Clinical Scorecard: Top 10 evidence-based essentials in surgery

At a Glance

Key Highlights

• The 2024 AHA/ACC perioperative cardiovascular management guideline updates the 2014 recommendations for adults undergoing noncardiac surgery.
• SAGES appendicitis guidance covers adult and pediatric diagnosis and management, including operative approaches, timing, drains, antibiotics, and interval appendectomy.
• In SUNRRISE, incisional negative pressure wound therapy did not significantly reduce 30-day surgical site infection compared with surgeon-selected dressings.
• EPCAT III found aspirin alone noninferior to rivaroxaban followed by aspirin for symptomatic venous thromboembolism prevention after hip or knee arthroplasty; PREVENT CLOT found aspirin noninferior to low-molecular-weight heparin for 90-day mortality after specified fractures.
• The ACS NSQIP Surgical Risk Calculator estimates patient-specific risks of 19 outcomes within 30 days following surgery.

Guideline-Based Recommendations

Diagnosis

• The SAGES appendicitis guideline addresses diagnosis in adult and pediatric patients.

Management

• The 2024 AHA/ACC guideline provides recommendations for cardiovascular evaluation and management of adults undergoing noncardiac surgery, including pharmacologic therapy, monitoring, and devices.
• SAGES appendicitis guidance includes conditional recommendations on operative management, timing, techniques, drain placement, postoperative antibiotic duration, and interval appendectomy after nonoperative treatment of complicated appendicitis.
• The 2025 SAGES guideline addresses intraoperative indocyanine green fluorescence imaging in gastrointestinal procedures, including identification of primary abdominal cancers, nonregional metastases, and lymph nodes during gastrointestinal cancer resection, and use during esophageal and left-sided colorectal anastomoses.
• The 2022 SSI prevention practice recommendation distinguishes essential acute-care hospital practices from additional approaches to consider when infections remain uncontrolled after essential practices are implemented.

Monitoring & Follow-up

• The 2024 AHA/ACC guideline addresses perioperative monitoring for adults undergoing noncardiac surgery.
• The ACS NSQIP Surgical Risk Calculator estimates patient-specific risks of 19 outcomes within 30 days following surgery.

Risks

• In SUNRRISE, 30-day surgical site infection occurred in 28% with negative pressure wound therapy and 27% with comparison dressings.
• In EPCAT III, venous thromboembolism occurred in less than 1% in each group; major or clinically relevant nonmajor bleeding occurred in 45 of 2,718 aspirin recipients and 54 of 2,647 recipients of rivaroxaban followed by aspirin.
• In PREVENT CLOT, nonfatal pulmonary embolism occurred in 1.49% in each group; deep vein thrombosis occurred in 2.5% with aspirin and 1.7% with low-molecular-weight heparin.
• In POISE-3, tranexamic acid was associated with fewer composite bleeding outcomes than placebo at 30 days, but noninferiority was not established for the composite cardiovascular outcome.
• In CODA, 29% of patients assigned to antibiotics underwent appendectomy within 90 days, including 41% with an appendicolith and 25% without one.

Patient & Prescribing Data

Trial populations included 840 adults undergoing emergency laparotomy (SUNRRISE), 5,429 patients undergoing hip or knee arthroplasty (EPCAT III), 12,211 adults with operatively treated extremity, pelvic, or acetabular fractures (PREVENT CLOT), 9,535 patients undergoing noncardiac surgery (POISE-3), and 1,552 adults with appendicitis (CODA).

CODA found antibiotic treatment noninferior to appendectomy for health status at 30 days. EPCAT III found aspirin alone noninferior to rivaroxaban followed by aspirin for symptomatic venous thromboembolism prevention. PREVENT CLOT found aspirin noninferior to low-molecular-weight heparin for 90-day mortality. POISE-3 reported fewer composite bleeding outcomes with tranexamic acid than placebo, without establishing cardiovascular noninferiority.

Clinical Best Practices

• Use the relevant perioperative guideline for cardiovascular evaluation and management of adults undergoing noncardiac surgery.
• Apply appendicitis recommendations with attention to disease complexity, timing, operative technique, postoperative antibiotics, and whether interval appendectomy is being considered.
• For acute-care hospital SSI prevention, implement essential practices and consider additional approaches when infections remain uncontrolled.
• Use the ACS NSQIP Surgical Risk Calculator with patient characteristics and the planned procedure to support surgical decision-making and informed consent.

Related Resources & Content

• 2024 AHA/ACC Perioperative Cardiovascular Management Guideline
• Society of American Gastrointestinal and Endoscopic Surgeons Appendicitis Guideline
• 2025 Society of American Gastrointestinal and Endoscopic Surgeons Fluorescence Image-Guided Surgery Guideline
• SHEA/IDSA/APIC Surgical Site Infection Prevention Practice Recommendation
• SUNRRISE Trial
• EPCAT III Trial
• PREVENT CLOT Trial
• POISE-3 Trial
• CODA Trial
• American College of Surgeons NSQIP Surgical Risk Calculator