bowel prep and oral antibiotics perioperative ... · bowel prep and oral antibiotics perioperative...

1

Preventing Surgical Site Infections

Prophylactic Antibiotics

Bowel Prep and Oral Antibiotics

Perioperative Hyperglycemia is Dangerous for both Diabetics and NONdiabetics

PreWarming and Warming for Perioperative Normothermia

Patchen Dellinger

Prophylactic Antibiotics

Antibiotics given for the purpose of preventing infection when infection is not present but the risk of postoperative infection is present

2

Prophylactic AntibioticsQuestions

• Which cases benefit?

• Which drug should you use?

• When should you start?

• How much should you give?

• How long should antibiotics be continued?

Relative Benefit from Antibiotic Surgical Prophylaxis

Operation Prophylaxis (%) Placebo (%) NNT*Colon 4-12 24-48 3-5Other (mixed) GI 4-6 15-29 4-9Vascular 1-4 7-17 10-17Cardiac 3-9 44-49 2-3Hysterectomy 1-16 18-38 3-6Craniotomy 0.5-3 4-12 9-29Spinal operation 2.2 5.9 27Total joint repl 0.5-1 2-9 12-100Brst & hernia ops 3.5 5.2 58

3

Antibiotic ProphylaxisDemonstrated Benefit

• G.I. Procedures (including appendicitis)

• Oropharyngeal procedures

• Vascular (abd & leg) procedures

• Open heart procedures

• Obstetrical and Gynecological procedures

• Orthopedic hardware placement

• Craniotomy

Antibiotic ProphylaxisDemonstrated Benefit: “Clean” Procedures

• Orthopedic joint replacements

• Open reduction of closed fractures

• Vascular prostheses

• Vascular procedures on the leg

• Median sternotomy

• Craniotomy

• Breast and hernia procedures

4

Antibiotic Prophylaxis for Inguinal Hernia Repair

Mazaki.JACS 2013; 217: 788-801

Antibiotic ProphylaxisDemonstrated Benefit: All Procedures??

• Review of prophylaxis meta-analyses suggests that there is a consistent relative risk of wound infection less than one associated with antibiotic prophylaxis.

• This is independent of the type of operation or of the baseline (placebo) rate of infection.

Bowater. Ann Surg 2009;249: 551–556

5

Relative Effect of Prophylactic Antibiotics Arranged by Wound Category

Bowater. Ann Surg 2009;249: 551–556

Prophylaxis for Clean procedures?Relative reduction of SSI with prophylaxis is the

same for all procedures (30-70%)

Absolute reduction is less if baseline rate with placebo is less.

Decision on whether to use depends on 1) cost of prophylaxis ($, side effects,

generating resistance) and

2) cost of infection ($, disability, etc).

6







7

Parenteral Prophylactic AntibioticsFor Colectomy

Are some parenteral antibiotics better than others?

Anaerobic Coverage for Colectomy

SSI

I.V. Cefotaxime, 2 g (n=280) 44 (16%)

I.V. Cefotaxime +Metronidazole, 1.5 g (n=130) 19 (7%)

p < 0.001

Hӓkansson. Eur J Surg 1993; 159: 177-80

8

Aerobic Coverage for Colectomy

SSI

I.V. Ticarcillin (n=131) 10 (8%)3 g preop and 2 h later

P.O. Tinidazole (n=130) 26 (20%)2 g 10 hr preop

p < 0.007

Aust N Z J Surg. 1986; 56: 209-13

Aerobic Coverage for Colectomy

SSI

Oral neomycin/erythromycin+ I.V. cefazolin (n=55) 4 (7%)

I.V. metronidazole alone (n=47) 14 (30%)

p < 0.007

Khubchandani. Dis Colon & Rectum 1989; 32: 17-20

9

Antibiotic Choice & SSI After Colectomy - Multivariate Analysis

Premier Data Base, n = 4634

Agent O.R. Range

Cefoxitin 1.0

Ertapenem 0.53 0.34 - 0.82

Cefazolin/Metron 0.58 0.33 - 1.04

Levo/Metron 0.59 0.30 - 1.14

Amp/sulbactam 0.62 0.33 - 1.15

Cefotetan 0.86 0.45 - 1.67

Eagye. Surg Infect 2011; 12: 451-7

Antibiotic Choice & SSI After Colectomy - Multivariate Analysis

MSQC, n = 4331

O.R. P

Ab SCIP compliant 0.67 0.04

Post-Op temp >36 0.40 0.01

POD #1 glucose >140 1.52 0.00

Oral antibiotics 0.54 0.00

Laparoscopic 0.59 0.00

Open time >100 min 1.65 0.00

BMI >30 1.36 0.03

Hendren. Ann Surg 2013;257.469

10

Antibiotic Choice & SSI After Colectomy

Cip

ro/M

etro

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Cef

az/M

etro

nid

Ert

apen

em

Am

p/S

ulb

act

Cef

azol

in

Cef

oxit

in

Cli

nd

a/G

ent

Cef

otet

an

Ad

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dd

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atio

s

Hendren. Ann Surg 2013;257.469

Antibiotic Choice & SSI After Colectomy

Cefazolin and metronidazole are compatible in the same I.V. bag, and the UWMC pharmacy has this combination pre-mixed and available in the O.R. pharmacy.

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Surgical Antibiotic Prophylaxis

Bacteroides expected -Cefazolin 2 g + metronidazole 1 g, IV in O.R.

Repeat cefazolin q 3 h during procedure

Bacteroides not expected -Cefazolin 1-2 g, IV in O.R.

Repeat q 2-3 h during procedure

Alternatives

Cefazolin

Other first generation cephalosporin

Cefuroxime, cefamandole, cefonicid

Oxacillin, etc

Cefazolin plus metronidazole

Aminoglycoside or quinolone plus clindamycin or metronidazole

Ertapenem

12

Special Cases?

• Patient allergic (anaphylactoid) to β-lactam antibiotics

• High rate of MRSA wound infections locally

• Recent prolonged course of antibiotics or ICU stay

Vancomycin vs B-lactam Prophylaxis in Cardiac Surgery and Arthroplasty

22,549 Procedures in Victoria, Australia

Adjusted Odds Ratio for any SSI

Variable OR 95% CI P

Proc. Duration, min 1.003 1.002-1.004 <0.001

ASA score > 3 1.71 1.42-2.07 <0.001

Vancomycin proph 1.40 1.02-1.93 0.04

Bull. Ann Surg 2012; 256: 1089-92

13

Vancomycin vs B-lactam Prophylaxis in Cardiac Surgery and Arthroplasty

22,549 Procedures in Victoria, Australia

Adjusted Odds Ratio for SSI with MSSA

Variable OR 95% CI P

Proc. Duration, min 1.003 1.002-1.004 <0.001

ASA score > 3 1.89 1.30-2.74 <0.001

Vancomycin proph 2.79 1.60-4.87 <0.001

Bull. Ann Surg 2012; 256: 1089-92


Which cases benefit?

Which drug should you use?

When should you start?

How much should you give?

How long should antibiotics be continued?

14

Burke. In: Hunt, ed. Wound Healing and Wound Infection, New York: Appleton, 1980:242.

Decisive Period For Development Of Wound Infection

Lesion Age (hrs)

Lesi

on S

ize,

(m

m)

Efficacy Of Prophylaxis Is Independent Of The Specific Antibiotic

Age of Lesion at Antibiotic Injection (Hours)

Les

ion

Siz

e, m

m (

24 H

ou

rs)

0

5

10

Penicillin, 40,000 U

Staph + Penicillin

Control

Chloramphenicol, 0.1 mg/Kg

Erythromycin, 0.1 mg/Kg

Tetracycline, 0.1 mg/Kg

0 2 4 6-2 0 2 4 6-2

0

5

10

0

5

10

0

5

10

Control Control

Control

Staph + Erythromycin

Staph + TetracyclineStaph + Chloramphenicol

Burke JF. Surgery. 1961;50:161.

15

0

1

2

3

4

≤-3 -2 -1 0 1 2 3 4 ≥5

Classen. NEJM. 1992;328:281.

Perioperative Prophylactic Antibiotics

Timing of AdministrationIn

fect

ions

(%

)

Hours From Incision

14/369

5/6995/1009

2/180

1/81

1/411/47

15/441

Timing of Prophylactic Antibiotic Administration for Total Hip Arthroplasty

van Kasteren. Clin Infect Dis 2007; 44:921

16

Timing of Prophylactic Antibiotic Administration – Cardiac, Arthroplasty, Hysterectomy

Steinberg. TRAPE. Ann Surg 2009; 250:10

Timing of Prophylactic Antibiotic Administrationand Risk of SSI

Koch.JACS 2013; 217: 628-35

4,453patients

4 minutes

Observed=444

17

Timing, Dose, Redose, Weight

All the evidence suggests that having effective drug levels in tissue and blood (more is better) during the entire operation reduces SSI risk.

Dosing close to incision, redosing, and using weight based dosing are logical ways to accomplish this.

Prophylactic AntibioticsTiming - Cefazolin

Serum Levels (mg/L)

On Call Anesth

Incision 87 148

1 hour 37 57

2 hours 25 39

DiPiro. Arch Surg 1985;120:829

18

Prophylactic AntibioticsTiming – Cefazolin

Incision

Wound closure

9

7

17

11

On Call Anesth

Muscle Levels

DiPiro JT et al. Arch Surg. 1985;120:829-832.

Prophylactic AntibioticsAdministration in the O.R.

Drugs Given I.V. Push over 5-10 Min

CefazolinDrug to incision 17 (7-29) minMuscle levels 76 (9-245) mg/kg

CefoxitinDrug to incision 22 (14-27) minMuscle levels 24 (13-45) mg/kg

DiPiro. Arch Surg 1985;120:829DiPiro. Personal Communication

19

Prophylactic AntibioticsTissue Levels at Wound Closure

Time No DrugCefoxitin of Closure Detectable

On Call 2.5 hr 38%

With Anesth 2.3 hr 14%

DiPiro. Arch Surg 1985;120:829







20

Prophylactic AntibioticsSize of Patient and Size of Dose

• Morbidly obese patients having bariatric operation

• Cefazolin levels lower than in non-obese patients at same dose

• Cefazolin dose changed from 1 g to 2 g

Infection rate at 1g: 16.5%

Infection rate at 2g: 5.6%

Forse RA. Surgery 1989;106:750

Cardiac Surgery ProphylaxisEffect of Serum Levels

None

Present

3/11 (27%)

2/175 (1.1%)

Antibiotic in Serumat Wound Closure Infection

Goldmann. J Thorac Cardiovasc Surg. 1977;73:470-479.

P = .002

21

Cardiac Surgery ProphylaxisEffect of Atrial Appendage Levels

Yes

No

6

13

InfectedCephalothin

(mg/l)

Platt. Ann Intern Med. 1984;101:770-774.

P = .02

Repeat Antibiotic Prophylaxis Doses in Gastrointestinal Procedures

0

1

2

3

4

5

6

7

Cefaz x 1 Cefaz x 2 Cefotetan

< 3 hr

> 3 hr

Surgical Site Infections

Per

cen

t

Scher. Am Surg 1997;63:59

22

Gentamicin Levels andSSI Risk for Colectomy

Close Gentlevel (mg/L) D.M. (%) Stoma (%) Age

SSI 1.3+1.0 29 50 59+14

No SSI 2.1+0.9 2 24 55+19

p 0.02 0.02 0.04 0.05

• Gent level < 0.5 at close 80% SSI rate (p=0.003).

Zelenitsky. Antimicrob Ag Chemother 2002;46:3026-30

Dose of Antibiotic for Prophylaxis

• Always give at least a full therapeutic dose of antibiotic.

• Consider the upper range of doses for large patients and/or long operations.

• Consider repeating doses for long operations.

23







Antibiotic ProphylaxisDuration

Most studies have confirmed efficacy of ≤12 hrs.

Many studies have shown efficacy of a single dose.

Whenever compared, the shorter course has been as effective as the longer course.

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Duration of ProphylaxisColorectal

Author Drug Duration Infection

Törnqvist 1981 doxycycline 1 dose 10%3 days 19%

Juul 1987 amp/metronid 1 dose 6%3 days 6%

Suzuki 2011 flomoxef 1 dose 8.4%flomoxef 4 days 7.2%

Duration of ProphylaxisGastrointestinal


Strachan 1977 cefazolin 1 dose 3%(biliary) 5 days 6%

placebo 17%

Stone 1979 cefamandole 3 doses 0(mixed) 5 days 3%

cephaloridine 5 days 4%

Hall 1989 moxalactam 1 dose 5%(mixed) 2 days 6%

25

Duration of ProphylaxisJoint Replacement


Pollard 1979 cephaloridine 12 hours 1.4%(hips) flucloxacillin 14 days 1.3%

Heydemann 1986 cefazolin 1 dose 0(hips and knees) 24 hours 1%

48 hours 07 days 1.5%

Duration of ProphylaxisCardiac


Conte 1972 cephalothin 1 dose 10%4 days 9%

Goldmann 1977 cephalothin 2 days 4%6 days 6%

Austin 1980 cephalothin 2 doses 11%3 days 9%

Geroulanos 1986 cefuroxime 2 days 1.1%(569 pts) cefazolin 4 days 2.5%

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Duration of Prophylaxis:Infection and Antibiotic Resistance

Risk in Cardiac Surgery

< 48 hr >48 hr OddsShort Long Ratio

Number 1502 1139

SSI 131 (8.7%) 100(8.8%) 1.0 (0.8-1.3)

Acq Ab Res 6% 1.6 (1.1-2.6)

Harbarth. Circulation 2000;101:2916

Single vs Multiple Dose Surgical Prophylaxis: Systematic Review

0.01

0.1

1

10

100

McDonald. Aust NZ J Surg 1998;68:388

All

stu

die

s, f

ixe

d

All

stu

die

s, r

and

om

Mu

lti

> 2

4h

Mu

lti

<2

4h

Fav

ors

sin

gle

do

seF

avo

rs m

ult

iple

do

se

27

Oral Antibioticsfor Colectomy

Nichols Showed that Mechanical Bowel Prep Did Not Reduce Colon Flora

(log 10)

Coliforms Bacteroides Clostridia

No Prep 4.5 – 7.5 7.9 – 9.5 1.8 – 3.6

Prep 3.0 – 4.3 7.8 – 9.0 0.7 – 2.5

Nichols. Dis Col & Rect 1971; 14: 123-7

28

Antibiotic and Mechanical Bowel Prep for Colectomy (48 hrs)

88% SSI Reduction

Any SSI

Placebo (63) 27 (43%)

Neomycin (68) 28 (41%)

Neo + Tetracycline (65) 3 (5%)

p<0.01

Washington. Ann Surg 1974;180:567-71


79% SSI Reduction

Any SSI

Placebo (56) 26 (43%)

Neo + Erythro (56) 5 (9%)

p=0.0001

Clarke. Ann Surg 1977; 186:251-9

29


Any SSI

Placebo (59) 25 (42%)

Neo + Metronidazole (51) 9 (18%)

p<0.01

Matheson. Br J Surg 1978; 65:597-600


Any SSI

Placebo (39) 16 (41%)

Kanamycin + Erythro (38) 3 (8%)

p<0.001

Wapnick. Surgery 1979; 85:317-21

30

Antibiotic and Mechanical Bowel Prep for Colectomy (18 - 48 hrs)

Bowel Prep + Placebo Oral Ab

1974 43% 5%

1977 43% 9%

1978 42% 18%

1979 41% 8%

“Evidence Based” Bundle to Prevent SSI in Colorectal Surgery

Process Measure Study Control

Mechanical Bowel Prep No Yes

Oral Antibiotics No Yes

PreOp Warming Yes No

IntraOp Warming Yes YesFiO2 80% 30%

I.V. FluidsLimited, Colloid

> Crystalloid Per Usual

Wound Protector Yes No

SCIP Parenteral Antibiotics Yes Yes

Anthony. Arch Surg 2010; 146: 263-9

31

“Evidence Based” Bundle to Prevent SSI in Colorectal Surgery With Removal of

Bowel Prep & Oral Antibiotics

Process Measure Study Control

Total Fluids 1800 ml 2500 ml

Crystalloid Fluids 1500 ml 2250 ml

First PACU Temp 36.7 36.3

Duration of Op 170 min 150 minAny SSI* 45% 24%

Organ/Space SSI 9% 6%

Anthony. Arch Surg 2010; 146: 263-9*p=0.003

49.3%

36.4%

11.3%

Mechanical PrepOnly

Mechanical Prepand PO

antibiotics

No Prep

Bowel Preparation Prior to Elective Colectomy in Michigan (n=1648)

Overall SSI Rate in Michigan is 8.0%

Englesbe. Ann Surg 2010;252: 514–520

All patientsGet I.V. antibiotics

32

11.2%

4.8%

10.6%

Mechanical PrepOnly

Mechanical Prepand PO antibiotics

No Prep

Surgical Site Infection Rates following Elective Colectomy

The Michigan Surgical Quality Collaborative

Propensity Matched Analysis(n=740)


n=195


56%

0%

5%

10%

15%

C.difficile colitis Prolonged Ileus

No Oral Antibiotics

Oral Antibiotics

Per

cen

t o

f p

atie

nts

* P < 0.05

Oral Antibiotics with a Bowel Preparation

A Propensity Matched Analysis (n=740)



33


1. Appropriate SCIP IV prophylactic antibiotics

2. Postop normothermia (T>98.6/37)

3. Oral antibiotics and bowel prep

4. Minimally invasive surgery

5. Short operative duration (<100 min)

Waits (MSQC). Surgery 2014;155: 602-6


Waits (MSQC). Surgery 2014;155: 602-6

34

Bowel Prep & Oral AntibioticsVASQIP Data – 9940 patients

Cannon. Dis Col Rectum 2012; 55: 1160-6

SSI Rate Significantly Lower with

oral prep and oral antibiotics

9% vs. 18.1%

Most Recent Cochrane Review

Comparison Odds Ratio Range

Ab Proph vs none 0.34 0.28 – 0.41

Oral + I.V. vs I.V. only 0.56 0.43 – 0.74

Oral + I.V. vs Oral only 0.56 0.40 – 0.76

Greater than 2300 pts in each comparison

GRADE evidence quality HIGH

Nelson RL, Cochrane Rev 2014; #5: CD001181

35

Oral Antibiotic Bowel Prep Significantly Reduces SSI Rates and Readmission Rates in Elective Colorectal Surgery

NSQIP data on 8,415 colectomy pts

Open and Laparoscopic

No Prep 2150 25%

Mech Prep Only 3779 45%

Oral Ab + Mech Prep 2486 30%

Morris. Ann Surg 2015; 261:1034-40


NSQIP data on 8,415 colectomy pts

Open and Laparoscopic

SSI

Oral Ab 6.5%

No Oral Ab 13%

Morris. Ann Surg 2015; 261:1034-40

36

Oral Antibiotic Bowel Prep Significantly Reduces Complication Rates in

Elective Colorectal Surgery

Reduced P

Anastomotic leak < 0.001

Ileus < 0.001

Return to O.R. 0.02

Readmission < 0.001

Mortality 0.001

Morris. Ann Surg 2015; 261:1034-40


Targeted Colorectal NSQIP data on 4,999 pts, Open and Laparoscopic with detailed data on mechanical prep, use of oral antibiotics, operative approach and multiple other risk factors.

Scarborough. Ann Surg 2015; 262(2):331-7

37


Mech Prep + Oral Ab (MBP+OAP) 1494 (30%)

Mech Prep Only (MBP) 2322 (47%)

Oral Ab Only (OAP) 91 (2%)

No Preop Prep at all (No Prep) 1092 (22%)

Total 4999


Oral Antibiotic Bowel Prep Significantly Reduces SSI Rates

AOR 0.33P<0.001


38

Oral Antibiotic Bowel Prep Significantly Reduces Anastomotic Leak

AOR 0.48P=0.001

AOR 0.71P=0.05


Oral Antibiotic Bowel Prep Might Reduce Mortality


AOR 0.40 (0.14, 1.18P=0.10

39

Oral Antibiotic Bowel Prep Significantly Reduces Readmission Rates in

Elective Colorectal Surgery

ReAdm Odds Ratio p

MBP+OAP 5.4% 0.72 0.04

MBP 6.4% 0.81 0.15

OAP 3.3% 0.41 0.14

No Prep 7.9% Ref


Bowel Prep inColon Cancer Surgery

Moghadamyeghaneh. JACS 2015; 220:912-20

Left Colectomy

40

Nationwide AnalysisBowel Prep in

Colon Cancer Surgery

No prep at all 1270 25%

Mech Prep only 2248 45%

Oral Ab + Mech Prep 1386 28%

Oral antibiotics only 117 2.3%


Left colectomy Adj Odds Ratio P

Morbidity 0.63 <0.01

Organ space SSI 0.48 <0.01

Superficial SSI 0.31 <0.01

Anastomotic leak 0.44 <0.01

Right colectomy

Superficial SSI 0.14 <0.01

Bowel Prep in Colon Cancer Surgery

Odds Ratio for Complications w Oral Ab & MBP


41

Lap Colorectal Surgery for Cancer579 Patients

I.V. Oral+I.V. p

SSI 12.8% 7.3% 0.028

Enteritis/diarrhea 3.1% 1.4% 0.17

C. Diff + 1.0% 0.3% 0.34

Ileus 1.7% 0.3%

Hata. Ann Surg 2016; epub

Hyperglycemia is

Dangerous to NonDiabetics

(and Diabetics)

42

Glucose Control and SSIsAfter Median Sternotomy

0

5

10

15

20

<200 200-249 250-299 >300

% I

nfe

ctio

ns

Latham. ICHE 2001; 22: 607-12

Hyperglycemia and Risk of SSI after Cardiac Operations

• Hyperglycemia - doubled risk of SSI• Hyperglycemic:

48% of diabetics12% of nondiabetics30% of all patients

• 47% of hyperglycemic episodes were in nondiabetics

Latham. Inf Contr Hosp Epidemiol. 2001;22:607Dellinger. Inf Contr Hosp Epidemiol. 2001;22:604

43

Deep Sternal SSI and Glucose

0

1

2

3

4

5

6

7

8

100-150 150-200 200-250 250-300

Day 1 Glucose (mg%)

% D

eep

Ste

rnal

In

fect

ion

Zerr. Ann Thorac Surg 1997;63:356

SCIP only mandates glucose control for cardiac surgery

44

Hyperglycemia and Infection

• Does it apply only to cardiac surgery?

• Do WBC struggling to work in syrup know whether they are in a median sternotomy or another incision?

Early (48h) Postoperative Glucose Levels and SSI after Vascular Surgery

Vriesendorp. Eur J Vasc Endovasc Surg 2004; 28:5

<103 mg%

103-117 mg%

117-151 mg%

>151 mg%

45

Perioperative Hyperglycemia in Noncardiac Surgical Patients

Ramos. Ann Surg 2008;248: 585–591

Mastectomy, Hyperglycemia,and SSI

260 patients, 5 glucose determinations (pre-op, at anesthesia induction, intra-op, in PACU, at 24 hrs)

OddsRisk Factor Ratio C.I.

Age > 50 3.7 (1.5-9.2)

Pre-Op ChemoRads 2.8 (1.4-5.8)

Any gluc > 150 mg% 2.9 (1.2-6.2)

Villar-Compte. AJIC 2008; 36:192-8

46

Postop Glucose (within 48h) and SSI – General Surgery

Ata. Arch Surg 2010: 145: 858-864

Glucose

Postoperative Glucose and Mortality in Noncardiac Surgery

Hyperglycemia in nondiabetic

patients was more dangerous

than hyperglycemia in diabetics!

Frisch. Diabetes Care. 2010; 33: 1883-8

47

Perioperative Hyperglycemia and Total Knee or Hip Arthroplasty

Fasting Blood Glucose POD #1

Mraovic. J Diab Science & Technol 2011; 5: 412-8

0.0%

2.0%

4.0%

6.0%

8.0%

10.0%

12.0%

14.0%

16.0%

<100 101-200 > 200

Infe

ctio

n r

ate

HgA1c and Postoperative Glucose – Abdominal Surgery

0

10

20

30

40

50

60

70

80

<5.7 5.7-6.4 6.5-7.0 >7.0

Relation of Preoperative A1c to Postoperative Glucose

Gluc<160 Gluc>160

Goodenough. J Amer Coll Surg 2015; 221: 854-61

HgA1c

per

cen

t

48

Glucose & Infection RiskNon-Cardiac Surgery & Diabetes

VASQIP – 55,408 patients

Multivariate analysis:• All the usual risk factors significant.

• HgbA1c NOT significant.

• PreOp glucose NOT significant.

• PostOp glucose > 150 very significant.

King. Ann Surg 2011; 253:158-65

Hgb A1c vs. Glucose as Risk Factor for SSI – Gastric Bypass

Multivariate Analysis

Odds ratio = 1.27 for every20 mg% increase in mean glucose level during hospitalization (p=0.008).

Mean glucose more significant than any single level above 200 Mg% or not.

Hgb A1c not significant.

Perna. Surg Obes Rel Dis 2012; 8: 685-90

49

SCOAP Data on Perioperative Glucose Levels and Insulin Use

Diabetic pts 4098 (35%)Hyperglycemic 2369 (58%)

Nondiabetic pts 7532 (65%)Hyperglycemic 1014 (13%)

30% of all hyperglycemic patients were not diabetic!

Kwon. Ann Surg. 2013; 257: 8-14

Composite InfectionHyperglycemia vs No Hyperglycemia

Nondiabetic Patients

0

5

10

15

20

All Pts Bariatric Colectomy

NormalGluc>180

All p<0.01

Kwon. Ann Surg. 2013; 257: 8-14

50

Composite Infection in Hyperglycemic Patients With

and Without Use of Insulin

Kwon. Ann Surg. 2013; 257: 8-14

Insulin reduces risk even when glucose control is not as good as desire

Operative Reintervention in Hyperglycemic Patients With

and Without Use of Insulin

Kwon. Ann Surg. 2013; 257: 8-14


51

Mortality in Hyperglycemic Patients With and Without Use

of Insulin

Kwon. Ann Surg. 2013; 257: 8-14


Glucose ControlProven important for SSI risk:

Cardiac surgery

General surgery

Colorectal surgery

Vascular surgery

Breast surgery

Gynecologic Oncology surgery

Hepato-pancreatico-biliary surgery

Orthopedic surgery

Trauma surgery

52

•Regardless of the Diagnosis of Diabetes(or not)

Hyperglycemia Increases

• Morbidity

• Mortality

• Length of Stay

Which Patients Are at Risk

for Hyperglycemia?

53

Glucose in NonDiabetics having Colectomy at Cleveland Clinic

Highest Gluc N (%)

< 125 mg% 816 (33%)

126-200 mg% 1289 (53%)

200 mg% 342 (14%)

All patients 2447 (100%)

Kiran, et al. Ann Surg 2013; 258:599-605

67%

Glucose in NonDiabetics having Colectomy at Cleveland Clinic

Kiran, et al. Ann Surg 2013; 258:599-605

Per

Cen

t in

cid

ence

0

1

2

3

4

5

6

7

8

<125 126-200 >200

Mort+

Sepsis¤

SSI*

Reop¤

*p<0.03, ¤ p<0.01, + p<0.05

54

Preoperative Glucose as a Screening Tool for Patients

Without Diabetes• Random glucose within 30 days of operation

• Average 8 days before operation

• 16% within one day and 29% within 3 days

• 6683 patients• <70 384 pts

• 70-99 4251 pts

• 100-139 1801 pts

• 140-179 187 pts

• >180 60 pts

Wang. J Surg Res. 2014; 186: 371-8

31%

Preoperative Glucose as a Screening Tool for Patients

Without Diabetes

Wang. J Surg Res. 2014; 186: 371-8

Pre-Op Glucose vs. Post-Op Infection, adjusted for age, gender, BMI, ASA, & type of operation.

55

SCOAP – NonDiabetics Less Likely to Receive Insulin for Hyperglycemia

Kotagal. Ann Surg 2015; 261:97-103

SCOAP Adverse Events with Hyperglycemia – Diabetics v. NonDiabetics

Kotagal. Ann Surg 2015; 261:97-103

56

PreOp CHO and Insulin ResistanceColorectal Surgery, 400 mL 3 h Preop

Wang. Br J Surg 2010; 97: 317-27

PreOp CHO and Insulin ResistanceColorectal Surgery, 400 mL 3 h Preop

Wang. Br J Surg 2010; 97: 317-27

Insu

lin

Sen

siti

vity

In

dex

57

PreOp CHO and Muscle Mass – Major Abdominal Surgery

800 mL evening, 400 mL 2 h Preop

Svanfeldt. Br J Surg 2007; 94: 1342-50

Triceps Skin Fold Arm Muscle Circum

Practice guidelines for preoperative fasting and the use of pharmacologic agents to reduce the risk of

pulmonary aspiration: application to healthy patients undergoing elective procedures: an updated report by the American Society of Anesthesiologists Committee

on Standards and Practice Parameters. Anesthesiology 2011;114:495-511

It is appropriate to fast from intake of clear liquids at least 2 h before elective procedures requiring general anesthesia, regional anesthesia, or sedation/analgesia. Examples of clear liquids include, but are not limited to, water, fruit juices without pulp, carbonated beverages, clear tea, and black coffee. . . . The volume of liquid ingested is less important than the type of liquid ingested.

58

Glucose Levels & SSI• The exact “best” level of glucose control in

the perioperative period is not known.

• High glucose levels unequivocally increase the risk of SSI and other perioperative infections.

• Tight glucose control in the perioperative period is tricky.

• Hypoglycemia increases the risk of morbidity and mortality.

• When algorithms are followed at UWMC hypoglycemia is very rare.

Temperature and Infection

59

Temperature and Tissue O2

tension• Subcut temp increase 4° C

• Subcut O2 tension increase 40 torr

• Linear correlation between temperature and O2 tension

• Threefold increase in local perfusion

Rabkin. Arch Surg 1987;122:221

Temperature and SSI Following Colectomy

Normo (104) Hypo (96) P

SSI 6 18 .009

Kurz. NEJM 1996;334:1209

60

Hypothermia During Anesthesia

0 2 4 6

² C o reT e m p

(°C )

El a p s e d T i m e (h )

-1

-3

-2

0

Redistribution Hypothermia

Core37°C

Vasoconstricted

Periphery31-35°C

Anesthesia

Periphery33-35°C

Core36°C

Vasodilated

61

Keeping Your Patient Warm in the O.R.

• Prewarming and active warming in the O.R. is much more important than the O.R. room temperature.

• If you raise O.R. room temperature from 20o to 27o, you still have an 10o gradient between the patient’s temperature and the room temperature and everyone in the room is miserable.

Prewarming at UWMC &First Postoperative TemperaturePost Anesthesia Care Unit (PACU) 2006

> 36o

7836/8132 (96.4%)

> 36o

& < 36.5o

1047/2647 (40%)

> 36.5o

1491/2647 (56%)

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Perioperative Warming, Intraoperative Temperature and Complications

----

Open Abdominal Bowel Resections

Wong. Br J Surgery 2007; 94: 423-6

PeriopN=47

StandardN=56 P value

Blood loss 200 ml 400 ml 0.011

Any complication 32% 54% 0.027

SSI 13% 33% 0.09

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