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De Waele JJ. Importance of timely and adequate source control in sepsis and septic shock. JOURNAL OF INTENSIVE MEDICINE 2024; 4:281-286. [PMID: 39035625 PMCID: PMC11258501 DOI: 10.1016/j.jointm.2024.01.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/07/2023] [Revised: 12/27/2023] [Accepted: 01/01/2024] [Indexed: 07/23/2024]
Abstract
Source control is defined as the physical measures undertaken to eliminate the source of infection and control ongoing contamination, as well as restore anatomy and function at the site of infection. It is a key component of the management of patients with sepsis and septic shock and one of the main determinants of the outcome of infections that require source control. While not all infections may require source control, it should be considered in every patient presenting with sepsis; it is applicable and necessary in numerous infections, not only those occurring in the abdominal cavity. Although the biological rationale is clear, several aspects of source control remain under debate. The timing of source control may impact outcome; early source control is particularly relevant for patients with abdominal infections or necrotizing skin and soft tissue infections, as well as for those with more severe disease. Percutaneous procedures are increasingly used for source control; nevertheless, surgery-tailored to the patient and infection-remains a valid option for source control. For outcome optimization, adequate source control is more important than the strategy used. It should be acknowledged that source control interventions may often fail, posing a challenge in this setting. Thus, an individualized, multidisciplinary approach tailored to the infection and patient is preferable.
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Affiliation(s)
- Jan J De Waele
- Department of Intensive Care Medicine, Ghent University Hospital, Ghent, Belgium
- Department of Internal Medicine and Pediatrics, Faculty of Medicine and Health Sciences, Ghent University, Ghent, Belgium
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Medline A, Muralidharan VJ, Codner J, Sharma J. Organ-Space Surgical Site Infections: Consequences and Prediction Using ACS-NSQIP. Am Surg 2022; 88:1773-1782. [PMID: 35438577 DOI: 10.1177/00031348221083944] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND The incidence of organ-space surgical site infections (OSIs) across the US has not decreased to the same extent as superficial and deep surgical site infections (SSIs). This study aimed to highlight the consequences and create a predictive model of OSIs using 2019 NSQIP data. MATERIALS AND METHODS The primary data source was the ACS NSQIP 2019 Participant Use Targeted File (PUF). Chi-squared and independent t-tests evaluated the association of OSIs and other postoperative complications. Variables of interest for our predictive model included 10 surgery types, 10 relevant preoperative laboratory values, and 26 other variables including demographics and comorbidities. A stepwise logistic regression model fit with OSIs as the outcome was used to calculate the predicted ROC and c-index. RESULTS A total of 1,076,441 cases submitted from 719 NSQIP-participating sites were included in our analysis, comprised of 16,751 (1.6%) OSIs with a median of 10 days (IQR: 11 days) between surgery and the development of an OSI. Forty-two variables were included in our final multivariable analysis. Esophageal and pancreatic surgeries yielded an approximate 4- and 6-fold higher increase in the odds of OSI, respectively (P < .001). ROC analysis yielded a c-index statistic of 0.846 (Figure 1). Associated consequences of OSIs included hospital readmission (OR = 20.74, 95% CI: 20.094-21.412, p < .001), sepsis (OR = 35.084; 95%CI: 33.75-36.47, p < .001) and higher probabilities of mortality (34% vs. 0.8%, p < .001) and morbidity (16% vs. 5.8%, p < .001). DISCUSSION OSIs have extensive consequences and may be predictable. These types of infections are multifactorial and require quality surveillance distinct from other SSIs.
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Affiliation(s)
- Alexandra Medline
- Department of General Surgery, 12239Emory University School of Medicine, Atlanta, GA, USA
| | | | - Jesse Codner
- Department of General Surgery, 12239Emory University School of Medicine, Atlanta, GA, USA
| | - Joe Sharma
- Department of General Surgery, 12239Emory University School of Medicine, Atlanta, GA, USA
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Timerbulatov MV, Grushevskaya EA, Grishina EE. [Risk factors of local infection after cholecystectomy and criteria of smooth postoperative period]. Khirurgiia (Mosk) 2020:23-28. [PMID: 32869611 DOI: 10.17116/hirurgia202008123] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
OBJECTIVE To identify the criteria of smooth postoperative period after cholecystectomy and risk factors of local surgical infection. MATERIAL AND METHODS A prospective analysis included 680 patients after laparoscopic cholecystectomy. We assessed incidence and risk factors of infectious complications. Major markers of acute inflammation, ultrasonic features of surgical site in early postoperative period were analyzed. RESULTS Postoperative infectious complications developed in 35 patients (5.1%). All studied risk factors except an age (obesity, cardiorespiratory diseases, surgery time over 150 min, violation of the principles of antibiotic therapy, intraoperative blood loss over 50 ml, drainage time over 5 days) significantly affected the development of infectious complications. Surgery time over 150 min and violation of the principles of antibiotic therapy were the most significant factors. Serum procalcitonin, erythrocyte sedimentation rate and C-reactive protein were characterized by the highest prognostic value on the 3rd postoperative day. Threshold values were defined. CONCLUSION Surgery time and violation of the rules of antibiotic prophylaxis were the most significant risk factors of postoperative infectious complications. We determined the criteria of smooth postoperative period: procalcitonin <1.5 mg/l, C-reactive protein <50 mg/l, erythrocyte sedimentation rate <39 mm/h, ultrasonic pattern of hypoechoic accumulation within the bed of the bladder (dimension <10 mm) without signs of intestinal insufficiency, abdominal or subhepatic effusion on the 3rd day after surgery.
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Abet E, Drissi F, Couëtte C, Jean MH, Denimal F, Podevin J, Duchalais E, Meurette G. Predictive value of inflammatory markers for postoperative recovery following colorectal surgery. Int J Colorectal Dis 2020; 35:1125-1131. [PMID: 32291509 DOI: 10.1007/s00384-020-03594-y] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/04/2020] [Indexed: 02/04/2023]
Abstract
BACKGROUND Using biological markers to predict serious complications and global postoperative recovery, to ensure safe and timely patient discharge after elective colorectal surgery represents a major challenge. The aim of this study was to demonstrate that C-reactive protein levels < 172 mg/l on postoperative day 3 were associated with postoperative recovery within 5 days. METHODS This is a prospective study of a consecutive bicentric cohort. Successive patients scheduled for bowel resection with anastomosis, without stoma, were included. The main composite endpoint for overall postoperative recovery included absence of fever, absence of pain > 2 on the visual analog scale, intestinal gas transit, and patient autonomy for mobility and body care. RESULTS One hundred sixty-height patients, with a mean age of 65 years old, were analyzed. Ninety patients (53%) underwent right colectomy and 131 (77%) were operated on by laparoscopy. Severe postoperative complications were observed in 11 patients (6%). One hundred twenty patients (71%) recovered within 5 days. C-reactive protein levels < 172 mg/L on postoperative day 3 had a negative predictive value of 80% to predict recovery within 5 days. Ninety-five percent of patients with C-reactive protein < 172 mg/L at postoperative day 3 had no severe postoperative complications. CONCLUSION Levels of C-reactive protein < 172 mg/L at postoperative day 3 corresponded with an early recovery in 80% of cases, thus allowing safe and early discharge without risk of serious complications.
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Affiliation(s)
- Emeric Abet
- Department of Digestive Surgery, Vendée Medical Center, Les Oudairies, 85000, La Roche-sur-Yon, France
| | - Farouk Drissi
- Department of Digestive Surgery, Vendée Medical Center, Les Oudairies, 85000, La Roche-sur-Yon, France. .,Department of Digestive and Endocrine Surgery, University Hospital of Nantes, 1, Place Alexis Ricordeau, 44093, Nantes, France.
| | - Clément Couëtte
- Department of Digestive Surgery, Vendée Medical Center, Les Oudairies, 85000, La Roche-sur-Yon, France
| | - Marc-Henri Jean
- Department of Digestive Surgery, Vendée Medical Center, Les Oudairies, 85000, La Roche-sur-Yon, France
| | - Fabrice Denimal
- Department of Digestive Surgery, Vendée Medical Center, Les Oudairies, 85000, La Roche-sur-Yon, France
| | - Juliette Podevin
- Department of Digestive and Endocrine Surgery, University Hospital of Nantes, 1, Place Alexis Ricordeau, 44093, Nantes, France
| | - Emilie Duchalais
- Department of Digestive and Endocrine Surgery, University Hospital of Nantes, 1, Place Alexis Ricordeau, 44093, Nantes, France
| | - Guillaume Meurette
- Department of Digestive and Endocrine Surgery, University Hospital of Nantes, 1, Place Alexis Ricordeau, 44093, Nantes, France
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Badia JM, Rubio Pérez I, Manuel A, Membrilla E, Ruiz-Tovar J, Muñoz-Casares C, Arias-Díaz J, Jimeno J, Guirao X, Balibrea JM. Surgical site infection prevention measures in General Surgery: Position statement by the Surgical Infections Division of the Spanish Association of Surgery. Cir Esp 2020; 98:187-203. [PMID: 31983392 DOI: 10.1016/j.ciresp.2019.11.010] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2019] [Revised: 11/19/2019] [Accepted: 11/20/2019] [Indexed: 02/07/2023]
Abstract
Surgical site infection is associated with prolonged hospital stay and increased morbidity, mortality and healthcare costs, as well as a poorer patient quality of life. Many hospitals have adopted scientifically-validated guidelines for the prevention of surgical site infection. Most of these protocols have resulted in improved postoperative results. The Surgical Infection Division of the Spanish Association of Surgery conducted a critical review of the scientific evidence and the most recent international guidelines in order to select measures with the highest degree of evidence to be applied in Spanish surgical services. The best measures are: no removal or clipping of hair from the surgical field, skin decontamination with alcohol solutions, adequate systemic antibiotic prophylaxis (administration within 30-60minutes before the incision in a single preoperative dose; intraoperative re-dosing when indicated), maintenance of normothermia and perioperative maintenance of glucose levels.
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Affiliation(s)
- Josep M Badia
- Servicio de Cirugía General y Aparato Digestivo, Hospital General de Granollers, Universitat Internacional de Catalunya, Barcelona, España
| | - Inés Rubio Pérez
- Servicio de Cirugía General y Aparato Digestivo, Hospital Universitario La Paz, Madrid, España.
| | - Alba Manuel
- Servicio de Cirugía General y Aparato Digestivo, Hospital Universitario de Guadalajara, Guadalajara, España
| | - Estela Membrilla
- Servicio de Cirugía General y Aparato Digestivo, Hospital del Mar, Barcelona, España
| | - Jaime Ruiz-Tovar
- Servicio de Cirugía General y Aparato Digestivo, Hospital Rey Juan Carlos, Madrid, Universidad Alfonso X, Madrid, España
| | - Cristóbal Muñoz-Casares
- Servicio de Cirugía General y Aparato Digestivo, Hospital Universitario Virgen del Rocío, Sevilla, España
| | - Javier Arias-Díaz
- Servicio de Cirugía General y Aparato Digestivo, Hospital Clínico San Carlos, Madrid, Facultad de Medicina, Universidad Complutense de Madrid, Madrid, España
| | - Jaime Jimeno
- Servicio de Cirugía General y Aparato Digestivo, Hospital Universitario Marqués de Valdecilla, Santander, España
| | - Xavier Guirao
- Servicio de Cirugía General y Aparato Digestivo, Parc Taulí, Hospital Universitari, Sabadell, España
| | - José M Balibrea
- Servicio de Cirugía General y Aparato Digestivo, Hospital Clínic de Barcelona, Universitat de Barcelona, Barcelona, España
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Shu W, Wan J, Chen J, He W, Zhu Y, Lu N, Xia L. Elevated arterial lactate level as an independent risk factor for pancreatic infection in moderately severe acute pancreatitis. Pancreatology 2019; 19:653-657. [PMID: 31196807 DOI: 10.1016/j.pan.2019.06.001] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/11/2018] [Revised: 03/02/2019] [Accepted: 06/04/2019] [Indexed: 12/11/2022]
Abstract
PURPOSE The present study aimed to research the relationships between arterial lactate levels and pancreatic infection in moderately severe acute pancreatitis. METHODS This study retrospectively analyzed data from 503 patients with moderately severe acute pancreatitis from January 1, 2013, to March 31, 2018. The baseline characteristics on admission were compared between patients with and without elevated arterial lactate levels. The parameters and laboratory data were compared between patients with and without pancreatic infections at admission. Univariate and multivariate logistic regression analyses were used to assess the value of elevated arterial lactate levels for identifying high-risk patients. P ≤ 0.05 was considered statistically significant. RESULTS A total of 49 (9.2%) patients were diagnosed with pancreatic infections. Compared with patients without pancreatic infections, pancreatic infection patients had significantly increased arterial lactate levels at admission (1.5 ± 0.7 vs. 2.5 ± 0.9; P < 0.01). Multivariate logic analysis still showed that higher arterial lactate levels in moderately severe acute pancreatitis was an independent risk factor for developing pancreatic infections (hazard ratio: 6.31, 95% CI 3.01-13.24; P < 0.01). Arterial lactate level ≥2.1 mmol/L and procalcitonin level ≥0.5 ng/mL at admission had area under the receiver operating characteristic curves of 0.83 and 0.72, with sensitivity of 67.2% and 87%, and specificity of 82.0% and 60%, respectively, for the prediction of pancreatic infection in moderately severe acute pancreatitis. CONCLUSIONS Our results indicate that a higher arterial lactate level is independently associated with pancreatic infection in patients with moderately severe acute pancreatitis and may be used as a tool to identify high-risk patients.
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Affiliation(s)
- Wenqing Shu
- Department of Gastroenterology, The First Affiliated Hospital of Nanchang University, Nanchang, PR China.
| | - Jianhua Wan
- Department of Gastroenterology, The First Affiliated Hospital of Nanchang University, Nanchang, PR China.
| | - Jie Chen
- Department of Gastroenterology, The First Affiliated Hospital of Nanchang University, Nanchang, PR China.
| | - Wenhua He
- Department of Gastroenterology, The First Affiliated Hospital of Nanchang University, Nanchang, PR China.
| | - Yin Zhu
- Department of Gastroenterology, The First Affiliated Hospital of Nanchang University, Nanchang, PR China.
| | - Nonghua Lu
- Department of Gastroenterology, The First Affiliated Hospital of Nanchang University, Nanchang, PR China.
| | - Liang Xia
- Department of Gastroenterology, The First Affiliated Hospital of Nanchang University, Nanchang, PR China.
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Guirao X. The dream of surgery without complications: A great step, much to do. Cir Esp 2017; 95:487-489. [PMID: 28738992 DOI: 10.1016/j.ciresp.2017.07.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2017] [Accepted: 07/02/2017] [Indexed: 11/28/2022]
Affiliation(s)
- Xavier Guirao
- Servicio de Cirugía General y del Aparato Digestivo, Parc Taulí Hospital Universitari. Institut d'Investigació i Innovació Parc Taulí I3PT, Universitat Autónoma de Barcelona, Sabadell, España.
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