Chapter 144: Antimicrobial Prophylaxis for Surgery: In Life, Preparation Is Everything Level II

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LEARNING OBJECTIVES

After completing this case study, the reader should be able to:

• Recommend appropriate antimicrobial prophylaxis for a given surgical procedure.

• Discuss the timing of antimicrobial prophylaxis for surgery, including doses prior to surgery and dosing after surgery.

• Describe the controversy regarding mechanical bowel preparation prior to colorectal surgery.

• Identify the pros and cons to using oral antimicrobial decontamination prior to colorectal surgery.

• Evaluate the need for perioperative β-blocker therapy in a specific surgical patient.

PATIENT PRESENTATION

Chief Complaint

“I have colon cancer and I’m here for surgery.”

HPI

Edward Adler is a 72-year-old man who was recently diagnosed with anemia and generalized weakness. The workup for anemia included a colonoscopy, which showed a malignant neoplasm of the proximal ascending colon. The neoplasm was identified, and the biopsy revealed moderately-differentiated adenocarcinoma. The patient denies any current abdominal pain or change in bowel habits, but reports a 20-lb weight loss over the past several months. He is eating but has less of an appetite than normal.

PMH

Positive for HTN, CAD, TIA, and chronic rhinitis; also mild osteoarthritis, for which he has required no regularly scheduled medications in the past. History of gastritis and anemia.

PSH

Tonsillectomy, left inguinal hernia repair, colonoscopy with biopsy.

SH

Positive for smoking history of one half of a pack daily; quit 20 years ago.

Meds

• Atenolol 100 mg PO daily

• Hydrochlorothiazide 12.5 mg PO daily

• Atorvastatin 40 mg PO daily

• Sertraline 100 mg PO daily

• Omeprazole 20 mg PO daily

• Aspirin 81 mg PO daily

• Triamcinolone nasal spray, two sprays in the morning

• Ferrous sulfate 325 mg PO TID

• Multivitamin one PO once daily

All

None

ROS

• Cardiopulmonary: Denies chest pain, shortness of breath, or wheezing.

• Gastrointestinal: Denies history of hepatitis, ulcers, or jaundice.

• Genitourinary: He has no history of hematuria or renal calculi.

• Musculoskeletal: Positive for arthritis of both wrists and hands.

• Psychiatric: Positive for some depression.

Physical Examination

Gen

He has the appearance of a normally developed white man who appears his stated age. He is alert, awake, and in no obvious distress.

VS

BP 132/86 mm Hg, P 68 bpm, RR 11, T 37.1°C; Wt 69 kg, Ht 172.7 cm

Skin

Warm and dry. Multiple seborrheic dermatomes over the abdomen and chest.

HEENT

Face reveals no asymmetry. Pupils are equal. Eyes ...