PERIOPERATIVE PRACTICE


The Global Guidelines are separated into preoperative and then intra and post operative guidance. The methods employed by the guideline group are consistent with development of international guidelines and WHO frameworks for guidelines development. It should be remembered when reading the guidance that a balanced approach was taken into account prior to the recommendations being made. In the guidelines, each specific


recommendation has a chapter related to it – the Lancet series highlights the key RCTs referenced and related to each recommendation. Meta analysis was undertaken where there were sufficient studies with comparable values to allow this. However, it is still disappointing that so


much of the evidence, certainly that cited for the intraoperative and post operative recommendations is of such low quality. In the preamble included in the series one


article, the authors identify that they decided to prioritise the development of evidence based recommendations for the prevention of surgical site infections. They say that there are many factors involved in the patient’s journey through surgery which contribute to the risk of SSI, and that prevention is complex and requires the integration of a range of measures before during and post operatively.


Conclusion


There are many good things to be found in the global guidelines and it is excellent that


Table 1: Preoperative recommendations7 Recommendation


Strength of


recommendation + (quality)


Immunosuppressive medication should not be discontinued before surgery.


Consider the administration of oral or enteral multiple nutrient- Conditional


Recommendation (very low)


enhanced nutritional formulas in underweight patients who undergo Recommendation major surgical operations.


Conditional (very low)


Patients should bathe or shower before surgery; either a plain soap Conditional or an antimicrobial soap may be used for this purpose.


Patients with known nasal carriage of S.aureus should receive


(Evidence relates to orthopaedic and cardiothoracic surgery.) Perioperative intranasal applications of mupirocin 2% ointment


with or without a combination of CHG bodywash are suggested to be used also in patients undergoing other types of surgery.


Preoperative oral antibiotics with MBP


(Mechanical Bowel Preparation) are suggested for use in adult patients undergoing elective colorectal surgery.


MBP alone (without the administration of oral antibiotics) should Strong


perioperative intranasal applications of mupirocin 2% ointment Recommendation with or without a combination of CHG bodywash.


(moderate) Conditional


recommendation (moderate)


Conditional


recommendation (moderate)


Strong


not be used in adult patients undergoing elective colorectal surgery. recommendation (moderate)


In patients undergoing any surgical procedure, hair should either not Strong be removed or, if absolutely necessary, it should be removed only recommendation with a clipper. Shaving is strongly discouraged at all times,


(moderate)


whether preoperatively or in the operating room. Administration of SAP (surgical antibiotic prophylaxis) should be


before the surgical incision when indicated. Strong


recommendation (low)


SAP should be administered within 120 minutes before the incision, Strong while considering the half life of the antibiotic.


Surgical hand preparation should be performed either by scrubbing Strong with a suitable antimicrobial soap and water or using a suitable alcohol based handrub before donning sterile gloves.


Alcohol based antiseptic solutions based on CHG for surgical site skin preparation should be used in patients undergoing surgical procedures.


Antimicrobial sealants should not be used after surgical site skin preparation for the purpose of reducing SSI.


16 I WWW.CLINICALSERVICESJOURNAL.COM Strong


recommendation (low to moderate)


Conditional


recommendation (very low)


recommendation (moderate)


recommendation (moderate)


Recommendation (moderate)


an update on the evidence has been undertaken by such a large range of experts. There is also a great deal of preventative action being taken to reduce the injudicious use of antibiotics when they are of no value to the patient, post surgery or during a surgical episode of care. Given the circumstances with the rise of antimicrobial resistance, this is to be welcomed. However, I believe there has been considerable compromise on some of the standards in the recommendations in order to enable the balance for low and middle income countries and high income countries. Equally, many of the recommendations are way above the reach of the middle income countries and impossible to consider for low income countries, who struggle to have running water in many of their hospitals so indicating the type of soap they must purchase for their patients to bathe pre- operatively seems more than ambitious. However, without standards to aspire to, no one moves forward. It will be interesting to see how many of the WHO new standards are incorporated into the new NaTSIPPs currently being devised to guide practice. It is essential that surgical teams are guided by the evidence to develop quality evidence based practice. The guidelines can contribute to this development to reduce surgical site infection for all surgical patients.


References


1 WHO. Global guidelines on the prevention of surgical site infection. November 2016 Accessed at http://www.who.int/gpsc/ssi-prevention- guidelines/en


2 Safe Surgery Saves Lives Checklist Accessed at http://www.who.int/patientsafety/safesurgery/ss_ checklist/en/


3 Soria-Aledo V, Da Silva ZA, Saturno PJ, Grau-Polan M, Carrillo-Alcaraz A. Difficulties in implementing a surgical checklist in operating theatres. Cir Esp 2012;90:180-5


4 Leaper D, Tanner J, Kiernan M, Assadian O, Edmiston CE. Surgical Site Infection: poor compliance with guidelines and care bundles. International Wound J 2014. Doi:10.111/iwj.12243


5 Carney BT, West P, Neily J, Mills PD, Bagian JP. Differences in nurse and surgeon perceptions of teamwork: implications for the use of a briefing checklist in the OR. AORNJ. 2010;91: 722-9


6 Birgand G, AzevedoC, Toupet G, Pissard-Gibollet R, Grandbastien B, Fleury E, Lucet JC. Attitudes, risk of infection and behaviours in the operating room: a prospective, cross sectional study. BMJ Open 2014;4:e004274.


7 Surgical Site infections 1. New WHO recommendations on preoperative measures for surgical site infection prevention: an evidence based global perspective. Accessed at www.thelancet.com/infection. Lancet Infect Dis 2016;16:e276-87


8 Surgical site Infections 2 New Who recommendations on intraoperative and post operative measures for surgical site infection prevention: an evidence-based global perspective. Lancet Inf Dis 2016; 16: e288-303


FEBRUARY 2017


CSJ


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