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Table 3 Therapeutic/preventive care, GRADE level of evidence and strength of recommendation*

From: The quality of clinical practice guidelines for preoperative care using the AGREE II instrument: a systematic review

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

  1. MRSA methicillin resistant Staphylococcus aureus
  2. *The presented level of evidence and recommendation strength comes from the EB-CPG with the highest overall and methodological rigor AGREE-II score. The level of evidence and recommendation strength by EB-CPG are presented in the online supplemental material 8.a