Bowel preparation; antimicrobial prophylaxis; endoscope decontamination; erythropoietin therapy

AORN Journal,  Sept, 2005  by George Allen

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This information is intended for general use only. The clinical implications are specific to the abstracted article only. Individuals intending to put these findings into practice are strongly encouraged to review the original article to determine its applicability to their setting.

Bowel preparation for colon surgery

Archives of Surgery March 2005

Bowel preparation before colonic surgical procedures generally includes mechanical bowel preparation and prophylactic antibiotics. The aim of mechanical bowel preparation is to rid the colon of solid stool, thus reducing the bacterial load and minimizing the risk of infection and anastomotic complication. Mechanical bowel preparation in elective colon surgery is controversial, however, because it may cause discomfort to the patient, prolong hospitalization, and cause water and electrolyte imbalance.

With improvements in surgical techniques and more effective prophylactic antibiotics, some practitioners believe that mechanical bowel preparation may no longer be necessary. The aim of this randomized, prospective study was to determine if there is a significant difference in the postoperative results of patients who undergo elective colon resection with mechanical bowel preparation compared to patients who undergo the same procedure but do not have mechanical bowel preparation. (1)

Patients (N = 329) undergoing elective colorectal procedures for nonobstructive large bowel pathologic features at a hospital in Israel between April 1999 and March 2002 were randomly assigned to one of two groups. Patients in group I (n = 164) received mechanical bowel preparation and patients in group II (n = 165) did not. All patients were admitted one day before surgery and received a low-residue diet. Patients in group I received 2.4 g of monobasic sodium phosphate and 0.9 g of dibasic sodium phosphate for mechanical bowel preparation on the day before surgery. All patients received antibiotic prophylaxis with 500 mg of IV metronidazole and 1 g of ceftriaxone one hour before induction.

After surgery, patients were assessed daily for possible complications, and they were assessed in the outpatient clinic at one, three, and six weeks after surgery. Wound infection was defined as the presence of pus or discharge resulting in a culture positive for bacteria and abdominal or pelvic discharge or abscess seen on ultrasonography or computed tomography with a positive culture from the puncture or drain. Wound rupture was defined as clinical evisceration. Anastomotic dehiscence was detected by radiologic imaging using water-soluble contrast. Common statistical procedures including chi-square and unpaired t tests were used to compare differences between the two groups.

Findings. Two patients from each group died. The incidence of postoperative wound infection was higher in group I (ie, the mechanical bowel preparation group) than in group II (ie, the group that did not undergo mechanical bowel preparation) (ie, 16 [9.8%] compared to 10 [6.1%]). Additionally pulmonary complications occurred more frequently in group I than in group II (ie, 16 patients [9.8%] versus 9 patients [5.5%]). Overall, no statistical difference in the frequency of complications was observed between the two groups (P = .64). There was a tendency, however, for fewer complications in group II (ie, 36.4%) compared to group I (P = .08).

Clinical implications. The results of this study suggest that mechanical bowel preparation is not necessary for elective colonic and colorectal surgical procedures where palpation of the entire colon during surgery or intra-operative colonoscopy is not required. In cases where mechanical bowel preparation is not used perioperatively, nurses should understand that the timely administration of prophylactic antibiotics is a critical component in preventing surgical site infections.

Antimicrobial prophytaxis in major surgery

Archives of Surgery February 2005

Since its introduction, the use of antimicrobial prophylaxis (ie, antibiotics administered shortly before the skin incision is made) rapidly has become an essential component of the standard of care for virtually all surgical procedures. Despite evidence of the effectiveness of antimicrobial prophylaxis in reducing the risk for postoperative surgical site infections, problems with inappropriate timing, selection, and excess duration of administration of antimicrobial prophylaxis may occur. The objectives of this national, retrospective, cohort study were to determine the proportion of patients

* who received antimicrobial prophylaxis in a timely manner,

* who received prophylaxis based on current published guidelines, and

* for whom the prophylaxis was discontinued within 24 hours after surgery. (2)

Data from a systematic random sample of 34,133 Medicare inpatients (ie, 788 from each state or territory) who had coronary artery bypass grafting, other open chest cardiac surgery, vascular surgery, general abdominal colorectal surgery, hip or knee total joint arthroplasty, abdominal hysterectomy, or vaginal hysterectomy from January through November 2001 were reviewed. Predefined criteria were used to record data elements, including