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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