Safe and affordable surgery and anaesthesia is a global health priority. There is strong evidence that poor perioperative care is a key factor limiting the net improvements in health which could be achieved through improved global access to surgery. One in six patients experience complications after surgery in LMICs, most commonly infections. Surgical complications reduce life expectancy, quality of life, prevent return to work and cause catastrophic expenditure. For patients undergoing major abdominal surgery, complication rates exceed 30%. Seventy million such procedures are performed worldwide each year (excluding caesarean section) making this the most important global cause of post-operative morbidity and mortality.
An important route of bacterial entry into the lower respiratory tract is aspiration of bacteria in oral and pharyngeal secretions during endotracheal intubation. This results in colonisation of the lower respiratory tract, which overwhelms the patient’s mechanical, humoral, and cellular defences to establish infection following surgery. One potential method to prevent pneumonia after surgery may be to ask patients to use an antiseptic mouthwash with 0.2% chlorhexidine prior to anaesthesia. This treatment is very simple and low in cost, making it ideal for widespread implementation in low and middle-income countries. An international consensus statement from 1,000 anaesthetists, intensive care specialists, surgeons, and epidemiologists identified chlorhexidine mouthwash as a potential inexpensive intervention that may reduce perioperative mortality. However, the statement highlighted the need for effectiveness trials testing chlorhexidine mouthwash before it can be adopted into clinical pathways like perioperative care.
World Health Organisation guidelines recommend the use of liberal inspired oxygen concentrations of 80% during surgery and up to four hours after extubation to help prevent SSI. However, many clinical experts question this recommendation and highlight flaws in the evidence on which it is based. SSIs are clearly important being the most frequent healthcare-associated infection in LMICs, affecting one in three patients undergoing contaminated or dirty surgery. The delivery of high inspired oxygen concentrations during anaesthesia is technically difficult and expensive in resource poor settings. There is also some concern that high inspired oxygen concentrations may even increase mortality amongst acutely ill patients. There is an urgent need for high quality evidence across different settings to evaluate the clinical benefits and harms of high inspired oxygen concentrations to prevent SSI.