Comprehensive Gynecology PDF - Preoperative Counseling & Management

24 24 Preoperative Counseling and Management Preoperative Evaluation, Informed Consent, Perioperative Pla...

24 24 Preoperative Counseling and Management Preoperative Evaluation, Informed Consent, Perioperative Planning, Surgical Site Infection Prevention, and Avoidance of Complications Jamie N. Bakkum-Gamez, Sean C. Dowdy, Fidel A. Valea KEY POINTS Optimal preparation for an operation facilitates a successful Serum electrolyte levels are ordered for women taking diuretics result and protects the patient and physician. or those with a history of renal disease or heart disease. Also, The most significant risk factors for postoperative morbidity serum electrolyte levels should be evaluated in women with are preoperative conditions. They may affect the operation, vomiting, diarrhea, ileus, bowel obstruction, or any condition anesthesia, and postoperative course and may preclude the that affects electrolyte balance. procedure altogether. Routine radiographs on all patients often do not affect periop- Approximately 0.5% of the general population and 1.5% erative management in elective gynecologic surgery, but they of women older than 55 years are receiving continuous should be ordered for women who are current or former glucocorticoids. smokers, women with cardiac or pulmonary symptoms, immi- Latex allergy is directly responsible for 12% of the periopera- grants who have not had a recent chest film, and women older tive anaphylactic reactions in adult women and for 70% in than 70 years. children. Health care workers, women with spinal cord injuries, A baseline preoperative electrocardiogram has been found to or those who have had to perform self-catheterization are at be cost effective in asymptomatic women 60 years and older higher risk for latex allergy. without a history of cardiac disease or significant risk factors. The preoperative physical examination should answer three In the present medicolegal climate, the absence of informed basic questions: consent is cited as a major problem in many lawsuits. - Has the primary gynecologic disease process changed since Preoperative orders should be standardized to avoid omissions, the initial diagnosis? and electronic order sets are standard at most institutions. - What is the effect of the primary gynecologic disease on If an enhanced recovery pathway is being used, the patient can other organ systems? usually eat solid food up until midnight and clear liquids until ~ What deficiencies in other organ systems may affect the 30 minutes before presenting to the hospital. proposed surgery and hospitalization? To avoid hypoglycemia, most enhanced recovery after surgery An examination while the patient is under anesthesia may (ERAS) protocols allow patients to eat solid food up to 6 provide additional information, help avoid intraoperative hours before surgery. surprises, and affect the surgical plan. Anesthesiologists classify surgical procedures according to the It is estimated that 60% of routinely ordered tests would not patient’s risk of mortality using the ASA risk class stratification have been performed if tests had been ordered only for an (classes 1 to 5). indication discovered by history or physical examination. An emergency operation doubles the mortality risks for ASA The American Society of Anesthesiologists (ASA) Practice classes 1, 2, and 3; produces a slightly increased risk in class 4; Advisory for Preanesthesia Evaluation states that routine and does not change the risk in class 5. preoperative tests, defined as a test ordered in the absence Enhanced recovery refers to a bundled process with the aim of of a clinical indication or purpose, should not be ordered. attenuating pathophysiologic changes and the stress response A preoperative complete blood cell count and blood type and occurring with surgery. These processes replace traditional but antibody screen should be performed before most major untested practices of perioperative care with the primary goal gynecologic surgeries. of hastening recovery. Other individualized preoperative laboratory testing should be Adoption of enhanced recovery has resulted in an average determined based on the age of the woman, extent of the surgi- reduction in length of stay of 2.5 days and a decrease in cal procedure, and findings at the time of complete history and complications by as much as 50%. physical examination. Enhanced recovery achieved the greatest benefit in patients Determining the preoperative creatinine or blood urea undergoing complex cytoreduction for ovarian cancer, of whom nitrogen level is especially important if the woman is going 57% underwent colonic or small bowel resection. to be treated with antibiotics excreted by the kidneys. The popularity of thoracic epidural anesthesia (TEA) after A pregnancy test may be appropriate, depending on contracep- major open gynecologic surgery is due to its effectiveness in tive and sexual history. The PREG criteria can be used to controlling pain and the quicker return of bowel function seen optimize screening for pregnancy in women 18 years and in patients with epidural anesthetics. older. A pregnancy test should almost always be performed The role of TEA in an ERAS care plan is less clear because it if the patient is a teenager, as menstrual history is at best an can compete at times with some of the ERAS goals and its use. imperfect indication of an early pregnancy. TEA has been associated with more interventions to treat Continued 543 544 PART III General Gynecology KEY POINTS—cont’d hypotension, longer length of hospital stay, and more complica- Approximately 25% of all SSIs are caused by Staphylococcus tions in one series of early stage endometrial cancer patients. aureus. A surgical site infection (SSI) is one of the most common com- Approximately 40% of deaths after gynecologic surgery are re- plications after surgery. SSIs dissatisfy patients and providers, lated to pulmonary emboli. Although the initial venous injury but they also increase the cost of surgical care, increase mor- most often occurs at the time of the operation, approximately bidity, and can increase mortality. 15% of symptomatic emboli do not present until the first week There are three classifications of SSIs according to the after discharge from the hospital. Centers for Disease Control and Prevention and the American Using the Caprini score, women in the very-low-risk group College of Surgeons National Surgical Quality Improvement have less than a 3% risk of venous thromboembolism (VTE), Program: (1) superficial incisional, (2) deep incisional, and women in the moderate group have a 10% to 30% risk, and (3) organ/space. women in the high-risk groups have a more than 30% risk Elements shown to decrease SSI that are often included in of a VTE. reduction bundles include preoperative nicotine cessation, pre- Low-molecular-weight heparin (LMWH) is superior to operative antiseptic showering and chlorhexidine preparation, standard unfractionated heparin because it has a longer half- using hair clippers instead of a razor, appropriate preoperative life, almost 100% bioavailability, dose-independent clearance, antibiotic selection, normothermia, and glycemic control. and a more consistent anticoagulation effect from dose There is abundant literature supporting the use of prophylactic to dose. antibiotics in gynecology. The incidence of febrile morbidity A meta-analysis of studies evaluating high-risk procedures may be reduced from 40% to 15% and the incidence of pelvic found perioperative and postoperative LMWH administration infection decreased from 25% to 5%. to be equally effective. The current guidelines for antimicrobial prophylaxis for In general, warfarin should be held for at least 5 days before vaginal or abdominal hysterectomy include the first- or surgery and the international normalized ratio should be less second-generation cephalosporins of cefazolin, cefotetan, than 1.5 before incision. cefoxitin, or ampicillin-sulbactam. Therapeutic dose aspirin should be held for 7 days before Among women with a !-lactam allergy, the recommended surgery. Once-daily dosing of baby aspirin (81 mg/day) can combinations are (1) clindamycin or vancomycin plus an usually be continued. aminoglycoside, or (2) aztreonam, or (3) a fluoroquinolone, Factor Xa inhibitors should be held for 2 to 3 days before metronidazole, and aminoglycoside, or (4) a fluoroquinolone surgery, depending on the individual drug’s half-life. Direct alone. thrombin inhibitors should be held for 2 to 4 days before Comparative studies have documented that single-dose therapy surgery, depending on renal function. is as effective as 24 hours of antibiotics. No advantage exists Patients with bleeding disorders usually present early in their to continuing prophylactic antibiotics beyond the immediate lives with bleeding. It is estimated that approximately 1% to operative period. 2% of patients in the United States have some type of bleeding Vaginal surgery continues to carry the lowest risks of SSI and diathesis, the most common of which is von Willebrand should remain the preferred surgical approach when feasible. disease. However, when minimally invasive approaches to hysterectomy Patients on chronic steroid therapy should receive their usual replace laparotomy, the risk of SSI can be reduced by up to preoperative dose of steroids on the day of surgery. Any further 16-fold. administration of steroids should be done using a risk-assessment Multiple studies have documented a two- to threefold increase model. If there is a clinical concern of adrenal insufficiency, in the SSI rate directly related to perioperative shaving; if the perioperative stress-dose steroid administration appears to carry hair is mechanically in the way, it should be clipped just before minimal risk compared with the risk of adrenal crisis. the operation. Pulmonary function tests of lung volumes and flow rates are only The use of chlorhexidine gluconate with 70% isopropyl alcohol indicated to evaluate women with a history or physical findings as a skin preparation demonstrated a 40% reduction in SSIs in suggestive of restrictive or obstructive pulmonary clean contaminated (type II) wound types compared with a disease. 10% povidone-iodine solution. Predisposing factors that increase the incidence of atelectasis in- The risk of an SSI is significantly increased in the setting of clude morbid obesity, smoking, pulmonary disease, and advanced smoking, and patients should be encouraged to stop as patients age. Increased pain, the supine position, abdominal distention, in a smoking cessation program had perioperative complication impaired function of the diaphragm, and sedation also contribute rates of 21% versus 41% in controls. to decreased lung volumes and reduced dynamic measurements Hypothermia has been shown to increase the incidence of of pulmonary function postoperatively. wound infections, postoperative myocardial events, and periop- The excessive mortality rate associated with a noncardiac erative blood loss; impair drug metabolism; and prolong operative procedure within 3 months of an acute myocardial postoperative recovery. Preventing intraoperative hypothermia infarct is 27% to 37%. After a 6-month interval, the chance improves surgical outcomes. of a reinfarction is 4% to 6% with elective operations. Glucose levels greater than 180 mg/dL among patients with The routine use of beta-blockers perioperatively to reduce and without diabetes increase the risk of SSI by twofold. the risk of nonfatal myocardial infarction is no longer Perioperative blood glucose levels should be maintained at practiced because of the increased risk of death, nonfatal less than 200 mg/dL for all patients. stroke, hypotension, and bradycardia. As a result, the common Category 1A evidence has demonstrated that strict glucose practice of perioperative beta-blockade has given way to its control (80 to 130 mg/dL) in both patients with diabetes and selective use. those without does not improve SSI rates over glucose levels The administration of prophylactic antibiotics solely to prevent less than 200 mg/dL. Strict control may have detrimental endocarditis is no longer recommended for patients who effects on postoperative outcomes. undergo genitourinary or gastrointestinal tract procedures.  CHAPTER 24 Preoperative Counseling and Management 545 Preoperative evaluation can involve both the art and science of woman and the surgical procedure that is being recommended. clinical medicine. Optimal preparation for the operation facili- However, even minor operations may have major complications, 24 tates a successful result and protects the patient and the physician. so it is important to be prepared for all possibilities. The task of obtaining preoperative information serves two Obtaining a detailed and comprehensive preoperative history goals. The first is to ensure that the procedure is appropriate for includes the use of open-ended questions and directed questions to · the patient’s diagnosis, relying heavily on the physician-patient relationship. The second goal, just as crucial as the first, is ensur- ing that the patient is safe for the procedure and that comorbidi- complete the preoperative picture. A standardized historical ques- tionnaire before the initial consultation is often requested by the surgeon or even required by the surgeon’s institution. With the ties are appropriately addressed. Some comorbidities will require broadening use of electronic medical records, a patient’s collated further consultation with other specialists, and it is important medical history may also be available. Regardless, each surgeon for the gynecologic surgeon to recognize when consultation develops his or her method of preparation for consultation. Review is needed. * CP clearance of the patient’s medical record, obtaining outside records and prior The gynecologic surgeon, as leader of the surgical team, has a operative reports, and pertinent imaging and pathology reports can responsibility to prepare the patient, her family, and the surgical team be done before the in-person consultation. This can allow for effi- for the surgical procedure. Even in emergency situations, preopera- cient evaluation, consultation, and preoperative referrals if needed. tive preparation should be detailed and complete. Most surgical Although this chapter does not review all the components of procedures are major events in a patient’s life and can be accompa- a complete history, it may be advantageous to group questions nied by anxiety and apprehension in anticipation of surgery. It is not under the specific organ systems. Specific questions should be uncommon for patients to experience ambivalence when deciding to included to cross-check the review of symptoms. Questions have an operation, elective or emergent. In all cases it is important for should be included that address prior problems with surgery, the surgeon to outline the natural history of the gynecologic disease anesthesia, or bleeding in the woman or her family. Medication and options for management. The risks, benefits, and alternatives - allergies and current medications should be reviewed. Reconcili- must be discussed. The impact of a surgical intervention on normal ation of prescribed and over-the-counter (OTC) medications as body function, sexuality, and cosmesis should also be addressed. If the well as vitamins, herbal medications, and supplements is critical patient is ambivalent about the need for a surgical procedure, a sec- because side effects and interactions with other medications can ond opinion may be warranted and should be offered. Some third- adversely affect coagulation and wound healing. Approximately party payer programs may require patients to obtain a second opin- 0.5% of the general population and 1.5% of women older ion before elective gynecologic surgery. than 55 years are receiving continuous glucocorticoids. Thus It is the surgeon’s responsibility to protect the patient’s a specific question about glucocorticoid therapy for chronic privacy and dignity throughout the perioperative period. The medical problems should be included. The patient’s primary care surgeon must appreciate that the preoperative period may be one physician (PCP), or subspecialty medical provider, depending on of great psychological stress for the patient and her support team. the medication, should be involved in the decision to temporarily Emotional responses may include vulnerability, helplessness, and stop certain medications before surgery. The patient’s PCP may grief associated with loss of a reproductive organ. The surgeon- also be able to provide guidance regarding anticoagulation bridg- patient relationship extends beyond the legal obligations. An ing and stress-dose steroid dosing if either are needed. important aspect of this relationship is that the surgeon and Patients often do not recognize aspirin or oral contracep- patient partner in shared decision making. Trust is established tives as medication; therefore specific questions regarding via mutual respect and open communication. these medications are needed. General questions regarding Preoperative consultation with the surgeon is a crucial first smoking, alcohol, exercise tolerance, and recent upper respira- step in successful surgery. Ideally, the surgeon, patient, and her tory infections should also be included. Specific questions should selected support team meet for a confidential consultation. A be directed toward sensitivity to iodine or latex. Latex allergy is thorough and detailed history and physical examination should directly responsible for 12% of the perioperative anaphylac- be performed during the surgical consultation. A number of stud- tic reactions in adult women and for 70% in children. Health ies have demonstrated that the most significant risk factors for care workers are particularly at risk for latex allergy. Women with postoperative morbidity are preoperative conditions. Known or spinal cord injuries, or those who have had to perform self-cath- unsuspected medical illnesses may affect the operation, anesthe- eterization, are at higher risk for latex allergy. sia, and postoperative course and may preclude the procedure The patient’s contraceptive history, including any recent altogether. It is also important to evaluate the impact of the gy- change, must be known. Ensuring that pregnancy is excluded ei- necologic diagnosis on other organ systems, such as a pelvic mass ther through the preoperative history or a pregnancy test is criti- on the ureters or menorrhagia on hemoglobin level. cal before gynecologic surgery. Included with the contraceptive This chapter outlines the preoperative preparations for gyneco- history are key questions concerning possible exposure to viruses logic surgery and perioperative management considerations. such as hepatitis B, hepatitis C, and human immunodeficiency The preparations and plans for surgery extend into the postopera- virus (HIV). Also, the surgeon should discuss the possibility and tive period in a continuous spectrum. Thus several topics will risks of blood transfusion and learn whether there are religious be introduced here and discussed further in Chapter 25. Emphasis objections if a blood transfusion is needed during surgery. is placed on obtaining a complete history, performing an adequate physical examination, counseling the patient, estab- lishing informed consent, and perioperative planning to PHYSICAL EXAMINATION reduce complications associated with gynecologic surgery. The preoperative physical examination should answer three basic questions: PREOPERATIVE HISTORY 1. Has the primary gynecologic disease process changed since A detailed complete history not only obtains information the initial diagnosis? but may also help relieve the patient’s fears and anxieties. 2. What is the effect of the primary gynecologic disease on other When the history is obtained in an unhurried manner, the pro- organ systems? cess can be reassuring. The extent and depth of the general his- 3. What deficiencies in other organ systems may affect the tory should be tailored to the age and general health of the proposed surgery and hospitalization? 546 PART III General Gynecology Observations and findings in the physical examination may Tests with indications prompt further laboratory and diagnostic tests. One of the most Tests without indications important features of the preoperative physical examination is Unindicated potentially significant abnormalities that it should be performed in a thorough and compulsive man- Unindicated abnormalities, not relevant to patient care ner. One should use the same sequence every time to help focus 0.2% 0.3% 0.3% 0.2% 0.4% 0.15% attention on the evaluation of each organ system and to prevent omissions. Two important axioms should be stressed. First, even in 100 emergency situations, it is imperative to perform a thorough 90 physical examination. This should include an evaluation of blood pressure and pulse in the recumbent and sitting positions; 80 orthostatic hypotension and tachycardia are crude indicators of % tests in sample 70 hypovolemia. Second, although it is important to perform a pelvic 60 examination during the initial consultation, it can also be informa- tive to perform a pelvic examination in the operating room im- 50 mediately before the surgical incision. An exam while the patient 40 is under anesthesia may provide additional information, help 30 avoid intraoperative surprises, and guide the surgical plan. 20 10 LABORATORY AND PREOPERATIVE DIAGNOSTIC 0 PROCEDURES ) 7) 0) ) ) ) ) The general purpose of preoperative laboratory testing is to 01 90 14 64 85 40 61 (2 (3 (5 (4 27 t( t( identify conditions that will alter or aid in perioperative manage- l( TT nt is se un un ys ta ou co /P ment. Screening tests are used to find unsuspected asymptomatic co co To al lc lu PT an et BC G el conditions that may affect the anticipated surgical procedure. el lc le C at tip tia Preoperative laboratory tests may also help establish the extent Pl ul en m of known disease and may influence the scheduling of elective er ed iff surgery. Being selective in ordering preoperative test avoids D at m unnecessary costs associated with test results that would to Au otherwise not affect the surgical plan. Additionally, special imaging procedures may be needed to determine the effects of Fig. 24.1 Proportions of indicated and unindicated preoperative tests, pelvic disease on other organ systems. drawn to scale. Numbers in parentheses represent sample sizes used. Age-appropriate screening tests should be reviewed with CBC, Complete blood cell; automated multiple analysis is the sixth each patient before gynecologic surgery. Papanicolaou (Pap) factor; PT/PTT, prothrombin time/partial thromboplastin time. (From tests should be up to date before elective gynecologic surgery. Kaplan EB, Scheiner LB, Boeckmann AJ, et al. The usefulness of Mammograms should at least be discussed with women 40 years preoperative laboratory screening. JAMA. 1985;253(24):3576-3581.) and older, and colonoscopy should be discussed with women older than 50 years. There is debate over which preoperative laboratory procedures coagulation studies are not cost effective and rarely provide use- should be standard. Attention has been drawn to the cost-benefit ful clinical information unless indicated by history and physical ratio of preoperative screening. Although the cost of each indi- examination, as the patient’s menstrual history should identify vidual test is usually low, the aggregate costs can be substantial. In women with bleeding disorders. a classic study, Kaplan and colleagues retrospectively studied the Other individualized preoperative laboratory testing should usefulness of preoperative laboratory procedures. They estimated be determined based on the age of the woman, extent of the sur- that 60% of routinely ordered tests, such as differential cell count, gical procedure, and findings at the time of complete history and platelet count, and 12-factor automated body chemistry analyses, physical examination. It may be indicated to order limited blood would not have been performed if tests had been ordered only for screening tests for women older than 40 years or who have posi- an indication discovered by history or physical examination. Most tive family histories or questionable histories of hepatic or renal important, only 0.22% of these tests demonstrated an abnormality disease. Determining the preoperative creatinine or blood urea that might influence perioperative management (Fig. 24.1). The nitrogen (BUN) level is especially important if the woman is go- final conclusion in their assessment of 2000 patients undergoing ing to be treated with antibiotics excreted by the kidneys. A elective operations was that in the absence of specific indications, pregnancy test may be appropriate, depending on contra- most routine preoperative laboratory tests do not signifi- ceptive and sexual history, but a preprocedure pregnancy cantly contribute to patient care and could be eliminated risk questionnaire may also be used as an effective history- (Kaplan, 1985). Additionally, the current American Society of based screen on the day of surgery for women 18 years and Anesthesiologists (ASA) Practice Advisory for Preanesthesia Eval- older (Fig. 24.2) (Wyatt, 2018). However, a preprocedure preg- uation states that routine preoperative tests, defined as a test or- nancy test should almost always be performed if the patient is a dered in the absence of a clinical indication or purpose, should not teenager, as menstrual history is at best an imperfect indication of be ordered. Preoperative tests should be ordered for indicated an early pregnancy. Serum electrolyte levels are ordered for purposes that guide or optimize perioperative care (Committee on women taking diuretics or those with a history of renal disease or Standards and Practice Parameters, Reaffirmed 2018). heart disease. Also, serum electrolyte levels should be evaluated However, a preoperative complete blood cell count and blood in women with vomiting, diarrhea, ileus, bowel obstruction, or type and antibody screen should be performed before most major any condition that affects electrolyte balance. Ideally, abnormal gynecologic surgeries. In the setting of anemia, the risks and results from any laboratory test ordered preoperatively should benefits of proceeding with gynecologic surgery should be con- result in some change in perioperative management. sidered. It is important that the blood bank have the capability of Routine chest radiographs on all patients often do not affect providing cross-matched blood within a reasonable period if seri- perioperative management in elective gynecologic surgery. A ous intraoperative bleeding were to occur. Routine preoperative history and physical examination are sufficient for screening, and  CHAPTER 24 Preoperative Counseling and Management 547 Pre-Procedure Pregnancy Reasonably Excluded Guide 24 (PREG) Page1 retained in medical record Discard after electronic entry. Page 2 instruction only, discard after use. Instructions: To determine if we need to do a pregnancy test today, review each. Check any and that apply. Mayo Clinic Number Patient Name (first, middle, last) Birth Date (Month, DD, YYYY) ! I am pregnant. ! I have had a bilateral tubal ligation (ie, “tubes tied”, Essure® with confirmatory testing). ! I have had a hysterectome or bilateral salpingo-oophorectomy (both ovaries removed), or both. A ! I am menopausal and more than 45 year old. I have not had a period spontaneously for the past 12 months. ! I have a current IUD (eg, Mirena®, Skyla™, Paragard®, Liletta™) in place. ! I have a current contraceptive implant (eg, Nexplanon®, Implanon®) in place. ! I have not had sexual intercourse with a man since the start of my last normal menstrual period. ! My partner has had a vasectomy and he has had a negative post-surgery semen analysis. B ! I started bleeding from a normal period within the last seven days. ! I raliably use hormonal contraception (eg, “the pill”, Depo-Provera® Shots, patch, ring). ! I think I may be pregnant or would like a pregnancy test. C ! None of the above in sections A–C apply. Fig. 24.2 Pre-Procedure Pregnancy Reasonably Excluded Guide (PREG). This guide is an effective history- based pregnancy screen that can be used on the day of surgery for women 18 years and older. IUD, Intrauterine device. (From Wyatt, MA, Ainsworth AJ, DeJong SR, Cope AG, Long ME. Implementation of the “Pregnancy Reasonably Excluded Guide” for pregnancy assessment: a quality initiative in outpatient gynecologic surgery. Obstet Gynecol. 2018;132(5):1222-1228. chest radiographs should be obtained in patients with positive information, when available, can be helpful. Psychological prepa- findings. A meta-analysis of studies of routine preoperative ration of the patient’s support team is equally important, and ar- chest radiographs demonstrated that false-positive results rangements for appropriate communication with the patient’s leading to invasive procedures and associated morbidity are family or support team during the operation should be made. more common than the discovery of new findings leading to Few concepts bring more ambivalence and concern to the a change in management. However, chest films should be or- physician than the doctrine of informed consent. In the present dered for women who are current or former smokers, women medicolegal climate, the absence of informed consent is cited as a with cardiac or pulmonary symptoms, immigrants who have not major problem in many lawsuits. Some of these issues are had a recent chest film, and women older than 70 years (Qaseem, discussed further in Chapter 6. It is important to differentiate 2006), although there appears to be institutional variability re- between the concepts of consent and informed consent. Consent garding the absolute age cutoff. involves a simple yes-no decision, but informed consent is A baseline preoperative electrocardiogram (ECG) has an educational process that also includes shared decision been found to be cost effective in asymptomatic women making between surgeon and patient. To obtain informed 60 years and older without a history of cardiac disease or signifi- consent, the surgeon must explain the following to the patient in cant risk factors. An ECG may also be indicated in younger understandable terms: the nature and extent of the disease pro- women with a history of smoking and those with diabetes or cess; the nature and extent of the contemplated operation; the renal disease, depending on the severity. anticipated benefits and results of the surgery, including a conser- Based on the complete history, physical examination, and pre- vative estimate of successful outcome; the risks and potential operative testing, the gynecologic surgeon should determine complications of the operative procedure; alternative methods of whether consultation with other specialists is necessary. This therapy; and any potential changes in sexual, reproductive, and decision should take into account the severity of comorbidities other functions. The surgeon should also discuss with the patient and the complexity of the proposed operation. what the operation will not accomplish. Questions from the pa- tient should be encouraged and addressed. Any details specific to the situation should be clarified in the consent note in addition to PATIENT EDUCATION AND INFORMED CONSENT stating that the procedure, alternative treatments, and risks have One of the primary responsibilities of the gynecologic surgeon is been discussed and questions have been answered. The possibility to educate the patient and her support team about the anticipated of unanticipated pathologic conditions should be discussed with surgical procedure, hospitalization, and recovery. Informed con- the woman and permission obtained on the written consent form sent is an important principle to ensure that the patient’s right to for the most extensive operative procedure that may be necessary. self-determination is respected. The ethical concept of the pro- One of the greatest dilemmas in the doctrine of informed cess of informed consent includes two components, compre- consent is the extent and depth of discussions concerning poten- hension and free consent. Throughout the educational process, tial complications of an operation. Attorneys who specialize in questions from the patient or her support team should be wel- defending gynecologic surgeons in medical malpractice litigation comed. Educating the patient can also address anxiety. Written strongly advise discussing the risks of all major complications, 548 PART III General Gynecology including death from surgery and rare, serious complications, TABLE 24.1 American Society of Anesthesiologists (ASA) Physical such as urinary tract fistulas after hysterectomy. Studies have Status Classification shown that approximately 70% of patients do not read the con- ASA Physical sent form before signing it. Ideally, to protect the surgeon, an- Status Class Description other member of the health care delivery team should witness the final discussion of the informed consent process. The surgeon 1 A normal healthy patient should document critical highlights of this discussion in the pa- 2 A patient with mild systemic disease tient’s medical record. 3 A patient with severe systemic disease The gynecologic surgeon must not only educate his or her patient but must be prepared to discuss other information that 4 A patient with severe systemic disease that is a the patient has received, including information from the lay press constant threat to life and Internet. During the preoperative educational process, so 5 A moribund patient who is not expected to survive much information may be given that it causes confusion. Studies without the operation have noted that the more information given, the less information is actually retained, much less correctly retained. A study by From Koo CY, Hyder JA, Wanderer JP, et al. A meta-analysis of the predictive accuracy of postoperative mortality using the American Sandberg and colleagues has noted that during the preoperative Society of Anesthesiologists’ Physical Status Classification System. evaluation, information given by anesthesiologists and other World J Surg. 2015;39(1):88-103. health care providers vastly exceeds the short-term capacity of patients (Sandberg, 2008). Thus it is extremely helpful to provide written preoperative instructions and important information. given during the procedure. It is acceptable for the patient PREOPERATIVE PREPARATION to take oral medications the morning of surgery. The 30 to Most procedures and orders are accomplished on an outpatient 60 mL of water needed to swallow the oral medication is basis because most patients undergo same-day admission before negligible compared with gastric fluid volumes. elective surgery. Preoperative orders should be standardized to Anesthesiologists classify surgical procedures according to the avoid omissions, and electronic order sets are standard at most patient’s risk of mortality. In 1961, Dripps first published guide- institutions. Orders individualized to a patient should be written lines to determine the risk of death related to major operative in specific detail to avoid confusion by nursing and other hospital procedures. This physical status scale (Table 24.1) has been personnel. adopted by the ASA and has been revalidated many times over Before presentation to the hospital, the patient should be pro- the years. With minor modifications, these anesthetic risk classes vided with a list of specific instructions for the 24 hours before are still widely used. An emergency operation doubles the mor- surgery. If an enhanced recovery pathway is being used, the tality risks for classes 1, 2, and 3; produces a slightly increased risk patient can usually eat solid food up until midnight and clear in class 4; and does not change the risk in class 5 (Koo, 2015). liquids until 30 minutes before presenting to the hospital. To avoid hypoglycemia, most enhanced recovery after surgery protocols allow patients to eat solid food up to 6 hours before PERIOPERATIVE MANAGEMENT surgery. Clear liquids are emptied from the stomach within min- utes; however, fatty foods delay gastric emptying. Incomplete Enhanced Recovery preparation of the upper gastrointestinal (GI) tract increases the Enhanced recovery refers to a bundled process with the aim risk of aspiration. Studies have documented the safety of allowing of attenuating pathophysiologic changes and the stress inpatients and outpatients to ingest clear liquids up until 2 hours response occurring with surgery. These processes replace tra- before elective surgery, and this is reflected in current ASA guide- ditional but untested practices of perioperative care with the lines (ASA Practice Guidelines, 2017). The extent of preoperative primary goal of hastening recovery. This challenge to traditional anxiety does not influence gastric fluid volume or acidity. surgical paradigms—such as mechanical bowel preparation, the overnight fasting rule, delayed postoperative feeding, hypervol- emia, and intravenous opioids—was first described in Europe in CONSULTATION WITH ANESTHESIOLOGIST the 1990s (Kehlet, 1997). There has been widespread uptake of Among patients with no or limited comorbidities, the consulta- formalized evidence-based enhanced recovery after surgery tion with their anesthesiologist may occur in the preoperative (ERAS) protocols internationally, particularly in colorectal sur- area on the day of surgery. During this time, the anesthesiologist gery. Adoption of ERAS has resulted in an average reduction reviews and obtains any additional medical information, evaluates in length of stay of 2.5 days (Chambers, 2014; Varadhan, the patient’s airway, determines the ASA risk score for the patient, 2010) and a decrease in complications by as much as 50%. and writes any preoperative medication orders. Among patients Similarities between gynecologic oncology procedures and with complex medical histories or comorbidities, prior complica- those performed in surgical specialties such as colorectal surgery tions with anesthesia, family history of anesthesia complications, suggest that patients with gynecologic cancer may obtain compa- or planned high complexity surgery, a preoperative evaluation rable benefits. Data also suggest women undergoing benign with an anesthesiologist in an outpatient clinic a day or more gynecologic surgery, including minimally invasive surgery (MIS), before surgery is warranted. The goal for this evaluation is to benefit from perioperative management on an ERAS pathway. ensure all preoperative assessments needed to optimize anesthe- In one investigation of patients undergoing gynecologic sur- sia safety have been performed. gery, 241 patients (81 complex cytoreductive, 84 staging, and Surgeons and anesthesiologists often have to determine 76 vaginal surgery cases) were managed with an ERAS protocol whether to continue or interrupt medications during the periop- and compared with 235 historical controls matched by procedure erative period. If the medication is prescribed for a chronic (Kalogera, 2013). The protocol included omission of preopera- medical illness, it is likely best to continue the drug throughout tive fasting (Brady, 2003), use of carbohydrate loading (Mathur, the perioperative period. However, it is essential to determine 2010; Nygren, 1995), omission of mechanical bowel preparation whether the drug will adversely affect the course of the anesthesia (G enaga, 2011), use of preemptive analgesia, nausea and vomit- or surgery and whether it will interact with other drugs to be ing prophylaxis, and maintenance of perioperative euvolemia  CHAPTER 24 Preoperative Counseling and Management 549 (Brandstrup, 2003). Laparotomy wounds were injected with bu- or omitted, whereas early feeding (Charoenkwan, 2007; Cutillo, pivacaine because epidural analgesia was not used for patients 1999; Minig, 2009), laxative use, and early mobilization were en- 24 undergoing laparotomy in this series (Kalogera, 2013). Intrathecal couraged (Table 24.2). The ERAS pathway achieved the greatest analgesia was used in more than 40% of vaginal cases in this series. benefit in patients undergoing complex cytoreduction for ovarian Nasogastric tubes (Nelson, 2007), surgical drains (Kalogera, cancer, of whom 57% underwent colonic or small bowel resec- 2012), and intravenous patient-controlled analgesia was avoided tion. Patient-controlled anesthesia use decreased from 99% to TABLE 24.2 Evidence-Based Enhanced Recovery after Surgery (ERAS) Protocol for Gynecologic Surgery Patients PREOPERATIVE Diet Evening before surgery: carbohydrate-loading drink; may eat until midnight May ingest fluids up to 4 hours before procedure Eliminate use of mechanical bowel preparation; rectal enemas still performed INTRAOPERATIVE Analgesia before OR entry Celecoxib 400 mg PO once Acetaminophen 1000 mg PO once Gabapentin 600 mg PO once Postoperative nausea and Before incision (" 30 min): dexamethasone 4 mg IV once # droperidol 0.625 mg IV once vomiting prophylaxis Before incision closure (" 30 min): granisetron 0.1 mg IV once Fluid balance Goal: maintain intraoperative euvolemia Decrease crystalloid administration Increase colloid administration if needed Analgesia Opioids IV at discretion of anesthesiologist supplemented with ketamine or ketorolac After incision closure: injection of bupivacaine at incision site Anesthesia in complex Subarachnoid block containing bupivacaine and hydromorphone (40-100 $g) vaginal surgery Sedation versus “light” general anesthetic at the discretion of the anesthesiologist Ketorolac 15 mg at the end of the procedure for patients able to tolerate it No wound infiltration with bupivacaine in this cohort POSTOPERATIVE Activity Evening of surgery: out of bed greater than 2 hours, including 1 or more walks and sitting in chair Day after surgery and until discharge: out of bed greater than 8 hours, including 4 or more walks and sitting in chair Patient up in chair for all meals Diet No nasogastric tube (NGT); if NGT used intraoperatively, remove at extubation Patient encouraged to start low-residue diet 4 hours after procedure Day of surgery: 1 box of liquid nutritional supplement. Encourage oral intake of at least 800 mL of fluid, but no more than 2000 mL by midnight. Day after surgery until discharge: 2 boxes of liquid nutritional supplement. Encourage daily oral intake of 1500-2500 mL of fluids. Osmotic diarrhetics: Senna and docusate sodium; magnesium oxide; magnesium hydroxide prn Analgesia Goal: no IV patient-controlled analgesia (PCA) Oral opioids Oxycodone 5-10 mg PO every 4 hours as needed for pain rated 4 or greater or greater than patient stated comfort goal (5 mg for pain rated 4-6 or 10 mg for pain rated 7-10). For patients who received intrathecal analgesia start 24 hours after intrathecal dose given. Scheduled acetaminophen* Acetaminophen 1000 mg PO every 6 hours for patients with no or mild hepatic disease; acetaminophen 1000 mg PO twice daily for patients with moderate hepatic disease; maximum acetaminophen should not exceed 4000 mg per 24 hours from all sources. Scheduled NSAIDs Ketorolac 15 mg IV every 6 hours for 4 doses (start no sooner than 6 hours after last intraoperative dose); then, ibuprofen 800 mg PO every 6 hours (start 6 hours after last Ketorolac dose administered) If patient unable to take NSAIDs Tramadol 100 mg PO four times a day (start at 6 a.m. day after surgery) for patients less than 65 years of age and no history of renal impairment or hepatic disease; tramadol 100 mg PO twice daily (start at 6 a.m. day after surgery) for patients 65 years of age or older or creatinine clearance less than 30 mL/min or history of hepatic disease. Breakthrough pain (pain greater than 7 more than 1 hour after receiving oxycodone) Hydromorphone 0.4 mg IV once if patient did not receive intrathecal medications; may repeat once after 20 minutes if first dose ineffective. IV PCA Hydromorphone PCA started only if continued pain despite two doses of IV hydromorphone Fluid balance Operating room fluids discontinued upon arrival to floor Fluids at 40 mL/hour until 8:00 a.m. on day after surgery, then discontinued Peripheral lock IV when patient had 600 mL PO intake or at 8:00 a.m. on day after surgery, whichever came first. From Kalogera E, Bakkum-Gamez JN, Jankowski CJ, et al. Enhanced recovery in gynecologic surgery. Obstet Gynecol. 2013;122(2 Pt 1):319-328. *Doses for patients greater than 80 kg and less than 65 years of age; doses adjusted as appropriate for patients less than 80 kg and/or 65 years of age or older. IV, Intravenous; NSAID, nonsteroidal antiinflammatory drug; OR, operating room; PO, administered orally. 550 PART III General Gynecology 33%, and total opioid use decreased by 80% in the first 48 hours paired. This is controversial in gynecologic surgery because the with no increase in pain scores. Hospital stay was reduced by preoperative determination of adnexal laterality is not always 4 days with 30-day cost savings of more than $7600 per patient reliable. If site marking is done, it should performed in the (18.8% reduction). In benign vaginal cases, mean pain scores preoperative area while the patient is awake and nonsedated. significantly improved and hospital stay was significantly reduced The patient should participate in Universal Protocol and by 1 day with the use of intrathecal analgesia. Ninety-five percent confirm which organ(s) will undergo surgery. Universal Pro- of patients rated satisfaction with perioperative care as excellent or tocol and site marking reduce the risks of wrong site, wrong very good. Other investigations in patients undergoing gyneco- procedure, and wrong person operations (Knight, 2010). logic surgery have shown that ERAS is safe and confers signifi- cant benefits in hospital length of stay, pain control, and overall recovery (Carter, 2012; Chase, 2008; Eberhart, 2008; Preoperative Briefing Gerardi, 2008; Kalogera, 2013; Marx, 2006; Wijk, 2014). It is now common practice to perform a preoperative briefing, or The popularity of thoracic epidural anesthesia (TEA) after “huddle,” before bringing the patient to the operating room. Usu- major open gynecologic surgery is due to its effectiveness in con- ally performed in the preoperative area, the entire surgical team trolling pain and the quicker return of bowel function seen in should be briefed on the patient’s diagnosis, surgical plan, patients with epidural anesthetics (Ferguson, 2009). However, positioning, relevant comorbidities, intraoperative orders, and the role of TEA in an ERAS care plan is less clear because it can perioperative considerations. Medications to be administered, compete at times with some of the ERAS goals such as early including antibiotics, prophylactic dose heparin, local analgesics, ambulation and voiding. The use of TEA has been associated and specialty medications such as local or systemic dye injections with more interventions to treat hypotension, longer length of or vasoactive medications should be discussed. The anesthesia hospital stay, and more complications in one series of early-stage plans and estimated blood loss for the procedure should be endometrial cancer patients (Belavy, 2013). The estimated length reviewed. Special equipment needed for the procedure should be of stay in most ERAS pathways for abdominal hysterectomy is noted so that it is immediately available when needed. The antici- approximately 1 to 2 days, and MIS hysterectomies are most of- pated wound classification should be noted so that it is accurately ten performed as outpatient procedures. TEA in these settings documented in the patient’s medical record. Ideally the entire not only represents poor use of resources but also will likely in- operating room team should be present for the briefing, including terfere with the expected expedient discharge from the hospital. the surgeon, resident/fellow, nurse, surgical assistant and techni- Further study is needed to determine whether TEA or other local cian, and anesthesia team. All team members’ questions should be or regional analgesic approaches in radical abdominal procedures answered before bringing the patient to the operating room. Once such as ovarian cancer debulking improve the return of bowel the patient is in the operating room and positioned and function or shorten hospital stays. before the start of the operation a surgical “time-out” is performed. The time-out involves the immediate members of the procedure team: the individual performing the procedure, Gastrointestinal Tract Considerations anesthesia providers, circulating nurse, operating room technician, If GI symptoms are present before gynecologic surgery, preopera- and any others who will be participating in the procedure. tive endoscopy or imaging studies of the GI tract should be consid- The patient is identified once again using two separate identifiers, ered to better understand the cause of these symptoms. The effect usually name and medical record number, and the surgical site and of nausea, vomiting, or diarrhea on serum electrolyte levels and on planned procedure are also verified. Patient allergies, medications the nutritional status of the patient also needs to be evaluated. The on the surgical table, and any special needs are reviewed. Finally, evaluation should be individualized to determine whether a primary performing a fire risk assessment is considered a “best practice” as gynecologic process is causing the GI symptoms. it increases awareness of the potential for fire, enhances communi- If a bowel preparation is necessary, a single day of an oral solu- cation among team members, and makes staff active participants in tion can be used. Magnesium citrate, sodium phosphate (Fleet fire prevention when confirmed by all present. phospho-soda), and polyethylene glycol (PEG; GoLYTELY) are the three most commonly used agents. Oliveria and colleagues reported a large randomized trial comparing sodium phosphate Positioning for Surgery and PEG-based oral lavage solutions. The efficacy of the two After anesthesia has taken effect and the abdominal wall is relaxed, preparations was similar. However, there was superior subjective a preoperative pelvic examination may be indicated depending on patient tolerance to the 90-mL dose of sodium phosphate the planned surgical procedure; if so, it should have been part of (Oliveira, 1997). Care must be taken in selecting patients who are the initial surgical consultation and informed consent process. to receive oral sodium phosphate as a bowel preparation because The findings may influence the choice of incision or operative it may lead to hypokalemia, has been associated with acute phos- approach. Additionally, the surgeon should supervise the position- phate nephropathy, and is contraindicated in women with he- ing of the patient to ensure that she is properly positioned for the patic, renal, or heart disease. As a result, the U.S. Food and Drug procedure being performed. Pressure points should be avoided to Administration (FDA) issued a warning in late 2008 regarding protect against neuromuscular and skin injury, especially over the use of all oral sodium phosphate preparations when used as a bony prominences (Irvin, 2004). bowel cleanser. Special care must be taken in patients older than 55 or younger than 18, patients taking medications that can affect kidney function, and patients who are dehydrated. Surgical Site Infection Prevention Surgical site infection (SSI) is one of the most common compli- cations after surgery. SSIs dissatisfy patients and providers, but REDUCING POSTOPERATIVE COMPLICATIONS they also increase the cost of surgical care, increase morbidity, and can increase mortality (Bakkum-Gamez, 2013; Tran, 2015). Site Marking and Universal Protocol Additionally, SSIs associated with hysterectomies performed Depending on the surgical procedure being performed, operative through abdominal incisions (laparotomy, laparoscopy, or ro- site marking may be required. Most institutions mandate site botic) are reported to the Centers for Medicare and Medicaid marking to be performed in the setting of surgical procedures Services (CMS) and are used to compare hospitals to the national that involve or remove one or both organs or structures that are benchmark for surgical quality. The occurrence of an SSI after  CHAPTER 24 Preoperative Counseling and Management 551 Age Obesity 24 Malnutrition Incision site Cancer Wound classification Diabetes Procedure duration Immunosuppression Hemostasis ASA score Drains/foreign bodies Disease severity Dead space Prior operations Urgency of surgery Prior chemotherapy Prior radiation Surgical Biologics procedures Host factors Surgical team and hospital practice Endogenous factors flora Razor shaves Nasal/skin carriage Intraoperative contamination Virulence Prophylactic antibiotics Adherence Preoperative cleansing Inoculum Preoperative screening for resistant organisms and decolonization Surgeon’s skill Surgical volume Fig. 24.3 The causes of surgical site infections are multifactorial. ASA, American Society of Anesthesiologists. hysterectomy may also influence third-party reimbursement. As (Cruse, 1980; Kj nniksen, 2002), appropriate preoperative antibi- such, there are multiple reasons to reduce SSI occurrences. otic selection (Bratzler, 2013), normothermia (Rajagopalan, 2008; The causes of SSIs are multifactorial. There are host and endog- Scott, 2006; Warttig, 2014), and glycemic control (Kwon, 2013). enous flora factors that may or may not be modifiable. Additionally, SSI reduction bundles that include various combinations of surgical procedures, the surgical team, hospital practice factors, and these elements as well as additional evidence-based and best prophylactic interventions influence the risk of SSI (Fig. 24.3). practices have been shown to decrease SSI after hysterectomy There are three categories of SSIs according to the Centers for by 40% to 80% (Revolus, 2014) and by more than 50% in general Disease Control and Prevention (CDC) and the American College surgery and colorectal surgery (Cima, 2013; Johnson, 2016; van der of Surgeons National Surgical Quality Improvement Program Slegt, 2013; Waits, 2014). The colorectal surgery SSI reduction (ACS NSQIP): (1) superficial incisional, (2) deep incisional, and (3) bundle at the Mayo Clinic (Fig. 24.4) has been validated in the organ/space (ACS NSQIP, 2011) (Box 24.1); each has different risk gynecologic surgery practice as well (Cima, 2013) and yielded an factors (Bakkum-Gamez, 2013). Given the implications of an SSI 82% reduction in SSIs (Johnson, 2016). Additionally, at least one diagnosis, it is important to ensure that if a wound complication study of patients undergoing colorectal surgery reported an inverse occurs, the surgeon classifies it appropriately. Additionally, if a association with SSI and the number of bundle elements used wound is opened intentionally to evacuate a symptomatic hema- (Waits, 2014), suggesting it is the combination of interventions, toma or seroma, it should be cultured because a wound opened by rather than one element alone, that yields the impact. the surgeon meets the definition of an SSI unless it is proven to be culture negative. Prophylactic Antibiotics The use of prophylactic antibiotics in gynecologic surgical Surgical Site Infection Reduction Bundles procedures has become standard practice. Rigidly defined, The combining of evidence-based medicine with consensus prophylactic antibiotic use involves the administration of antibi- best practices into “bundles” of interventions has been shown otics to patients without evidence of current infection to prevent to have some of the greatest impact in reducing SSIs. The term postoperative morbidity related to infection. The goal of antibi- bundle has been defined by the Institute for Healthcare Improve- otic therapy is to prevent SSI by the endogenous flora of the ment (IHI) as a structured way of improving the processes of care lower female reproductive tract. There is abundant literature and patient outcomes or a small, straightforward set of evidence- supporting the use of prophylactic antibiotics in gynecologic based practices that, when performed collectively and reliably, have surgery. The incidence of febrile morbidity may be reduced been proved to improve patient outcomes. Elements shown to de- from 40% to 15% and the incidence of pelvic infection crease SSI that are often included in reduction bundles include decreased from 25% to 3% (Mahdi, 2014). The current guide- preoperative nicotine cessation (S rensen, 2012), preoperative lines for antimicrobial prophylaxis for any mode of hysterectomy antiseptic showering (Webster, 2007) and chlorhexidine prepara- include the first- and second-generation cephalosporins cefazo- tion (Darouiche, 2010), using hair clippers instead of a razor lin, cefotetan, cefoxitin, and ampicillin-sulbactam. Among women 552 PART III General Gynecology approaches to hysterectomy replace laparotomy, the risk of SSI BOX 24.1 Classification of Surgical Site Infections (SSI) by the can be reduced by up to 16-fold (Bakkum-Gamez, 2013; Colling, Centers for Disease Control and Prevention (CDC) and American 2015). As such, the use of minimally invasive surgery is a critical College of Surgeons National Surgical Quality Improvement modifiable factor in the SSI prevention bundle. Program (ACS NSQIP) SUPERFICIAL INCISIONAL SSI* Hair Removal 1. Purulent incisional drainage from above the fascia Multiple studies have documented a two- to threefold increase 2. Organisms isolated from an aseptically obtained culture of fluid in SSI rate directly related to perioperative shaving. Cruse and or tissue from the superficial incision Foord studied approximately 63,000 operations over a 10-year 3. Pain/tenderness, wound swelling, redness, or heat and the period and found a 0.9% incidence of SSI when patients were not superficial incision is deliberately opened by the surgeon shaved as opposed to 2.5% when they were shaved (Cruse, 1980). (unless it is culture negative) Razors produce macroscopic and microscopic nicks and cuts that DEEP INCISIONAL SSI (INVOLVES DEEP SOFT TISSUES, allow a protective environment for colonization by skin bacteria. SUCH AS THE FASCIA OR MUSCLE LAYERS OF THE Depilatory agents often produce intense burning if used on the INCISION) perineum. A systematic review by Kj nniksen and associates has 1. Purulent drainage from the deep incision concluded that if the hair is mechanically in the way, it should be 2. Spontaneous dehiscence or deliberate opening of the fascia in clipped just before the operation (Kj nniksen, 2002). Patients should the setting of fever or localized pain/tenderness (unless it is also be advised not to shave themselves before surgery for this reason. culture negative) 3. An abscess is found involving the deep incision via physical Chlorhexidine/Alcohol Skin Preparation examination, reoperation, or radiologic examination A randomized trial comparing chlorhexidine gluconate with 70% ORGAN/SPACE SSI isopropyl alcohol versus an aqueous solution of 10% povidone- 1. Purulent drainage from an intraperitoneal drain iodine for skin preparation in the operating room showed a 40% 2. Presence of organisms in culture of fluid obtained aseptically reduction in SSIs in clean contaminated (type II) wound types from an organ or space (Darouiche, 2010). The solution is highly flammable, and care 3. Abscess or other infection involving an organ or space on must be taken to ensure adequate drying time to avoid a fire physical examination, reoperation, histopathologic or radiologic when electrocautery is used. examination Smoking From ACS NSQIP. Classic, essential, small-rural, targeted, and Florida variables & definitions. American College of Surgeons National Surgical The risk of an SSI is significantly increased in the setting of smok- Quality Improvement Program Operations Manual. Chicago: ACS; ing (van Walraven, 2013). Ideally, patients should stop smoking for 2011:24-26. at least 8 weeks before surgery. However, abstinence from ciga- *Surgeon diagnosis of any of the three types of SSI also meets NSQIP rettes for 2 to 4 weeks preoperatively is still beneficial. Providing criteria. nicotine replacement is helpful in alleviating the symptoms of acute nicotine withdrawal. Referral to preoperative smoking cessa- tion programs not only decreases smoking around the time of surgery and related perioperative complications but also leads to with a beta-lactam allergy, the recommended combinations are an increased incidence of long-term smoking cessation. In one (1) clindamycin or vancomycin plus an aminoglycoside; or multicenter study, Lindström and associates noted that the patients (2) aztreonam; or (3) a fluoroquinolone, metronidazole, and in a smoking cessation program had perioperative complication aminoglycoside; or (4) a fluoroquinolone alone (Bratzler, 2013). rates of 21% versus 41% in controls (Lindström, 2008). Emphasis has focused on short duration of therapy for prophy- lactic antibiotics. Comparative studies have documented that single-dose therapy is as effective as 24 hours of antibiotics. No Normothermia advantage exists to continuing prophylactic antibiotics beyond the Hypothermia, often defined as a core body temperature less than immediate operative period. This short duration of administration 36° C, has been shown to increase the incidence of SSI and postop- also reduces cost and complications. The incidence of serious erative myocardial events, increase perioperative blood loss, impair complications, such as drug allergy and resistant bacteria, is directly drug metabolism, and prolong postoperative recovery (Rajagopalan, related to the length of administration of the antibiotic. 2008; Scott, 2006; Warttig, 2014). Patients undergoing laparotomy The Surgical Care Improvement Project (SCIP) implemented are at high risk of hypothermia as a result of prolonged periods with by CMS focused on appropriate antibiotic selection and timing of an open abdomen. Furthermore, general anesthesia induces periph- administration with the goal of reducing SSI rates by 25% between eral vasodilation, leading to accelerated heat loss. Esophageal probes 2006 and 2010. Despite high compliance to SCIP measures, which are often used to monitor temperature, and methods to maintain later included normothermia, glucose control, and hair removal normothermia include the use of forced air devices (Galv o, 2010), guidelines, SSI rates do not correlate with SCIP compliance (Hawn, underbody warming mattresses (Perez-Protto, 2010), and warmed 2011). Although antibiotic prophylaxis is an important element intravenous fluids (Campbell, 2015). Whichever method is used, it is in SSI reduction, antibiotics alone cannot mitigate the SSI risk. important to understand that preventing intraoperative hypother- mia improves surgical outcomes. Minimally Invasive Surgery With the introduction of laparoscopy and robotic surgery, the arma- Glucose Control in Patients with and without Diabetes mentarium of minimally invasive gynecologic surgery approaches The prevalence of diabetes is approximately 10% in women older changed dramatically. Vaginal surgery continues to carry the lowest than 65, and the incidence increases rapidly as women get older. The risks of SSI (Lake, 2013) and should remain the preferred surgical stress of surgery often produces changes in glucose tolerance and approach when feasible. However, when minimally invasive insulin resistance. Because pancreatic reserve is a continuum, even  CHAPTER 24 Preoperative Counseling and Management 553 Chlorhexidine cloths @ AM admission 24 Pre-operative Patient Hibiclens® shower night before and processes cleansing day of surgery Ensure understanding by reading pamphlet “Preventing SSI” Ensure SCIP compliance 1. Right antibiotics 2. Administer 60 min prior to incision 3. Discontinued within 24 h Antibiotic administration Ensure re-dose of cefazolin within 3–4 h after incision Chloraprep applied - use appropriate Intra-operative amount to ensure complete coverage processes of incisional area Use closing tray for closure Closing of fascia and skin protocol at time of fascia Reduce SSI Glove change by staff before closure by 50% closure of fascia (10 → 5%) Practice good hand hygiene Patient shower with Hibiclens® after dressing removal Post-operative Patient and processes hand hygiene Hand cleansing agent readily available Signage encouraging hand hygiene Purell® hand wipes made available to patients Ensure dressing removal within 48 h Dismiss patient with 4 oz bottle of Hibiclens® Post- Patient education on wound care and hospitalization recognizing infection symptoms processes Follow-up phone call from nurses Fig. 24.4 Surgical site infection (SSI) reduction bundle in colorectal surgery at Mayo Clinic. SSIs were reduced by more than 50% with the implementation of this full bundle. (From Cima R, Dankbar E, Lovely J, et al. Colorectal surgery surgical site infection reduction program: a national surgical quality improvement program–driven multidisciplinary single-institution experience. J Am Coll Surg. 2013;216(1):23-33.) 554 PART III General Gynecology infection or colonization, obesity, or diabetes) likely benefit from BOX 24.2 Mechanisms Causing Adverse Outcomes From Poorly preoperative S. aureus screening by nasal culture. If positive Controlled Diabetes cultures are documented, eradication of colonization with chlorhexidine baths and twice-daily intranasal mupirocin has been Hyperglycemia shown to decrease the rate of SSI. Bode and colleagues demon- Dehydration strated a decrease in SSI from 7.7% to 3.4% when S. aureus was Academia from keto acids and lactate detected and decolonization performed (Bode, 2010). Nonenzymatic glycosylation of proteins central to immune function: complement, impaired IgG, inhibited neutrophil activity Fatigue and muscle wasting from lipolysis and protein catabolism Venous Thromboembolism Prevention Increased circulating fatty acids Venous thromboembolism (VTE) of the pelvic or leg veins is a Increased skeletal muscle breakdown common complication of gynecologic surgery. Studies using Cell membrane instability 125 I-fibrinogen scanning techniques have documented that approxi- Decline in myocardial contractility and increased cardiac mately 15% of women having gynecologic surgery for a benign arrhythmias disease and approximately 22% of women having surgery for malig- Inhibited endothelial function nant disease develop VTE (Bonnar, 1985). Most of these women will Insulin resistance be asymptomatic. Several aspects of pelvic surgery predispose Increased lipolysis women to VTE, including venous stasis, surgical injury to the Presence of insulin inhibits inflammatory factors walls of large veins, associated anaerobic infection, and hormonal Decreased endothelial-derived relaxing factor—nitric oxide status. Gynecologic malignancy also increases the risk of VTE. Insulin and glucose inhibit proinflammatory cytokines Approximately 40% of deaths after gynecologic surgery are related to pulmonary emboli. Although the initial venous Modified from the American College of Endocrinology. Position statement on injury most often occurs at the time of the operation, approxi- inpatient diabetes and metabolic control. Endocr Pract. 2004;10(1):77-82. mately 15% of symptomatic emboli cases do not present until the first week after discharge from the hospital. Because of the sig- nificant morbidity and mortality associated with a postoperative pulmonary embolus, every effort should be made to reduce the women who do not have diabetes by standard blood glucose criteria incidence of thrombophlebitis. may develop detrimental hyperglycemia secondary to the physiologic One method commonly used to determine the VTE risk for stresses of surgery. Glucose levels greater than 180 mg/dL among an individual patient is to calculate the Caprini score, which takes patients with and without diabetes increase the risk of SSI into consideration risk factors such as a history of previous VTE twofold (Kwon, 2013). Perioperative blood glucose levels among and personal or family history of hypercoagulability. The pres- both patients with and without diabetes should be maintained ence of such a history should also prompt an evaluation for a at less than 200 mg/dL. Category 1A evidence has demonstrated thrombophilia. Other risk factors for VTE include active malig- that strict glucose control (80 to 130 mg/dL) in patients with and nancy, previous radiation therapy, congestive heart failure, without diabetes does not improve SSI rates compared with glucose chronic pulmonary disease, nephrotic syndrome, morbid obesity, levels less than 200 mg/dL (Chan, 2009), and strict control may have venous disease, edema of the legs, active pelvic infection, age detrimental effects on postoperative outcomes (Gandhi, 2007). older than 40 years, current use of oral contraceptives or hor- In 2004, the American College of Endocrinology published mone replacement therapy up to the time of the operation, a position paper, “Inpatient Diabetes and Metabolic Control,” length of immobilization or preoperative hospitalization, and the emphasizing not only the effects of elevated blood glucose levels length of the planned surgical procedure (Table 24.3). A Caprini but the beneficial effects of adequate insulin (Box 24.2). Insulin score of 0 is very low risk for VTE, 1 to 2 is low risk, 3 to 4 is decreases lipolysis. Elevated free fatty acid levels are associated moderate risk, and 5 or more is considered high risk for VTE. with arrhythmias. Insulin inhibits several inflammatory media- Women in the very low-risk group have less than a 3% risk of tors, especially the proinflammatory cytokines, and adequate VTE, women in the moderate group have a 10% to 30% risk,