To the Editor:—
Dr. Warters et al. 1provide several good reasons why anesthesia personnel should administer preoperative antibiotics. Based on our experience of doing so, we offer additional reasons.
Because of unexpected changes in operating room availability, a patient may have his or her surgery delayed after administration of the antibiotic. This can lead to a delay between antibiotic administration and the start of surgery. This has the potential to decrease the effectiveness of the prophylactic antibiotic.2
At my institution, the ordering of prophylactic antibiotics is at the discretion of each individual surgeon; we do not have an institutional protocol. Because we are responsible for administering the antibiotic, if a patient comes to the operating room without an antibiotic for us to administer, it is now our routine to ask the surgeon whether he or she wants an antibiotic administered. This double check helps to prevent errors of omission, which still occur. Errors of omission may be more likely to occur in institutions with surgical training programs.
Delays in the patient’s arrival in the operating room because of waiting for the establishment of intravenous access only for the administration of the antibiotic can be eliminated. These delays can lead to wasteful downtime of operating rooms. Overextended floor nurses benefit by having one less task to perform.
The previous insertion of an intravenous catheter only for antibiotic administration may use one or more of the few (or only) remaining peripheral veins that are suitable for satisfactory perioperative intravenous access. The intravenous catheter may not be appropriately sized or appropriately located. Additional intravenous access may need to be established, sometimes before induction of regional or general anesthesia, which is a wasteful of time and supplies, uncomfortable to the patient, and may now be more difficult to accomplish. Patients may then ask, “Why do I need another intravenous? Why can’t you use the one that was just put in?” Scared and nervous patients may lose confidence in the system.
Even if the previously established intravenous catheter is of suitable size and location, because at our institution we have been unable to agree on an intravenous tubing design that is satisfactory for both the operating room and the floor, a second intravenous tubing set and bag of crystalloid may be required. Changing the tubing set while leaving the catheter in situ risks infectious contamination, loss of catheterization, and discomfort to the patient from removal of the tape or adhesive dressing.
There may be two exceptions in which it may be preferable to have the antibiotic administered before arrival in the holding area. First, because vancomycin may require up to 1 h to infuse, there may be insufficient time for us to administer the full dose before skin incision. The second situation is when antibiotics are administered for bacterial endocarditis prophylaxis.
I agree with Dr. Warters et al. that the administration, but not the selection, of prophylactic antibiotics is a responsibility that anesthesiologists should assume.1Although there are many tasks required of us to start a case, this responsibility should also be considered a priority so that the full administration is accomplished before skin incision (and tourniquet inflation).
Thomas Jefferson School of Medicine, Philadelphia, Pennsylvania. email@example.com