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