Preoperative Protocols in orthopaedic Surgery

I. Patient Preparation:

Patients who undergo elective surgery should ideally enter the hospital at least one day
before surgery.
Pre-operative showers: are done by taking a chlorhexidine shower the night before and the
morning of surgery or the patient can shower at home before the surgery. Instruct the patient
not to shave near the surgical site prior to surgery.
Once a patient is admitted for surgery a nurse provides them with preoperative education
and cleans the operative site with Chlorhexidine gluconate. The patient's nares are treated
with an antiseptic solution to further reduce the risk of infection from organisms that are
commonly found in the nose. Each patient receives their own disposable gowns, blood
pressure cuff and pulse oximetry monitor that stays with them throughout their stay.
Consider preoperative screening for MRSA colonization for major orthopedic operation
within 30 days of their scheduled surgery. Patients that test positive for MRSA
preoperatively are treated with Mupiricin ointment and given Chlorhexidine gluconate
(CHG) bathing cloths for 5 days. Repeat cultures are collected at least 48 hours after
treatment is completed to determine if the patient is still colonized with MRSA. Patients
who continue to test positive for MRSA are placed in contact precautions during their stay
to reduce the risk of transmission.
Hair removal - either a clippers or depilatory agent immediately before surgery, razors are
not appropriate. Hair removal is done outside the operating room.
Maintain normothermia (temperature of 35.5C or more) during the perioperative period.
Each patient is wrapped in a warming blanket preoperatively, throughout their surgical
procedure and during post anesthesia recovery.
Observe and review operating room personnel and the environment of care in the operating
room. In addition, surgical attire is required by all staff and visitors that enter the OR area
as well as hair covers and masks. All members of the operative team should wear double
glove and change gloves when perforation is noted.

II. Prophylactic Antibiotics:

Recommendations for the Use of Prophylactic Antibiotics in Orthopaedic Surgery
Choice of Antimicrobial Agent

Cephalosporin (cefazolin, cefuroxime)

If -lactam allergy, use clindamycin or vancomycin
Consider preoperative screening for MRSA1 colonization
If infected or colonized with MRSA1, use vancomycin

Timing of Administration

Start up to 60 min before incision: cefazolin, Cefuroxime, Clindamycin

Start up to 120 min before incision: vancomycin
Infusion completed 10 min before tourniquet inflation

Dosing

Cefazolin, 1-2 g (2 g for patient weighing > 80 kg)

Cefuroxime, 1.5 g
Vancomycin and Clindamycin dosing based on patient mass
Pediatric dosing based on patient mass

Duration of Antimicrobial Use

Single preoperative dose

Re-dose antimicrobial intraoperatively: prolonged procedure or significant blood loss.
When using postoperative doses, discontinue within 24 h after wound closure

III. Surgical Site Prep:

Preoperative cleansing of the patients skin with chlorhexidine-alcohol.

Wipe with alcohol (kills transient flora).
Povidone-iodine solution prep.
Dry surgical area.
Apply one-step iodophor-alcohol product.
Plastic Adhesive Drapes.

IV. Hand Scrub: Antimicrobial soap for 2-6 minutes, dry hands and apply alcoholbased product.
V. Traffic: Limiting the number of and movement of OR personnel.

VI. Irrigation Techniques and antiseptic wound lavage:

Pulsatile lavage most effective.

Antibiotic solutions.
Dilute Povidone iodine.
Minimum of 4 liters recommended in total joint surgery.

VII. Antibiotic Cement:

May be used in primary surgery.

Should be used for revision surgery.

Prepared by:
Assistant Professor Ayyoub A. Mohammed Al-Dolaymi,
Consultant Orthopaedic Surgeon at ABMMC medical center.
15/05/2016