and G. Kristo
Wound Protectors
Use of an impervious plastic wound protector can prevent SSI in open abdominal
surgery [10, 11]. Evidence is strongest for elective colorectal and biliary tract procedures [10].
Antibiotic Sutures
Given evidence of decreased risk of SSI with use of triclosan antibiotic sutures [31],
their use is recommended for wound closure [10–12] in any type of surgery [11].
Gloves/Instruments
Double gloving decreases the risk of holes to the inner glove, and so routine double
gloving is recommended to protect the surgeon and reduce surgical crosscontamination [32].
Although there is no evidence to support the practice of changing gloves before
closure and the use of new instruments, these practices are recommended for
colorectal cases, based on expert consensus and evidence supporting bundles that
incorporate these practices [33]. Rescrubbing before closure in colorectal cases is
not recommended [10].
Adhesive Drapes
Plastic adhesive incise drapes, with or without antimicrobial properties, are not necessary for the prevention of SSI and should not be used [10–12]. Application of
microbial sealant immediately after intraoperative skin preparation is not needed.
Incisional Wound Irrigation
Incisional wound irrigation with an aqueous povidone-iodine solution before
closure can be considered, as it might have a benet in reducing SSI, particularly
in clean and clean-contaminated wounds [11, 12]. Intraperitoneal lavage with
antibacterial solution in contaminated or dirty abdominal procedures is not necessary [12]. Antibiotic incisional wound irrigation before closure should not be
used because it is associated with an unnecessary risk of antimicrobial resistance. [11]
6 Reducing Surgical Site Infections
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Operating Room Ventilation
The air in operating room should be kept at a higher pressure than in corridors and
adjacent areas [12]. This positive pressure prevents the ow of air from less sterile
areas into the operating room and can help prevent SSI [34].
Laminar (unidirectional) airow ventilation systems have shown no benets in
reducing SSI and should not be used for patients undergoing total arthroplasty surgery. [11]
Wound Care
No type of advanced dressing should be used over a standard dressing on primarily
closed surgical wounds [10]. Use of wound vacuum therapy over stapled skin can reduce
SSI in open colorectal (abdominal incision) and vascular (groin incision) cases [10, 11].
It has been common practice to protect closed incisions with a sterile dressing for
24–48h postoperatively [8, 12] in order to protect the wound from microorganisms
and subsequent infection. However, there is no evidence that timing of dressing
removal increases SSI risk. Furthermore, early showering (12h postoperative) does
not increase the risk of SSI [10].
Daily probing of closed wounds after contaminated surgery can decrease
SSI [10].
Post-hospital Interventions
Adequate SSI surveillance after discharge is very important, as a substantial number
of SSIs occur after patients leave the hospital. However, currently there is insufcient research exploring post-hospital discharge interventions to prevent SSI.
Conclusion
Sustained efforts from all healthcare providers and organizational leaders are crucial to prevent SSIs. Guidelines for SSI prevention are important, but their success
depends on sound implementation and compliance. Structuring available guidelines
in simple bundles of care by multidisciplinary teams, based on institution characteristics and resources, has been shown to improve standardization, automation, and
education of staff and patients, ultimately decreasing the rate of SSI.
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Perioperative Deep Vein Thrombosis
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Prophylaxis
MohammadRachadWehbe, CharbelF.Matar, AliTaher,
andJamalJ.Hoballah
Introduction
Venous thromboembolism (VTE) is a serious medical pathology associated with
signicant morbidity and mortality. VTE usually comprises both deep vein thrombosis (DVT) and pulmonary emboli (PE).
DVT can form in the deep veins of upper/lower extremities, the pelvis and, less
frequently, in the renal veins, vena cava, and the heart. These thrombi might break
down and dislodge to travel within the blood stream as emboli to occlude the pulmonary artery, forming a PE that might be fatal or cause a cryptogenic stroke in the
presence of a patent foramen ovale (PFO) [1].
Perioperative prophylaxis against VTE is of utmost importance and is considered
a patient-safety measure in most mandates and quality initiatives. Any patient
undergoing major surgical intervention with greater than minimal risk should be
placed on thromboprophylaxis. This prophylaxis can be achieved using mechanical
and/or pharmacological interventions.
7
M. R. Wehbe
Division of Vascular Surgery, Department of Surgery, University of Rochester,
Rochester, NY, USA
C. F. Matar
Department of Internal Medicine, University of Connecticut, Farmington, CT, USA
A. Taher
Division of Hematology and Oncology, Department of Internal Medicine, American
University of Beirut Medical Center, Beirut, Lebanon
J. J. Hoballah (*)
Department of Surgery, American University of Beirut Medical Center, Beirut, Lebanon
e-mail: jh34@aub.edu.lb
© Springer Nature Switzerland AG 2024
J. J. Hoballah et al. (eds.), Principles of Perioperative Safety and Efciency,
https://doi.org/10.1007/978-3-031-41089-5_7
103
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M. R. Wehbe et al.
Risk Factors forVTE
As VTE became the third cause of death from cardiovascular origin, identication
of the population at risk is one of the most important elements in VTE prophylaxis [2].
Preexisting risk factors for developing VTE include any previous history of VTE,
heart failure, COPD, lower limb venous insufciency, body mass index I>30kg/
m2, limb immobility, complete rest over 72h, nephrotic syndrome, myeloproliferative disorder, pregnancy, inammatory bowel disease, increasing age, higher
American Society of Anesthesiologists (ASA) classication, multiple trauma, and
cerebrovascular accidents (ischemic or hemorrhagic). Moreover, having active cancer is considered to be among the highest risk factor, increasing the risk by six-fold
compared to non-cancer patients. The risk is particularly high in cancer patients on
active treatment (chemotherapy, radiotherapy, hormonal or angiogenesis inhibitors)
or those with disease progression [3].
In addition, congenital and acquired thrombophilia alterations as protein C, S,
anti-thrombin III deciencies, hyperhomocysteinemia, elevated antiphospholipid
antibodies, factor V Leiden, and prothrombin mutations all place patients at a higher
risk for VTE [4].
Although VTE is a common cause of death in surgical patients, it remains a preventable one. The risk of VTE in surgical subpopulations ranges widely from 0.4 to
80%, attributed to variations in the anatomic site of the veins involved, type of
operation, and patient comorbidities [5].
Neurosurgical patients are among those in whom the VTE risk is among the
highest, at 25%, with the risk of PE specically reaching 3% and being associated with mortality rates as high as 50%. The expected incidence in moderaterisk neurosurgical patients of distal and proximal DVT is 10%–40% and 2%–8%,
respectively, with 1%–8% and 0.1%–4% being for symptomatic and fatal PE,
respectively. These gures are increased by a factor of two in high-risk
patients [1].
A study by Rogers etal. that evaluated 183,069 patients with vascular or general surgical procedures identied 15 independent variables associated with
higher VTE risk [5]. These included patient-related factors (e.g., female gender,
higher ASA class, ventilator dependence, preoperative dyspnea, disseminated
cancer, chemotherapy within 30days, and >4units of packed red blood cell transfusion in the 72h before operation); preoperative laboratory values (e.g., albumin
<3.5mg/dL, bilirubin >1 mg/dL, sodium >145mmol/L, and hematocrit <38%);
and operative characteristics, for example, (type of surgical procedure, emergency
operation, work relative value units, and infected/contaminated wounds). An
assessment risk index in general and vascular surgical patients was created based
on these factors.
Cancer and venous thromboembolic disease are interrelated. Armand Trosseau
was the rst to describe the relationship between visceral malignancy and thrombophlebitis as its presenting sign more than 150 years ago. Since then, blood
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