Documentation that prophylactic antibiotics were given within 4 hours prior to surgical incision or given intraoperatively (PERI 2)
CPT4 code
Name of the Procedure:
Prophylactic Antibiotic Administration before Surgery (PERI 2)
Summary
Prophylactic antibiotics are medications given to patients within 4 hours before a surgical incision or during surgery to prevent infections. This practice helps to minimize the risk of surgical site infections, which can lead to complications.
Purpose
Prophylactic antibiotics are administered to reduce the likelihood of postoperative infections. The main goal is to protect the patient from potential infections that could occur as a result of the surgical procedure.
Indications
Indications for administering prophylactic antibiotics include:
- Any surgical procedure that poses a risk of infection.
- Patients with weakened immune systems.
- Procedures involving the insertion of foreign devices or implants.
Preparation
Patients may receive specific instructions before surgery, including:
- Fasting from midnight before the procedure.
- Adjusting or stopping certain medications as instructed by the healthcare provider.
- Undergoing pre-operative assessments like blood tests or imaging studies.
Procedure Description
- The healthcare team reviews the patient's medical history and allergies.
- An appropriate prophylactic antibiotic, based on the type of surgery and patient factors, is selected.
- The antibiotic is administered intravenously within 4 hours before the surgical incision or during the operation.
- Sterile techniques and appropriate dosages are strictly followed.
Duration
The actual administration of the antibiotic typically takes a few minutes, though the timing is crucial to ensure it is within the four-hour window.
Setting
Prophylactic antibiotic administration is performed in the hospital setting, either in the pre-operative area or the operating room.
Personnel
- Surgeons
- Anesthesiologists
- Perioperative nurses
Risks and Complications
- Common risks: mild allergic reactions, minor gastrointestinal upset.
- Rare complications: severe allergic reactions (anaphylaxis), antibiotic resistance.
Benefits
- Reduced risk of surgical site infections.
- Enhanced recovery capability.
- Decreased hospital stay and associated costs.
Recovery
No specific recovery steps are needed for the antibiotic administration itself, but the overall post-surgical care will include monitoring for infection signs and managing any surgical pain or discomfort.
Alternatives
- Observation without antibiotics (not generally recommended).
- Use of antiseptics or other infection control measures.
The alternatives are less effective in preventing infections compared to prophylactic antibiotic administration.
Patient Experience
Patients typically will not feel the administration of the antibiotic if already under anesthesia. Afterward, they may be monitored for any immediate adverse reactions but usually do not experience significant discomfort specifically from the antibiotic.
Pain management and comfort measures will focus on the surgical site and overall recovery from the surgery itself.