Surgical Site Infection Prevention

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S. Shawki et al.

to skilled nursing facilities should also be considered to be high risk.

Surgical Site Infection Prevention

Surgical site infections (SSI) are the most common surgical complications and are associated with increased morbidity, length of stay, and readmissions. Emerging data supports the implementation of bundled evidence-based interventions to reduce the risk of SSI.Important bundle elements include: mechanical and antibiotic bowel preparation (discussed previously), appropriate skin preparation, use of wound protectors, and preoperative intravenous antibiotics. Administration of preoperative systemic antibiotics has been shown to reduce the incidence of SSI.SCIP guidelines recommend that antibiotics be given within 1h prior to surgical incision and that prophylactic antibiotics be discontinued within 24 h of surgery. In colorectal surgery, appropriate antibiotic selection requires adequate coverage of aerobic and anaerobic ora and while considering a patient’s allergies. Antibiotics need to be re-dosed if the procedure lasts longer than two half-lives of the selected agent. We favor a single dose at induction of anesthesia, re-dosing for longer procedures.

Meticulous skin preparation with an appropriate agent is another critical component of SSI prevention. A large randomized controlled trial compared Chloraprep (2% chlorhexidine gluconate and 70% isopropyl alcohol) to povidone- iodine in clean-contaminated cases. Patients in the Chloraprep group had signicantly lower incidence of supercial and deep SSI.Small randomized controlled trials and a recent meta- analysis have shown that the use of wound-protectors is associated with nearly a 50% reduction in SSI in gastrointestinal surgery. Other measures that are recommended to reduce the incidence of SSI, include maintaining perioperative normothermia, euglycemia, and euvolemia. To achieve optimal results, it is important to standardize care and incorporate these individual best-practice measures as part of a bundle within an ERP.

Role ofAnesthesia

An anesthesia team can contribute tremendously towards more efcient ERPs, as the team is actively involved in different aspects including preoperative evaluation, attenuation of surgical stress, appropriate uid management, proper analgesia, maintaining acceptable blood glucose level, and pre-emptive treatment of postoperative nausea and vomiting (PONV). Strategies to prevent PONV include: avoiding nitrous oxide and volatile anesthetics, using propofol for induction and maintenance of anesthesia, and minimizing intraoperative opioids. Another key aspect of PONV prevention is the prophylactic treatment with antiemetics such as dexamethasone and ondansetron, especially in patients at high risk for PONV. Another important intraoperative aspect is maintenance of normothermia. Hypothermia induced shivering and associated vasoconstriction trigger body stress response and been associated with increased SSI.Residual post-operative paralysis from neuromuscular blockade can be difcult to recognize and has been shown to increase complications and ICU admissions. Good communication between the surgery and anesthesia teams about the progression of the case allows for improved timing of the administration of paralytics and reversal agents to minimize any residual post-operative paralysis. In general, ongoing open communication between surgeon and anesthesiologist is critical to achieve compliance with ERP measures and prevent complications.

Avoiding Unnecessary Tubes, Drains, andLines

Current literature has shown that the routine use of nasogastric tubes does not prevent postoperative complications such as ileus, anastomotic leaks, pulmonary complications, or SSI.In fact, avoiding prophylactic placement of nasogastric tubes (NGT) in gastrointestinal surgery is associated with accelerated regain of bowel function and less pulmonary complications. Early removal of Foley catheters is recommended to reduce postoperative urinary tract infection rates.

6 Enhanced Recovery Pathways inColorectal Surgery

For some procedures, the catheter may be removed as early as immediate postoperatively prior to leaving the operating room. Post-void residual monitoring protocols using bladder scan may be used to rule out urinary retention while straight catheterization is used as needed.

C.Postoperative Recovery

Postoperative Analgesia

As discussed above, a comprehensive multimodal approach to analgesia should start in the pre-operative phase. While preemptive analgesia is started preoperatively, achieving adequate pain control becomes one of the critical milestones for recovery in the postoperative phase. There is a ne line between maintaining adequate pain control, promoting recovery, and patients’ satisfaction while preventing side effects, tolerance, and abuse. The main goal of multimodal pain management strategies is to adequately control pain while minimizing the use of opioids. There are a variety of non-opioid bases strategies that can be incorporated in this approach including: Acetaminophen, NSAIDs, gabapentinoids, systemic lidocaine, anti-NMDA agents such as Ketamine, wound inltration with local anesthetics, abdominal trunk blocks, and spinal or epidural anesthesia. Thoracic epidural analgesia (TEA) has been shown by some studies to provide improved pain control while decreasing the need for systemic opioids and accelerate gastrointestinal recovery, but only if those epidurals are opioid-free. Many published ERPs and guidelines include TEA as a cornerstone of multimodal pain management. However, randomized controlled trials have shown that within the context of an ERP, TEA does not result in earlier discharges or decreased complications. In fact, in laparoscopic colorectal surgery, studies have shown that in the context of an ERP, TEA actually delays hospital discharge and increases the risk for complications such as urinary retention and hypotension. In our practice, epidurals are only used selectively in patients undergoing open surgery based on patient history of chronic opioid

use or patient preference. For both laparoscopic and open procedures, our routine post-op order sets include around the clock acetaminophen PO, ketorolac IV (transitioned to ibuprofen PO on day 2), gabapentin PO, and as needed oxycodone PO or hydromorphone IV.Systemic patient controlled analgesia (PCA) with hydromorphone is used selectively, in patients requiring frequent IV breakthrough medications and discontinued as soon as tolerated. Acetaminophen and ibuprofen are continued after discharge with oxycodone for breakthrough pain, with the instruction to wean off narcotics as soon as possible.

Intravenous Fluid Management

Judicious administration of intravenous uids continues in the postoperative phase, with data indicating that restricting intravenous uids to less than 2L/day is associated with faster recovery of gastrointestinal function, increased gastric emptying, and overall less morbidity and LOS.With the demonstrated safety and feasibility of early oral intake, ERPs allow for decreased intravenous uid usage. Most patients who are tolerating ad lib oral liquids on postoperative day one should not require any supplemental uids. On the other hand, in patients who develop a post-operative ileus with nausea and vomiting, or high stoma output, excessive uid losses should be judiciously repleted. Unless otherwise indicated, intravenous uids should be minimized or stopped within postoperative day 1–2.

Early Oral Feeding

While traditionally, patients were kept fasting postoperatively until demonstrating return of bowel function, ERPs have dramatically changed post-operative care by allowing early initiation of postoperative diet. Early postoperative feeding has been shown to be safe and feasible in about 70–90% of patients without increasing the risk of aspiration pneumonia. Furthermore, early feeding seems to decrease insulin resistance, hyperglycemia, and wound infection rates. Early restarting

S. Shawki et al.

oral intake within rst day of surgery has been integrated in many institutional ERPs without delay in discharge. It is important to bear in mind that nausea, vomiting, and postoperative ileus still occur in a proportion of patients, generally in the order of 5–10%. Patients need to be monitored for these symptoms and in cases of ileus with signicant gastric distention, management with prompt nasogastric tube insertion is required.

Early Ambulation

Early mobilization and ambulation is an important step in accelerating postoperative recovery and is a critical component of ERPs. Early ambulation is also a marker of success of the program due to successful preoperative patient preparation and proper pain control. It promotes early return of bowel function and prevents pulmonary complications, reduced work capacity, and loss of muscle mass associated with prolonged bed rest. Patient compliance and motivation can be improved by setting out daily goals in the preoperative phase that are then reinforced with posters or signs on the ward.

Postoperative Ileus: Prevention andTreatment

Postoperative ileus, characterized by a transitory cessation of normal bowel function, is one of the most common complications following colorectal surgery resulting in prolongation of hospital stays and readmissions. Despite a lack of an accepted uniform denition for what constitutes a POI or prolonged POI, it is estimated that it occurs in approximately 10–15% of patients undergoing colorectal surgery. POI is a signicant cause of healthcare expenditure, accounting for approximately $750 million per year. Many of the important components of ERPs described above aim to enhance and accelerate recovery by reducing the incidence of POI. Minimally invasive surgery, early post-op mobilization and nutrition, opioid sparing strategies, and avoiding uid overload have all been shown to accelerate recovery of

bowel function. There is conicting data on whether gum chewing accelerates return of bowel function and decreases LOS in the context of an ERP.However, some benet was noted with gum chewing and it is an inexpensive and well tolerated intervention. In terms of pharmacological interventions, despite laxatives (such as bisacodyl and magnesium oxide) and prokinetic agents (such as metoclopramide and erythromycin) frequently being used for the prevention and treatment of POI, data are limited and no impact on LOS was demonstrated. Randomized controlled trials evaluating alvimopan, a peripheral- acting mu-opioid receptor antagonist, have shown a decrease in the time to return of gastrointestinal function and a decrease in POI and LOS after open colorectal surgery with a primary anastomosis. These benets have been shown to offset the cost associated with the drug and in fact result in overall signicantly decreased hospital expenditures. While some retrospective studies support the use of Alvimopan in laparoscopic bowel resections, there is no convincing evidence that it is benecial and cost-effective in laparoscopic colorectal surgery in the context of an ERP. Thus, we use alvimopan for patients undergoing segmental resection, and give a single dose to laparoscopic patients at high risk of conversion to open surgery, stopping the medication if the operation is completed laparoscopically.

As discussed previously, there is no role for nasogastric tube insertion as a preemptive measure to prevent PONV or POI.However, for the treatment of POI, nasogastric decompression and short-term bowel rest are established measures to comfort the patient and avoid aspiration.

Discharge Planning, Follow-Up, andCoordination ofCare

Integral to any ERP are clearly formulated discharge criteria that are understood by the patients and all care providers, including trainees and nurses. In this way, patients are continuously evaluated for discharge readiness as early as on the rst day after surgery. Discharge criteria for open and laparoscopic surgery are identical.

6 Enhanced Recovery Pathways inColorectal Surgery

Patients should be discharged when they are tolerating a diet, pain is controlled with oral medications, vital signs are stable, bowel function (including stoma output) is appropriate, and any home going needs have been addressed. Careful preoperative evaluation of frailty allows for the identication of patients at risk for increased nursing and rehabilitation needs at discharge. Arranging post-discharge care pre-operatively, can help prevent any prolongation of hospitalizations for these high risk patients. For all patients, it is important to establish follow-up appointments and coordination of care with primary and other involved healthcare providers prior to discharge. Post-discharge phone calls can help identify patients who would benet from earlier follow-up to address questions or complications that can be addressed in the ambulatory setting and thereby prevent emergency room visits and readmissions.

D.Quality Pathway Evaluation Measures

Various members and teams contribute to patient care include surgeons, anesthesiologists, residents, nurse practitioners, physician assistants, nurses, ostomy and wound care team, physical therapy, and social workers. One important method to ensure efcient process ow while eliminating variability and facilitating compliance with an ERP is the utilization of electronic medical records. The capability of creating order set(s) during many phases of patient care, provides a reproducible blueprint that is a key in maintaining consistent, standardized care. Compliance with the designed ERP and optimization of individual measures within the ERP depend on continuous audit of processes and outcomes. Especially for newly designed ERPs, monitoring of outcomes and costs associated with the pathway are critical to demonstrate the value to patients, physicians, and the institution. Participation in quality improvement projects, such as the well-described American College of Surgeons (ACS) national quality improvement project (NSQIP), has been shown to signicantly

reduce morbidity and mortality. The Enhanced Recovery in NSQIP (ERIN) is a new collaborative to help teams implement colorectal pathways including measures such as multimodal analgesia, early nutrition and ambulation, and goal directed uid management. Besides participant “buy-in” to allow for pathway implementation, sustainability is just as important in achieving long-term enhanced value through ERPs. Audit with continual monitoring and analysis of outcomes is essential to maintain the improvements that are provided by ERPs. Compliance with the individual pathway elements needs to be monitored, analyzed, and corrected as needed. The most important outcomes that need to be measured are LOS, perioperative complications (using a standardized scoring system such as the Clavien-Dindo classication), and readmissions. The safety and efcacy of ERPs has been demonstrated in numerous randomized controlled trials and meta-analyses. It is critical for each institution and surgical team to demonstrate that the implemented pathway replicates the results observed in trials and to optimize processes based on real-life data.

Conclusion

A successful surgical practice relies on the delivery of patient-centered, high-quality care, prompting the need to integrate all elements of perioperative patient care, eliminate variability of practice, and engage patients and their caregivers in the effort to improve outcomes. ERPs are a multimodal and interdisciplinary evidencebased approach resulting in standardization of patient care, minimizing variability, and maximizing efciency and value. Well-designed ERPs cover the whole health care episode, and result in a reduction in morbidity and mortality, decreased length of hospital stay without an increase in readmission rates. Accomplishing these goals directly benets not only patients but also helps to improve the efciency with which healthcare is provided by decreasing length of hospital stay (LOS) and costs associated with complications.

S. Shawki et al.

Refer to Algorithm in Fig. 7.1

Types andAssessment (Table 7.1)

A. Melena

Melena is dened as the passage of black or tarry stools. The black color of melena is a result of the oxidizing effects of the intestinal and bacterial enzymes on heme that produce hematin. This nding can occur with the loss of as little as 50ml of blood and can persist for as long as 5days after the actual bleeding event. Stool could remain positive for occult blood several weeks after a bleeding episode. Melena can be associated with blood loss anywhere along the gastrointestinal (GI) tract from the mouth to the ascending colon. Black stools may also result from iron intake, consumption of dyes, such as tannins in red wine or the reaction of intestinal contents with bismuth in over-the-counter chewable antacids.

B. Minor/Moderate Hematochezia

Hematochezia (Greek haima = blood, chez(ein) to defecate) means the passage of bright red, easily identiable blood or blood clots from the anus. Sometimes hematochezia

A. S. Kumar (*) Department of Medical Education and Clinical Sciences, Washington State University, Spokane, WA, USA

J. Ayscue MedStar Colorectal Surgery Program, MedStar Washington Hospital Center, Washington, DC, USA

and melena are interchanged mistakenly and can lead to confusion regarding the proper meaning of these terms.

We divide acute hematochezia into “severe” and “moderate” bleeding because the management of these patients differs.

Anoscopy is a crucial part of the initial evaluation. If the patient is young with a recent onset of hematochezia consisting of “wipe” bleeding or blood in the toilet with bowel movements and symptoms attributable to hemorrhoids or an anal ssure, it is reasonable to begin a trial of conservative therapy appropriate to the diagnosis (see Fig. 7.2, below). In the absence of pathology seen on anoscopy, an in-ofce rigid proctoscopy can be performed after administration of an enema. Some ofces are equipped with inofce endoscopy, in which case a exible sigmoid proctoscopy can be considered. If these in-ofce attempts fail to declare a source of bleeding, the patient should be set up for an elective colonoscopy +/− upper endoscopy.

C. Severe Hematochezia. +/− Hematemesis

For the purposes of this discussion, “severe” bleeding means that the patient bleeds more than 1500ml in 24h or has signs of shock on admission. These patients have a risk of exsanguination.

Resuscitation of the patient is imperative to prevent shock. After resuscitation, it is often possible to continue with diagnostic

https://doi.org/10.1007/978-3-319-65942-8_7

Clean base

Flat spot

Adherent Clot

Active bleeding

Ulcer Characteristics

Prevalence Rate

Rebleeding Rate

Surgery Rate

Mortality Rate

A. S. Kumar and J. Ayscue

Clean base

Flat spot

Adherent clot

Visible vessel

Active bleeding

Fig. 7.1 Ulcer characteristics and correlations

Table 7.1 Types of anorectal, lower gastrointestinal, small bowel bleeding and melena and evaluation

Risk assessment at presentation Evaluation (in this order) Melena

[A]

Minor/moderate hematochezia [B]

Severe hematochezia [C]

42%

20%

17%

18%

1. History and physical exam

2. Colonoscopy

3. Esophagogastroduodenoscopy (EGD)

4. Enteroscopy

1. History and Physical Exam

2. Anoscopy

3. In-ofce proctoscopy (rigid or exible)

4. Colonoscopy

1. Fluid/blood product resuscitation to point of hemodynamic stability

2. History and Physical Exam

3. Nasogastric Tube (NGT) Lavage Test

4. EGD

5. Colonoscopy (rapid prep)

6. Enteroscopy

10%

22%

43%

55%

0.5%

10%

34%

35%

11%

maneuvers. However, it may be necessary to proceed with the diagnostic procedures at the same time as the resuscitation if the bleeding continues. Fortunately, colorectal bleeding seldom leads to an uncontrollable situation and will stop spontaneously in about 70–80% of cases; therefore, generally there is time for diagnosis and treatment.

Along with the standard clinical examination, if there is no perineal pain, it is mandatory to perform anoscopy and rigid proctoscopy after an enema.

History can elicit if the patient has previously experienced hematochezia (consider chronic causes), prior diarrhea (consider inammatory bowel disease) or has known liver disease with impaired coagulation. Use of anticoagulant therapy or nonsteroidal antiinammatory drugs (NSAIDS) are all important clues to the etiology and possible therapeutic options. Dates and ndings of the last endoscopy performed are useful.

In the case of a patient with a known aortic aneurysm repair who has severe hematemesis,

7 Hematochezia andMelena

prompt attention by the vascular surgery service may be lifesaving.

Upper endoscopy should be performed if clinically indicated and technically feasible. At the very least, a nasogastric tube should be inserted and bilious non-bloody drainage conrmed. If the colonoscopy fails to reveal the site of bleeding and the bleeding has stopped, a lavage-type (i.e., rapid) bowel preparation can be given and a more thorough colonoscopy is repeated either later the same day or the next day.

Refer to Algorithm in Fig. 7.2

Melena Caused by Upper Gastrointestinal Bleeding

D. Pre-malignant/Malignant Lesion (Found on

Endoscopy)

Endoscopy may reveal a bleeding polyp, or a gastric, duodenal or small bowel neoplasia. While small polyps may be amenable to endoscopic treatment alone, malignant pathology will require biopsy, staging work up, multidisciplinary tumor board discussion and consideration of treatment options (neoadjuvant therapy, surgery, adjuvant therapy) as appropriate for the lesion.

E. Variceal

Massive hematemesis due to esophageal varices is, perhaps, the most dreaded sequela of portal hypertension. Overall, ~90% present with hematemesis. This problem most commonly occurs secondary to hepatic cirrhosis, although it may also be due to pre- and posthepatic obstructive phenomenon. As always, initial stabilization of the patient is the rst goal, and often requires a signicant transfusion requirement. Patient mortality with an acute bleed from esophageal varices approaches 50%. This high fatality is related not only to the severity of the bleeding but also to the underlying nutritional, hepatic and pulmonary dysfunction encountered in these patients.

Therapy is guided by endoscopic evaluation of the varices since as many as half of the

patients with known cirrhosis and active GI bleeding have sources of hemorrhage other than their varices at the time of acute GI bleeding. Control of the hemorrhage can be accomplished using endoscopic techniques, systemic pitressin therapy, beta-blockade, placement of a Sengstaken Blakemore tube, or utilization of a trans-jugular intrahepatic portosystemic shunt (TIPS).

Surgical options include a nonselective end to side portocaval shunt, which is technically simpler but has a high incidence of encephalopathy or a side to side portocaval or mesocaval shunt. Options to be considered in the more elective setting include distal splenorenal shunts with total pancreatic disconnection in patients with adequate liver reserve, and liver transplantation in carefully selected patients with poor liver function.

F. Non-variceal

The most common cause of upper GI bleeding are peptic ulcer disease (PUD) 45%. Esophageal varices is 20%, gastritis is 20%, and Mallory-Weiss tear is 10%

PUD affects approximately ten million Americans. It is most common in male smokers between the ages of 20 and 60 years.

Gastric ulcers are mostly related to mucosal barrier breakdown. Types (1) normal fundic ulcer, (2) gastric and duodenal ulcer, (3) pre-pyloric ulcer, (4) juxto-cardiac ulcer. Approximately 85% of ulcers will improve with conservative medical treatment. However, it is important to obtain biopsies and washings as well as to consider re-endoscopy to conrm healing in any questionable lesion since 10% of ulcers are malignant. Medical management should also include treatment for H. pylori.

Endoscopic treatment should control 90% of these lesions.

Medical treatment includes H2 histamine blockers, volume resuscitation correction of coagulation defects, and careful hemodynamic monitoring. Patients who should be considered for surgical intervention include those whose initial bleeding episode lead to syncope or hypotension, persistent slow

Angiography with

embolization (P)

Therapeutic

colonoscopy (if

pathology is

localized to

colon)

Positive test,

pathology localized

CT angiogram (P),

radionuclide scan

(O) (may repeat this

if bleeding is

intermittent

Segmental

resection (Q)

A. S. Kumar and J. Ayscue

Continued instability

despite resuscitation,

rigid proctoscopy +

total abdominal

colectomy, end

ileostomy(Q)

Consider

gastrointestinal (GI)

source (D)

Esophagogastroduo-

denoscopy

(EGO) confirms upper

Hematemesis

present or

nasogastric tube

(NGT) lavage with

blood (C)

duodenoscopy (post

pylorus evaluation),

Continued bleeding

Patient stable

endoscopy, upper

No lesion

encountered

GI contrast studies

(N)

Colonoscopy

Bleeding stops

No hematemesis

NGT bilious

without blood (C)

Address lesion

Lesion encountered

after rapid prep (M)

Severe

hematochezia

causing

hemodynamic

instability (C)

Fig. 7.2 Algorithm severe hematochezia causing hemodynamic instability. NGT nasogastric tube

7 Hematochezia andMelena

bleeding lasting >24h while on appropriate treatments, loss of >1500ml of blood during an 8-h period, requirement of >6 units of blood, a second acute episode while in the hospital or the endoscopic presence of predictors of high-risk re-bleeding (Table 7.1). Within this latter category are a giant duodenal ulcer >2cm, a visible vessel with a clot, or active bleeding not amenable to endoscopic control.

Vagotomy should be added to treatment of

Type II and Type III gastric ulcers.

Gastritis is commonly associated with shock, sepsis, burns (Curling’s ulcer) and CNS problems (Cushing’s ulcers). Although gastritis was once a common and often lethal problem in the ICU setting, its incidence has decreased due to the prophylactic use of antacids and enteral nutritional support.

Mallory Weiss tears are longitudinal tears in the gastric mucosa at the level of the GE junction most often related to forceful emesis. Average length of the tear is 2cm. 15% of patients may have 2 or more tears. These lesions most often stop spontaneously and the associated mortality in non-cirrhotic patients is essentially 0%.

Angiodysplasia, which is synonymous with arteriovenous malformation and vascular ectasia, can be found in 2% of individuals older than 50. The bleeding, which comes from venule dilation, is responsible for 30% of all colon bleeds. Almost 80% of these vascular malformations are found in the right colon, but they can also be found in the small bowel in younger patients. There is an association with aortic stenosis and von Willebrand disease

G. Mass

Hemangiomas and leiomyomas are the most common masses responsible for bleeding. Other less likely etiologies include lipomas, broadenomas, hamartomas, sarcomas and adenocarcinomas. Regardless, these masses usually require operative resection after appropriate preoperative staging and therapy.

Refer toTable 7.3

Hematochezia Caused by Anorectal Bleeding

H. Pruritus

Anal itching, or perineal dermatologic disorders, can cause minor anorectal bleeding. The diagnosis is usually one of exclusion. In severe cases, a biopsy may be needed to rule out more sinister pathology. Typically, non-operative interventions such as changes in diet and hygiene, barrier creams or shortcourse topical anti-inammatory agents will diminish the bleeding.

I. Fissure

Anal ssures are usually associated with pain; yet in some cases, chronic ssures can manifest as bleeding without in the absence of pain. The bleeding, however, is typically associated with bowel movements, though when it occurs between bowel movements, it is usually self-limited. Treatment for anal ssures is covered in Chap. 10 of this book, for the purposes of the bleeding workup, as with the other anorectal pathologies discussed below, it is critical to rule out a more proximal source.

J. Anal Mass

Warts (i.e., condyloma) can be friable at the base, and are not necessarily associated with pain, but will be palpable on digital examination. HPV-related precancerous lesions are typically not associated with masses and will also not bleed, but the invasive type will result in a mass-effect and occasionally bleeding.

K. Hemorrhoids

Internal hemorrhoidal disease can bleed without pain or masses (Table 7.4 and Fig.7.2). It is important to distinguish rectal varices due to cirrhosis from hemorrhoids before any ofce-based procedures (such as banding) are considered.

L. Proctitis

Inammation of the rectal wall can cause bleeding. This can be caused by infection

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Surgical Site Infection Prevention

Postoperative Analgesia

Intravenous Fluid Management

Early Oral Feeding

Early Ambulation

Conclusion

Suggested Reading

Refer to Algorithm in Fig. 7.1

Refer to Algorithm in Fig. 7.2

Melena Caused by Upper Gastrointestinal Bleeding

Hematochezia Caused by Anorectal Bleeding