Drinking the Kool Aid: Systematic Review of Surgical Site Infection Prevention Guideline Recommendations for Maintenance of Homeostasis in the Perioperative Period
Myron Yaster MD, Genie Heitmiller MD, Jayant K. Deshpande MD
“The phrase "drinking the Kool-Aid" describes someone who believes in a possibly doomed or dangerous idea, often due to perceived high rewards. This phrase has a negative connotation but can also be used ironically or humorously to describe adopting an idea or preference due to popularity or persuasion. More recently, it has come to signify extreme dedication to a cause, to the point of being willing to die for it. “ Wikipedia
“Surgical site infections (SSIs) are a major complication of surgery, affecting between 1 and 12% of surgeries. These infections double the average length of stay, cause significant patient morbidity and have an estimated 5.8% case fatality rate at day 30.”1,2 I was fortunate to work at the Johns Hopkins Hospital during the Patient Safety and Quality Improvement revolution that occurred under the direction of Dr. Peter Pronovost (now the Chief Quality & Clinical Transformation Officer at University Hospitals (UH) and President of the UH Veale Healthcare Transformation Institute in Cleveland, OH) and his colleagues in the early 2000s.3,4 I must admit that I was initially reluctant to believe that bundles, checklists and simply washing my hands (and prepping the skin) with Chlorhexidine alcohol would really make a difference in central line and surgical site infections. But the results that he and his team produced made me into an impassioned believer (I drank the Kool Aid). What I learned, or really what hit me right between the eyes, was that we as anesthesiologists hold a pivotal role in preventing surgical site infections through targeted management of intraoperative homeostasis.
Dr. Genie Heitmiller was the leader of the pediatric arm of this revolution and is now a member of the PAAD’s executive council. Obviously, I asked her and Dr. Jay Deshpande the current leader of Wake Up Safe to assist in today’s PAAD. Myron Yaster MD
Original article
Le Couteur J, Druce P, Myles PS, Peel T. Systematic Review of Surgical Site Infection Prevention Guideline Recommendations for Maintenance of Homeostasis in the Perioperative Period. Anesthesiology. 2025 Jun 1;142(6):1150-1165. doi: 10.1097/ALN.0000000000005438. Epub 2025 May 13. PMID: 40358339.
“Most surgical site infections (SSIs) can be prevented if appropriate strategies are implemented. These infections are typically caused when bacteria from the patient's endogenous flora are inoculated into the surgical site at the time of surgery. Development of an infection depends on various factors such as the health of the patient's immune system, presence of foreign material, degree of bacterial wound contamination, and use of antibiotic prophylaxis. Although numerous strategies are recommended by international organizations to decrease surgical site infection, only 6 general strategies are supported by randomized trials. Interventions that are associated with lower rates of infection include (1) avoiding razors for hair removal (4.4% with razors vs 2.5% with clippers); (2) decolonization with intranasal antistaphylococcal agents and antistaphylococcal skin antiseptics for high-risk procedures (0.8% with decolonization vs 2% without); (3) use of chlorhexidine gluconate and alcohol-based skin preparation (4.0% with chlorhexidine gluconate plus alcohol 6.5% or with povidone iodine plus alcohol); (4) maintaining normothermia with active warming such as warmed intravenous fluids, skin warming, and warm forced air to keep the body temperature warmer than 36 °C (4.7% with active warming vs 13% without); (5) perioperative glycemic control (9.4% with glucose <150 mg/dL vs 16% with glucose >150 mg/dL); and (6) use of negative pressure wound therapy (9.7% with vs 15% without). Guidelines recommend appropriate dosing, timing, and choice of preoperative parenteral antimicrobial prophylaxis.”2
Today’s PAAD by Le Couteur et al.,1 is a systematic review of SSI prevention BUT surprisingly does not discuss the appropriate dosing, timing, and choice of preoperative parenteral antimicrobial prophylaxis nor best methods of washing one’s hands or skin preparation prior to surgery. It does highlight 4 perioperative variables that affect SSI risk, namely, glycemic control, oxygenation, temperature regulation, and fluid balance.
Here is a concise review of their findings and recommendations:
Glycemic control
Target glucose levels range from < 110 mg/dl to < 200 mg/dl across guidelines.
Intensive control may reduce infections but increase hypoglycemia risk.
One pivotal trial found lower SSI rates in patients with tight glucose control (80–110 mg/dl).
Normothermia
All guidelines stress the importance of maintaining body temperature.
Evidence supports the use of forced-air warming and warmed IV fluids.
Optimal core temperature: generally ≥ 36°C.
Oxygenation
Mixed guidance on supplemental oxygen.
WHO and ACS/SIS recommend 80% FiO₂ intraoperatively and postoperatively.
CDC cites “uncertain trade-offs” and suggests further research.
Normovolemia
Goal-directed fluid therapy is endorsed by WHO, APSIC, and others.
Excess fluid and hypo and hypervolemia both impair tissue healing.
Trials show mixed results; more high-quality studies are needed.
Le Couteur et al conclude that “while current guidelines offer a roadmap, discrepancies highlight the urgent need for further research and standardized practices. By championing evidence-based interventions, anesthesiologists can significantly reduce SSIs and improve surgical outcomes globally.”1
Interestingly, the article makes no mention of studies that include pediatric patients or whether the guidance they provide is equally effective in the population we (pediatric anesthesiologists) serve and a quick review of the literature reveals a paucity of pediatric data. Hypothermia in neonates and infants can lead to respiratory distress, metabolic acidosis, hypoglycemia, coagulopathy, and increased risk of late-onset sepsis and intraventricular hemorrhage. There is a paucity of data on the effect of hypothermia on SSI. Furthermore, perioperative hyperthermia may be associated with increased SSI risk in children. The patient’s nutritional status prior to surgery can impact surgical outcomes including higher SSI risk for under/malnourished children. Tight glucose control has been recommended in adults. However, the risks of hypoglycemia in infants and children are real. Keeping glucose within normal to slightly elevated levels likely reduces the chance of hypo- or hyper-glycemia without increasing the risk of SSI.
The harmful effects of hypoxia are well-known. However, hyperoxia also can have detrimental effects on the lungs, brain and other organs. As an example, the neonatal resuscitation guidelines of the AHA state: “Reasonable initial supple mental oxygen concentrations are 21% in newborns > 35 weeks’ gestation and 21% to 30% in newborns < 35 weeks’ gestation with subsequent oxygen titration based on pulse oximetry.” There are few data on the proper “dose” of oxygen in the perioperative period. Therefore, supplemental oxygen to keep the SPO2 in the normal range and hyperoxia seems reasonable.
The few reports which exist on the impact of intraoperative fluid management in children on SSI are aligned with the recommendations made by LeCouteur et al.
Interestingly, the authors of the current article nearly completely ignore the issue of preoperative antibiotic prophylaxis. The proper drug, dose and, for the anesthesiologist - timing, of the antibiotic have been much debated for numerous years. In pediatric patients, these issues remain to be clarified. For instance, Shah et al.5 found in a retrospective study that “Children who received antibiotics were more likely to suffer an SSI compared with those who did not.” Yet their conclusion was that, “Proper administration of preoperative antibiotics in pediatric patients is one of the few modifiable and significant factors in prevention of SSI.” Khoshbin et al.6 performed a prospective cohort study and found that antibiotic prophylaxis reduced SSI risk by 30%. However, a more recent systematic review by Nthumba and colleagues7 of randomized trials and observational studies concluded that their “review and metanalysis did not find a preventive action of SAP against SSI”, and their results suggested that “SAP should not be used in surgical wound class I procedures in children. However, considering the poor quality of included studies, the principal message of this study is in highlighting the absence of quality data to drive evidence-based decision-making in SSI prevention in children, and in advocating for more research in this field.” Similarly, Srivastava et al.8 found that in pyloromyotomy cases (which are considered clean surgical wounds), there was no difference in SSI between patients who received SAP and those who did not.
So perhaps a slightly modified version of the old adage from our mentors, “avoid hypoxia and hypotension” during the case is still relevant: avoid hypoxia, hypotension, hypoglycemia and hypothermia”.
Are you following the Le Couteur guidelines in your practice? How tightly do you control glucose in the ORs and in the ICUs in diabetic and nondiabetic patients, particularly in patients undergoing cardiac surgery? Do you use “goal directed fluid therapy”? and if so how? Send your thoughts and comments to Myron who will post in a Friday reader response.
References
1. Le Couteur J, Druce P, Myles PS, Peel T: Systematic Review of Surgical Site Infection Prevention Guideline Recommendations for Maintenance of Homeostasis in the Perioperative Period. Anesthesiology 2025; 142: 1150–1165
2. Seidelman JL, Mantyh CR, Anderson DJ: Surgical Site Infection Prevention: A Review. Jama 2023; 329: 244–252
3. Pronovost P, Needham D, Berenholtz S, Sinopoli D, Chu H, Cosgrove S, Sexton B, Hyzy R, Welsh R, Roth G, Bander J, Kepros J, Goeschel C: An intervention to decrease catheter-related bloodstream infections in the ICU. N Engl J Med 2006; 355: 2725–32
4. Hales BM, Pronovost PJ: The checklist--a tool for error management and performance improvement. J.Crit Care. 2006; 21: 231–235
5. Shah GS, Christensen RE, Wagner DS, Pearce BK, Sweeney J, Tait AR: Retrospective evaluation of antimicrobial prophylaxis in prevention of surgical site infection in the pediatric population. Paediatr Anaesth 2014; 24: 994–8
6. Khoshbin A, So JP, Aleem IS, Stephens D, Matlow AG, Wright JG: Antibiotic Prophylaxis to Prevent Surgical Site Infections in Children: A Prospective Cohort Study. Ann Surg 2015; 262: 397–402
7. Nthumba PM, Huang Y, Perdikis G, Kranzer K: Surgical Antibiotic Prophylaxis in Children Undergoing Surgery: A Systematic Review and Meta-Analysis. Surg Infect (Larchmt) 2022; 23: 501–515
8. Srivatsa S, Read M, Rachwal B, Zhang Y, Griffin K, Mansfield S, Van Arendonk K: Reevaluating Surgical Antibiotic Prophylaxis in Pediatric Pyloromyotomy: Insights From the NSQIP-Pediatric Database. J Pediatr Surg 2025; 60: 162355