Recommendation | Level of evidence | Strength of recommendation |
---|---|---|
General recommendations | ||
1. Smoking cessation | ||
Smoking cessation advice | Low | Strong for |
2. Fast | ||
Stop fluid intake in children and adults at least 2 h before elective surgery in | Moderate | Strong for |
Stop intake of solids in children and adults 6 h before surgery | Moderate | |
Stop intake in infants up to 4 h before surgery and 6 h in those who consume other milk | Low | |
Intake of clear fluids (including water, clear juice, and tea or coffee without milk) in children and adults up to 2 h before elective surgery. | Moderate | |
3. Carbohydrate intake | ||
Intake until 2 h before surgery in nondiabetics | Moderate | Strong for |
Taking high carbohydrate drinks to 2 h before elective surgery even in diabetic patients | High | |
Drinking liquids rich in carbohydrates before elective surgery improves subjective well-being, reduces thirst and hunger and reduces postoperative insulin resistance | High | |
4. Alcohol intake | ||
Avoid drinking 4 weeks before, especially in rectal surgery. | Moderate | Strong for |
5. Bowel preparation (cleansing) | ||
With or without planned bowel resection | Moderate | Strong against |
6. Antimicrobial prophylaxis (see Annex 2 for specific antibiotic recommendation details) | ||
Antibiotics intravenous (first generation cephalosporin or amoxicillin/clavulanate) routinely 60 min before the incision. Further doses for prolonged surgery, severe blood losses and obese patients | Low | Weak for |
Vancomycin monotherapy | Low | Weak against |
For insertion of a pacemaker or cardiac defibrillator, in open surgery including coronary bypass and valve prosthesis placement | High | Strong for |
For lung resection | Moderate | Strong for |
For clean-contaminated head and neck surgery | High | Strong for |
For adenotonsillectomy | High | Weak against |
For ear surgery including myringoplasty | High | Strong against |
For nasal and paranasal sinus surgeries | Moderate | Strong against |
For clean head and neck surgery | Very low | Strong against |
For colorectal surgery | High | Strong for |
For oncological breast surgery and reduction mammoplasty | High | Strong for |
For endoscopic gastrostomy and stomach and duodenum surgery | Moderate | Strong for |
For clean-contaminated procedures esophagus and small intestine | Very low | Weak for |
For appendectomy, open biliary surgery, liver resection surgery, pancreatic surgery, breast augmentation | High | Strong for |
For inguinal hernia repair with or without use of prosthetic material, laparoscopic hernia surgery with or without prosthetic material, diagnostic laparoscopy and excisional lymph node biopsy | High | Strong against |
For laparoscopic cholecystectomy surgery | High | Strong against |
Intranasal mupirocin in adult patients undergoing surgery with a high risk of major morbidity due to S. aureus or MRSA | High | Strong for |
For craniotomy and cerebrospinal flow deviation | High | Strong for |
For induction of abortion and cesarean section | High | Strong for |
For abdominal and vaginal hysterectomy | Moderate | Strong for |
For salpingo-oophorectomy and ovarian tissue excision or reconstruction | High | Strong against |
For ankle prosthesis implantation | High | Strong for |
For knee prosthesis implantation | Low | Strong for |
For closed fracture fixation, mounting a prosthetic device when there is no direct evidence available, ankle fracture repair | High | Strong for |
For spinal surgery | Moderate | Strong for |
For elective orthopedic surgeries without use of prosthesis | Very low | Strong against |
For transurethral resection of the prostate, lithotripsy | High | Strong for |
For transrectal prostate biopsy, radical prostatectomy, radical cystectomy, surgery of renal parenchyma, nephrectomy and removal of hydrocele | Moderate | Strong for |
For transurethral resection of bladder tumors | Very low | Strong against |
For lower limb amputation and arterial surgery in the abdomen or lower extremities | Moderate | Strong for |
For carotidal thromboendarterectomy, endarterectomy, tubal surgery varicose veins and other venous occlusions | Very low | Strong against |
Antibiotic must have a spectrum of action against likely contaminants | Very low | Weak for |
Avoid beta-lactam antibiotics in patients with a history of anaphylaxis, urticaria, or rash appearing immediately after treatment with penicillin | Low | Weak for |
Antibiotic prophylaxis should begin immediately before anesthesia and, in any case, of 30 to 60 min before the first skin incision | High | Strong for |
More than single antibiotic dose (except in special situations) | Very low | Strong against |
Additional intraoperative dose of antibiotic in adults, to be held after the fluid replenishment, if a loss of more than 1500 ml of blood is verified during the operation or after hemodilution of more 15 ml per kg | Very low | Weak for |
Consider the increased risk clostridium difficile infection associated with some antibiotics like cephalosporins, clindamycin, fluoroquinolones, carbapenems | Low | Weak for |
Consider glycopeptides for prophylaxis in patients undergoing high-risk surgery that are positive for MRSA | High | Strong for |
Registering a minimum set of data on medical history and treatment forms to assess the suitability of perioperative antibiotic prophylaxis | Very low | Strong for |
7. Preanesthetic medication | ||
Benzodiazepines | Moderate | Weak against |
8. Thromboprophylaxis | ||
Compression stockings | High | Strong for |
Low molecular weight heparin | ||
Continuation of contraceptives | ||
9. Surgical site preparation | ||
Alcohol-chlorhexidine use | High | Strong for |
Antimicrobial agents (i.e., ointments, solutions, or powders) for prevention of surgical site infection | Low | Strong against |
Hair clipping | High | Strong for |
Adhesive strips of plastic with or without antimicrobial properties | Moderate | Weak against |
Microbial sealant after intraoperative skin preparation | Low | Weak against |
Patients bath with antiseptic agent at least one night before surgery | Moderate | Strong for |
10. Prokinetic | ||
For obstetrical patients | Moderate | Strong for |
For non-obstetrical patients | Moderate | Strong against |
Specific recommendations by some clinical specialties | ||
Renal recommendation | ||
11. Adjustments of insulin therapy in diabetic patients | ||
50% reduction in long-acting insulin | Low | Strong for |
Correction with short-acting insulin | Low | Strong for |
Oral hypoglycemic agents | Low | Strong for |
Cardiovascular recommendations | ||
12. Beta-blockers | ||
Continuation of beta-blockers | Low | Weak for |
For patients with positive test for myocardial ischemia undergoing vascular surgery | Low | Weak for |
Start the day of surgery treatment regardless of the condition to be treated | High | Strong against |
13. Statins | ||
Continuation of statins or start before undergoing noncardiac surgery patients with significant atherosclerosis as secondary prevention | Low | Weak for |
Treatment naïve patients undergoing noncardiac surgery without significant atherosclerosis | Low | Strong against |
14. Aspirin | ||
Suspending aspirin three or more days before noncardiac surgery and not restart within a week after it | High | Strong for |
Continuation of aspirin (75–100 mg daily) in patients who presented acute coronary syndrome in the last 12 months or history of percutaneous coronary intervention | Low | Weak for |
Start or not to suspend treatment prior to surgery | High | Strong against |
15. Renin-angiotensin system inhibitors | ||
Suspend them the day of surgery in chronically medicated patients and restart immediately in hemodynamically stable conditions | Low | Weak for |
Start in patients with severe hypertension or ventricular dysfunction if suspending the day of surgery | ||
Start treatment the day of surgery in patients who do not receive it chronically | Low | Strong against |
16. Calcium channel blockers | ||
Suspend the single preoperative dose the day of the surgery in chronically medicated patients | Low | Weak for |
Starting treatment in patients with inducible myocardial ischemia or suspected coronary vasospasm during preoperative evaluation and suspend the single dose the day of surgery | ||
Starting calcium channel blockers in the preoperative surgery in patients who do not receive chronically | Low | Strong against |