capstick 10 k
TRANSCRIPT
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Antibiotics, Normothermia and Normoglycemia
Dr. Jim Capstick MD, FRCP(C)Nanaimo Regional General Hospital
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Antibiotic Prophylaxis
• Right procedure• Right antibiotic• Right dose • Right time• Redose if necessary• Restrict antibiotic coverage post-op
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Right Procedure
• Antibiotic prophylaxis not indicated for:– Clean procedures– Elective low risk laparoscopy– Clean head and neck, M&T– Orthopedics – clean operations on hand, knee or
foot without placement of hardware (ie. arthroscopy)
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Right Antibiotic
• Ideal antibiotic:1. Active against pathogens most likely to cause SSI2. Appropriate dose & time to achieve adequate
tissue concentrations3. Safe4. Administered for shortest period to minimize:
– adverse effects– drug resistance– costs
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Clinical practice guidelines for antimicrobial prophylaxis in surgery. Am J Health-Syst Pharm. 2013;70:195–283.
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Clinical practice guidelines for antimicrobial prophylaxis in surgery. Am J Health-Syst Pharm.
2013;70:195–283.
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Right Time
• Within 60 minutes of skin incision or tourniquet inflation
• Within 120 minutes for vancomycin and flouroquinolones
• Who administers?
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Redose
• If OR duration exceeds two half-lives of the antibiotic
• If excessive bleeding• Consider no redose if antibiotic half life is
prolonged due to renal insufficiency/failure
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Clinical practice guidelines for antimicrobial prophylaxis in surgery. Am J Health-Syst Pharm.
2013;70:195–283.
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Restrict Coverage
• Single dose prophylactic antibiotic sufficient in most cases
• Discontinue prophylactic antibiotics within 24hr post-op
• Risk of C.Difficile and/or resistant organisms increases with prolonged administration
• Adopt standard clinical order sets
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Normothermia
• Maintain core temperature 36° to 38°C• Pre-Op• Intra-Op• Post-Op
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Perioperative Heat Balance Anesthesiology. 2000;92(2):578.
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Perioperative Heat Balance Anesthesiology. 2000;92(2):578.
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Perioperative Heat Balance Anesthesiology. 2000;92(2):578.
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Perioperative Heat Balance Anesthesiology. 2000;92(2):578.
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Normothermia
• Measure temperature!• Warm Room - 20°-23°C• Warm Fluids - use fluid warmer• Warm Patient– Convective air re-warming– May be best to avoid heat deficit– Pre-operative warming
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Pre-Operative Warming
Downloaded from: https://promo.3m.com/go/3MMEDICAL/BairPawsSampleKit
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Pre-Operative Warming
BJA 1998; 80:159-163.
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Perioperative Glucose Control
• Target BG 7.8 - 10.0 mmol/L• Avoid strict glucose control – BG ≤ 6.1 mmol/L increases risk of hypoglycemia
• Identify hyperglycemic patients!– Obtain random CBG in PAC in at risk patients– Obtain diagnostic HbA1C if CBG>10– Obtain recent HbA1C in all diabetic patients– HbA1C correlates with wound complications– HbA1C > 10 may require insulin tx pre-op
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Perioperative Management
• Standard protocols, order sets• Standardize terminology– Type 1 (5-10%) • auto-immune -> loss β cells -> insulin deficient• require insulin
– Type 2 (90%) • insulin resistant • diet controlled, OHAs, insulin
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Perioperative Management
• Day of Surgery• Schedule surgery early in the day• Hold OHAs• CBG on admission (recommended for all SDA patients)• Notify anesthesia and/or surgeon if CBG>10• Use weight based basal insulin dose +
nutritional/correctional dose• CBG q2h throughout periop period for all
diabetic/hyperglycemic patients• Sliding scale highly ineffective
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Questions? Comments?