APACHE II score validation in emergency abdominal surgery. A post hoc analysis of the InCare trial

Prediction of the risk of severe small bowel obstruction and effects of Houpu Paiqi mixture in patients undergoing surgery for small bowel obstruction

AIM

Small bowel obstruction is a common condition that requires emergency surgery. Slow recovery of bowel function after surgery or the occurrence of one or more complications can exacerbate the disease and result in severe small bowel obstruction (SSBO), significantly impacting recovery. It is characterized by a failure to regain enteral nutrition promptly, requiring long-term intensive care. Therefore, it is necessary to identify factors that predict SSBO, to allow early intervention for patients likely to develop this condition.

METHODS

Of the 260 patients who underwent emergency or elective surgery for small bowel obstruction between January 2018 and December 2022, 45 developed SSBO. The least absolute shrinkage and selection operator regression model was applied to optimize factor selection and multivariable logistic regression analysis was used to construct a predictive model. The performance and clinical utility of the nomogram were determined and internal validation was conducted. In addition, the effects of the Houpu Paiqi mixture on postoperative recovery were analyzed by comparing the clinical data of 28 patients who were treated with the mixture and 61patients who did not receive it.

RESULTS

The predictors included in the prediction nomogram were age, peritonitis, intestinal resection and anastomosis, complications, operation time, Acute Physiology and Chronic Health Evaluation II score, white blood cell count, and procalcitonin level. The model had an area under the receiver operating characteristic curve of 0.948 (95% confidence interval: 0.814-0.956). Decision curve analysis demonstrated that the SSBO risk nomogram had a good net clinical benefit. In addition, treatment with the Houpu Paiqi mixture reduced postoperative exhaust time, postoperative defecation time, time to first postoperative liquid feed, and length of stay in hospital.

CONCLUSIONS

We developed a nomogram that can assist clinicians in identifying patients at greater risk of SSBO, which may aid in early diagnosis and intervention. Additionally, we found that the Houpu Paiqi mixture promoted postoperative recovery.

Ertapenem combined with metronidazole for treatment of complex abdominal infections: Efficacy and impact on serum inflammatory indicators and T lymphocyte subsets

BACKGROUND

Complex intra-abdominal infections (cIAIs), often associated with abdominal trauma, have a complex etiology, are acute and severe, and have a high risk. They are an important cause of death in patients with abdominal trauma. Safe and effective treatment strategies are the factors affecting the prognosis of such patients.

AIM

To investigate the efficacy and safey of ertapenem combined with metronidazole in the treatment of cIAIs as well as the impact on serum inflammatory markers and T lymphocyte subsets, recovery status, and treatment costs.

METHODS

A total of 92 patients with cIAIs treated at our hospital from June 2021 to January 2023 were randomly divided into a control group and a study group, with 46 cases in each group. After admission, both groups received puncture drainage, continuous double-cannula irrigation, anti-infection therapy, organ function support, nutritional support, and other treatments. On this basis, the control group was treated with piperacillin/tazobactam combined with metronidazole, while the study group was treated with ertapenem combined with metronidazole. The therapeutic effects, recovery conditions, treatment costs, serum inflammatory indicators [procalcitonin (PCT), Toll-like receptor 4 (TLR-4), tumor necrosis factor-α (TNF-α), and C-reactive protein (CRP)], T lymphocyte subsets (CD3⁺, CD4⁺, and CD4⁺/CD8⁺ ratio), acute physiology and chronic health evaluation Ⅱ (APACHE Ⅱ) score, sequential organ failure assessment (SOFA) score, adverse reactions, and bacterial culture results were compared between the two groups.

RESULTS

The total effective rate of the study group was 93.48%, significantly higher than that of the control group (78.26%; P < 0.05). After 3 d and 7 d of treatment, the levels of serum PCT, TLR-4, TNF-α, and CRP in the study group were significantly lower and the levels of serum CD3⁺ and CD4⁺ T lymphocytes and CD4⁺/CD8⁺ ratio were significantly higher than those of the control group (P < 0.05). The APACHEⅡ score and SOFA score of the study group were significantly lower than those of the control group after 3 d and 7 d of treatment (P < 0.05). The time to fever resolution, ICU stay duration, and hospital stay in the study group were significantly shorter than those of the control group, and the costs of drugs and other resources were less than those of the control group (P < 0.05). The incidence of adverse reactions in the study group was 4.35%, significantly lower than that of the control group (17.39%; P < 0.05). There was no significant difference in the distribution of pathogenic bacteria between the two groups before and after treatment (P > 0.05).

CONCLUSION

Ertapenem combined with metronidazole is effective in the treatment of cIAIs, which can reduce inflammation, improve immune function, control disease progression, reduce the risk of organ failure, reduce the economic burden of patients, and improve treatment safety.

Benchmarking a Center of Excellence in Vascular Surgery: Using Acute Physiology and Chronic Health Evaluation II to Validate Outcomes in a Tertiary Care Institute

OBJECTIVE

The Society of Vascular Surgery (SVS) has made it a top priority to implement verification of vascular "centers of excellence". Our institutional aortic network was established in 2008 in order to standardize care of patients with suspected acute aortic pathology. The implementation and success of this program has been previously reported. We sought to use our experience as a benchmark for which to develop prognostic modeling to quantify clinical status upon admission and help predict outcomes. Our objective was to validate the Acute Physiology and Chronic Health Evaluation (APACHE) II scoring system using a cohort of aortic emergencies transferred by an organized transfer network.

METHOD

This was a retrospective, single institution review of patients transferred through an institutional aortic network for acute aortic pathology from 2017-2018. Demographics, comorbidities, aortic diagnosis, APACHE II score, as well as 30-day mortality were recorded. Associations with 30-day mortality were evaluated using two-sample t-tests, ANOVA models, Pearson chi-square tests and Fisher exact tests. Receiver operating characteristic (ROC) curves were fit overall and by pathology to predict 30-day mortality by Apache II total score.

RESULTS

There were 395 consecutive transfers were identified. The mean age was 64.7 years. Diagnoses included Type A Dissection (n = 134), Type B (n = 81), Aortic Aneurysm (n = 122), and PAU/IMH (n = 27). Mean APACHE II score on arrival was 12. Overall there were 53 deaths (13.4%) in the cohort. Patients that died had significantly higher Apache II total scores (11.3 vs 16.5, P < .001). The area under the receiver operator characteristic (ROC) curve (AUC) was .66 for the full cohort, indicating a poor clinical prediction test.

CONCLUSION

APACHE II score is a poor predictor of 30-day mortality in a large transfer network accepting all aortic emergencies. The authors believe further refining a prognostic model for diverse population will not only help in predicting outcomes but to objectively quantify illness severity in order to have a basis for comparison among institutions and verification of "centers of excellence".

Outcome of early cholecystectomy compared to percutaneous drainage of gallbladder and delayed cholecystectomy for patients with acute cholecystitis: systematic review and meta-analysis

BACKGROUND

Compare outcomes of early laparoscopic cholecystectomy (ELC) and percutaneous trans-hepatic drainage of gallbladder (PTGBD) as an initial intervention for AC and to compare operative outcomes of ELC and delayed laparoscopic cholecystectomy (DLC).

METHODS

English-language studies published until December 2020 were searched. Randomised controlled trials (RCTs) and observational studies compared EC and PTGBD with delayed cholecystectomy for patients presented with acute cholecystitis were considered. Main outcomes were mortality, conversion to open, complications and length of hospital stay.

RESULTS

Out of 1347 records, 14 studies were included. 205,361 (94.7%) patients had EC and 11,565 (5.3%) patients had PTGBD as an initial intervention for AC. Mortality was higher in PTGBD; HR, 95% CI: [3.68 (2.13, 6.38)]. In contrast, complication rate was significantly higher in EC group (47%) vs PTGBD group (8.7%) in patients admitted to ICU; P-value = 0.011. Patients who had ELC were at higher risk of post-operative complications compared to DLC; RR [95% CI]: 2.88 [1.78, 4.65]. Risk of bile duct injury was six folds more in ELC; RR [95% CI]: 6.07 [1.67, 21.99].

CONCLUSION

ELC may be a preferred treatment option over PTGBD in AC. However, patient and disease specific factors should be considered to avoid unfavourable outcomes with ELC.

Emergency Surgery Score as an Effective Risk Stratification Tool for Patients Undergoing Emergency Surgeries: A Narrative Review

Several risk stratification tools have been described for quantifying perioperative morbidity, mortality, and adverse events in patients undergoing elective and emergency surgeries. These tools help in decision-making, determining the prognosis and communicating it with patients and family members, and planning admissions to the intensive care units (ICU) if necessary. Emergency surgery poses quite a unique challenge in terms of deranged physiology, age, and comorbid conditions, and often carries a higher incidence of morbidity and mortality. Very few risk stratification tools are available to reliably predict the risk posed by emergency surgical interventions. One of the recently described tools is the Emergency Surgery Score (ESS), which comprises three demographic variables, 10 comorbidities, and nine laboratory variables, the scores of which add up to 29. Several studies have demonstrated that ESS reliably predicts morbidity, mortality, and the need for ICU admission, predicting infectious complications like pneumonia and renal failure. In this review, we analyze the current literature to investigate the efficacy and reliability of ESS as a risk stratification tool for patients undergoing emergency surgeries.

Trauma and nontrauma damage-control laparotomy: The difference is delirium (data from the Eastern Association for the Surgery of Trauma SLEEP-TIME multicenter trial)

BACKGROUND

Damage-control laparotomy (DCL) has been used for traumatic and nontraumatic indications. We studied factors associated with delirium and outcome in this population.

METHODS

We reviewed DCL patients at 15 centers for 2 years, including demographics, Charlson Comorbidity Index (CCI), diagnosis, operations, and outcomes. We compared 30-day mortality; renal failure requiring dialysis; number of takebacks; hospital, ventilator, and intensive care unit (ICU) days; and delirium-free and coma-free proportion of the first 30 ICU days (DF/CF-ICU-30) between trauma (T) and nontrauma (NT) patients. We performed linear regression for DF/CF-ICU-30, including age, sex, CCI, achievement of primary fascial closure (PFC), small and large bowel resection, bowel discontinuity, abdominal vascular procedures, and trauma as covariates. We performed one-way analysis of variance for DF/CF-ICU-30 against traumatic brain injury severity as measured by Abbreviated Injury Scale for the head.

RESULTS

Among 554 DCL patients (25.8% NT), NT patients were older (58.9 ± 15.8 vs. 39.7 ± 17.0 years, p < 0.001), more female (45.5% vs. 22.1%, p < 0.001), and had higher CCI (4.7 ± 3.3 vs. 1.1 ± 2.2, p < 0.001). The number of takebacks (1.7 ± 2.6 vs. 1.5 ± 1.2), time to first takeback (32.0 hours), duration of bowel discontinuity (47.0 hours), and time to PFC were similar (63.2 hours, achieved in 73.5%). Nontrauma and T patients had similar ventilator, ICU, and hospital days and mortality (31.0% NT, 29.8% T). Nontrauma patients had higher rates of renal failure requiring dialysis (36.6% vs. 14.1%, p < 0.001) and postoperative abdominal sepsis (40.1% vs. 17.1%, p < 0.001). Trauma and NT patients had similar number of hours of sedative (89.9 vs. 65.5 hours, p = 0.064) and opioid infusions (106.9 vs. 96.7 hours, p = 0.514), but T had lower DF/CF-ICU-30 (51.1% vs. 73.7%, p = 0.029), indicating more delirium. Linear regression analysis indicated that T was associated with a 32.1% decrease (95% CI, 14.6%-49.5%; p < 0.001) in DF/CF-ICU-30, while achieving PFC was associated with a 25.1% increase (95% CI, 10.2%-40.1%; p = 0.001) in DF/CFICU-30. Increasing Abbreviated Injury Scale for the head was associated with decreased DF/CF-ICU-30 by analysis of variance (p < 0.001).

CONCLUSION

Nontrauma patients had higher incidence of postoperative abdominal sepsis and need for dialysis, while T was independently associated with increased delirium, perhaps because of traumatic brain injury.

LEVEL OF EVIDENCE

Therapeutic study, level IV.

Influence of frailty in the outcome of surgical patients over 70 years old with admission criteria in ICU

INTRODUCTION

Frailty degree can influence more than age or severity in the outcome of patients older than 70 years undergoing surgery of the digestive system that require immediate postoperative control in the ICU.

METHODS

A prospective and observational study of patients over 70 years of age who were admitted to the surgical ICU of a third level hospital immediately after an elective or emergent surgical intervention on the digestive system from June 1, 2018 until June 1, 2019. The variables age, frailty Clinical Frailty Scale (CFS), and modified Frailty Index (mFI), severity (APACHE II), type of surgery, surgical pathology were recorded upon admission. A bivariate analysis was performed to assess the influence of frailty and severity on hospital morbidity and mortality and baseline situation of the patient (in terms of dependence) at 6 months.

RESULTS

A total of 90 patients were recruited, 54.4% of whom were reoperated; 74.4% were initially discharged from the ICU, with 28.4% of readmission and directly associated to frailty (CFS and mFI: P<0.01). The overall mortality at 6 months was 44.5% being CFS (OR = 64.3; P<0.05, 95% CI: 12.3-333.9) and APACHE II (OR = 1.17; P<0.05; 95% CI: 1.04-1.32) the covariates that best related.

CONCLUSIONS

The estimation of frailty by CSF and mFI is directly associated to the surgical morbidity and readmission of elderly and severe patients admitted to the ICU. In addition, CFS and mFI has been efficient as a predictive of mortality at 6 months.