Antibiotics, Normothermia and Normoglycemia

Dr. Jim Capstick MD, FRCP(C)Nanaimo Regional General Hospital

Antibiotic Prophylaxis

• Right procedure• Right antibiotic• Right dose • Right time• Redose if necessary• Restrict antibiotic coverage post-op

Right Procedure

• Antibiotic prophylaxis not indicated for:– Clean procedures– Elective low risk laparoscopy– Clean head and neck, M&T– Orthopedics – clean operations on hand, knee or

foot without placement of hardware (ie. arthroscopy)

Right Antibiotic

• Ideal antibiotic:1. Active against pathogens most likely to cause SSI2. Appropriate dose & time to achieve adequate

tissue concentrations3. Safe4. Administered for shortest period to minimize:

– adverse effects– drug resistance– costs

Clinical practice guidelines for antimicrobial prophylaxis in surgery. Am J Health-Syst Pharm. 2013;70:195–283.

Clinical practice guidelines for antimicrobial prophylaxis in surgery. Am J Health-Syst Pharm.

2013;70:195–283.

Right Time

• Within 60 minutes of skin incision or tourniquet inflation

• Within 120 minutes for vancomycin and flouroquinolones

• Who administers?

Redose

• If OR duration exceeds two half-lives of the antibiotic

• If excessive bleeding• Consider no redose if antibiotic half life is

prolonged due to renal insufficiency/failure

Clinical practice guidelines for antimicrobial prophylaxis in surgery. Am J Health-Syst Pharm.

2013;70:195–283.

Restrict Coverage

• Single dose prophylactic antibiotic sufficient in most cases

• Discontinue prophylactic antibiotics within 24hr post-op

• Risk of C.Difficile and/or resistant organisms increases with prolonged administration

• Adopt standard clinical order sets

Normothermia

• Maintain core temperature 36° to 38°C• Pre-Op• Intra-Op• Post-Op

Perioperative Heat Balance Anesthesiology. 2000;92(2):578.

Perioperative Heat Balance Anesthesiology. 2000;92(2):578.

Perioperative Heat Balance Anesthesiology. 2000;92(2):578.

Perioperative Heat Balance Anesthesiology. 2000;92(2):578.

Normothermia

• Measure temperature!• Warm Room - 20°-23°C• Warm Fluids - use fluid warmer• Warm Patient– Convective air re-warming– May be best to avoid heat deficit– Pre-operative warming

Pre-Operative Warming

Downloaded from: https://promo.3m.com/go/3MMEDICAL/BairPawsSampleKit

Pre-Operative Warming

BJA 1998; 80:159-163.

Perioperative Glucose Control

• Target BG 7.8 - 10.0 mmol/L• Avoid strict glucose control – BG ≤ 6.1 mmol/L increases risk of hypoglycemia

• Identify hyperglycemic patients!– Obtain random CBG in PAC in at risk patients– Obtain diagnostic HbA1C if CBG>10– Obtain recent HbA1C in all diabetic patients– HbA1C correlates with wound complications– HbA1C > 10 may require insulin tx pre-op

Perioperative Management

• Standard protocols, order sets• Standardize terminology– Type 1 (5-10%) • auto-immune -> loss β cells -> insulin deficient• require insulin

– Type 2 (90%) • insulin resistant • diet controlled, OHAs, insulin

Perioperative Management

• Day of Surgery• Schedule surgery early in the day• Hold OHAs• CBG on admission (recommended for all SDA patients)• Notify anesthesia and/or surgeon if CBG>10• Use weight based basal insulin dose +

nutritional/correctional dose• CBG q2h throughout periop period for all

diabetic/hyperglycemic patients• Sliding scale highly ineffective

Questions? Comments?