Considerations in prevention of surgical site infections following cardiac surgery: when your patient is diabetic

The Perth Surgical Wound Dehiscence Risk Assessment Tool (PSWDRAT): development and prospective validation in the clinical setting

OBJECTIVE

The worldwide volume of surgery today is considerable and postoperative wound healing plays a significant part in facilitating a patient's recovery and rehabilitation. While contemporary surgical procedures are relatively safe, complications such as surgical wound dehiscence (SWD) or breakdown of the incision site may occur despite advances in surgical techniques, infection control practices and wound care. SWD impacts on patient mortality and morbidity and significantly contributes to prolonged hospital stay. Preoperative identification of patients at risk of SWD may be valuable in reducing the risk of postoperative wound complications.

METHOD

A three-phase study was undertaken to determine risk factors associated with SWD, develop a preoperative patient risk assessment tool and to prospectively validate the tool in a clinical setting. Phases 1 and 2 were retrospective case control studies. Phase 1 determined variables associated with SWD and these informed the development of a risk assessment tool. Univariate analysis and multiple logistic regression were applied to identify predictors of surgical risk. Phase 2 used the receiver operator curve statistic to determine the predictive power of the tool. Phase 3 involved a prospective consecutive case series validation to test the inter-rater reliability and predictive power of the tool.

RESULTS

In addition to those already identified in the literature, one independent risk predictor for SWD was identified: previous surgery in the same anatomical location (p<0.001, odds ratio [OR] 4). Multiple combined factors were integrated into the tool and included: age (p<0.019, OR 3), diabetes (p<0.624, OR 2), obesity (p<0.94, OR 1.4), smoking (p<0.387, OR 2), cardiovascular disease (p<0.381 OR 3) and peripheral arterial disease (p<0.501, OR 3). The predictive power of the tool yielded 71% in a combined data sample.

CONCLUSION

Patients with previous surgery in the same anatomical location were four times more likely to incur a dehiscence. Identification of at-risk patients for complications postoperatively is integral to reducing SWD occurrence and improving health-related outcomes following surgery.

Cultural Sensitivity and Challenges in Management of the Transgender Patient With ESRD in Transplantation

Transgender patients with end-stage renal disease (ESRD) present with specific challenges during the transplant evaluation, perioperative management, and postoperative phase of care. Demographic information, health-care records, chosen name, and gender identity along with documentation of specific health-care needs can become a challenge when gender assigned at birth is incongruent with the patients gender identity. Medical care involves addressing the end-organ disease as well as addressing those aspects of care specific to the transgender patient. This review article provides information on defining transgender, the impact of ESRD, and transgender in the transplant process and considerations in the throughout phases of care. Current recommendations for management of this unique population are provided.

Obesity is a predictor of morbidity in 1,629 patients who underwent adrenalectomy

BACKGROUND

We examined the impact of obesity on 30-day outcomes of adrenalectomy using a multi-institutional database.

METHODS

Patients who underwent adrenalectomy in 2005-2008 according to the American College of Surgeons-National Surgical Quality Improvement Project (ACS-NSQIP) data set were grouped by body mass index (BMI): normal weight (BMI=18.5-24.9 kg/m2), overweight (BMI=25.0-29.9 kg/m2), obese (BMI=30.0-34.9 kg/m2), and morbidly obese (BMI≥35 kg/m2). Outcomes of the higher BMI groups were compared to those of the normal BMI group using χ2, analysis of variance (ANOVA), and multivariate regression.

RESULTS

There were 1,629 patients in the study: 22% were normal weight, 31% overweight, 22.2% obese, and 24.7% morbidly obese. Compared to normal-weight patients, obese and morbidly obese patients had a 12.5 and 16.7% increase in operation times (129 vs. 145 and 150 min, respectively, p≤0.01) and sustained more wound complications (0.2 vs. 0.4 and 1.2%, p<0.001), including superficial and deep wound infections (p<0.001 and p<0.01, respectively). Morbid obesity independently predicted overall complications (odds ratio [OR] 2.9, 95% confidence interval [CI]: 1.7-5.7), wound complications (OR 6.1, 95% CI: 2.0-18.9), and septic complications (OR 3.1, 95% CI: 1.1-8.8). Obesity independently predicted longer total time in the operating room (p<0.006). There were no differences in rates of reoperation and length of hospital stay by BMI category.

CONCLUSION

Obesity is an independent risk factor that needs to be considered in surgical decisions regarding adrenalectomy. Morbidly obese adrenalectomy patients are particularly at risk for wound and septic complications.

To pump or not to pump?

Coronary artery bypass grafting is performed on the beating heart and thus requires the use of cardiopulmonary bypass. To avoid the complications associated with cardiopulmonary bypass, off-pump bypass (OPB) is viewed as a desirable alternative. Technological advancements have made OPB a viable option in an expanding population of patients. As a result, the number of OPB surgeries performed annually in the United States has increased. Critical care nurses are increasingly likely to provide care for patients after off-pump surgery. The differences between on-pump and OPB surgeries affect the postoperative nursing care requirements. While there are many common aspects of postoperative cardiac care for these 2 groups of surgical patients, there is a need to focus on the unique aspects of care for OPB patients. Despite promising short-term results in OPB patients, questions surrounding this procedure remain. Studies are under way to determine long-term graft patency.