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Li H, Zheng X, Gao J. Comprehensive analysis of risk factors for postoperative wound infection following open reduction and internal fixation of Rib fractures. BMC Infect Dis 2024; 24:1013. [PMID: 39300348 DOI: 10.1186/s12879-024-09946-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2024] [Accepted: 09/17/2024] [Indexed: 09/22/2024] Open
Abstract
BACKGROUND Postoperative wound infections (PWIs) significantly impact patient outcomes following open reduction and internal fixation (ORIF) of rib fractures. Identifying and understanding risk factors associated with these infections are crucial for improving surgical outcomes and patient care. METHODS This retrospective study, conducted from January 2020 to October 2023 at our institution, aimed to analyze the risk factors for PWIs in patients undergoing ORIF for rib fractures. A total of 150 patients were included, with 50 in the infected group and 100 in the non-infected control group, matched for demographic and clinical characteristics. Data on variables such as intraoperative blood loss, hospital stay duration, body mass index (BMI), operation time, presence of anemia, drainage time, diabetes mellitus status, smoking habits, and age were collected. Statistical analysis involved univariate and multivariate logistic regression using SPSS software (Version 27.0), with p-values < 0.05 considered statistically significant. RESULTS Univariate analysis revealed no significant association between intraoperative blood loss or hospital stay duration and PWIs. However, operation time ≥ 5 h, anemia, drainage time ≥ 7 days, diabetes mellitus, smoking, and age ≥ 60 years were significantly associated with higher PWI rates. Multivariate logistic regression confirmed these factors as independent predictors of PWIs, with operation time and diabetes mellitus showing particularly strong associations. CONCLUSIONS Prolonged operation time, anemia, extended drainage, diabetes mellitus, smoking, and advanced age significantly increase the risk of PWIs following ORIF for rib fractures. Early identification and targeted management of these risk factors are essential to reduce the incidence of infections and improve postoperative outcomes.
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Affiliation(s)
- Hong Li
- Cardio-Thoracic Surgery Department, Qionghai People's Hospital, Qionghai City, 571400, Hainan Province, China
| | - Xufeng Zheng
- Cardio-Thoracic Surgery Department, Qionghai People's Hospital, Qionghai City, 571400, Hainan Province, China
| | - Jie Gao
- Gynecology-Breast And Thyroid Surgery Department, Qionghai People's Hospital, No. 33 Fuhai Road, Jiaji Town, Qionghai City, 571400, Hainan Province, China.
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Talwar A, Bansal A, Knight G, Caicedo JC, Riaz A, Salem R. Adverse Events of Surgical Drain Placement: An Analysis of the NSQIP Database. Am Surg 2024; 90:672-681. [PMID: 37490700 DOI: 10.1177/00031348231192063] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/27/2023]
Abstract
BACKGROUND Surgical site drainage is important to prevent hematoma, seroma, and abscess formation. However, the placement of drain placement also predispose patients to several postoperative complications. The aim of this study is to clarify the risk-benefit profile of surgical drain placement. METHODS The American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) Procedure-Targeted Databases were used to identify patients who underwent hepatectomy, pancreatectomy, nephrectomy, cystectomy, and prostatectomy. Patients who underwent each procedure were divided into 2 groups based on intraoperative drain placement. Propensity score-matched cohorts of these 2 groups were compared in terms of postoperative adverse events, readmission, reoperation, and length of stay. RESULTS Hepatectomy patients with drains experienced organ space infections (P < .001), sepsis (P < .001), and readmission (P = .021) more often than patients without drains. Patients who underwent pancreatectomy and had drains placed experienced wound dehiscence less frequently than those without drains (P = .04). For hepatectomy, pancreatectomy, nephrectomy, and prostatectomy populations, patients with drains had longer lengths of stay (P < .05). Matched populations across all procedures did not differ in terms of reoperation rate. DISCUSSION Prophylactic surgical drain placement may be associated with increased infectious complications and prolonged length of stay. Further studies are needed to elucidate the complete adverse event profile of surgical drains. Nonetheless, outcomes may be improved with better patient selection or advancements in drain technology.
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Affiliation(s)
- Abhinav Talwar
- Department of Otolaryngology-Head and Neck Surgery, Northwestern University, Chicago, Illinois, USA
| | - Ashir Bansal
- Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - Gabriel Knight
- Department of Radiology, Section of Interventional Radiology, Northwestern University, Chicago, IL, USA
| | - Juan-Carlos Caicedo
- Department of Surgery, Division of Transplant Surgery, Northwestern University, Chicago, IL, USA
| | - Ahsun Riaz
- Department of Radiology, Section of Interventional Radiology, Northwestern University, Chicago, IL, USA
| | - Riad Salem
- Department of Radiology, Section of Interventional Radiology, Northwestern University, Chicago, IL, USA
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Almonacid-Cardenas F, Rivas E, Auron M, Hu L, Wang D, Liu L, Tolich D, Mascha EJ, Ruetzler K, Kurz A, Turan A. Association between preoperative anemia optimization and major complications after non-cardiac surgery: a retrospective analysis. BRAZILIAN JOURNAL OF ANESTHESIOLOGY (ELSEVIER) 2024; 74:744474. [PMID: 38043700 DOI: 10.1016/j.bjane.2023.11.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/16/2023] [Revised: 11/17/2023] [Accepted: 11/22/2023] [Indexed: 12/05/2023]
Abstract
BACKGROUND Anemia is common in the preoperative setting and associated with increased postoperative complications and mortality. However, it is unclear if preoperative anemia optimization reduces postoperative complications. We aimed to assess the association between preoperative anemia optimization and a composite endpoint of major cardiovascular, renal, and pulmonary complications and all-cause mortality within 30 days after noncardiac surgery in adult patients. METHODS In this retrospective analysis preoperative anemia was defined as hemoglobin concentration below 12.0 g.dl-1 in women and 13.0 g.dl-1 in men within 6 months before surgery. A propensity score-based generalized estimating equation analysis was used to determine the association between preoperative anemia optimization and the primary outcome. Moreover, mediation analysis was conducted to investigate whether intraoperative red blood cell transfusion or duration of intraoperative hypotension were mediators of the relation between anemia optimization and the primary outcome. RESULTS Fifty-seven hundred anemia optimized, and 8721 non-optimized patients met study criteria. The proportion of patients having any component of the composite of major complications and all-cause mortality was 21.5% in the anemia-optimized versus 18.0% in the non-optimized, with confounder-adjusted odds ratio estimate of 0.99 (95% CI 0.86‒1.15) for anemia optimization versus non-optimization, p = 0.90. Intraoperative red blood cell transfusion had a minor mediation effect on the relationship between preoperative anemia optimization and the primary outcome, whereas duration of intraoperative hypotension was not found to be a mediator. CONCLUSION Preoperative anemia optimization did not appear to be associated with a composite outcome of major in-hospital postoperative cardiovascular, renal, and pulmonary complications and all-cause in-hospital mortality.
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Affiliation(s)
| | - Eva Rivas
- Cleveland Clinic, Anesthesiology Institute, Department of Outcomes Research, Cleveland, USA; Universidad de Barcelona, Hospital Clinic of Barcelona, IDIBAPS, Department of Anesthesia, Barcelona, Spain
| | - Moises Auron
- Cleveland Clinic, Department of Blood Management, Cleveland, USA
| | - Lucille Hu
- Cleveland Clinic, Anesthesiology Institute, Department of Outcomes Research, Cleveland, USA
| | - Dong Wang
- Cleveland Clinic, Anesthesiology Institute, Department of Outcomes Research, Cleveland, USA; Cleveland Clinic, Department of Quantitative Health Sciences, Cleveland, USA
| | - Liu Liu
- Cleveland Clinic, Anesthesiology Institute, Department of Outcomes Research, Cleveland, USA; Cleveland Clinic, Department of Quantitative Health Sciences, Cleveland, USA
| | - Deborah Tolich
- Cleveland Clinic, Department of Blood Management, Cleveland, USA
| | - Edward J Mascha
- Cleveland Clinic, Anesthesiology Institute, Department of Outcomes Research, Cleveland, USA; Cleveland Clinic, Department of Quantitative Health Sciences, Cleveland, USA
| | - Kurt Ruetzler
- Cleveland Clinic, Anesthesiology Institute, Department of Outcomes Research, Cleveland, USA; Cleveland Clinic, Anesthesiology Institute, Department of General Anesthesia, Cleveland, USA
| | - Andrea Kurz
- Cleveland Clinic, Anesthesiology Institute, Department of Outcomes Research, Cleveland, USA; Cleveland Clinic, Anesthesiology Institute, Department of General Anesthesia, Cleveland, USA
| | - Alparslan Turan
- Cleveland Clinic, Anesthesiology Institute, Department of Outcomes Research, Cleveland, USA; Cleveland Clinic, Anesthesiology Institute, Department of General Anesthesia, Cleveland, USA.
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Tkatschenko D, Hansen S, Koch J, Ames C, Fehlings MG, Berven S, Sekhon L, Shaffrey C, Smith JS, Hart R, Kim HJ, Wang J, Ha Y, Kwan K, Hai Y, Valacco M, Falavigna A, Taboada N, Guiroy A, Emmerich J, Meyer B, Kandziora F, Thomé C, Loibl M, Peul W, Gasbarrini A, Obeid I, Gehrchen M, Trampuz A, Vajkoczy P, Onken J. Prevention of Surgical Site Infections in Spine Surgery: An International Survey of Clinical Practices Among Expert Spine Surgeons. Global Spine J 2023; 13:2007-2015. [PMID: 35216540 PMCID: PMC10556889 DOI: 10.1177/21925682211068414] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
STUDY DESIGN Questionnaire-based survey. OBJECTIVES Surgical site infection (SSI) is a common complication in spine surgery but universal guidelines for SSI prevention are lacking. The objectives of this study are to depict a global status quo on implemented prevention strategies in spine surgery, common themes of practice and determine key areas for future research. METHODS An 80-item survey was distributed among spine surgeons worldwide via email. The questionnaire was designed and approved by an International Consensus Group on spine SSI. Consensus was defined as more than 60% of participants agreeing to a specific prevention strategy. RESULTS Four hundred seventy-two surgeons participated in the survey. Screening for Staphylococcus aureus (SA) is not common, whereas preoperative decolonization is performed in almost half of all hospitals. Body mass index (BMI) was not important for surgery planning. In contrast, elevated HbA1c level and hypoalbuminemia were often considered as reasons to postpone surgery. Cefazoline is the common drug for antimicrobial prophylaxis. Alcohol-based chlorhexidine is mainly used for skin disinfection. Double-gloving, wound irrigation, and tissue-conserving surgical techniques are routine in the operating room (OR). Local antibiotic administration is not common. Wound closure techniques and postoperative wound dressing routines vary greatly between the participating institutions. CONCLUSIONS With this study we provide an international overview on the heterogeneity of SSI prevention strategies in spine surgery. We demonstrated a large heterogeneity for pre-, peri- and postoperative measures to prevent SSI. Our data illustrated the need for developing universal guidelines and for testing areas of controversy in prospective clinical trials.
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Affiliation(s)
- Dimitri Tkatschenko
- Department of Neurosurgery, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Sonja Hansen
- Department of Hygiene and Environmental Medicine, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Julia Koch
- Department of Neurosurgery, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Christopher Ames
- Department of Neurological Surgery, University of California, San Francisco, CA, USA
| | - Michael G. Fehlings
- Division of Neurosurgery and Spine Program, Department of Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Sigurd Berven
- Orthopedic Surgery, UCSF Spine Center, San Francisco, CA, USA
| | | | - Christopher Shaffrey
- Departments of Neurosurgery and Orthopaedic Surgery, Duke Medical Center, Durham, NC, USA
| | - Justin S. Smith
- Department of Neurosurgery, University of Virginia Health System, Charlottesville, VA, USA
| | - Robert Hart
- Department of Orthopaedic Surgery, Oregon Health and Science University, Portland, OR, USA
| | - Han Jo Kim
- Hospital for Special Surgery, New York, NY, USA
| | | | - Yoon Ha
- Department of Neurosurgery, Spine, and Spinal Cord Institute, Yonsei University College of Medicine, Seoul, Korea
| | - Kenny Kwan
- Department of Orthopaedics and Traumatology, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Pokfulam, Hong Kong
| | - Yong Hai
- Department of Orthopedics, Beijing Chao-yang Hospital, Capital Medical University, Beijing, China
| | - Marcelo Valacco
- Department of Orthopaedics, Churruca Hospital de Buenos Aires, Buenos Aires, Argentina
| | - Asdrubal Falavigna
- Department of Neurosurgery, University of Caxias do Sul, Caxias do Sul, Brazil
| | | | - Alfredo Guiroy
- Spine Unit, Orthopedic Department, Hospital Español, Mendoza, Argentina
| | - Juan Emmerich
- Department of Neurological Surgery, Children’s Hospital, La Plata, Argentina
| | - Bernhard Meyer
- Department of Neurosurgery, Technische Universität München, Munich, Germany
| | - Frank Kandziora
- Centre for Spinal Surgery and Neurotraumatology, BG Unfallklinik, Frankfurt am Main, Germany
| | - Claudius Thomé
- Department of Neurosurgery, Medical University of Innsbruck, Tyrol, Austria
| | - Markus Loibl
- Department of Spine Surgery, Schulthess Klinik Zürich Switzerland and Department of Trauma Surgery, University Medical Center, Regensburg, Germany
| | - Wilco Peul
- University Neurosurgical Center Holland, Leiden University Medical Center, Haaglanden Medical Center & Haga Teaching Hospital, Leiden and The Hague, The Netherlands
| | - Alessandro Gasbarrini
- Department of Oncologic and Degenerative Spine Surgery, IRCCS Istituto Ortopedico Rizzoli, Bologna, Italy
| | - Ibrahim Obeid
- Clinique du Dos, Elsan Jean Villar Private Hospital, Bordeaux, France
| | - Martin Gehrchen
- Spine Unit, Department of Orthopedic Surgery, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Andrej Trampuz
- Center for Musculoskeletal Surgery (CMSC), Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Peter Vajkoczy
- Department of Neurosurgery, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Julia Onken
- Department of Neurosurgery, Charité - Universitätsmedizin Berlin, Berlin, Germany
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Wang Q, Cao M, Tao H, Fei Z, Huang X, Liang P, Liu B, Liu J, Lu X, Ma P, Si S, Wang S, Zhang Y, Zheng Y, Zang L, Chen X, Dong Z, Ge W, Guo W, Hu X, Huang X, Li L, Liang J, Liu B, Liu D, Liu L, Liu S, Liu X, Miao L, Ren H, Shi G, Shi L, Sun S, Tao X, Tong R, Wang C, Wang B, Wang J, Wang J, Wang X, Wang X, Xie J, Xie S, Yang H, Yang J, You C, Zhang H, Zhang Y, Zhao C, Zhao Q, Zhu J, Ji B, Guo R, Hang C, Xi X, Li S, Gong Z, Zhou J, Wang R, Zhao Z. Evidence-based guideline for the prevention and management of perioperative infection. J Evid Based Med 2023; 16:50-67. [PMID: 36852502 DOI: 10.1111/jebm.12514] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/08/2022] [Accepted: 01/09/2023] [Indexed: 03/01/2023]
Abstract
BACKGROUND We have updated the guideline for preventing and managing perioperative infection in China, given the global issues with antimicrobial resistance and the need to optimize antimicrobial usage and improve hospital infection control levels. METHODS We conducted a comprehensive evaluation of the evidence for prevention and management of perioperative infection, based on the concepts of the Grading of Recommendations Assessment, Development and Evaluation (GRADE) system. The strength of recommendations was graded and voted using the Delphi method and the nominal group technique. Revisions were made to the guidelines in response to feedback from the experts. RESULTS There were 17 questions prepared, for which 37 recommendations were made. According to the GRADE system, we evaluated the body of evidence for each clinical question. Based on the meta-analysis results, recommendations were graded using the Delphi method to generate useful information. CONCLUSIONS This guideline provides evidence to perioperative antimicrobial prophylaxis that increased the rational use of prophylactic antimicrobial use, with substantial improvement in the risk-benefit trade-off.
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Affiliation(s)
- Qiaoyu Wang
- Department of Pharmacy, Beijing Tiantan Hospital, Capital Medical University, Beijing, P. R. China
| | - Mingnan Cao
- Department of Pharmacy, Beijing Tiantan Hospital, Capital Medical University, Beijing, P. R. China
| | - Hua Tao
- Department of Pharmacy, Beijing United Family Hospital, Beijing, P. R. China
| | - Zhimin Fei
- Department of Neurosurgery, Shuguang Hospital Affiliated to Shanghai University of Traditional Chinese Medicine, Shanghai, P. R. China
| | - Xiufeng Huang
- Department of Gynecology, Women's Hospital, School of Medicine, Zhejiang University, Hangzhou, P. R. China
| | - Pixia Liang
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, P. R. China
| | - Baiyun Liu
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, P. R. China
| | - Jianping Liu
- Centre for Evidence-Based Medicine, Beijing University of Chinese Medicine, Beijing, P. R. China
| | - Xiaoyang Lu
- The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, P. R. China
| | - Penglin Ma
- Department of Respiratory and Critical Care Medicine, Peking University Third Hospital, Beijing, P. R. China
| | - Shuyi Si
- Institute of Medicinal Biotechnology, Chinese Academy of Medical Sciences, Beijing, P. R. China
| | - Shuo Wang
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, P. R. China
| | - Yuewei Zhang
- Department of General Surgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, P. R. China
| | - Yingli Zheng
- Department of Pharmacy, Fuwai Hospital, Chinese Academy of Medical Sciences, Beijing, P. R. China
| | - Lei Zang
- Department of Orthopedics, Beijing Chao-Yang Hospital, Capital Medical University, Beijing, P. R. China
| | - Xiao Chen
- Department of Pharmacy, First Affiliated Hospital, Sun Yat-Sen University, Guangzhou, P. R. China
| | - Zhanjun Dong
- Department of Pharmacy, Hebei General Hospital, Shijiazhuang, P. R. China
| | - Weihong Ge
- Department of Pharmacy, Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School, Nanjing, P. R. China
| | - Wei Guo
- Department of Emergency, Beijing Tiantan Hospital, Capital Medical University, Beijing, P. R. China
| | - Xin Hu
- Department of Pharmacy, Beijing Hospital, Beijing, P. R. China
| | - Xin Huang
- Department of Pharmacy, The First Affiliated Hospital of Shandong First Medical University/Shandong Province Qianfoshan Hospital, Jinan, P. R. China
| | - Ling Li
- Department of Pharmacy, Tongren Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, P. R. China
| | - Jianshu Liang
- Department of Nursing, Beijing Tiantan Hospital, Capital Medical University, Beijing, P. R. China
| | - Baoge Liu
- Department of Orthopedics, Beijing Tiantan Hospital, Capital Medical University, Beijing, P. R. China
| | - Dong Liu
- Department of Pharmacy, Tongji Hospital, Tongji Medical College, HUST, Wuhan, P. R. China
| | - Linna Liu
- Department of Pharmacy, The Second Affiliated Hospital of Air Force Medical University, Xi'an, P. R. China
| | - Songqing Liu
- Department of General Surgery, The Third Affiliated Hospital of Chongqing Medical University, Chongqing, P. R. China
| | - Xianghong Liu
- Department of Pharmacy, Qilu Hospital of Shandong University, Jinan, P. R. China
| | - Liyan Miao
- Department of Pharmacy, The First Affiliated Hospital of Soochow University, Suzhou, P. R. China
| | - Haixia Ren
- Department of Pharmacy, Tianjin First Central Hospital, Tianjin, P. R. China
| | - Guangzhi Shi
- Department of Intensive Care Unit, Beijing Tiantan Hospital, Capital Medical University, Beijing, P. R. China
| | - Luwen Shi
- Department of Pharmaceutical Administration, School of Pharmaceutical Sciences, Peking University, Beijing, P. R. China
| | - Shumei Sun
- Department of Pediatrics, Nanfang Hospital of Southern Medical University, Guangzhou, P. R. China
| | - Xia Tao
- Department of Pharmacy, Second Affiliated Hospital of Naval Medical University, Shanghai, P. R. China
| | - Rongsheng Tong
- Department of Pharmacy, Sichuan Academy of Medical Sciences, Sichuan Provincial People's Hospital, Chengdu, P. R. China
| | - Cheng Wang
- Department of Pharmacy, The Affiliated Suzhou Science & Technology Town Hospital of Nanjing Medical University, Suzhou, P. R. China
| | - Bin Wang
- Department of Pharmacy, Huashan Hospital, Fudan University, Shanghai, P. R. China
| | - Jincheng Wang
- Orthopaedic Medical Center, The 2nd Hospital of Jilin University, Changchun, P. R. China
| | - Jingwen Wang
- Department of Pharmacy, Xijing Hospital, Fourth Military Medical University, Xi'an, P. R. China
| | - Xiaoling Wang
- Department of Pharmacy, Beijing Children's Hospital, Capital Medical University, Beijing, P. R. China
| | - Xiaoyan Wang
- Department of Cardiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, P. R. China
| | - Jian Xie
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, P. R. China
| | - Shouxia Xie
- Department of Pharmacy, Shenzhen People's Hospital, Shenzhen, P. R. China
| | - Hua Yang
- Department of Neurosurgery, The Affiliated Hospital of Guizhou Medical University, Guiyang, P. R. China
| | - Jianxin Yang
- Department of Intervention Neuroradiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, P. R. China
| | - Chao You
- Department of Neurosurgery, West China Hospital Sichuan University, Chengdu, P. R. China
| | - Hongyi Zhang
- Department of General Surgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, P. R. China
| | - Yi Zhang
- Department of Pharmacy, Tianjin First Central Hospital, Tianjin, P. R. China
| | - Chengson Zhao
- Department of Pharmacy, The First Affiliated Hospital of Soochow University, Jiangsu Suzhou, P. R. China
| | - Qingchun Zhao
- Department of Pharmacy, General Hospital of Northern Theater Command, Shenyang, P. R. China
| | - Jiangguo Zhu
- Department of Pharmacy, The First Affiliated Hospital of Soochow University, Suzhou, P. R. China
| | - Bo Ji
- Clinical Pharmacy, General Hospital of Southern Theatre Command of PLA, Guangzhou, P. R. China
| | - Ruichen Guo
- Department of Pharmacy, Qilu Hospital of Shandong University, Jinan, P. R. China
| | - Chunhua Hang
- Department of Neurosurgery, Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School, Nanjing, P. R. China
| | - Xiaowei Xi
- Department of Gynecological Oncology, Shanghai General Hospital, Shanghai Jiao Tong University, Shanghai, P. R. China
| | - Sheyu Li
- Department of Endocrinology and Metabolism/China Evidence-based Medicine Center, West China Hospital Sichuan University, Chengdu, P. R. China
| | - Zhicheng Gong
- Department of Pharmacy, Xiangya Hospital, Central South University, Changsha, P. R. China
| | - Jianxin Zhou
- Department of Intensive Care Unit, Beijing Tiantan Hospital, Capital Medical University, Beijing, P. R. China
| | - Rui Wang
- Department of Drug Clinical Trial, PLA General Hospital, Beijing, P. R. China
| | - Zhigang Zhao
- Department of Pharmacy, Beijing Tiantan Hospital, Capital Medical University, Beijing, P. R. China
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Kiyatkin ME, Mladinov D, Jarzebowski ML, Warner MA. Patient Blood Management, Anemia, and Transfusion Optimization Across Surgical Specialties. Anesthesiol Clin 2023; 41:161-174. [PMID: 36871997 PMCID: PMC10066799 DOI: 10.1016/j.anclin.2022.10.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/07/2023]
Abstract
Patient blood management (PBM) is a systematic, evidence-based approach to improve patient outcomes by managing and preserving a patient's own blood and minimizing allogenic transfusion need and risk. According to the PBM approach, the goals of perioperative anemia management include early diagnosis, targeted treatment, blood conservation, restrictive transfusion except in cases of acute and massive hemorrhage, and ongoing quality assurance and research efforts to advance overall blood health.
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Affiliation(s)
- Michael E Kiyatkin
- Department of Anesthesiology, Albert Einstein College of Medicine, Montefiore Medical Center, 111 East 210th Street, Bronx, NY 10467, USA.
| | - Domagoj Mladinov
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, 75 Francis Street, Boston, MA 02115, USA
| | - Mary L Jarzebowski
- Department of Anesthesiology, University of Michigan, 1540 East Hospital Drive, Ann Arbor, MI 48109, USA
| | - Matthew A Warner
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, 200 1st Street, Rochester, MN 55905, USA
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7
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Chaudhry YP, Mekkawy KL, Hasan SA, Rao SS, Amin R, Oni JK, Sterling RS, Khanuja HS. Transfusion Rates in the Operative Treatment of Prosthetic Hip and Knee Infection. Orthopedics 2022; 45:353-359. [PMID: 36098575 DOI: 10.3928/01477447-20220907-04] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
Surgery for prosthetic joint infection (PJI) can often lead to significant blood loss, necessitating allogeneic blood transfusion (ABT). The use of ABT is associated with higher rates of morbidity and death in revision total joint arthroplasty, particularly in the treatment of PJI. We compared ABT rates by procedure type among patients treated for PJI. We retrospectively reviewed 143 operative cases of hip and knee PJI performed at our institution between 2016 and 2018. Procedures were categorized as irrigation and debridement (I&D) with modular component exchange (modular component exchange), explantation with I&D and placement of an antibiotic spacer (explantation), I&D with antibiotic spacer exchange (spacer exchange), or antibiotic spacer removal and prosthetic reimplantation (reimplantation). Rates of ABT and the number of units transfused were assessed. Factors associated with ABT were assessed with a multilevel mixed-effects regression model. Of the cases, 77 (54%) required ABT. The highest rates of ABT occurred during explantation (74%) and spacer exchange (72%), followed by reimplantation (36%) and modular component exchange (33%). A lower preoperative hemoglobin level was associated with higher odds of ABT. Explantation, reimplantation, and spacer exchange were associated with greater odds of ABT. Antibiotic spacer exchange and explantation were associated with greater odds of multiple-unit transfusion. Rates of ABT remain high in the surgical treatment of PJI. Antibiotic spacer exchange and explantation procedures had high rates of multiple-unit transfusions, and additional units of blood should be made available. Preoperative anemia should be treated when possible, and further refinement of blood management protocols for prosthetic joint infection is necessary. [Orthopedics. 2022;45(6):353-359.].
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Abdulkadir A, Mohammed B, Sertse E, Mengesha MM, Gebremichael MA. Treatment outcomes of penetrating abdominal injury requiring laparotomy at Hiwot Fana Specialized University Hospital, Harar, Ethiopia. Front Surg 2022; 9:914778. [PMID: 36081591 PMCID: PMC9445211 DOI: 10.3389/fsurg.2022.914778] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2022] [Accepted: 07/15/2022] [Indexed: 11/13/2022] Open
Abstract
Background Penetrating abdominal injury (PAI) is a public health problem and accounts for significant mortality and disability in both developing and developed countries. It often causes damage to internal organs, resulting in shock and infection. In this study, we assessed the outcomes of PAI and factors associated with post-surgical outcomes including surgical site infection (SSI) and in-hospital death. Methods An institution-based cross-sectional study was conducted from 15 January to January 30, 2020, using a standard checklist to review the clinical charts of patients who presented to Hiwot Fana Specialized University Hospital (HFSUH) with PAI and underwent laparotomy between January 2015 and September 2019. Descriptive statistics were used to describe the characteristics of patients, and odds ratios (ORs) with a 95% confidence interval (CI) were reported for factors included in binary logistic regression. The statistical significance was declared at a P-value <0.05. Results A total of 352 charts of patients with PAI were reviewed. A majority of them (84.9%) were males and the mean age was 26.5 years. The anterior abdomen was the most common site of injury, accounting for 285 patients (81%), 329 patients (93.5%) suffered organ injury, 204 (62%) had a single organ injury, and 125 (38%) had more than one organ injury. The leading injured organs were small intestines 194 (55.1%), followed by the colon 88 (25%) and liver 40 (11.4%). The magnitude of SSI and hospital death was 84 (23.9%) and 12 (3.4%), respectively. Patients above 45 years of age (AOR = 2.9, 95% CI: 1.2, 9.2), with fluid collection (AOR = 2.7, 95% CI: 1.2, 5.9), colostomy (AOR = 3.9, 95% CI: 1.9, 7.8), body temperature >37.5 °C (AOR = 3.8,95% CI:1.9,7.6), and Hgb < 10 mg/dl (AOR = 7.4, 95% CI: 3.4,16.1) had a higher likelihood of SSI. Those patients admitted to the intensive care unit (AOR = 21.3, 95% CI: 1.1, 412.3) and who underwent damage control surgery (AOR = 9.6, 95% CI: 1.3, 73.3) had a higher likelihood of mortality. Conclusions SSI and death among patients with PAI were high. Age, fluid collection, colostomy, body temperature, and hemoglobin level were statistically associated with SSI, and intensive care unit and damage control surgery were statistically associated with death. Therefore, health professionals working in surgical wards should consider these factors to alleviate SSI and prevent death. Broadly speaking, the guidelines of the World Society of Emergency Surgery (WSES) should consider these factors in their recommendations.
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Affiliation(s)
- Adnan Abdulkadir
- School of Medicine, College of Health and Medical Sciences, Haramaya University, Harar, Ethiopia
| | - Burka Mohammed
- School of Medicine, College of Health and Medical Sciences, Haramaya University, Harar, Ethiopia
| | - Elias Sertse
- School of Medicine, College of Health and Medical Sciences, Haramaya University, Harar, Ethiopia
| | - Melkamu Merid Mengesha
- Department of Epidemiology and Biostatistics, School of Public Health, College of Medicine and Health Sciences, Arba Minch University, Arba Minch, Ethiopia
| | - Mathewos Alemu Gebremichael
- Department of Public Health, College of Health Sciences, Bonga University, Bonga, Ethiopia
- Correspondence: Mathewos Alemu Gebremichael
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Birhanu A, Amare HH, G/Mariam M, Girma T, Tadesse M, Assefa DG. Magnitude of surgical site infection and determinant factors among postoperative patients, A cross sectional study. Ann Med Surg (Lond) 2022; 83:104324. [PMID: 36389196 PMCID: PMC9661638 DOI: 10.1016/j.amsu.2022.104324] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2022] [Revised: 07/27/2022] [Accepted: 07/31/2022] [Indexed: 11/29/2022] Open
Abstract
Background Surgical site infections (SSIs) are infections that occur within 30 days of surgery or within 1 year in patients with implants at or around the surgical site. They are among the dangerous complications of surgical procedures that expose patients to higher costs and increase the risk of death because of severe morbidity and associated longer hospital stays. This study aimed to determine the extent and determinants of surgical site infections in surgically treated cases during the study period. Methods A hospital-based cross-sectional study was conducted among surgically treated patients at Dilla University Referral Hospital in the surgical department. The calculated sample size was 408, calculated using the single population proportion formula, and the required information was collected from the medical records of the study participants using checklists. Bivariate logistic regression was performed to identify candidate variables, and all candidate variables with a P-value < of 0.25 were included in multivariable logistic regression. Variables with a P-value < 0.05 were considered statically significant, and the strength of association was measured by odds ratio (OR) with 95% confidence intervals (CIs). Result As our finding showed magnitude of surgical site infections was 19.3%. The factors which had significant association with surgical wound infections were blood transfusion (AOR = 0.16 (0.04–0.73), hemoglobin level < 7 g/dl (AOR = 10.40 (3.39–32.49), shock (AOR = 19.09 (4.69–77.51), previous surgery (AOR = 11.53(3.73–35.61), hospitalization 7–14 days (AOR = 5.51(1.52–19.91) and hospitalization >14 days (AOR = 8.18(1.84–36.75). Conclusion The percentage of surgical site infections was high. Shock, low haemoglobin level, blood transfusion, previous surgery, and longer length of hospital stay were significantly related to surgical site infections. Magnitude of Surgical site infection was high. Low haemoglobin level has significant association with occurrence of surgical site infection. Longer hospital stay has association with development of surgical site infection.
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Affiliation(s)
| | | | | | - Timsel Girma
- Department of Anesthesiology, Dilla University, Dilla, Ethiopia
- Corresponding author.
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Pre-operative iron increases haemoglobin concentration before abdominal surgery: a systematic review and meta-analysis of randomized controlled trials. Sci Rep 2022; 12:2158. [PMID: 35140245 PMCID: PMC8828750 DOI: 10.1038/s41598-022-05283-y] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2021] [Accepted: 12/08/2021] [Indexed: 11/09/2022] Open
Abstract
Professional surgical societies recommend the identification and treatment of pre-operative anaemia in patients scheduled for abdominal surgery. Our aim was to determine if pre-operative iron allows correction of haemoglobin concentration and decreased incidence of peri-operative blood transfusion in patients undergoing major abdominal surgery. MEDLINE, Embase and CENTRAL were searched for RCTs written in English and assessing the effect of pre-operative iron on the incidence of peri-operative allogeneic blood transfusion in patients undergoing major abdominal surgery. Pooled relative risk (RR), risk difference (RD) and mean difference (MD) were obtained using models with random effects. Heterogeneity was assessed using the Q-test and quantified using the I2 value. Four RCTs were retained for analysis out of 285 eligible articles. MD in haemoglobin concentration between patients with pre-operative iron and patients without pre-operative iron was of 0.81 g/dl (3 RCTs, 95% CI 0.30 to 1.33, I2: 60%, p = 0.002). Pre-operative iron did not lead to reduction in the incidence of peri-operative blood transfusion in terms of RD (4 RCTs, RD: − 0.13, 95% CI − 0.27 to 0.01, I2: 65%, p = 0.07) or RR (4 RCTs, RR: 0.57, 95% CI 0.30 to 1.09, I2: 64%, p = 0.09). To conclude, pre-operative iron significantly increases haemoglobin concentration by 0.81 g/dl before abdominal surgery but does not reduce the need for peri-operative blood transfusion. Important heterogeneity exists between existing RCTs in terms of populations and interventions. Future trials should target patients suffering from iron-deficiency anaemia and assess the effect of intervention on anaemia-related complications.
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Quiroga-Centeno AC, Hoyos-Rizo K, Chaparro-Zaraza AF, Pinilla-Merchán PF, Pinilla Chávez MC, Serrano-Pastrana JP, Gómez Ochoa SA. Infección temprana de la malla quirúrgica en herniorrafia incisional. Incidencia, factores de riesgo y desenlaces en más de 60.000 pacientes. REVISTA COLOMBIANA DE CIRUGÍA 2022. [DOI: 10.30944/20117582.1119] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Introducción. La infección de la malla en cirugía de reparación de hernias de pared abdominal es un desenlace pobre, asociado a un incremento en el riesgo de complicaciones. El objetivo del presente estudio fue analizar la incidencia, los factores asociados y desenlaces en pacientes llevados a herniorrafia incisional con malla con posterior diagnóstico de infección temprana.
Métodos. Estudio de cohorte retrospectiva. Se utilizaron los datos de egresos hospitalarios de la National Inpatient Sample (NIS) de los Estados Unidos de América para identificar a todos los pacientes adultos llevados a herniorrafia incisional durante los años 2010 a 2015. Se utilizaron modelos de regresión logística bivariada y multivariada para evaluar los factores de riesgo en infección temprana de la malla, y finalmente, modelos de regresión logística y lineal, según el tipo de variable dependiente, de tipo stepwise forward para evaluar la asociación entre el diagnóstico de infección de malla y los desenlaces adversos.
Resultados. En total se incluyeron 63.925 pacientes. La incidencia de infección temprana de la malla fue de 0,59 %, encontrando como factores asociados: comorbilidades (obesidad, desnutrición proteico calórica, anemia carencial y depresión), factores clínico-quirúrgicos (adherencias peritoneales, resección intestinal, cirugía laparoscópica y complicaciones no infecciosas de la herida) y administrativos o asistenciales.
Conclusiones. La infección temprana, aunque infrecuente, se asocia con un aumento significativo en el riesgo de complicaciones. La optimización prequirúrgica con base en los factores de riesgo para este desenlace nefasto es un elemento clave para la reducción de la incidencia y mitigación del impacto de la infección en los pacientes con herniorrafía incisional con malla.
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Incidence and Predictors of Surgical Site Infection Complications in Diabetic Patients Undergoing Lower Limb Amputation. Ann Vasc Surg 2021; 81:343-350. [PMID: 34780963 DOI: 10.1016/j.avsg.2021.09.040] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2021] [Revised: 08/25/2021] [Accepted: 09/08/2021] [Indexed: 01/21/2023]
Abstract
BACKGROUND Surgical site infections (SSIs) following lower extremity amputations (LEAs) are a major cause of patient morbidity and mortality. The objectives of this study are to investigate the annual incidence of SSI and risk factors associated with SSI after LEA in diabetic patients. METHODS LEAs performed on diabetic patients between 2005 and 2017 were retrospectively analyzed from the American College of Surgeons National Surgical Quality Improvement Program database. Incidence rates were calculated and analyzed for temporal change. Multivariable logistic regression was conducted to identify the independent predictors of SSIs in LEA. RESULTS In 21,449 diabetic patients, the incidence of SSIs was 6.8% after LEA, with an overall decreasing annual trend (P = 0.013). Amputation location (below-knee in reference to above-knee) [OR (95% CI): 1.35 (1.20 - 1.53), P <0.001], smoking [OR (95% CI): 1.25 (1.11 - 1.41), P <0.001)], female sex [OR (95% CI): 1.16 (1.03 - 1.30)], preoperative sepsis [OR (95% CI): 1.24 (1.10 - 1.40), P <0.001], P = 0.013], emergency status [OR (95% CI): 1.38 (1.17 - 1.63), P <0.001], and obesity [OR (95% CI): 1.59 (1.12 - 2.27), P = 0.009] emerged as independent predictors of SSIs, while moderate/severe anemia emerged as a risk-adjusted protective factor [OR (95% CI): 0.75 (0.62 - 0.91), P = 0.003]. Sensitivity analysis found that moderate/severe anemia, not body mass index (BMI) class, remained a significant risk factor in the development of SSIs in below-the-knee amputations; in contrast, higher BMI, not preoperative hematocrit, was significantly associated with an increased risk for SSI in above-the-knee amputations. CONCLUSIONS The incidence of SSIs after LEA in diabetic patients is decreasing. Overall, below-knee amputation, smoking, emergency status, and preoperative sepsis appeared to be associated with SSIs. Obesity increased SSIs in above-the-knee amputations, while moderate/severe preoperative anemia appears to protect against below-the-knee SSIs. Surgeons should take predictors of SSI into consideration while optimizing care for their patients, and future studies should investigate the role of preoperative hematocrit correction and how it may influence outcomes positively or negatively.
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Surgeons' view of the PREVENTT trial. Comment on Br J Anaesth 2021; 126: 9-11. Br J Anaesth 2021; 126:e84-e86. [PMID: 33358044 DOI: 10.1016/j.bja.2020.11.025] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2020] [Revised: 11/19/2020] [Accepted: 11/19/2020] [Indexed: 12/11/2022] Open
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Single-Dose Prophylactic Antibiotic Versus Extended Usage for Four Days in Clean-Contaminated Oncological Surgeries: a Randomized Clinical Trial. Indian J Surg Oncol 2020; 11:378-386. [PMID: 33013114 DOI: 10.1007/s13193-020-01163-x] [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: 09/24/2019] [Accepted: 07/07/2020] [Indexed: 10/23/2022] Open
Abstract
The optimal duration of prophylactic antimicrobial usage in clean-contaminated elective oncological surgeries is not clear. This single-center randomized trial evaluated the effectiveness of single-dose antimicrobial prophylaxis in clean-contaminated surgeries for the reduction of surgical site infection (SSI). Between April 2018 and January 2019, 315 patients undergoing major oncological clean-contaminated surgeries where the gastrointestinal or genital tract was opened under controlled conditions were randomized into 2 groups i.e., single dose versus extended dose groups. The single dose group received a 1.5 g dose of cefuroxime immediately before surgery while the extended group received the same dose of cefuroxime thrice daily for 4 days from the day of surgery till postoperative day 3. In addition, patients undergoing esophageal and colorectal surgeries received metronidazole. The overall SSI rate of the single dose group was not significantly different from that of the extended group (11.3% vs. 14.7%, respectively, p 0.40), with absolute difference of 3.4% and relative risk of 0.85 (95% C.I, 0.59 to 1.22). The rate of remote site infection was also not different between the two groups (14.4% vs 10.2%, p 0.31) with absolute difference of 4.2% and relative risk 1.19 (95% C.I, 0.89 to 1.59). In univariate analysis, parameters like nodal dissection, colorectal surgery, smoking, and hospital stay were significantly associated with SSI. In multivariate analysis, age, smoking, nodal dissection, and hospital stay retained significance. Single-dose antimicrobial prophylaxis is as effective as extended usage for 4 days in the prevention of postoperative SSI in patients undergoing clean-contaminated major oncological surgeries. Trial was registered with the clinical trial registry of India (CTRI/2018/06/014344).
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15
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Serum proteomics of active tuberculosis patients and contacts reveals unique processes activated during Mycobacterium tuberculosis infection. Sci Rep 2020; 10:3844. [PMID: 32123229 PMCID: PMC7052228 DOI: 10.1038/s41598-020-60753-5] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2019] [Accepted: 02/17/2020] [Indexed: 01/24/2023] Open
Abstract
Tuberculosis (TB) is the most lethal infection among infectious diseases. The specific aim of this study was to establish panels of serum protein biomarkers representative of active TB patients and their household contacts who were either infected (LTBI) or uninfected (EMI-TB Discovery Cohort, Pontevedra Region, Spain). A TMT (Tamdem mass tags) 10plex-based quantitative proteomics study was performed in quintuplicate containing a total of 15 individual serum samples per group. Peptides were analyzed in an LC-Orbitrap Elite platform, and raw data were processed using Proteome Discoverer 2.1. A total of 418 proteins were quantified. The specific protein signature of active TB patients was characterized by an accumulation of proteins related to complement activation, inflammation and modulation of immune response and also by a decrease of a small subset of proteins, including apolipoprotein A and serotransferrin, indicating the importance of lipid transport and iron assimilation in the progression of the disease. This signature was verified by the targeted measurement of selected candidates in a second cohort (EMI-TB Verification Cohort, Maputo Region, Mozambique) by ELISA and nephelometry techniques. These findings will aid our understanding of the complex metabolic processes associated with TB progression from LTBI to active disease.
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16
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Bolz NJ, Zarling BJ, Markel DC. Long-Term Sustainability of a Quality Initiative Program on Transfusion Rates in Total Joint Arthroplasty: A Follow-Up Study. J Arthroplasty 2020; 35:340-346. [PMID: 31548114 DOI: 10.1016/j.arth.2019.08.056] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/27/2019] [Revised: 07/16/2019] [Accepted: 08/27/2019] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND There are significant variations in transfusion rates among institutions performing total joint arthroplasty. We previously demonstrated that implementation of an educational program to increase awareness of the American Association of Blood Banks' transfusion guidelines led to an immediate decrease in transfusion rates at our facilities. It remained unclear how this initiative would endure over time. We report the long-term success and sustainability of this quality program. METHODS We reviewed the Michigan Arthroplasty Collaborative Quality Initiative data from 2012 through 2017 of all patients undergoing primary hip and knee arthroplasty at our institutions for preoperative and postoperative hemoglobin level, transfusion status, and number of units transfused and transfusions outside of protocol to identify changes surrounding our blood transfusion educational initiative. We calculated the transfusions prevented and cost implications over the course of the study. RESULTS We identified 6645 primary hip and knee arthroplasty patients. There was a significant decrease in transfusion rate and overall transfusions in each group when compared to pre-education values. Subgroup analysis of TKA and THA independently showed significant decreases in both transfusion rate and overall transfusions. Over the final 3 years of the study, only 2 patients were transfused outside of the American Association of Blood Banks protocol. We estimate prevention of 519 transfusions over the study period. CONCLUSION Application of this quality initiative was an effective means of identifying opportunities for quality improvement. The program was easily initiated, had significant early impact, and has been shown to be sustainable.
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Affiliation(s)
- Nicholas J Bolz
- Section of Orthopaedic Surgery, Ascension Providence Hospital, Novi, MI; Detroit Medical Center/Wayne State University Orthopedic Residency Program, Detroit, MI
| | - Bradley J Zarling
- Section of Orthopaedic Surgery, Ascension Providence Hospital, Novi, MI; Detroit Medical Center/Wayne State University Orthopedic Residency Program, Detroit, MI
| | - David C Markel
- Section of Orthopaedic Surgery, Ascension Providence Hospital, Novi, MI; Detroit Medical Center/Wayne State University Orthopedic Residency Program, Detroit, MI; The Core Institute, Novi, MI
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Bertschi D, Weber WP, Zeindler J, Stekhoven D, Mechera R, Salm L, Kralijevic M, Soysal SD, von Strauss M, Mujagic E, Marti WR. Antimicrobial Prophylaxis Redosing Reduces Surgical Site Infection Risk in Prolonged Duration Surgery Irrespective of Its Timing. World J Surg 2019; 43:2420-2425. [PMID: 31292675 DOI: 10.1007/s00268-019-05075-y] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
BACKGROUND Long-duration surgery requires repeated administration of antimicrobial prophylaxis (amp). Amp "redosing" reduces incidence of surgical site infections (SSI) but is frequently omitted. Clinical relevance of redosing timing needs to be investigated. Here, we evaluated the effects of compliance with amp redosing and its timing on SSI incidence in prolonged duration surgery. METHODS Data from >9000 patients undergoing visceral, trauma, or vascular surgery with elective or emergency treatment in two tertiary referral Swiss hospitals were analyzed. All patients had to receive amp preoperatively and redosing, if indicated. Antibiotics used were cefuroxime (1.5 or 3 g, if weight >80 kg), or cefuroxime and metronidazole (1.5 and 0.5 g, or 3 and 1 g doses, if weight >80 kg). Alternatively, in cases of known or suspected allergies, vancomycin (1 g), gentamicin (4 mg/Kg), and metronidazole or clindamycin (300 mg) with or without ciprofloxacin (400 mg) were used. Association of defined parameters, including wound class, ASA scores, and duration of operation, with SSI incidence was explored. RESULTS In the whole cohort, SSI incidence significantly correlated with duration of surgery (ρ = 0.73, p = 0.031). In 593 patients undergoing >240 min long interventions, duration of surgery was the only parameter significantly (p < 0.001) associated with increased SSI risk, whereas wound class, ASA scores, treatment areas, and emergency versus elective hospital entry were not. Redosing significantly reduced SSI incidence as shown by multivariate analysis (OR 0.60, 95% CI 0.37-0.96, p = 0.034), but exact timing had no significant impact. CONCLUSIONS Long-duration surgery associates with higher SSI incidence. Irrespective of its exact timing, amp redosing significantly decreases SSI risk.
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Affiliation(s)
- Daniela Bertschi
- Department of Visceral Surgery, Kantonsspital Chur, Chur, Switzerland
| | - Walter P Weber
- Department of General Surgery, University Hospital Basel, Basel, Switzerland
| | - Jasmin Zeindler
- Department of General Surgery, University Hospital Basel, Basel, Switzerland
| | - Daniel Stekhoven
- NEXUS Personalized Health Technologies, ETH Zurich, Zurich, Switzerland
| | - Robert Mechera
- Department of General Surgery, University Hospital Basel, Basel, Switzerland
| | - Lilian Salm
- Department of Visceral Surgery, Kantonsspital Aarau, Chirurgieaarau, Bahnhofstrasse 24, 5000, Aarau, Switzerland
| | - Marco Kralijevic
- Department of General Surgery, University Hospital Basel, Basel, Switzerland
| | - Savas D Soysal
- Department of General Surgery, University Hospital Basel, Basel, Switzerland
| | - Marco von Strauss
- Department of Visceral Surgery, Kantonsspital Aarau, Chirurgieaarau, Bahnhofstrasse 24, 5000, Aarau, Switzerland
| | - Edin Mujagic
- Department of General Surgery, University Hospital Basel, Basel, Switzerland
| | - Walter R Marti
- Department of Visceral Surgery, Kantonsspital Aarau, Chirurgieaarau, Bahnhofstrasse 24, 5000, Aarau, Switzerland.
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Liang R, Li J, Tang X, Liu Y. The prognostic role of preoperative systemic immune-inflammation index and albumin/globulin ratio in patients with newly diagnosed high-grade glioma. Clin Neurol Neurosurg 2019; 184:105397. [PMID: 31306893 DOI: 10.1016/j.clineuro.2019.105397] [Citation(s) in RCA: 28] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2019] [Revised: 06/19/2019] [Accepted: 06/23/2019] [Indexed: 02/05/2023]
Abstract
OBJECTIVE Preoperative systemic immune-inflammation index (SII) and the albumin/globulin ratio (AGR) have been used as prognostic markers in many malignancies. This study was conducted to evaluate the clinical significance of the preoperative SII and AGR in high-grade glioma (HGG) patients. PATIENTS AND METHODS A total of 169 patients with newly diagnosed HGG were enrolled in the current study. Overall survival (OS) of these patients was estimated by Kaplan-Meier analyses. Univariate and multivariate Cox regression analyses were performed to examine the relationships between OS and prognostic variables in patients with HGG. RESULTS The cut-off values for SII and AGR were 324.38 × 109/L and 1.35, respectively. An inverse correlation was observed between SII and AGR. The Kaplan-Meier survival analyses demonstrated that high SII and low AGR were associated with poor OS of patients with HGG (P = 0.002 and P = 0.012, respectively). Multivariate analyses revealed that both SII (HR 1.641, 95% CI: 1.071-2.515; P = 0.023) and AGR (HR 0.566, 95% CI: 0.335-0.956; P = 0.033) were independent predictive indicators of OS of HGG patients. CONCLUSIONS In conclusion, this study demonstrated that high SII and low AGR values may serve as promising prognostic markers to identify HGG patients with poor prognosis.
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Affiliation(s)
- Ruofei Liang
- Department of Neurosurgery, Affiliated Hospital of North Sichuan Medical College, China
| | - Junhong Li
- Department of Neurosurgery, West China Hospital, Sichuan University, China
| | - Xiaoping Tang
- Department of Neurosurgery, Affiliated Hospital of North Sichuan Medical College, China
| | - Yanhui Liu
- Department of Neurosurgery, West China Hospital, Sichuan University, China.
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Higgins RM, Helm MC, Kindel TL, Gould JC. Perioperative blood transfusion increases risk of surgical site infection after bariatric surgery. Surg Obes Relat Dis 2019; 15:582-587. [DOI: 10.1016/j.soard.2019.01.023] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2018] [Revised: 01/02/2019] [Accepted: 01/28/2019] [Indexed: 12/21/2022]
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Ji C, Zhu Y, Liu S, Li J, Zhang F, Chen W, Zhang Y. Incidence and risk of surgical site infection after adult femoral neck fractures treated by surgery: A retrospective case-control study. Medicine (Baltimore) 2019; 98:e14882. [PMID: 30882697 PMCID: PMC6426521 DOI: 10.1097/md.0000000000014882] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/28/2017] [Revised: 02/12/2019] [Accepted: 02/20/2019] [Indexed: 11/26/2022] Open
Abstract
Surgical site infections (SSI) are devastating complications after surgery for femoral neck fractures. There are a lot of literature have shown a strong association between diabetic patients and SSI. This study aimed to identify diabetes as an independent risk factor of SSI, focusing on femoral neck fractures, and to investigate the other potential risk factors for SSI.We retrospectively collected data from patients who underwent surgery for femoral neck fractures through the medical record management system at a single level 1 hospital between January 2015 and June 2016. Demographic and clinical patient factors and characteristics of SSI were recorded. The case group was defined as patients with SSI and the control group was defined as patients without SSI. Univariate and multivariate analyses were performed to determine the risk factors for SSI.Data were provided for 692 patients, among whom 26 had SSI, representing an incidence rate of 3.67%. In the SSI group, 24 (3.47%) patients had superficial infection and 2 (0.29%) had deep infection. On multivariate analysis, diabetes (P < .001) was determined an independent risk factor of SSI, so were surgery performed between May and September (P = .04), body mass index (P = .031), corticosteroid therapy (P = .003), anemia (P = .041), and low preoperative hemoglobin levels.Our results suggest that clinicians should recognize patients with these factors, particularly diabetes. And taking management optimally in the preoperative period will prevent the SSI after femoral neck fracture.
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Affiliation(s)
- Chenni Ji
- Department of Orthopaedic Surgery, The Third Hospital of Hebei Medical University
- Key Laboratory of Biomechanics of Hebei Province, Shijiazhuang, Hebei
| | - Yanbin Zhu
- Department of Orthopaedic Surgery, The Third Hospital of Hebei Medical University
- Key Laboratory of Biomechanics of Hebei Province, Shijiazhuang, Hebei
| | - Song Liu
- Department of Orthopaedic Surgery, The Third Hospital of Hebei Medical University
- Key Laboratory of Biomechanics of Hebei Province, Shijiazhuang, Hebei
| | - Jia Li
- Department of Orthopaedic Surgery, The Third Hospital of Hebei Medical University
- Key Laboratory of Biomechanics of Hebei Province, Shijiazhuang, Hebei
| | - Fei Zhang
- Department of Orthopaedic Surgery, The Third Hospital of Hebei Medical University
- Key Laboratory of Biomechanics of Hebei Province, Shijiazhuang, Hebei
| | - Wei Chen
- Department of Orthopaedic Surgery, The Third Hospital of Hebei Medical University
- Key Laboratory of Biomechanics of Hebei Province, Shijiazhuang, Hebei
| | - Yingze Zhang
- Department of Orthopaedic Surgery, The Third Hospital of Hebei Medical University
- Key Laboratory of Biomechanics of Hebei Province, Shijiazhuang, Hebei
- Chinese Academy of Engineering, Beijing, P.R. China
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21
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Maezawa K, Nozawa M, Yuasa T, Gomi M, Igarashi E, Sato H, Sugimoto M, Kaneko K. Postoperative hemoglobin and recovery of hip muscle strength after total hip arthroplasty. J Orthop 2018; 15:886-888. [PMID: 30166805 DOI: 10.1016/j.jor.2018.08.016] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/10/2018] [Accepted: 08/05/2018] [Indexed: 10/28/2022] Open
Abstract
Background The presence/absence of postoperative anemia are presumed to have an impact on early recovery after surgery. This study was performed to compare hip muscle strength and hemoglobin during the perioperative period in 82 patients undergoing THA. Methods Evaluation of presence/absence of anemia was performed by calculating the 10-day postoperative/preoperative Hb ratio. Muscle strength was investigated before and 2 months after surgery. Results Postoperative SLR strength showed a significant difference between the patients whose 10-day postoperative/preoperative Hb ratio was <85% and ≧ 85%. Conclusion We need to consider perioperative strategies to minimize anemia in order to improve patient outcomes.
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Affiliation(s)
- Katsuhiko Maezawa
- Department of Orthopaedic Surgery, Juntendo University Urayasu Hospital, 2-1-1 Tomioka, Urayasu City, Chiba, 279-0021, Japan
| | - Masahiko Nozawa
- Department of Orthopaedic Surgery, Juntendo University Nerima Hospital, 3-1-10 Takanodai, Nerima, Tokyo, 177-8521, Japan
| | - Takahito Yuasa
- Department of Orthopaedic Surgery, Juntendo University Urayasu Hospital, 2-1-1 Tomioka, Urayasu City, Chiba, 279-0021, Japan
| | - Motosi Gomi
- Department of Orthopaedic Surgery, Juntendo University Urayasu Hospital, 2-1-1 Tomioka, Urayasu City, Chiba, 279-0021, Japan
| | - Emi Igarashi
- Department of Nursing, Juntendo University Urayasu Hospital, 2-1-1 Tomioka, Urayasu City, Chiba, 279-0021, Japan
| | - Hironobu Sato
- Department of Orthopaedic Surgery, Juntendo University Urayasu Hospital, 2-1-1 Tomioka, Urayasu City, Chiba, 279-0021, Japan
| | - Munehiko Sugimoto
- Department of Orthopaedic Surgery, Juntendo University School of Medicine, 2-1-1 Hongo, Bunkyo-ku, Tokyo, 113-8421, Japan
| | - Kazuo Kaneko
- Department of Orthopaedic Surgery, Juntendo University School of Medicine, 2-1-1 Hongo, Bunkyo-ku, Tokyo, 113-8421, Japan
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22
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Stoicea N, Moran K, Mahmoud AR, Glassman A, Ellis T, Ryan J, Granger J, Joseph N, Salon N, Ackermann W, Rogers B, Niermeyer W, Bergese SD. Tranexamic acid use during total hip arthroplasty: A single center retrospective analysis. Medicine (Baltimore) 2018; 97:e10720. [PMID: 29794747 PMCID: PMC6392984 DOI: 10.1097/md.0000000000010720] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Tranexamic acid (TXA) is an antifibrinolytic agent that has shown promise in reducing blood loss during total hip arthroplasty (THA). Several studies have reported side effects of high-dose TXA administration, including myocardial infarction (MI), thromboembolic events, and seizures. These possible side effects have prevented the widespread adoption of TXA in the surgical community. METHODS We conducted a retrospective chart review of 564 primary and revision THAs performed at a single academic center. Surgical patients received either no TXA or 1 g IV TXA at the beginning of surgery followed by a second bolus just before the surgical wound closure, at the surgeon's discretion. We analyzed differences in hemoglobin (Hb), hematocrit (Hct), estimated blood loss (EBL), and adverse events in patients receiving TXA versus patients not receiving TXA up to 2 days following surgery. RESULTS Significantly higher Hb and Hct values were found across all time points among patients undergoing primary posterior or revision THA who had received TXA. In addition, transfusion rates were significantly decreased in both primary posterior THAs and revision THAs when TXA was administered. Patients who received TXA experienced significantly fewer adverse events than those who did not for all surgery types. CONCLUSION Administration of low-dose intravenous (IV) and intra-articular (IA) TXA does not appear to increase rates of adverse events and may be effective in minimizing blood loss, as reflected by Hb and Hct values following THA.
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Affiliation(s)
| | | | - Abdel-Rasoul Mahmoud
- Center for Biostatistics, Department of Biomedical Informatics, The Ohio State University, Columbus, OH
| | - Andrew Glassman
- Department of Orthopaedics, The Ohio State University Wexner Medical Center, Columbus
| | | | - John Ryan
- Department of Orthopaedics, The Ohio State University Wexner Medical Center, Columbus
| | - Jeffrey Granger
- Department of Orthopaedics, The Ohio State University Wexner Medical Center, Columbus
| | | | - Nathan Salon
- Weinberg College of Arts and Sciences, Northwestern University, Evanston, IL
| | | | | | | | - Sergio D. Bergese
- Department of Anesthesiology
- Department of Neurological Surgery, The Ohio State University Wexner Medical Center, Columbus, OH
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23
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Markel DC, Allen MW, Hughes RE, Singal BM, Hallstrom BR. Quality Initiative Programs Can Decrease Total Joint Arthroplasty Transfusion Rates-A Multicenter Study Using the MARCQI Total Joint Registry Database. J Arthroplasty 2017; 32:3292-3297. [PMID: 28697866 DOI: 10.1016/j.arth.2017.06.009] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/04/2017] [Revised: 05/29/2017] [Accepted: 06/05/2017] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND The Michigan Arthroplasty Registry Collaborative Quality Initiative (MARCQI) noted wide variability between member hospitals in blood transfusion rates after primary total hip and knee arthroplasty (THA and TKA). Blood transfusion has substantial risks and accepted recommendations exist to guide transfusion practices. MARCQI began an initiative to decrease unnecessary transfusions by identifying/reporting outliers, discussing conservative transfusion practices, and recommending transfusion guidelines. There was a later recommendation to consider intraoperative use of tranexamic acid. METHODS All MARCQI-registered unilateral TKA and THA cases from the 28 member hospitals (pre-November 2013) were included. For 3 time periods (before November 13, 2013; November 13, 2013, to November 12, 2014; and after November 12, 2014), we calculated average risk and range of transfusion, transfusion with nadir hemoglobin >8 g/dL, mean length of stay, and 90-day risk of discharge to nursing home, readmission, deep infection, and emergency department visits. RESULTS For THA, risk and range of transfusion decreased over the 3 time periods: 12.6% (2.5%-36.2%), 7.6% (2.2%-23.8%), and 4.5% (0.7%-14.4%); for TKA, 6.3% (1.3%-15.6%), 3.1% (0%-12.5%), and 1.3% (0%-7.4%). Decreases were also noted for transfusion with a nadir hemoglobin >8 g/dL with a near elimination of "unnecessary" transfusions. There was no evidence of increase in length of stay, discharge to nursing home, readmission, deep infection, or emergency department visits. CONCLUSION A simple intervention can decrease unnecessary blood transfusions during and after elective primary unilateral THA or TKA. A collaborative registry can be used effectively to improve the quality of patient care and set a new benchmark for transfusion.
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Affiliation(s)
- David C Markel
- Department of Orthopaedics, The CORE Institute, Novi, Michigan
| | - Mark W Allen
- Department of Orthopaedics, The CORE Institute, Phoenix, Arizona
| | - Richard E Hughes
- Department of Industrial and Operations Engineering, University of Michigan, Ann Arbor, Michigan; Department of Orthopedic Surgery, University of Michigan Health System, Ann Arbor, Michigan; Department of Biomedical Engineering, University of Michigan, Ann Arbor, Michigan
| | - Bonita M Singal
- Orthopedic Surgery, American Association for the Advancement of Sciences, Science and Technology Policy Fellow, Energy Policy and Systems Analysis, United States Department of Energy, Washington, DC
| | - Brian R Hallstrom
- Department of Orthopaedic Surgery, University of Michigan Health System, A. Alfred Taubman Health Care Center, Ann Arbor, Michigan
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24
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Itani KMF, Dellinger EP, Mazuski J, Solomkin J, Allen G, Blanchard JC, Kelz R, Berríos-Torres SI. Surgical Site Infection Research Opportunities. Surg Infect (Larchmt) 2017; 18:401-408. [PMID: 28541807 DOI: 10.1089/sur.2017.060] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Much has been done to identify measures and modify risk factors to decrease the rate of surgical site infection (SSI). Development of the Centers for Disease Control and Prevention (CDC) Core recommendations for the prevention of SSI revealed evidence gaps in six areas: Parenteral antimicrobial prophylaxis, glycemic control, normothermia, oxygenation, antiseptic prophylaxis, and non-parenteral antimicrobial prophylaxis. Using a modified Delphi process, seven SSI content experts identified nutritional status, smoking, obesity, surgical technique, and anemia as additional areas for SSI prevention research. Post-modified Delphi process Staphylococcus aureus colonization and SSI definition and surveillance were also deemed important topic areas for inclusion. For each topic, research questions were developed, and 10 were selected as the final SSI research questions.
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Affiliation(s)
- Kamal M F Itani
- 1 VA Boston Health Care System, Boston University and Harvard Medical School , Boston, Massachusetts
| | - E Patchen Dellinger
- 2 Department of Surgery, Division of General Surgery, University of Washington , Seattle, Washington
| | - John Mazuski
- 3 Section of Acute and Critical Care Surgery, Department of Surgery, Washington University School of Medicine , St. Louis, Missouri
| | - Joseph Solomkin
- 4 Department of Surgery, University of Cincinnati , Cincinnati, Ohio
| | - George Allen
- 5 Downstate Medical Center and SUNY College of Health Related Professions , Brooklyn, New York
| | - Joan C Blanchard
- 6 Association of periOperative Registered Nurses, Inc. , Denver, Colorado
| | - Rachel Kelz
- 7 Department of Surgery, Perelman School of Medicine, Leonard Davis Institute of Healthcare Economics, Wharton School, University of Pennsylvania , Philadelphia, Pennsylvania
| | - Sandra I Berríos-Torres
- 8 Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention , Atlanta, Georgia
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25
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Mujagic E, Marti WR, Coslovsky M, Zeindler J, Staubli S, Marti R, Mechera R, Soysal SD, Gürke L, Weber WP. The role of preoperative blood parameters to predict the risk of surgical site infection. Am J Surg 2017; 215:651-657. [PMID: 28982517 DOI: 10.1016/j.amjsurg.2017.08.021] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2017] [Revised: 08/17/2017] [Accepted: 08/21/2017] [Indexed: 01/13/2023]
Abstract
BACKGROUND Routine preoperative blood work is not recommended but selected biochemical markers may predict the risk of surgical site infection (SSI). This study examines the association between preoperative biochemical markers and the risk of SSI. METHODS This observational cohort study, nested in a randomized controlled trial, was conducted at two tertiary referral centers in Switzerland. RESULTS 122 (5.8%) of 2093 patients experienced SSI. Preoperative increasing levels of albumin (OR 0.93), CRP (OR 1.34), hemoglobin (OR 0.87) and eGFR (OR 0.90) were significantly associated with the odds of SSI. The same accounts for categorized parameters. The highest area under the curve from ROC curves was 0.62 for albumin. Positive predictive values ranged from 6.4% to 9.5% and negative predictive values from 94.8% to 95.7%. The association of CRP, mildly and moderately decreased eGFR and hemoglobin with the odds of SSI remained significant on multivariate analysis. CONCLUSIONS Our results do not support generally delaying elective surgery based on preoperative blood results. However, it may be considered in situations with potentially severe sequelae of SSI.
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Affiliation(s)
- Edin Mujagic
- Department of Surgery, University Hospital of Basel, Spitalstrasse 21, 4031, Basel, Switzerland.
| | - Walter R Marti
- Department of Surgery, Kantonsspital Aarau, Tellstrasse, 5001, Aarau, Switzerland.
| | - Michael Coslovsky
- University of Basel, University Hospital, Department of Clinical Research, Clinical Trial Unit, Spitalstrasse 12, 4031, Basel, Switzerland.
| | - Jasmin Zeindler
- Department of Surgery, University Hospital of Basel, Spitalstrasse 21, 4031, Basel, Switzerland.
| | - Sebastian Staubli
- Department of Surgery, University Hospital of Basel, Spitalstrasse 21, 4031, Basel, Switzerland.
| | - Regula Marti
- Department of Surgery, Kantonsspital Aarau, Tellstrasse, 5001, Aarau, Switzerland.
| | - Robert Mechera
- Department of Surgery, University Hospital of Basel, Spitalstrasse 21, 4031, Basel, Switzerland.
| | - Savas D Soysal
- Department of Surgery, University Hospital of Basel, Spitalstrasse 21, 4031, Basel, Switzerland.
| | - Lorenz Gürke
- Department of Surgery, University Hospital of Basel, Spitalstrasse 21, 4031, Basel, Switzerland.
| | - Walter P Weber
- Department of Surgery, University Hospital of Basel, Spitalstrasse 21, 4031, Basel, Switzerland.
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26
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Jannasch O, Klinge T, Otto R, Chiapponi C, Udelnow A, Lippert H, Bruns CJ, Mroczkowski P. Risk factors, short and long term outcome of anastomotic leaks in rectal cancer. Oncotarget 2017; 6:36884-93. [PMID: 26392333 PMCID: PMC4742217 DOI: 10.18632/oncotarget.5170] [Citation(s) in RCA: 68] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2015] [Accepted: 09/04/2015] [Indexed: 12/12/2022] Open
Abstract
Background An anastomotic leak (AL) after colorectal surgery is one major reason for postoperative morbidity and mortality. There is growing evidence that AL affects short and long term outcome. This prospective German multicentre study aims to identify risk factors for AL and quantify effects on short and long term course after rectal cancer surgery. Methods From 1 January 2000 to 31 December 2010 381 hospitals attributed patients to the prospective multicentre study Quality Assurance in Colorectal Cancer managed by the Otto-von-Guericke-University Magdeburg (Germany). Included were 17 867 patients with histopathologically confirmed rectal carcinoma and primary anastomosis. Risk factor analysis included 13 items of demographic patient data, surgical course, hospital volume und tumour stage. Results In 2 134 (11.9%) patients an AL was diagnosed. Overall hospital mortality was 2.1% (with AL 7.5%, without AL 1.4%; p < 0.0001). In multivariate analysis male gender, ASA-classification ≥III, smoking history, alcohol history, intraoperative blood transfusion, no protective ileostomy, UICC-stage and height of tumour were independent risk factors. Overall survival (OS) was significantly shorter for patients with AL (UICC I-III; UICC I, II or III - each p < 0.0001). Disease free survival (DFS) was significantly shorter for patients with AL in UICC I-III; UICC II or UICC III (each p < 0.001). Rate of local relapse was not significantly affected by occurrence of AL. Conclusion In this study patients with AL had a significantly worse OS. This was mainly due to an increased in hospital mortality. DFS was also negatively affected by AL whereas local relapse was not. This emphasizes the importance of successful treatment of AL related problems during the initial hospital stay.
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Affiliation(s)
- Olof Jannasch
- Department for General, Visceral and Vascular Surgery, Otto-von-Guericke-University, Magdeburg, Germany.,Department for General and Abdominal Surgery, AMEOS Hospital, Haldensleben, Germany
| | - Tim Klinge
- Department for General, Visceral and Vascular Surgery, Otto-von-Guericke-University, Magdeburg, Germany
| | - Ronny Otto
- Institute for Quality Assurance in Operative Medicine, Otto-von-Guericke-University, Magdeburg, Germany
| | - Costanza Chiapponi
- Department for General, Visceral and Vascular Surgery, Otto-von-Guericke-University, Magdeburg, Germany
| | - Andrej Udelnow
- Department for General, Visceral and Vascular Surgery, Otto-von-Guericke-University, Magdeburg, Germany
| | - Hans Lippert
- Institute for Quality Assurance in Operative Medicine, Otto-von-Guericke-University, Magdeburg, Germany
| | - Christiane J Bruns
- Department for General, Visceral and Vascular Surgery, Otto-von-Guericke-University, Magdeburg, Germany
| | - Pawel Mroczkowski
- Department for General, Visceral and Vascular Surgery, Otto-von-Guericke-University, Magdeburg, Germany.,Institute for Quality Assurance in Operative Medicine, Otto-von-Guericke-University, Magdeburg, Germany
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Perioperative Allogeneic Blood Transfusion Is Associated With Surgical Site Infection After Abdominoperineal Resection-a Space for the Implementation of Patient Blood Management Strategies. Int Surg 2016; 100:797-804. [PMID: 26011197 DOI: 10.9738/intsurg-d-14-00174.1] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
Allogeneic blood transfusion (ABT) has been reported as a major risk factor for surgical site infection (SSI) in patients undergoing colorectal surgery. However, the association of ABT with SSI in patients undergoing abdominoperineal resection (APR) and total pelvic exenteration (TPE) still remains to be evaluated. Here, we aim to elucidate this association. The medical records of all patients undergoing APR and TPE at our institution in the period between January 2000 and December 2012 were reviewed. Patients without SSI (no SSI group) were compared with patients who developed SSI (SSI group), in terms of clinicopathologic features, including ABT. In addition, data for 262 patients who underwent transabdominal rectal resection at our institution in the same period were also enrolled, and their data on differential leukocyte counts were evaluated. Multivariate analysis showed that intraoperative transfusion was an independent predictive factor for SSI after APR and TPE (P = 0.004). In addition, the first-operative day lymphocyte count of patients undergoing APR, TPE, and transabdominal rectal resection was significantly higher in nontransfusion patients compared with transfusion ones (P = 0.026). ABT in the perioperative period of APR and TPE may have an important immunomodulatory effect, leading to an increased incidence of SSI. This fact should be carefully considered, and efforts to avoid allogeneic blood exposure while still achieving adequate patient blood management would be very important for patients undergoing APR and TPE as well.
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Hallstrom B, Singal B, Cowen ME, Roberts KC, Hughes RE. The Michigan Experience with Safety and Effectiveness of Tranexamic Acid Use in Hip and Knee Arthroplasty. J Bone Joint Surg Am 2016; 98:1646-1655. [PMID: 27707851 DOI: 10.2106/jbjs.15.01010] [Citation(s) in RCA: 54] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND The efficacy of tranexamic acid (TXA) in reducing blood loss and transfusion requirements in total hip and knee arthroplasty has been well established in small controlled clinical trials and meta-analyses. The purpose of the current study was to determine the risks and benefits of TXA use in routine orthopaedic surgical practice on the basis of data from a large, statewide arthroplasty registry. METHODS From April 18, 2013, to September 30, 2014, there were 23,236 primary total knee arthroplasty cases and 11,489 primary total hip arthroplasty cases completed and registered in the Michigan Arthroplasty Registry Collaborative Quality Initiative (MARCQI). We evaluated the association between TXA use and hemoglobin drop, transfusion, length of stay (LOS), venous thromboembolism (VTE), readmission, and cardiovascular events by fitting mixed-effects generalized linear and mixed-effects Cox models. We used inverse probability of treatment weighting to enhance causal inference. RESULTS For total hip arthroplasty, TXA use was associated with a smaller drop in hemoglobin (mean difference = -0.65 g/dL; 95% confidence interval [CI] = -0.60 to -0.71 g/dL), decreased odds of blood transfusion (odds ratio [OR] = 0.72; 95% CI = 0.60 to 0.86), and decreased readmissions (OR = 0.77; 95% CI = 0.64 to 0.93) compared with no TXA use. There was no effect on VTE (hazard ratio [HR] = 0.91; 95% CI = 0.62 to 1.33), LOS (incident rate ratio [IRR] = 1.00; 95% CI = 0.97 to 1.03), or cardiovascular events (OR = 0.85; 95% CI = 0.47 to 1.52). For total knee arthroplasty, TXA was associated with a smaller drop in hemoglobin (mean difference = -0.68 g/dL; 95% CI = -0.64 to -0.71 g/dL) and one-fourth the odds of blood transfusion (OR = 0.26; 95% CI = 0.21 to 0.31). There was an association with decreased risk of VTE within 90 days after surgery (HR = 0.56; 95% CI = 0.42 to 0.73), slightly decreased LOS (IRR = 0.93; 95% CI = 0.92 to 0.95), and no association with readmissions (OR = 0.90; 95% CI = 0.79 to 1.04) or cardiovascular events (OR = 1.12; 95% CI = 0.74 to 1.71). CONCLUSIONS In routine orthopaedic surgery practice, TXA use was associated with decreased blood loss and transfusion risk for both total knee and total hip arthroplasty, without evidence of increased risk of complications. TXA use was also associated with reduced risk of readmission among total hip arthroplasty patients and reduced risk of VTE among total knee arthroplasty patients, and did not have an adverse effect on cardiovascular complications in either group. LEVEL OF EVIDENCE Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Brian Hallstrom
- Department of Orthopaedic Surgery, University of Michigan Medical Center, Ann Arbor, Michigan
| | - Bonita Singal
- Department of Orthopaedic Surgery, MARCQI Coordinating Center, University of Michigan, Ann Arbor, Michigan
| | - Mark E Cowen
- Quality Institute, St. Joseph Mercy Hospital, Ann Arbor, Michigan
| | - Karl C Roberts
- West Michigan Orthopaedics, GRMEP-MSU Orthopaedic Surgery Residency Program, Spectrum Health Hospitals, Grand Rapids, Michigan
| | - Richard E Hughes
- Department of Orthopaedic Surgery, University of Michigan Medical Center, Ann Arbor, Michigan
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Restrictive versus Liberal Transfusion Strategy in the Perioperative and Acute Care Settings. Anesthesiology 2016; 125:46-61. [DOI: 10.1097/aln.0000000000001162] [Citation(s) in RCA: 117] [Impact Index Per Article: 14.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
Abstract
Background
Blood transfusions are associated with morbidity and mortality. However, restrictive thresholds could harm patients less able to tolerate anemia. Using a context-specific approach (according to patient characteristics and clinical settings), the authors conducted a systematic review to quantify the effects of transfusion strategies.
Methods
The authors searched MEDLINE, EMBASE, CENTRAL, and grey literature sources to November 2015 for randomized controlled trials comparing restrictive versus liberal transfusion strategies applied more than 24 h in adult surgical or critically ill patients. Data were independently extracted. Risk ratios were calculated for 30-day complications, defined as inadequate oxygen supply (myocardial, cerebral, renal, mesenteric, and peripheral ischemic injury; arrhythmia; and unstable angina), mortality, composite of both, and infections. Statistical combination followed a context-specific approach. Additional analyses explored transfusion protocol heterogeneity and cointerventions effects.
Results
Thirty-one trials were regrouped into five context-specific risk strata. In patients undergoing cardiac/vascular procedures, restrictive strategies seemed to increase the risk of events reflecting inadequate oxygen supply (risk ratio [RR], 1.09; 95% CI, 0.97 to 1.22), mortality (RR, 1.39; 95% CI, 0.95 to 2.04), and composite events (RR, 1.12; 95% CI, 1.01 to 1.24—3322, 3245, and 3322 patients, respectively). Similar results were found in elderly orthopedic patients (inadequate oxygen supply: RR, 1.41; 95% CI, 1.03 to 1.92; mortality: RR, 1.09; 95% CI, 0.80 to 1.49; composite outcome: RR, 1.24; 95% CI, 1.00 to 1.54—3465, 3546, and 3749 patients, respectively), but not in critically ill patients. No difference was found for infections, although a protective effect may exist. Risk estimates varied with successful/unsuccessful transfusion protocol implementation.
Conclusions
Restrictive transfusion strategies should be applied with caution in high-risk patients undergoing major surgery.
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Abstract
Previously undiagnosed anemia is often identified during routine assessment of surgical patients. Although studies suggest that perioperative anemia is associated with worse outcomes and a strong predictor for postoperative red cell transfusions, anemia is frequently ignored. Preoperative optimization of patients undergoing elective surgical procedures associated with significant blood loss, along with strategies to minimize intraoperative blood loss, shows promise for reducing postoperative transfusions and improving outcomes. In most situations, anemia can be corrected prior to elective surgeries and interventions. Future research should assess the timing and methods of optimization of preoperative anemia in surgery and which patients are best candidates for therapy.
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Affiliation(s)
- Ankit J Kansagra
- Department of Hematology/Oncology, Baystate Medical Center, Tufts University, 376 Birnie Avenue, Springfield, MA 01199, USA.
| | - Mihaela S Stefan
- Division of Hospital Medicine, Department of General Medicine, Tufts University, 759 Chestnut Street, S2660, Springfield, MA 01199, USA
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Lejus C, De Windt A, LeBoeuf-Pouliquen D, Le Roux C, Bérard L, Asehnoune K. A retrospective study about cerebral near-infrared spectroscopy monitoring during paediatric cardiac surgery and intra-operative patient blood management. Anaesth Crit Care Pain Med 2015; 34:259-63. [PMID: 26071122 DOI: 10.1016/j.accpm.2015.01.007] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2014] [Accepted: 01/20/2015] [Indexed: 10/23/2022]
Abstract
OBJECTIVES Cerebral non-invasive monitoring of oxygen saturation by near-infrared spectroscopy (rSO2) during paediatric cardiac surgery is supposed to decrease the risk of neurological complications. Since haemoglobin level is one of the factors changing rSO2, we aimed to explore if rSO2 monitoring influences intra-operative RBC (red blood cell) transfusion threshold and volumes, as well as the duration of ICU stay. METHODS The design was a retrospective analysis involving 91 children less than 2 years of age (including 16 neonates) with a congenital heart disease requiring surgical treatment with or without cardiopulmonary bypass from January 2006 to August 2009. Systematic rSO2 monitoring was introduced after September 2007 (n=56). The independent factors associated with the intra-operative transfusion threshold haemoglobin (Hb) level>9.5g/dL, total volume of intra-operative RBC transfusion<30mL/kg and ICU stay<6 days were identified by multivariate analysis logistic regression. Data were expressed as medians (25-75%). RESULTS Cardiac malformations and demographic characteristics were similar in both periods. Two independent factors, weight and rSO2 monitoring, were identified as independent factors associated with the three end-points. The transfusion threshold, total transfusion volume and ICU stay with and without rSO2 were 9.8 (8.9 to 10.3) versus 8.7 (8.2 to 9.6) g/dL (P<0.0001), 20 (14-49) versus 36 (22.5-51.5) mL/kg (P=0.0165) and 5 (3-8) versus 7 (5-10.7) days (P=0.0084), respectively. CONCLUSION rSO2 monitoring changed our transfusion strategy with an earlier transfusion but a reduced total RBC volume and decreased the length of ICU stay.
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Affiliation(s)
- Corinne Lejus
- Service d'anesthésie et de réanimation chirurgicale, Hôtel Dieu-RCH, hôpital Mère-Enfant, CHU de Nantes, place Alexis-Ricordeau, 44093 Nantes cedex 01, France.
| | - Ariane De Windt
- Service d'anesthésie et de réanimation chirurgicale, Hôtel Dieu-RCH, hôpital Mère-Enfant, CHU de Nantes, place Alexis-Ricordeau, 44093 Nantes cedex 01, France
| | - Delphine LeBoeuf-Pouliquen
- Service d'anesthésie et de réanimation chirurgicale, Hôtel Dieu-RCH, hôpital Mère-Enfant, CHU de Nantes, place Alexis-Ricordeau, 44093 Nantes cedex 01, France
| | - Corinne Le Roux
- Service d'anesthésie et de réanimation chirurgicale, Hôtel Dieu-RCH, hôpital Mère-Enfant, CHU de Nantes, place Alexis-Ricordeau, 44093 Nantes cedex 01, France
| | - Luc Bérard
- Service d'anesthésie et de réanimation chirurgicale, Hôtel Dieu-RCH, hôpital Mère-Enfant, CHU de Nantes, place Alexis-Ricordeau, 44093 Nantes cedex 01, France
| | - Karim Asehnoune
- Service d'anesthésie et de réanimation chirurgicale, Hôtel Dieu-RCH, hôpital Mère-Enfant, CHU de Nantes, place Alexis-Ricordeau, 44093 Nantes cedex 01, France
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Gregersen M, Damsgaard EM, Borris LC. Blood transfusion and risk of infection in frail elderly after hip fracture surgery: the TRIFE randomized controlled trial. EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY AND TRAUMATOLOGY 2015; 25:1031-8. [DOI: 10.1007/s00590-015-1609-2] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/17/2014] [Accepted: 01/29/2015] [Indexed: 01/28/2023]
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Shander A, Goodnough LT, Javidroozi M, Auerbach M, Carson J, Ershler WB, Ghiglione M, Glaspy J, Lew I. Iron Deficiency Anemia—Bridging the Knowledge and Practice Gap. Transfus Med Rev 2014; 28:156-66. [DOI: 10.1016/j.tmrv.2014.05.001] [Citation(s) in RCA: 80] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2013] [Revised: 04/24/2014] [Accepted: 05/09/2014] [Indexed: 12/18/2022]
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Evaluating the optimal timing of surgical antimicrobial prophylaxis: study protocol for a randomized controlled trial. Trials 2014; 15:188. [PMID: 24885132 PMCID: PMC4040488 DOI: 10.1186/1745-6215-15-188] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2014] [Accepted: 05/07/2014] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Surgical site infections are the most common hospital-acquired infections among surgical patients. The administration of surgical antimicrobial prophylaxis reduces the risk of surgical site infections . The optimal timing of this procedure is still a matter of debate. While most studies suggest that it should be given as close to the incision time as possible, others conclude that this may be too late for optimal prevention of surgical site infections. A large observational study suggests that surgical antimicrobial prophylaxis should be administered 74 to 30 minutes before surgery. The aim of this article is to report the design and protocol of a randomized controlled trial investigating the optimal timing of surgical antimicrobial prophylaxis. METHODS/DESIGN In this bi-center randomized controlled trial conducted at two tertiary referral centers in Switzerland, we plan to include 5,000 patients undergoing general, oncologic, vascular and orthopedic trauma procedures. Patients are randomized in a 1:1 ratio into two groups: one receiving surgical antimicrobial prophylaxis in the anesthesia room (75 to 30 minutes before incision) and the other receiving surgical antimicrobial prophylaxis in the operating room (less than 30 minutes before incision). We expect a significantly lower rate of surgical site infections with surgical antimicrobial prophylaxis administered more than 30 minutes before the scheduled incision. The primary outcome is the occurrence of surgical site infections during a 30-day follow-up period (one year with an implant in place). When assuming a 5% surgical site infection risk with administration of surgical antimicrobial prophylaxis in the operating room, the planned sample size has an 80% power to detect a relative risk reduction for surgical site infections of 33% when administering surgical antimicrobial prophylaxis in the anesthesia room (with a two-sided type I error of 5%). We expect the study to be completed within three years. DISCUSSION The results of this randomized controlled trial will have an important impact on current international guidelines for infection control strategies in the hospital. Moreover, the results of this randomized controlled trial are of significant interest for patient safety and healthcare economics. TRIAL REGISTRATION This trial is registered on ClinicalTrials.gov under the identifier NCT01790529.
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Agus MSD, Asaro LA, Steil GM, Alexander JL, Silverman M, Wypij D, Gaies MG. Tight glycemic control after pediatric cardiac surgery in high-risk patient populations: a secondary analysis of the safe pediatric euglycemia after cardiac surgery trial. Circulation 2014; 129:2297-304. [PMID: 24671945 DOI: 10.1161/circulationaha.113.008124] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
BACKGROUND Our previous randomized, clinical trial showed that postoperative tight glycemic control (TGC) for children undergoing cardiac surgery did not reduce the rate of health care-associated infections compared with standard care (STD). Heterogeneity of treatment effect may exist within this population. METHODS AND RESULTS We performed a post hoc exploratory analysis of 980 children from birth to 36 months of age at the time of cardiac surgery who were randomized to postoperative TGC or STD in the intensive care unit. Significant interactions were observed between treatment group and both neonate (age ≤30 days; P=0.03) and intraoperative glucocorticoid exposure (P=0.03) on the risk of infection. The rate and incidence of infections in subjects ≤60 days old were significantly increased in the TGC compared with the STD group (rate: 13.5 versus 3.7 infections per 1000 cardiac intensive care unit days, P=0.01; incidence: 13% versus 4%, P=0.02), whereas infections among those >60 days of age were significantly reduced in the TGC compared with the STD group (rate: 5.0 versus 14.1 infections per 1000 cardiac intensive care unit days, P=0.02; incidence: 2% versus 5%, P=0.03); the interaction of treatment group by age subgroup was highly significant (P=0.001). Multivariable logistic regression controlling for the main effects revealed that previous cardiac surgery, chromosomal anomaly, and delayed sternal closure were independently associated with increased risk of infection. CONCLUSIONS This exploratory analysis demonstrated that TGC may lower the risk of infection in children >60 days of age at the time of cardiac surgery compared with children receiving STD. Meta-analyses of past and ongoing clinical trials are necessary to confirm these findings before clinical practice is altered. CLINICAL TRIAL REGISTRATION URL http://www.clinicaltrials.gov. Unique identifier: NCT00443599.
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Affiliation(s)
- Michael S D Agus
- From the Division of Medicine Critical Care (M.S.D.A., G.M.S., J.L.A., M.S.) and Department of Cardiology (L.A.A., D.W.), Boston Children's Hospital and Harvard Medical School, Boston, MA; Department of Biostatistics, Harvard School of Public Health, Boston, MA (D.W.); and Division of Pediatric Cardiology, C.S. Mott Children's Hospital and University of Michigan Medical School, Ann Arbor (M.G.G.).
| | - Lisa A Asaro
- From the Division of Medicine Critical Care (M.S.D.A., G.M.S., J.L.A., M.S.) and Department of Cardiology (L.A.A., D.W.), Boston Children's Hospital and Harvard Medical School, Boston, MA; Department of Biostatistics, Harvard School of Public Health, Boston, MA (D.W.); and Division of Pediatric Cardiology, C.S. Mott Children's Hospital and University of Michigan Medical School, Ann Arbor (M.G.G.)
| | - Garry M Steil
- From the Division of Medicine Critical Care (M.S.D.A., G.M.S., J.L.A., M.S.) and Department of Cardiology (L.A.A., D.W.), Boston Children's Hospital and Harvard Medical School, Boston, MA; Department of Biostatistics, Harvard School of Public Health, Boston, MA (D.W.); and Division of Pediatric Cardiology, C.S. Mott Children's Hospital and University of Michigan Medical School, Ann Arbor (M.G.G.)
| | - Jamin L Alexander
- From the Division of Medicine Critical Care (M.S.D.A., G.M.S., J.L.A., M.S.) and Department of Cardiology (L.A.A., D.W.), Boston Children's Hospital and Harvard Medical School, Boston, MA; Department of Biostatistics, Harvard School of Public Health, Boston, MA (D.W.); and Division of Pediatric Cardiology, C.S. Mott Children's Hospital and University of Michigan Medical School, Ann Arbor (M.G.G.)
| | - Melanie Silverman
- From the Division of Medicine Critical Care (M.S.D.A., G.M.S., J.L.A., M.S.) and Department of Cardiology (L.A.A., D.W.), Boston Children's Hospital and Harvard Medical School, Boston, MA; Department of Biostatistics, Harvard School of Public Health, Boston, MA (D.W.); and Division of Pediatric Cardiology, C.S. Mott Children's Hospital and University of Michigan Medical School, Ann Arbor (M.G.G.)
| | - David Wypij
- From the Division of Medicine Critical Care (M.S.D.A., G.M.S., J.L.A., M.S.) and Department of Cardiology (L.A.A., D.W.), Boston Children's Hospital and Harvard Medical School, Boston, MA; Department of Biostatistics, Harvard School of Public Health, Boston, MA (D.W.); and Division of Pediatric Cardiology, C.S. Mott Children's Hospital and University of Michigan Medical School, Ann Arbor (M.G.G.)
| | - Michael G Gaies
- From the Division of Medicine Critical Care (M.S.D.A., G.M.S., J.L.A., M.S.) and Department of Cardiology (L.A.A., D.W.), Boston Children's Hospital and Harvard Medical School, Boston, MA; Department of Biostatistics, Harvard School of Public Health, Boston, MA (D.W.); and Division of Pediatric Cardiology, C.S. Mott Children's Hospital and University of Michigan Medical School, Ann Arbor (M.G.G.)
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Okazaki M, Matsukuma S, Suto R, Miyazaki K, Hidaka M, Matsuo M, Noshima S, Zempo N, Asahara T, Nomoto K. Perioperative synbiotic therapy in elderly patients undergoing gastroenterological surgery: A prospective, randomized control trial. Nutrition 2013; 29:1224-30. [DOI: 10.1016/j.nut.2013.03.015] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2012] [Revised: 01/31/2013] [Accepted: 03/14/2013] [Indexed: 12/12/2022]
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Risk Factor Analysis and Microbial Etiology of Surgical Site Infections following Lower Segment Caesarean Section. ACTA ACUST UNITED AC 2013. [DOI: 10.1155/2013/283025] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Background. Lower segment caesarean section (LSCS) is a common mode of delivery now and surgical site infection is the second most common infectious complication in these patients. This study was planned with this background to have a comprehensive approach to SSI following LSCS. Methods. 500 consecutive patients undergoing LSCS, irrespective of indication, were studied. A questionnaire was developed to assess the risk factors associated with development of SSI. All patients were followed up from day one of surgery till discharge and then up till the postoperative day 30 after discharge. Results. SSI was identified in 121 (24.2%) out of 500 patients. In all age groups, Gram-negative bacilli were the commonest finding. The commonest isolate was Acinetobacter species (32.03%) followed by Staphylococcus aureus and coagulase negative Staphylococcus (21.09%). 23.8% of Staphylococcus aureus strains were MRSA. By multivariate logistic regression premature rupture of membrane (PROM), antibiotics given earlier than 2 hours and increased duration of stay in the hospital were found to be significant. Conclusions. A proper assessment of risk factors that predispose to SSI and their modification may help in reduction of SSI rates. Also, frequent antimicrobial audit and qualitative research could give an insight into the current antibiotic prescription practices and the factors affecting these practices.
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Chen AF, Klatt BA, Yazer MH, Waters JH. Blood utilization after primary total joint arthroplasty in a large hospital network. HSS J 2013; 9:123-8. [PMID: 24009534 PMCID: PMC3757482 DOI: 10.1007/s11420-013-9327-y] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/01/2012] [Accepted: 01/04/2013] [Indexed: 02/07/2023]
Abstract
BACKGROUND Since a study in orthopedic hip fracture patients demonstrated that a liberal hemoglobin (Hb) threshold does not improve patient morbidity and mortality relative to a restrictive Hb threshold, the standard of care in total joint arthroplasty (TJA) should be examined to understand the variability of red blood cell (RBC) transfusion following TJA. QUESTIONS/PURPOSES The study aimed to answer the following questions: (1) What is the blood utilization rate after primary TJA for individual surgeons within a large hospital network? (2) What is the comparison of hospital charges, length of stay (LOS), and discharge locations among TJA patients who were and were not transfused? METHODS A retrospective study was conducted on 3,750 primary total knee arthroplasties (TKAs) and 2,070 primary total hip arthroplasties (THAs), and data was retrospectively collected over a 15-month period on the number of RBCs transfused per patient, along with demographic and cost details. The number of patients who received at least 1 RBC unit and the number of RBCs transfused per patient was calculated and stratified by surgeon. RESULTS In the postoperative period, 19.3% TKA patients and 38.5% THA patients received a RBC transfusion. Transfusion rates following TJA varied widely between surgeons (TKA 4.8-63.8%, THA 4.3-86.8%). Transfused TKA patients received an average of 1.65 ± 0.03 RBCs, and THA patients received an average of 1.97 ± 0.14 RBCs. LOS and hospital charges for blood transfusion patients were higher than nontransfused patients. CONCLUSION Blood utilization after primary TJA varies greatly among surgeons, suggesting that resources may be misallocated. These findings highlight the need to standardize RBC transfusion practice following TJA.
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Affiliation(s)
- Antonia F. Chen
- Department of Orthopaedic Surgery, University of Pittsburgh Medical Center, 5230 Centre Avenue, Suite 415, Pittsburgh, PA 15232 USA
| | - Brian A. Klatt
- Department of Orthopaedic Surgery, University of Pittsburgh Medical Center, 5230 Centre Avenue, Suite 415, Pittsburgh, PA 15232 USA
| | - Mark H. Yazer
- Department of Pathology, University of Pittsburgh Medical Center, 5230 Centre Avenue, Suite 415, Pittsburgh, PA 15232 USA
- The Institute for Transfusion Medicine, 3636 Blvd. of the Allies, Pittsburgh, PA 15213 USA
| | - Jonathan H. Waters
- Department of Anesthesiology, University of Pittsburgh Medical Center, 300 Halket Street, Suite 3510, Pittsburgh, PA 15213 USA
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Partridge J, Harari D, Gossage J, Dhesi J. Anaemia in the older surgical patient: a review of prevalence, causes, implications and management. J R Soc Med 2013; 106:269-77. [PMID: 23759887 DOI: 10.1177/0141076813479580] [Citation(s) in RCA: 43] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023] Open
Abstract
This review provides the clinician with a summary of the causes, implications and potential treatments for the management of anaemia in the older surgical patient. The prevalence of anaemia increases with age and is frequently identified in older surgical patients. Anaemia is associated with increased postoperative morbidity and mortality. Allogenic blood transfusion is commonly used to treat anaemia but involves inherent risks and may worsen outcomes. Various strategies for the correction of pre- and postoperative anaemia have evolved. These include correction of nutritional deficiencies and the use of intravenous iron and erythropoesis stimulating therapy. Clear differences exist between the elective and emergency surgical populations and the translation of research findings into these individual clinical settings requires more work. This should lead to a standardized approach to the management of this frequently encountered clinical scenario.
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Adamina M, Gié O, Demartines N, Ris F. Contemporary perioperative care strategies. Br J Surg 2012; 100:38-54. [DOI: 10.1002/bjs.8990] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/27/2012] [Indexed: 12/15/2022]
Abstract
Abstract
Background
Historically, the preoperative and postoperative care of patients with gastrointestinal cancer was provided by surgeons. Contemporary perioperative care is a truly multidisciplinary endeavour with implications for cancer-specific outcomes.
Methods
A literature review was performed querying PubMed and the Cochrane Library for articles published between 1966 to 2012 on specific perioperative interventions with the potential to improve the outcomes of surgical oncology patients. Keywords used were: fast-track, enhanced recovery, accelerated rehabilitation, multimodal and perioperative care. Specific interventions included normothermia, hyperoxygenation, surgical-site infection, skin preparation, transfusion, non-steroidal anti-inflammatory drugs, thromboembolism and antibiotic prophylaxis, laparoscopy, radiotherapy, perioperative steroids and monoclonal antibodies. Included articles had to be randomized controlled trials, prospective or nationwide series, or systematic reviews/meta-analyses, published in English, French or German.
Results
Important elements of modern perioperative care that improve recovery of patients and outcomes in surgical oncology include accelerated recovery pathways, thromboembolism and antibiotic prophylaxis, hyperoxygenation, maintenance of normothermia, avoidance of blood transfusion and cautious use of non-steroidal anti-inflammatory drugs, promotion of laparoscopic surgery, chlorhexidine–alcohol skin preparation and multidisciplinary meetings to determine multimodal therapy.
Conclusion
Multidisciplinary management of perioperative patient care has improved outcomes.
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Affiliation(s)
- M Adamina
- Department of Surgery, Kantonsspital St Gallen, St Gallen, Switzerland
- Institute for Surgical Research and Hospital Management, University of Basel, Basel, Switzerland
| | - O Gié
- Department of Visceral Surgery, Centre Hospitalier Universitaire Vaudois, Lausanne, Switzerland
| | - N Demartines
- Department of Visceral Surgery, Centre Hospitalier Universitaire Vaudois, Lausanne, Switzerland
| | - F Ris
- Division of Visceral and Transplantation Surgery, Geneva University Hospitals, Geneva, Switzerland
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Nielsen K, Meyhoff CS, Johansson PI, Jorgensen LN, Rasmussen LS. Transfusion practice and complications after laparotomy - an observational analysis of a randomized clinical trial. Vox Sang 2012; 103:294-300. [DOI: 10.1111/j.1423-0410.2012.01626.x] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Risk factors for surgical site infections after elective gastrectomy. J Gastrointest Surg 2012; 16:1107-15. [PMID: 22350727 DOI: 10.1007/s11605-012-1838-1] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/05/2011] [Accepted: 02/02/2012] [Indexed: 01/31/2023]
Abstract
OBJECTIVE The aim of this study was to identify the risk factors for surgical site infections (SSIs) after elective gastrectomy. METHODS This study reviewed the medical records of 842 patients who underwent elective gastrectomy. Multivariate analyses were performed to determine the risk factors for SSIs. RESULTS Superficial incisional, deep incisional, and organ/space SSIs were detected in 50 (5.9%) patients, 2 (0.2%) patients, and 90 (10.7%) patients, respectively. A multivariate analysis demonstrated that female gender (p = 0.0332) and allogenic blood transfusion (p = 0.0266) were independent predictors for superficial incisional SSIs, while a male gender (p = 0.0355), corticosteroid therapy (p = 0.037), total gastrectomy (p < 0.0001), and a duration of operation ≥300 min (p = 0.0062) were independent predictors for organ/space SSIs. The median length of postoperative hospital stay was significantly longer in patients with organ/space SSIs in comparison to those without SSIs (p < 0.0001) and with superficial incisional SSIs (p < 0.0001). The patients with organ/space SSIs had a significantly higher re-operation rate in comparison to those without SSIs (p < 0.0001). CONCLUSIONS The risk factors both for incisional SSIs and for organ/space SSIs are strongly associated with surgical results. Meticulous surgical techniques are therefore required to prevent SSIs.
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Toshima T, Shirabe K, Yoshiya S, Muto J, Ikegami T, Yoshizumi T, Maehara Y. Outcome of hepatectomy for hepatocellular carcinoma in patients with renal dysfunction. HPB (Oxford) 2012; 14:317-24. [PMID: 22487069 PMCID: PMC3384851 DOI: 10.1111/j.1477-2574.2012.00452.x] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
OBJECTIVES There are few reports on the efficacy of hepatectomy for hepatocellular carcinoma (HCC) in patients with renal dysfunction (RD). This study aimed to clarify the validity of hepatectomy for treating HCC in RD patients, and to compare postoperative courses in RD and non-RD patients. METHODS The clinical features of 722 HCC patients who underwent curative hepatectomy between 1986 and 2009 were retrospectively reviewed. Seventeen patients (2.4%) with preoperative serum creatinine levels of >2.0 mg/dl were defined as the RD group, and, of these, seven who did not receive preoperative haemodialysis were defined as borderline patients. Clinicopathological characteristics and postoperative outcomes were compared between the RD group (n= 17) and the non-RD group (n= 705). The postoperative courses of borderline patients were reviewed in detail. RESULTS Overall survival (P= 0.177) and disease-free survival (P= 0.942) after hepatectomy did not differ significantly between the groups. Incidences of massive ascites (35.3% vs. 14.3%; P= 0.034) and pleural effusion (52.9% vs. 17.6%; P= 0.001), defined as massive effusion (ME), were significantly higher in the RD group than in the non-RD group. Hypoalbuminaemia (≤2.8 g/dl; P= 0.031), heavy blood loss (≥1000 ml; P= 0.012) and intraoperative blood transfusion (P= 0.007) were risk factors for ME. Among the borderline patients, serum creatinine values were not increased immediately after surgery and four patients underwent haemodialysis. CONCLUSIONS Preoperative hypoalbuminaemia, heavy blood loss and blood transfusion are independent risk factors for ME in RD patients. Preoperative improvement of anaemia and reduction of blood loss by meticulous surgical techniques may prevent ME in RD patients who require hepatectomy for HCC.
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Affiliation(s)
- Takeo Toshima
- Department of Surgery and Science, Graduate School of Medical Sciences, Kyushu University, 3-1-1 Maidashi, Higashi-ku, Fukuoka, Japan.
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Shander A, Javidroozi M, Ozawa S, Hare G. What is really dangerous: anaemia or transfusion? Br J Anaesth 2011; 107 Suppl 1:i41-59. [DOI: 10.1093/bja/aer350] [Citation(s) in RCA: 350] [Impact Index Per Article: 26.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
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Acklin YP, Widmer AF, Renner RM, Frei R, Gross T. Unexpectedly increased rate of surgical site infections following implant surgery for hip fractures: problem solution with the bundle approach. Injury 2011; 42:209-16. [PMID: 21047637 DOI: 10.1016/j.injury.2010.09.039] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/02/2010] [Revised: 08/26/2010] [Accepted: 09/30/2010] [Indexed: 02/02/2023]
Abstract
INTRODUCTION Surgical site infections (SSIs) are the most common nosocomial infections after surgery.However, clinical guidance on how to handle any suspicious clusters of SSI in orthopaedic surgery is missing. We report on problem analysis and solution finding following the observation of an increased rate of SSI in trauma implant surgery. SETTING Trauma unit of a university hospital. METHODS Over a 2-year observation period, all patients (n = 370) following surgical stabilisation of proximal femur fractures in a trauma unit of a university hospital were consecutively followed using a standardised case report form. First, a retrospective cohort of 217 patients was collected for whom an increased SSI rate was detected. Based on risk analysis, new standard perioperative procedures were developed and implemented. The impact was evaluated in a prospective cohort of 153 comparable patients. Uni- and multivariable analysis of factors associated with the risk for SSI was undertaken. RESULTS The intervention bundle resulted in a significant reduction of an initially increased SSI incidence of 6.9 (down) to 2.0% (p = 0.029). Multivariable analysis revealed four risk factors significantly associated with a higher risk of SSI caused by different bacteria: duration of surgery (p = 0.002), hemiarthroplasty(p = 0.002), haematoma (p = 0.004) and the presence of two operating room staff members (p < 0.001 and 0.035). CONCLUSIONS A standardised prospective SSI protocol and detection system offering the simultaneous use of data should guarantee every institution immediate alarm registration to avoid comparable problem situations. Detailed interdisciplinary analysis followed by the implementation of coherent interventions, based on a best-evidence structured bundle approach, may adequately resolve similar critical incidence episodes.
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Affiliation(s)
- Yves P Acklin
- Department of Surgery, Kantonsspital Graubünden, Loëstrasse 170, CH-7000 Chur, Switzerland
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Hachenberg T, Sentürk M, Jannasch O, Lippert H. [Postoperative wound infections. Pathophysiology, risk factors and preventive concepts]. Anaesthesist 2011; 59:851-66; quiz 867-8. [PMID: 20830460 DOI: 10.1007/s00101-010-1789-4] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Postoperative wound infections are the third most common type of nosocomial infection in German emergency hospitals after pneumonia and urinary infections. They are associated with increased morbidity and mortality, prolonged hospital stay and increased costs. The most important risk factors include the microbiological state of the skin surrounding the incision, delayed or premature prophylaxis with antibiotics, duration of surgery, emergency surgery, poorly controlled diabetes mellitus, malignant disease, smoking and advanced age. Anesthesiological measures to decrease the incidence of wound infections are maintaining normothermia, strict indications for allogenic blood transfusions and timely prophylaxis with antibiotics. Blood glucose concentrations should be kept in the range of 8.3-10 mmol/l (150-180 mg/dl) as lower values are associated with increased complications. Intraoperative and postoperative hyperoxia with 80% O(2) has not been shown to effectively decrease wound infections. The application of local anesthetics into the surgical wound in clinically relevant doses for postoperative analgesia does not impair wound healing.
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Affiliation(s)
- T Hachenberg
- Klinik für Anaesthesiologie und Intensivtherapie, Universitätsklinikum A.ö.R., Otto-von-Guericke-Universität, Leipziger Strasse 44, 39120 Magdeburg.
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Preoperative anemia associated in-hospital mortality and morbidity in isolated coronary artery bypass graft surgery. Open Med (Wars) 2010. [DOI: 10.2478/s11536-009-0094-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
AbstractAnemia is an indisputable finding in patients scheduled for coronary artery bypass graft (CABG) that can occur any time preoperatively. In presence of severe coronary artery disease, anemia can dramatically affect surgical outcomes. Therefore, we conducted this study to determine the effect of low preoperative hemoglobin (Hgb) on postoperative outcome in patients who underwent coronary artery bypass graft (CABG). In all, 4432 patients who had undergone isolated CABG at Tehran Heart Center over the 2-year period from March 2006 to February 2008 were studied. All medical records of the aforementioned patients were derived from our hospital surgery data bank. After adjustment for confounders, the association of different preoperative levels of Hgb with risk of cardiac, pulmonary, infectious, and ischemic complications, and also with prolonged ventilation and resource utilization, were assessed in a multivariable model. After adjustment for confounders that may affect mortality and morbidities, we found that cardiac, infectious, ischemic, and pulmonary complications, as well as postoperative mortality, were significantly higher in anemic patients compared to those with normal Hgb levels. In addition, total ventilation time, total intensive care unit hour stay (ICU), hospital length of stay (HLOS), and postsurgery length of stay (PLOS) were significantly longer in anemic patients. We concluded that isolated CABG patients with preoperative anemia have significantly higher mortality and morbidity, and use more health care resources. Preoperative anemia is an independent variable for increased resource utilization, morbidity, and mortality.
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