Pre-operative IV Antibiotics Most Improve Surgical Safety
In this 35-year-old woman with acute appendicitis, fever >38°C, and stable asthma scheduled for laparoscopic appendectomy, administering pre-operative intravenous antibiotics 30–60 minutes before surgical incision is the single most evidence-based intervention to improve surgical safety and reduce postoperative infectious complications. 1, 2
Why Pre-operative Antibiotics Are Critical
A single IV dose of broad-spectrum antibiotics (e.g., cefazolin 1–2 g or piperacillin-tazobactam) given 0–60 minutes before skin incision significantly reduces surgical site infections and intra-abdominal abscesses in appendectomy patients, with the highest level of evidence (Class 1, Level A) supporting this practice. 1, 2
The presence of fever >38°C signals systemic inflammation and likely complicated appendicitis (perforation, abscess, or peritonitis), making timely antibiotic prophylaxis especially critical—this patient is at higher risk for postoperative infectious complications than afebrile patients. 1
Prophylactic antibiotics must achieve therapeutic tissue concentrations before the surgical incision; administering them intra-operatively does not provide the documented benefit. 3
For cefazolin specifically, the FDA label confirms administration ½ to 1 hour prior to the start of surgery for perioperative prophylaxis. 4
Why the Other Options Are Inadequate or Dangerous
Site Marking and Equipment Preparation (Option A)
Site marking is primarily relevant for lateralized procedures; the appendix has a fixed anatomical location, making additional marking unnecessary and not independently associated with improved outcomes in appendectomy. 2
While equipment preparation is a baseline requirement, it does not independently reduce morbidity or mortality compared to the proven infection-prevention benefit of pre-operative antibiotics. 2
Research shows that surgical site marking practices are highly variable, with only 36–59% of markings visible post-draping, and surgeons are divided on its value for non-lateralized procedures. 5, 6
Ignoring Asthma History (Option C)
Ignoring a patient's asthma history breaches fundamental peri-operative care standards and is unsafe, even when asthma is well-controlled without recent exacerbations. 1, 2
Laparoscopic pneumoperitoneum alters respiratory mechanics, making documented asthma history clinically relevant for intra-operative ventilation planning and anesthetic risk stratification. 2
The anesthesia team must be informed to optimize bronchodilator therapy, avoid histamine-releasing agents, and have rescue medications immediately available to prevent intra-operative bronchospasm. 1, 2
Omitting Informed Consent (Option D)
Informed consent is a legal and ethical prerequisite for all surgical procedures, regardless of complexity; appendectomy is not a "minor" surgery and carries risks including bleeding, infection, bowel injury, and possible conversion to open surgery. 1, 2
Specific risks that must be disclosed include injury to adjacent structures, anesthetic complications, and the possibility of extended postoperative antibiotics if complicated appendicitis is found intra-operatively. 1
Additional Safety Considerations for This Patient
Surgery should be performed within 24 hours of admission; however, the presence of fever may necessitate more urgent intervention (within 8 hours) to limit disease progression. 1, 2
Laparoscopic appendectomy is the preferred approach, offering reduced postoperative pain, lower surgical site infection rates, shorter hospital stay, and faster recovery compared to open surgery. 3, 1
No postoperative antibiotics are required for uncomplicated appendicitis with adequate source control; if intra-operative findings reveal complicated disease, limit postoperative antibiotics to 3–5 days. 1, 2
Common Pitfalls to Avoid
Do not delay surgery for additional imaging once the diagnosis is established and antibiotics have been administered. 1
Do not assume that stable asthma eliminates the need for peri-operative planning; communicate the asthma history to the anesthesia team. 1, 2
Do not administer antibiotics after the incision has been made; the prophylactic benefit is lost if tissue concentrations are not established before contamination occurs. 3, 2
Anticipate the possibility of conversion to open surgery or the need for extended postoperative antibiotics in febrile patients with suspected complicated appendicitis. 1