Summary of consensus statements
Preventing SSI
Preventing pneumonia and aspiration
Preventing urinary tract infection
Preventing CLABSI
Background
Type | Rate infections, n = 432,756 colorectal proceduresa (%) | Median (interquartile range) days from operation to infectious complication | NSQIP definitionsb
| Criteria |
---|---|---|---|---|
Any infectious complication | 15.1 | – | Composite variable of the below. | N/A |
Superficial SSI | 5.3 | 9 (6–14) | Infection involving only skin or subcutaneous tissue of the incision. | Requires symptoms (pain, erythema, swelling, heat) and presence of pus or a positive culture or intentional opening of the wound. |
Deep incisional SSI | 1.3 | 10 (6–16) | Infection involving deep soft tissues. Deep soft tissues are typically any tissue beneath the skin and immediate subcutaneous fat, for example, fascial and muscle layers. | Pus must not be from organ space or deep incision spontaneously dehisces or is deliberately opened by a surgeon when the patient has at least one of the following signs or symptoms: fever (>38 °C), localized pain, or tenderness, unless the site is culture-negative direct examination, during reoperation, or by histo-pathologic or radiologic examination radiographic evidence of abscess. |
Organ/space SSI | 6.4 | 10 (7–16) | Infection involving any part of the anatomy (e.g., organs or spaces), other than the incision, which was opened or manipulated during an operation. | Pus from a drain that is placed through a stab wound into the organ/space. Organisms isolated from an aseptically obtained culture of fluid or tissue in the organ/space. An abscess or other evidence of infection involving the organ/space that is found on direct examination, during reoperation, or by histo-pathologic or radiologic examination. |
Pneumonia | 2.5 | 5 (3–10) | An infection of one or both lungs caused by bacteria, viruses, fungi, or aspiration. Pneumonia can be community acquired or acquired in a healthcare setting. | Requires CXR or CT chest evidence of infiltrate, consolidation, opacity, or cavitation as well as 2 signs, symptoms, or lab values. |
UTI | 2.6 | 9 (5–16) | Infection in the urinary tract (kidneys, ureters, bladder, and urethra). | Requires 1 of the following 6 criteria: fever (>38 °C or 100.4 °F), urgency, frequency, dysuria, suprapubic tenderness, costovertebral angle pain or tenderness and a positive urine culture OR 2 of the above criteria and 2 urine cultures or empiric treatment for presumptive UTI. |
Sepsis | 3.7 | 7 (3–13) | ||
Septic shock | 2.2 | 4 (1–9) | ||
CLABSI | – | – | Not presently included in NSQIP. |
Methods
Preventing surgical site infection
Defining incisional vs. abdominopelvic infectious complications
Phase of care | Element |
Preoperative at home | Smoking cessation |
Preoperative at home | Diabetes optimization (check and treat HbA1c) |
Preoperative at home | Anemia optimization (folate, iron, vitamin C, Venofer) |
Preoperative at home | Chlorhexidine showers |
Preoperative at hospital | Clipping (not shaving) surgical site |
Preoperative at hospital | Chlorhexidine towelettes |
Intraoperative | Active warming to prevent hypothermia |
Intraoperative | Appropriate (selection, dose, timing) IV antibiotic within 60 min of incision, discontinued within 24 h |
Intraoperative | Routine use of a wound protector |
Intraoperative | Routine use alcohol-containing skin prep |
Intraoperative | Routine intra-op high-concentration supplemental oxygen |
Intraoperative | Reduce unnecessary traffic in the operating room |
Intraoperative | Routine use of separate fascial closure tray or separate anastomotic tray |
Global | Adherence to hand hygiene |
Global | Active surveillance program with education, compliance, and feedback |
Global | Optimize preoperative glucose control, Maintain blood glucose <180 through POD 2 |
Drain use and abdominopelvic infectious complications
Infection prevention bundles
Combined oral antibiotic and mechanical bowel prep
Mechanical bowel prep alone
Isosmotic vs. hyperosmotic mechanical bowel preps
Name | Advantages | Disadvantages |
---|---|---|
Polyethylene glycol (PEG) | Safe | Large volume, poor taste |
Sulfate-free PEG | Safe, better taste | Large volume |
Low-volume PEG and bisacodyl | Safe, lower volume (2 vs. 4 L) | Still large volume |
Sodium phosphate | Small volume | Electrolyte and fluid shifts, caution in cardiac/liver/renal dysfunction/elderly/dehydrated |
Magnesium citrate | Low volume | Electrolyte and fluid shifts |
Prevention of pneumonia after CRS
Risk assessment
Patient factors | (a) Full stomach |
· Emergency surgery | |
· Inadequate fasting time | |
· Gastrointestinal obstruction | |
(b) Delayed gastric emptying | |
· Systemic diseases, i.e., diabetes mellitus, chronic kidney disease | |
· Recent trauma | |
· Opioids | |
· Raised intracranial pressure | |
· Previous gastrointestinal surgery | |
· Pregnancy (including active labor) | |
(c) Incompetent lower esophageal sphincter | |
· Hiatus hernia | |
· Recurrent regurgitation | |
· Dyspepsia | |
· Previous upper gastrointestinal surgery | |
· Pregnancy | |
(d) Esophageal diseases | |
· Previous gastrointestinal surgery | |
· Morbid obesity | |
Surgical factors | Upper gastrointestinal surgery |
· Lithotomy or head down position | |
· Laparoscopy | |
· Cholecystectomy | |
Anesthetic factors | Light anesthesia |
· Supraglottic airways | |
· Positive pressure ventilation | |
· Length of surgery >2 h | |
· Difficult airway | |
Device factors
| First-generation supraglottic airway devices |
Optimizing lung function
Nasogastric tubes and early postoperative feeding
Nasogastric tube use
Recognizing ileus
Preventing urinary tract infection
Optimal urinary catheter use
Managing early postoperative urinary retention
Preventing CLABSI
Avoid routine central line use
Earliest possible removal of central lines
Future directions: prevention of postop SSIs
Conclusions
Acknowledgements
Funding
Availability of data and materials
Authors’ contributions
Competing interests
Consent for publication
Ethics approval and consent to participate
POQI work groups
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Timothy E Miller, Department of Anesthesiology, Duke University Medical Center, NC, USA
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Andrew D Shaw, Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, TN, USA
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Monty G Mythen, Department of Anaesthesia, University College London, London, UK
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Tong J Gan, Department of Anesthesiology, Stony Brook University School of Medicine, NY, USA
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Matthew D. McEvoy, Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, TN, USA (chair)
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Michael J. Scott, Department of Anaesthesia, Royal Surrey County NHS Foundation Hospital, Surrey, UK (co-chair)
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Deborah Gordon, RN, Department of Anesthesiology and Pain Medicine, University of Washington
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Stuart Grant, Department of Anesthesiology, Duke University Medical Center, NC, USA
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Julie K.M. Thacker, Division of Advanced Oncologic and GI Surgery, Duke University Medical Center, NC, USA
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Christopher L. Wu, Department of Anesthesiology, The Johns Hopkins University School of Medicine, MD, USA
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Robert H. Thiele, Departments of Anesthesiology and Biomedical Engineering, University of Virginia School of Medicine, VA, USA (chair)
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Karthik Raghunathan, Department of Anesthesiology, Duke University Medical Center, USA (co-chair)
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CS Brudney, Department of Anesthesiology, Duke University Medical Center, USA
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Dileep N Lobo, Division of Gastrointestinal Surgery, Nottingham University Hospitals and University of Nottingham, Nottingham, UK
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Dr. Daniel Martin, Royal free Perioperative Research Group, Royal Free Hospital, London, UK
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Anthony Senagore, Department of Surgery, University of Texas-Medical Branch at Galveston, Galveston, TX, USA
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Stefan D Holubar, Department of Surgery, Dartmouth-Hitchcock Medical Center, NH, USA (chair)
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Traci Hedrick, Department of Surgery, University of Virginia School of Medicine, VA, USA (co-chair)
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John Kellum, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
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Ruchir Gupta, Department of Anesthesiology, Stony Brook University School of Medicine, NY, USA
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Mark Hamilton, Department of Anaesthesia, St. George’s Hospital and Medical School, London, UK
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S. Ramani Moonesinghe, Department of Anaesthesia, University College London, London, UK (chair)
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Mike PW Grocott, Department of Anesthesia and Critical Care Medicine, University of Southampton, UK (co-chair)
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Elliott Bennett-Guerrero, Department of Anesthesiology, Stony Brook University School of Medicine, NY, USA
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Thomas J Hopkins, Department of Anesthesiology, Duke University Medical Center, NC, USA
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Roberto Bergamaschi, Department of Surgery, Stony Brook University School of Medicine, NY, USA
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Stuart McCluskey, Department of Anesthesia, University of Toronto, ON, Canada