American Society for Enhanced Recovery (ASER) and Perioperative Quality Initiative (POQI) joint consensus statement on prevention of postoperative infection within an enhanced recovery pathway for elective colorectal surgery

Abstract

BackgroundColorectal surgery (CRS) patients are an at-risk population who are particularly vulnerable to postoperative infectious complications. Infectious complications range from minor infections including simple cystitis and superficial wound infections to life-threatening situations such as lobar pneumonia or anastomotic leak with fecal peritonitis. Within an enhanced recovery pathway (ERP), there are multiple approaches that can be used to reduce the risk of postoperative infections.MethodsWith input from a multidisciplinary, international group of experts and through a focused (non-systematic) review of the literature, and use of a modified Delphi method, we achieved consensus surrounding the topic of prevention of postoperative infection in the perioperative period for CRS patients.DiscussionAs a part of the first Perioperative Quality Initiative (POQI-1) workgroup meeting, we sought to develop a consensus statement describing a comprehensive, yet practical, approach for reducing postoperative infections, specifically for CRS within an ERP. Surgical site infection (SSI) is the most common postoperative infection. To reduce SSI, we recommend routine use of a combined isosmotic mechanical bowel preparation with oral antibiotics before elective CRS and that infection prevention strategies (also called bundles) be routinely implemented as part of colorectal ERPs. We recommend against routine use of abdominal drains. We also give consensus guidelines for reducing pneumonia, urinary tract infection, and central line-associated bloodstream infection (CLABSI).

Enhanced recovery after surgery in children: Promising, evidence‐based multidisciplinary care

“…When discussing evidence for or against bowel preparation, type (isosmotic vs hyperosmotic) and antibiotic use (intravenous, oral, combined, or none) are key. There is growing evidence that, at least for adult colorectal resections, isosmotic bowel preparation combined with oral and intravenous antibiotics minimizes the risk of postoperative infection without worsening overall recovery in the context of an ERAS program . There remains scant evidence for this approach in children, and practices are quite varied when pediatric surgeons are polled.…”

Enhanced recovery for elective colorectal surgery: from safety bundles to package deals

“…A registry study concluded that the highest and lowest quintiles of both liberal and restrictive intra‐operative fluid volume were associated with respiratory morbidity and acute kidney injuries, respectively . A consensus statement of the American Society for Enhanced Recovery (ASER) recommended routine use of iso‐osmotic mechanical bowel preparation with oral antibiotics in order to reduce rates of SSI . Another consensus statement of the ASER redefined postoperative ileus as postoperative gastrointestinal dysfunction (POGD) occurring despite the implementation of ERPs .…”

Perioperative fluid and hemodynamic management within an enhanced recovery pathway

“…This reduces the incidence of perioperative hyperglycemia, which is a risk factor for nosocomial infection. A recent randomized clinical trial (RCT) of 880 patients showed that an oral CHO drink is effective in avoiding a blood glucose level >180 mg/dL, with an incidence of 2.4% compared to 16% in the placebo group ( P < 0.001) . Overall, although larger studies are needed to better examine the impact on meaningful clinical outcomes, based on a low risk of harm, as well as better insulin sensitivity and patient satisfaction, most ERPs incorporate a preoperative CHO drink (except in type I diabetics due to their insulin deficiency state) …”

“…It is a common misconception that all MBPs cause significant dehydration: isosmotic MBP does not have the same deleterious effect as older hyperosmolar solutions and most patients can take isosmotic MBP in combination with oral intake without adverse effects. The use of hyperosmotic MBP solutions is not recommended …”

“…A recent randomized clinical trial (RCT) of 880 patients showed that an oral CHO drink is effective in avoiding a blood glucose level >180 mg/dL, with an incidence of 2.4% compared to 16% in the placebo group (P < 0.001). 11 Overall, although larger studies are needed to better examine the impact on meaningful clinical outcomes, based on a low risk of harm, as well as better insulin sensitivity and patient satisfaction, most ERPs incorporate a preoperative CHO drink (except in type I diabetics due to their insulin deficiency state). 10 The use of a mechanical bowel preparation (MBP) is controversial, however recent evidence recommends the routine use of an isosmotic MBP combined with concurrent oral antibiotics before elective colorectal surgery.…”