SCIP guidelines

[TheLoneWolf]

Have a handful of GYN surgeons who outright refuse all antibiotics for diagnostic laparoscopies, ectopic pregnancies ; just iodine over the belly and go. Digging around in the pelvis, mobilizing and cutting tissues for hour or two without antibiotics seems bizarre to me. Any laparoscopic surgeries by gen surg include preincision antibiotics as per SCIP. Where is the line if we feel it is clearly indicated and the surgeon outright refuses other then to proceed and document their refusal. Still dont like it because it is clearly counter to established norms. Am I missing something here? Do they have data that wound infection rates are similar with our without antibiotics that I am not aware of?

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[FiO2@21]

Have a handful of GYN surgeons who outright refuse all antibiotics for diagnostic laparoscopies, ectopic pregnancies ; just iodine over the belly and go. Digging around in the pelvis, mobilizing and cutting tissues for hour or two without antibiotics seems bizarre to me. Any laparoscopic surgeries by gen surg include preincision antibiotics as per SCIP. Where is the line if we feel it is clearly indicated and the surgeon outright refuses other then to proceed and document their refusal. Still dont like it because it is clearly counter to established norms. Am I missing something here? Do they have data that wound infection rates are similar with our without antibiotics that I am not aware of?

We have that here too. They frequently say “not indicated” and to be honest I never followed up and actually read up on whatever guidelines they might be referring to.

 

[Twiggidy]

Laparoscopic, low risk has no indication. You can very much so give antibiotics and at worst you’re increasing our chances for antibiotic resistance and angering a surgeon. In contrast, if indicated, you MUST give it. The younger gyns or the well read older ones are usually the one’s who saying you dont need the antibiotic, but the others who are most old school just give to everyone.

https://www.ashp.org/surgical-guidelines

 

[MirrorTodd]

You could just give it and not tell them. We are doctors after all, we can decide indications ourselves.

 

[GassYous]

You could just give it and not tell them. We are doctors after all, we can decide indications ourselves.

Nothing says "I'm a doctor too" like hiding your decisions from your peers because you're scared

 

[MirrorTodd]

Nothing says "I'm a doctor too" like hiding your decisions from your peers because you're scared

**** man, it's not hiding it. Do you tell them how much prop and roc youre giving? Hey surgeon, how much fentanyl do you want me to give this guy? For that matter, how many times have you done the ole, " yep, here's a little more "roc". Pt relaxed enough now?" If the surgeon doesn't want to give antibiotics even though they are indicated, then screw them. I never said to lie, just don't ****in tell em. There's no need to.

 

[coffeebythelake]

The surgeons presumably know the SSI rates for their particular surgeries. They have to deal with the consequences and SSIs are tracked closely. If they say they are very low risk and abx not indicated i will trust them.

 

[Twiggidy]

You won’t get dinged for giving abx when you’re not supposed to, but you will if you don’t when you’re supposed to

 

[coffeebythelake]

Also understand that SCIP guidelines aren't exactly 100% evidence based. For instance thr whole premise of giving about within 1 hr prior to incision was and still remains contentious.

 

[chessknt]

You could just give it and not tell them. We are doctors after all, we can decide indications ourselves.

Who has to deal with an infection if it occurs? Do you see their patients in clinic post-op? It would be like if I decided to start an antidepressant on a suicidal person in the ICU when the psychiatrist told me to wait until they're in inpatient psych. Have some faith that they know what they're doing man.

 

[MirrorTodd]

Who has to deal with an infection if it occurs? Do you see their patients in clinic post-op? It would be like if I decided to start an antidepressant on a suicidal person in the ICU when the psychiatrist told me to wait until they're in inpatient psych. Have some faith that they know what they're doing man.

Not gonna lie, that reads like Pontius Pilate washing his hands.

 

[chessknt]

Not gonna lie, that reads like Pontius Pilate washing his hands.

If deferring to a specialist to make a decision that they have more knowledge about than you (and they have to own the consequences of the decision which you also don't) evokes a sense of patient abandonment I think you need to stop and examine your own cognitive biases here.

How many cases that you have given abx to got an infection anyways? What was the course of that infection? How would you feel if the ob decided to tell you what type of anesthetic to run based on what they had empirically seen done before?

 

[MirrorTodd]

If deferring to a specialist to make a decision that they have more knowledge about than you (and they have to own the consequences of the decision which you also don't) evokes a sense of patient abandonment I think you need to stop and examine your own cognitive biases here.

How many cases that you have given abx to got an infection anyways? What was the course of that infection? How would you feel if the ob decided to tell you what type of anesthetic to run based on what they had empirically seen done before?

Do they really have more knowledge than you or I? And if so, then why? I argue that we are responsible for the antibiotics we give or don't give as well. There are lots of things that we admittedly don't really know much about. Antibiotics really shouldnt be one of those things in my opinion.

 

[Hork Bajir]

https://www.jogc.com/article/S1701-2163(16)35222-7/pdf

“06 . Antibiotic prophylaxis is not recommended for laparoscopic procedures that involve no direct access from the abdominal cavity to the uterine cavity or vagina . (l-E)”

I-E meaning there is good RCT evidence to support the recommendation

 

[chessknt]

Do they really have more knowledge than you or I? And if so, then why? I argue that we are responsible for the antibiotics we give or don't give as well. There are lots of things that we admittedly don't really know much about. Antibiotics really shouldnt be one of those things in my opinion.

Of course they do unless you are routinely following every single anesthetic you do for several weeks to see what their outcomes are.

 

[GassYous]

**** man, it's not hiding it. Do you tell them how much prop and roc youre giving? Hey surgeon, how much fentanyl do you want me to give this guy? For that matter, how many times have you done the ole, " yep, here's a little more "roc". Pt relaxed enough now?" If the surgeon doesn't want to give antibiotics even though they are indicated, then screw them. I never said to lie, just don't ****in tell em. There's no need to.

I don't need to try to fool my surgeons, we have a good working relationship. There's only one idiot who doesn't understand why no more relaxation means no more relaxation and always whines for more. Obviously a gynecologist. I just say no.

 

[C4C]

I only give antibiotics per surgical request. I don't order them; I don't caution the patient about the risks and benefits; I don't consider them part of my anesthetic.

I can perform an anesthetic safely without antibiotics.

As a convenience to my surgical colleagues, I'm happy to fill his or her order for antibiotics. The antibiotics are never ordered for routine risks of infection from the anesthetic, but are routinely ordered for risks of infection from the surgery.

I always chart "PSR" on antibiotics. Always. If there's a complication from the antibiotic, I want it understood that my role was simply one of filling the surgeon's orders.

Broad enough coverage? Specific enough coverage, in keeping with the latest cultures and sensitivities? Cost effective, given the particular facility's formulary? Appropriate, given the likely regimen the patient will continue with at home, and with which brand or formulation his or her insurer might prefer? Appropriate dosing interval? Those questions are beyond my expertise.

 

[Hork Bajir]

I only give antibiotics per surgical request. I don't order them; I don't caution the patient about the risks and benefits; I don't consider them part of my anesthetic.

I can perform an anesthetic safely without antibiotics.

As a convenience to my surgical colleagues, I'm happy to fill his or her order for antibiotics. The antibiotics are never ordered for routine risks of infection from the anesthetic, but are routinely ordered for risks of infection from the surgery.

I always chart "PSR" on antibiotics. Always. If there's a complication from the antibiotic, I want it understood that my role was simply one of filling the surgeon's orders.

Broad enough coverage? Specific enough coverage, in keeping with the latest cultures and sensitivities? Cost effective, given the particular facility's formulary? Appropriate, given the likely regimen the patient will continue with at home, and with which brand or formulation his or her insurer might prefer? Appropriate dosing interval? Those questions are beyond my expertise.

I hear what you’re saying, and no disrespect here... But this kind of attitude is the reason that surgeons treat us like techs and nurses treat us as equals, calling us by first name and talking down to us. It’s no mystery why this specialty has a PR problem. If you want to be treated like a doctor, gotta act like a doctor.

Again no disrespect intended here. Just sharing my opinion, and suggesting to the trainees on here that they think carefully before adopting this sort of “that’s not my job I’m just following the surgeons orders” attitude.

 

[DirtDocMD]

I kinda look at it as “staying in my lane”. They don’t tell me how much propofol to give, and I don’t dictate their antibx (within reason). What happens when you give “non-indicated” antibx, and the pt has a reaction (or heaven forbid, anaphylaxis)??

“They need more relaxation!”- I say they’re fully relaxed, if they are.

“Do they need antibx?”-It’s not indicated, they say, if they’re not.

I see more infected c-section incisions, then I do hysterectomy/gyn incisions.

 

[DocVapor]

ABx are ordered by the surgeons. They should be started by the nurses on call to OR. My giving them is really a courtesy to the nurses, not the surgeon. The fact that we get dinged for abx when it's not our order or really our place to be ordering them is a travesty that needs to be rectified.

 

[deleted59964]

Laparoscopic, low risk has no indication. You can very much so give antibiotics and at worst you’re increasing our chances for antibiotic resistance and angering a surgeon. In contrast, if indicated, you MUST give it. The younger gyns or the well read older ones are usually the one’s who saying you dont need the antibiotic, but the others who are most old school just give to everyone.

https://www.ashp.org/surgical-guidelines

nah - at very very worst they get anaphylaxis and die

 

[deleted59964]

my attitude is that nothing I do to the patient requires antibiotic prophylaxis.
therefore antibiotics are not part of my anaesthetic.

I administer antibiotics during my anaesthetic, at the request of the surgeon.

 

[Airway]

I comment on abx and try to facilitate a conversation: if I think it's inappropriate, too little or too much. My current job is in an academic center. (Unnecessary) double coverage often happens with multiple service surgery, and often we have critically ill patients on multiple abx (do they really need more cefazolin?). The surgical residents (and anesthesiology) rarely know coverage. If it lends credibility, I attend in multiple ICUs

Re scip guidelines: I hate cookbook medicine that turns thought off.

 

[coffeebythelake]

An aside to the direction of this thread, specifically back to SCIP recommendations.

As I'm sure you are all aware, SCIP guidelines were retired several years ago although many hospitals developed their perioperative antibiotics recommendations based on them. SCIP guidelines have actually not been shown to reduce the incidence of SSI and it has been criticized for setting up broad recommendations using a limited number of flawed studies.

If you see Classen et al, 1992 (NEJM) you will notice that in categorical groupings, there is no statistical significance in SSI rates when given 0-2 hours before incision vs. 0-3 hours post incision. The only differences that exist are when abx given either far earlier or far later. This has been critiqued by Barash and others in their review (Anesthesiology, 2009). Hawn et al., 2013 (JAMA surgery) goes further by saying that SCIP guidelines do not correlate to SSI when adjusted for patient and surgical factors (p=0.5), and while adherence is not bad care, it does not mean better care.

Bottom line, perioperative antibiotics matter. But exactly when they are given might not matter so much.

 

[nimbus]

Does everybody redose cefoxitin q2 hours intraop?

 

[GassYous]

Does everybody redose cefoxitin q2 hours intraop?

Ain't nobody got time for that
4 hours

 

[abolt18]

Does everybody redose cefoxitin q2 hours intraop?

Yes... Per hospital protocol

 

[Twiggidy]

Does everybody redose cefoxitin q2 hours intraop?

Yep. Cefoxitin q2 and cefazolin q4. I have to remind myself of that when I’m involved in one of our longer hearts or vascular cases.