Surgical site infections (SSIs) remain one of the most significant complications in surgical care, affecting up to 12% of procedures worldwide. These infections not only elevate patient morbidity and mortality but also impose substantial economic costs, with estimates exceeding $20,000 per infection in the United States alone. A recent comprehensive review published in Anesthesiology by Le Couteur et al. underscores the indispensable role anesthesiologists play in SSI prevention through the meticulous maintenance of intraoperative homeostasis.

The global burden and why it matters

• Surgical conditions account for approximately 11% of the global disease burden.
  
• SSIs contribute significantly to this, with a 5.8% case-fatality rate within 30 days post-surgery.
  
• Beyond health implications, SSIs also mean extended hospital stays and increased healthcare costs.

Anesthesiologists: key players in SSI prevention

The review highlights anesthesiologists’ influence over several perioperative variables that affect SSI risk:

• Glycemic control
• Oxygenation
• Normothermia (temperature regulation)
• Normovolemia (fluid balance)

These factors are crucial in ensuring optimal tissue perfusion and immune function during and after surgery.

Guideline overview: global and national perspectives

Eight major guidelines from reputable bodies like the WHO, CDC, NICE, and APSIC were examined. There was broad consensus on the importance of homeostasis, but recommendations varied significantly:

• WHO and CDC: Emphasize evidence-based practices but differ on specifics like glucose and oxygenation targets.
  
• NICE: Advocates for patient-specific considerations and recommends against routine insulin in non-diabetics.
  
• APSIC and Spanish guidelines: Provide less detailed or divergent recommendations.

Key SSI prevention strategies

1. Glycemic control

• Target glucose levels range from < 110 mg/dl to < 200 mg/dl across guidelines.
• Intensive control may reduce infections but increase hypoglycemia risk.
• One pivotal trial found lower SSI rates in patients with tight glucose control (80–110 mg/dl).
  

2. Normothermia

• All guidelines stress the importance of maintaining body temperature.
• Evidence supports the use of forced-air warming and warmed IV fluids.
• Optimal core temperature: generally ≥ 36°C.
  

3. Oxygenation

• Mixed guidance on supplemental oxygen.
• WHO and ACS/SIS recommend 80% FiO₂ intraoperatively and postoperatively.
• CDC cites “uncertain trade-offs” and suggests further research.
  

4. Normovolemia

• Goal-directed fluid therapy is endorsed by WHO, APSIC, and others.
• Excess fluid and hypovolemia both impair tissue healing.
• Trials show mixed results; more high-quality studies are needed.

Research gaps and future directions

• More randomized controlled trials are needed, with a specific focus on SSIs.
  
• Adaptive platform trials may help evaluate multiple interventions simultaneously.
  
• Customized guidelines per surgical type and patient profile are recommended.

Conclusion

Anesthesiologists hold a pivotal role in preventing surgical site infections through targeted management of intraoperative homeostasis. While current guidelines offer a roadmap, discrepancies highlight the urgent need for further research and standardized practices. By championing evidence-based interventions, anesthesiologists can significantly reduce SSIs and improve surgical outcomes globally.

Reference: Le Couteur J et al. Systematic Review of Surgical Site Infection Prevention Guideline Recommendations for Maintenance of Homeostasis in the Perioperative Period. Anesthesiology. 2025;142:1150-1165. 

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