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Documentation that administration of prophylactic parenteral antibiotic was initiated within 1 hour (if fluoroquinolone or vancomycin, 2 hours) prior to surgical incision (or start of procedure when no incision is required) as ordered (PERI 2)

CPT4 code

Name of the Procedure:

Prophylactic Parenteral Antibiotic Administration Prior to Surgical Incision (PERI 2)

Summary

This procedure involves administering an antibiotic injection to help prevent infections before a surgical operation. This is done within a specified timeframe: within one hour before surgery for most antibiotics, or within two hours if fluoroquinolone or vancomycin is used.

Purpose

The procedure addresses the risk of post-surgical infections. The primary goal is to reduce the likelihood of infections that can complicate surgical recovery and overall health outcomes.

Indications

  • Patients scheduled for surgery.
  • Conditions requiring preventive measure against possible bacterial infections during or after surgery.
  • High-risk surgeries with an increased chance of infection.

Preparation

  • Fasting might be required depending on the type of surgery.
  • Adjustments to existing medications may be necessary. Patients should consult with their healthcare provider.
  • Preoperative diagnostic tests, such as blood tests or imaging, may be required to assess patient’s overall health.

Procedure Description

  1. The patient is informed about the antibiotic administration.
  2. The patient’s identity and allergies are confirmed to ensure the correct antibiotic is administered.
  3. The antibiotic is selected based on the type of surgery and any patient-specific factors such as known allergies.
  4. The antibiotic is administered via injection into a vein (intravenously).
  5. The timing is crucial: the antibiotic must be given within one hour before the incision starts or within two hours if using fluoroquinolone or vancomycin.

Duration

The antibiotic administration typically takes a few minutes, but preparation and monitoring may extend the time to about 15-30 minutes.

Setting

This procedure is performed in a hospital, surgical center, or outpatient clinic.

Personnel

  • Nurses or trained healthcare technicians administer the antibiotic.
  • The surgical team, including the surgeon and anesthesiologist, are informed of the administration.

Risks and Complications

  • Allergic reactions to the antibiotic, ranging from mild rash to severe anaphylaxis.
  • Potential side effects such as nausea or diarrhea.
  • Rare complications include antibiotic resistance or adverse interaction with other medications.

Benefits

  • Significantly reduced risk of postoperative infections.
  • Improved surgical outcomes and recovery.
  • Peace of mind for the patient and healthcare team.

Recovery

  • No special post-procedure care related to the antibiotic itself.
  • Standard post-surgical recovery protocols will apply, including wound care and follow-up appointments.
  • Patients should report any unusual symptoms (e.g., signs of infection or allergic reactions).

Alternatives

  • Oral antibiotics, though less effective immediately before surgery.
  • Enhanced sterilization techniques during surgery, though not as effective alone.
  • Custom infection prevention protocols tailored to the specific surgery and patient.

Patient Experience

  • The administration is usually painless but may cause mild discomfort at the injection site.
  • Patients are typically monitored for any immediate allergic reactions or side effects.
  • Pain management options and comfort measures will be provided as a part of pre-surgical care.

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