Evidence-Based Gynecologic Surgery Best Practices: The AHRQ Safety Program

SUMMARY:

The AHRQ, American College of Surgeons and Armstrong Institute at Johns Hopkins have developed a safety program to assess and help incorporate evidence-based practices into surgical care. An evidence review of gynecologic surgery was conducted, supporting the protocol elements in the AHRQ Safety Program that include the following best practices

Preoperative

Patient Education

• ‘Potential’ association between preoperative patient education and improved outcomes (low level evidence)

Immediate Preoperative

Bowel Prep

• Minimally invasive gyn surgery
  • Oral mechanical bowel prep should be abandoned (strong level evidence)
• When bowel prep is desired (patients at high risk such as colorectal resection)
  • Based on colorectal surgery evidence, oral mechanical bowel prep alone is not effective
  • Use one of the following regimens (moderate level evidence)
    • Oral mechanical bowel prep and oral antibiotic
    • Oral antibiotic alone
  • Note: The review states “Data from non-randomized studies suggest that bowel preparation may be omitted within a well-developed ERP (enhanced recovery pathways) that incorporates a SSI reduction bundle even when bowel resection is anticipated”

Intraoperative

Drains

• Routine nasogastric tube
  • Associated patient discomfort with no known benefit (high level evidence)
• Routine peritoneal drains
  • Prophylactic use is not beneficial following lympadenectomy for gyn surgery
  • Avoid unless there is a rectal anastomosis within 6 cm of the anal verge and no diversion or patient at high risk for pelvic collections (moderate level evidence)

Postoperative

Early Mobilization

• Beneficial – avoid prolonged bedrest (moderate level evidence)

Early Alimentation

• Early oral feeding is safe (high level of evidence)
  • Well tolerated
  • Shorter hospital length of stay
  • Initiate as early as 4 hours following gyn surgery with or without bowel resection

Early Urinary Bladder Catheter Removal

• Use catheters for <24 hours (moderate level evidence)
  • However, it is appropriate to consider fall risk and necessity of urine output monitoring for some patients
• Uncomplicated surgeries
  • Removal at 6 hours balances rates of infection vs retention
• Complicated surgeries (e.g., urogynecologic or gynecologic oncology procedures)
  • Morning after may be more appropriate

Prevention of Ileus and accelerate return of bowel function

• Standardized use of postoperative laxatives
  • Recommended for gyn surgery (low level evidence)
  • Examples: Senna with docusate | Docusate | Magnesium oxide or magnesium hydroxide | Bisacodyl
• Chewing gum
  • Recommended for gyn surgery (high level of evidence)
• Alvimopan (novel peripheral μ-opioid antagonist)
  • May not be beneficial in benign gyn surgery
  • May decrease ileus in ovarian cancer surgery and can be considered for use in patients undergoing bowel resection (moderate level evidence)

Early IV Fluid discontinuation

• Discontinue maintenance IV fluids within 12 to 24 hours following surgery, especially with early fluid and solid intake (low level of evidence)
  • Urine output as low as 20 mL/hour
    • Recognize as normal perioperative stress response
    • Intervention not required

KEY POINTS:

Other Evidence-Based Perioperative Interventions

• Surgical site infection bundles (see ‘Related ObG Topics’ below)
  • Use of surgical site infection bundles should be considered (high level evidence)
• Glucose management
  • Perioperative glucose goal: ≤ 180 mg/dL (10.0 mmol/L) (high level evidence)

Venous Thromboembolism (VTE) Prophylaxis

• Preoperative
  • Intermittent pneumatic compression alone for (moderate level evidence)
    • Minimally invasive surgery for any indication or
    • Laparotomy for benign disease
  • Add preoperative pharmacologic prophylaxis for patients undergoing laparotomy for gynecologic malignancies
    • Weak level evidence from observational studies but consideration given to high rate of VTE in this population
    • Supported by multiple societies
  • Postoperative
    • Use mechanical prophylaxis for the duration of hospitalization in all gynecologic surgical patients and mechanical and/or pharmacologic prophylaxis for gynecologic oncology surgical patients (high level of evidence)
    • Gyn oncology: Extend VTE chemoprophylaxis for 4 weeks following surgery
      • Supported by multiple guidelines, but further research required on long-term benefits

Learn More – Primary Sources:

Surgical Technical Evidence Review for Gynecologic Surgery Conducted for the AHRQ Safety Program for Improving Surgical Care and Recovery Related Website link

ACOG Guidance on Preventing Gynecologic Post-Procedure Infection

SUMMARY:  

The ACOG Practice Bulletin on the prevention of infection following gynecologic procedures incorporates many of the CDC 2017 recommendations for the prevention of surgical site infection, (see ‘Learn More – Primary Sources’ section below).

• • Preop Prophylaxis
  • Intraop Prophylaxis
  • Procedure-Based Antibiotic Regimens
  • History of MRSA Colonization or Infection
  • Penicillin Allergy

The key highlights of the ACOG document include the following:

Preop Prophylaxis  

• Treat remote infections prior to elective surgeries (e.g., UTIs) 
• Do not shave the incision site unless there is concern about interference with the procedure  
  • Clippers preferable  
  • Do not use a razor  
• Glycemic control  
  • Target <200 mg/dL with or without diabetes (CDC guidance) 
  • Screen women pre-operatively for diabetes if at high risk  
• Shower or full body bath 
  • CDC recommendation does not specify a particular soap or antiseptic, but ACOG states that chlorhexidine “is a reasonable choice based on limited evidence that suggests increased efficacy compared with soap or placebo” 
• Preop surgical skin prep with alcohol-based agent unless contraindicated (CDC) 
  • ACOG states “Chlorhexidine–alcohol is an appropriate choice” and that while iodophors also have broad spectrum coverage, they tend to be aqueous and not alcohol based  
  • Povidone-iodine: For abdominal surgery, scrub time may be as long as 5 minutes, followed with towel removal and then painting with topical povidone-iodine solution; dry for 2 minutes prior to draping  
  • Chlorhexidine–alcohol: Scrub for 2 minutes for moist sites (inguinal fold and vulva) and 30 seconds for dry sites (abdomen); dry for 3 minutes prior to draping  
• Vaginal cleansing prior to hysterectomy or vaginal surgery 
  • Use 4% chlorhexidine gluconate or povidone–iodine  
    • Only povidone–iodine FDA approved for vaginal prep  
  • High alcohol concentration (70% isopropyl alcohol) chlorhexidine gluconate is contraindicated for vaginal prep due to risk of irritation  
    • 4% chlorhexidine gluconate soap (4% alcohol) is well tolerated and an alternative to iodine-based preparations in cases of allergy or when surgeon preference  
  • Maintain aseptic technique by all members of scrubbed staff  
  • Minimize traffic in the OR  

Intraop Prophylaxis  

• Minimize wound disruption and use excellent surgical technique (e.g., hemostatis, gentle tissue handling, avoidance of hypothermia etc.)   
  • Data lacking as to whether there is benefit in closure of subcutaneous dead space in gyn surgery  
• Appropriate use of antimicrobial prophylaxis (see detail in ‘Key Points’ below)  
  • Administer within 1 hour prior to procedure  
  • Obesity: Increase dosing based on weight   
  • Long procedure: Redose cefazolin 4 hours from the preoperative dose (not from start of procedure)  
  • Excessive blood loss: Additional dose of cefazolin if blood loss >1,500 mL  
• Preop screening for bacterial vaginosis  
  • Screening and initiation of therapy with metronidazole or one of the other CDC-recommended treatment regimens “can be considered”
  • If the therapy duration of 5–7 days encroaches on the scheduled time for surgery, it would be reasonable to continue therapy perioperatively for at least 4 days

KEY POINTS:  

Procedure-Based Antibiotic Regimens  

• Hysterectomy (vaginal/abdominal/laparoscopic/robotic) 
  • ≤120 kg: 2 g IV cefazolin 
  • >120 kg: 3 g IV cefazolin 
• Uterine evacuation (suction D&C/D&E) 
  • 200 mg doxycycline (equally effective IV or orally) 
  • Metronidazole is an appropriate 2nd line agent  
• Colporrhaphy 
  • ≤120 kg: 2 g IV cefazolin 
  • >120 kg: 3 g IV cefazolin 
• Vaginal sling 
  • ≤120 kg: 2 g IV cefazolin 
  • >120 kg: 3 g IV cefazolin 
• Laparotomy (no entry into bowel or vagina) 
  • May “consider” cefazolin  
  • ≤120 kg: 2 g IV cefazolin 
  • >120 kg: 3 g IV cefazolin 
• Cervical tissue excision procedures (LEEP/biopsy/ECC) 
  • Not recommended 
• Cystoscopy 
  • Not recommended 
  • If UTI identified, treat appropriately  
• Endometrial biopsy 
  • Not recommended 
• Laparoscopic procedures (no entry into bowel or vagina) 
  • Not recommended 
• HSG (chromotubation/saline infusion sonography) 
  • Not recommended  
• Hysteroscopy (operative/diagnostic) 
  • Not recommended 
• Endometrial ablation  
  • Not recommended  
• IUD insertion 
  • Not recommended 
• Oocyte retrieval and embryo transfer  
  • Not recommended 
• D&C for nonpregnancy indications 
  • Not recommended 
• Urodynamics 
  • If UTI identified, treat appropriately

History of MRSA Colonization or Infection 

• The following is recommended 
  • Hospital-recommended MRSA antibiotic prophylaxis protocol OR  
  • Adjustment of the preoperative prophylactic antibiotic regimen to include a single preoperative intravenous dose of vancomycin is recommended 
• Joint guidelines of the American Society of Health-System Pharmacists, Infectious Diseases Society of America, Surgical Infection Society, and the Society for Healthcare Epidemiology of America recommend Vancomycin 15 mg/kg for prophylaxis

Penicillin Allergy  

No immediate hypersensitivity reaction (anaphylaxis, urticaria, bronchospasm) 

• Can use cephalosporin  
• Cephalosporin allergy: Clindamycin 900 mg or metronidazole 500 mg PLUS Gentamicin 5mg/kg or aztreonam 2 g  

Immediate hypersensitivity reaction or Stevens-Johnson syndrome 

• Cephalosporin allergy: Clindamycin 900 mg or metronidazole 500 mg PLUS Gentamicin 5mg/kg or aztreonam 2 g  

Additional Notes

• Interval to repeat  
  • Clindamycin: 6 hours 
  • Aztreonam: 4 hours  
• First generation cephalosporins may provide better prophylaxis than second line agents  
  • Therefore, important to obtain an accurate allergy history to not inadvertently limit access to first generation cephalosporins

Learn More – Primary Sources:

ACOG Practice Bulletin 195: Prevention of Infection After Gynecologic Procedures 

Centers for Disease Control and Prevention Guideline for the Prevention of Surgical Site Infection, 2017