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Oliveira AM, Oliveira A, Vidal R, Gonçalves-Pereira J. Infectious Foci, Comorbidities and Its Influence on the Outcomes of Septic Critically Ill Patients. Microorganisms 2024; 12:1705. [PMID: 39203547 PMCID: PMC11357211 DOI: 10.3390/microorganisms12081705] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2024] [Revised: 08/13/2024] [Accepted: 08/16/2024] [Indexed: 09/03/2024] Open
Abstract
Sepsis is among the most frequent diagnoses on admission to the intensive care unit (ICU). A systemic inflammatory response, activated by uncontrolled infection, fosters hypoperfusion and multiorgan failure and often leads to septic shock and mortality. These infections arise from a specific anatomic source, and how the infection foci influence the outcomes is unknown. All patients admitted to the ICU of Hospital de Vila Franca de Xira, between 1 January 2017 and 31 June 2023, were screened for sepsis and categorized according to their infection foci. During the study period, 1296 patients (32.2%) had sepsis on admission. Their mean age was 67.5 ± 15.3 and 58.1% were male; 73.0% had community-acquired infections. The lung was the main focus of infection. Septic shock was present in 37.9% of the patients and was associated with hospital mortality. Severe imbalances were noted in its incidence, and there was lower mortality in lung infections. The hospital-acquired infections had a slightly higher mortality but, after adjustment, this difference was non-significant. Patients with secondary bacteremia had a worse prognosis (one-year adjusted hazard ratio of 1.36, 95% confidence interval 1.06-1.74, p = 0.015), especially those with an isolated non-fermenting Gram-negative infection. Lung, skin, and skin structure infections and peritonitis had a worse prognosis, whilst urinary, biliary tract, and other intra-abdominal infections had a better one-year outcome.
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Affiliation(s)
- Ana Maria Oliveira
- Unidade Cuidados Intensivos, Unidade Local de Saúde Estuário do Tejo, 2600-009 Vila Franca de Xira, Portugal; (A.M.O.); (A.O.)
| | - André Oliveira
- Unidade Cuidados Intensivos, Unidade Local de Saúde Estuário do Tejo, 2600-009 Vila Franca de Xira, Portugal; (A.M.O.); (A.O.)
| | - Raquel Vidal
- Faculdade de Medicina, Universidade de Lisboa, 1649-028 Lisboa, Portugal;
| | - João Gonçalves-Pereira
- Unidade Cuidados Intensivos, Unidade Local de Saúde Estuário do Tejo, 2600-009 Vila Franca de Xira, Portugal; (A.M.O.); (A.O.)
- Grupo de Investigação e Desenvolvimento em Infeção e Sépsis, Clínica Universitária de Medicina Intensiva, Faculdade de Medicina, Universidade de Lisboa, 1649-028 Lisboa, Portugal
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Zickler WP, Zambetti BR, Zickler CL, Zickler MK, Byerly S, Garrett HE, Magnotti LJ. Impact of Patient and Procedural Factors on Outcomes Following Mesenteric Bypass. Am Surg 2024; 90:377-385. [PMID: 37655480 DOI: 10.1177/00031348231198118] [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: 09/02/2023]
Abstract
BACKGROUND Mesenteric bypass (MB) for patients with acute (AMI) and chronic mesenteric ischemia (CMI) is associated with cardiovascular (CV) and pulmonary morbidity. METHODS Patients with AMI and CMI from 2008 to 2019 were identified to determine independent predictors of CV (cardiac arrest, MI, DVT, and stroke) and pulmonary (pneumonia and ventilator time>48 h) morbidities in patients undergoing MB. RESULTS 377 patients were identified. Patients with AMI had higher rates of preoperative SIRS/sepsis (28 vs 12%, P < .0001), were more likely to be ASA class 4/5 (55 vs 42%, P = .005), were more likely to require bowel resection (19 vs 3%, P < .0001), and were more likely to have vein utilized as their bypass conduit (30 vs 14%, P < .0001). There were no differences in use of aortic or iliac inflow (P = .707) nor in return to the OR (24 vs 19%, P = .282). Both postoperative sepsis (12 vs 2.6%, P = .003) and mortality (31.4% vs 9.8%, P < .0001) were significantly increased in patients with AMI. After adjusting for both patient and procedural factors, multivariable logistic regression (MLR) identified international normalized ratio (INR) (OR 3.16; 95% CI 1.56-6.40, P = .001) and chronic heart failure (CHF) (OR 5.88; 95% CI 1.15-29.97, P = .033) to be independent predictors of pulmonary morbidity, while preoperative sepsis (OR 1.96; 95% CI 1.45-2.66, P < .0001) alone was predictive of CV morbidity in all patients undergoing MB. DISCUSSION Mesenteric bypass for mesenteric ischemia leads to high rates of morbidity and mortality, whether done in an acute or chronic setting. Preoperative sepsis, independent of AMI or CMI, predicts CV morbidity, regardless of bypass configuration or conduit, while elevated INR or underlying CHF carries a higher risk of pulmonary morbidity.
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Affiliation(s)
| | - Benjamin R Zambetti
- Department of Surgery, University of Maryland Medical Center, Baltimore, MD, USA
| | - Christine L Zickler
- Florida International University Herbert Wertheim College of Medicine, Miami, FL, USA
| | | | - Saskya Byerly
- Department of Surgery, University of Tennessee Health Science Center, Memphis, TN, USA
| | - H Edward Garrett
- Department of Surgery, University of Tennessee Health Science Center, Memphis, TN, USA
| | - Louis J Magnotti
- Department of Surgery, University of Arizona College of Medicine, Tucson, AZ, USA
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Kent I, Ghuman A, Sadran L, Rov A, Lifschitz G, Rudnicki Y, White I, Goldberg N, Avital S. Emergency Colectomies in the Elderly Population—Perioperative Mortality Risk-Factors and Long-Term Outcomes. J Clin Med 2023; 12:jcm12072465. [PMID: 37048549 PMCID: PMC10095288 DOI: 10.3390/jcm12072465] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2023] [Revised: 03/05/2023] [Accepted: 03/13/2023] [Indexed: 03/28/2023] Open
Abstract
Background: As the population ages emergency surgeries among the elderly population, including colonic resections, is also increasing. Data regarding the short- and long-term outcomes in this population is scarce. Methods: A retrospective study was performed to investigate mortality and mortality risk factors associated with emergent colectomies in older compared to younger patients in a single university affiliated tertiary hospital. Patients with metastatic disease, colectomy due to trauma or index colectomy within 30 days prior to emergent surgery were excluded. Results: Operative outcomes compared among age groups, included 30-day mortality, mortality risk-factors and long-term survival. 613 eligible patients were included in the cohort. Mean age was 69.4 years, 45.1% were female. Patients were divided into four age groups: 18–59, 60–69, 70–79 and ≥80-years. Thirty-day mortality rates were 3.2%, 11%, 29.3% and 37.8%, respectively and 22% for the entire cohort. Risk-factors for perioperative death in the younger group were related to severity of ASA score and WBC count. In groups 60–69, 70–79, main risk-factors were ADL dependency and ASA score. In the ≥80 group, risk-factors affecting perioperative mortality, included ASA score, pre-operative albumin, creatinine, WBC levels, cancer etiology, ADL dependency, and dementia. Long-term survival differed significantly between age groups. Conclusion: Perioperative mortality with emergency colectomy increases with patients’ age. Patients older than eighty-years undergoing urgent colectomies have extremely high mortality rates, leading to a huge burden on medical services. Evaluating risk-factors for mortality and pre-operative discussion with patients and families is important. Screening the elderly population for colonic pathologies can result in early diagnosis potentially leading to elective surgeries with decreased mortality.
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Diagnostic challenges in postoperative intra-abdominal sepsis in critically ill patients: When to reoperate? POSTEP HIG MED DOSW 2022. [DOI: 10.2478/ahem-2022-0032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
Abstract
The present paper was done to review common diagnostic techniques used to help surgeons find the most suitable way to diagnose postoperative intra-abdominal sepsis (IAS). The topic was searched on MEDLINE, Embase, and Cochrane Library databases. Collected articles were classified and checked for their quality. Findings of selected research were included in this study and analyzed to find the best diagnostic method for intra-abdominal sepsis. IAS presents severe morbidity and mortality, and its early diagnosis can improve the outcome. Currently, there is no consensus among surgeons on a single diagnostic modality that should be used while deciding reoperation in patients with postoperative IAS. Though it has a high sensitivity for abdominal infections, computed tomography has limited applications due to mobility and time constraints. Diagnostic laparoscopy is a safe process that produces usable images, and can be used at the bedside. Diagnostic peritoneal lavage (DPL) has high sensitivity, and the patients testing positive through DPL can be subjected to exploratory laparotomy, depending on severity. Abdominal Reoperation Predictive Index (ARPI) is the only index reported as an aid for this purpose. Serial intra-abdominal pressure measurement has also emerged as a potential diagnostic tool. A proper selection of diagnostic modality is expected to improve the outcome in IAS, which presents high mortality risk and a limited time frame.
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Presl J, Varga M, Mittermair C, Mitterwallner S, Weitzendorfer M, Gabersek A, Borhanian K, Heuberger A, Weiss H, Emmanuel K, von Rahden B, Koch OO. Impact of the COVID-19 pandemic lockdown on the utilization of acute surgical care in the State of Salzburg, Austria: retrospective, multicenter analysis. Eur Surg 2021; 53:48-54. [PMID: 33686347 PMCID: PMC7930888 DOI: 10.1007/s10353-021-00692-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2021] [Accepted: 01/30/2021] [Indexed: 12/24/2022]
Abstract
Background Some medical disciplines have reported a strong decrease of emergencies during the coronavirus disease 2019 (COVID-19) pandemic; however, the effect of the lockdown on general surgery emergencies remains unclear. Methods This study is a retrospective, multicenter analysis of general surgery emergency operations performed during the period from 1 March to 15th 2020 lockdown and in the same time period of 2019 in three medical centers providing emergency surgical care to the area Salzburg-North, Austria. Results In total 165 emergency surgeries were performed in the study period of 2020 compared to 287 in 2019. This is a significant decrease of 122 (42.5%) emergency surgeries during the COVID-19 lockdown (p = 0.005). The length of hospital stay was reduced to 3 days in 2020 compared to 4 in 2019. Appendectomy remained the most performed emergency surgery for both periods; however the number of surgeries was reduced to less than a half, with 72 cases in 2019 and 33 cases in 2020 (p = 0.118). Emergency colon surgery observed the strongest decrease of 75% from 17 cases in 2019 to 4 in 2020. In addition, the emergency abdominal wall hernia, cholecystectomies for acute cholecystitis, small surgeries and proctological emergencies recorded drops of 70%, 39%, 33% and 47% respectively. The strongest reduction in frequencies of emergency surgeries was reported from the designated COVID center in the examined region. Conclusions Emergency general surgery is an essential service that continues to run under all circumstances. Our data show that COVID-19-related restrictions have resulted in a significant decrease in the utilization of acute surgical care.
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Affiliation(s)
- Jaroslav Presl
- Department of Surgery, Paracelsus Medical Private University (PMU) Salzburg, University Hospital Salzburg (SALK), Müllner Hauptstr. 48, 5020 Salzburg, Austria
| | - Martin Varga
- Department of Surgery, Paracelsus Medical Private University (PMU) Salzburg, University Hospital Salzburg (SALK), Müllner Hauptstr. 48, 5020 Salzburg, Austria
| | - Christof Mittermair
- Department of Surgery, Saint John of God Hospital, Teaching Hospital of the Paracelsus Medical Private University (PMU) Salzburg, Kajetanerpl. 1, 5010 Salzburg, Austria
| | - Stefan Mitterwallner
- Department of Surgery, Hospital Oberndorf, Teaching Hospital of the Paracelsus Medical Private University (PMU) Salzburg, Paracelsusstrasse 37, 5110 Oberndorf, Austria
| | - Michael Weitzendorfer
- Department of Surgery, Paracelsus Medical Private University (PMU) Salzburg, University Hospital Salzburg (SALK), Müllner Hauptstr. 48, 5020 Salzburg, Austria
| | - Ana Gabersek
- Department of Surgery, Paracelsus Medical Private University (PMU) Salzburg, University Hospital Salzburg (SALK), Müllner Hauptstr. 48, 5020 Salzburg, Austria
| | - Kurosch Borhanian
- Department of Surgery, Paracelsus Medical Private University (PMU) Salzburg, University Hospital Salzburg (SALK), Müllner Hauptstr. 48, 5020 Salzburg, Austria
| | - Andreas Heuberger
- Department of Surgery, Hospital Oberndorf, Teaching Hospital of the Paracelsus Medical Private University (PMU) Salzburg, Paracelsusstrasse 37, 5110 Oberndorf, Austria
| | - Helmut Weiss
- Department of Surgery, Saint John of God Hospital, Teaching Hospital of the Paracelsus Medical Private University (PMU) Salzburg, Kajetanerpl. 1, 5010 Salzburg, Austria
| | - Klaus Emmanuel
- Department of Surgery, Paracelsus Medical Private University (PMU) Salzburg, University Hospital Salzburg (SALK), Müllner Hauptstr. 48, 5020 Salzburg, Austria
| | - Burkhard von Rahden
- Department of Surgery, Paracelsus Medical Private University (PMU) Salzburg, University Hospital Salzburg (SALK), Müllner Hauptstr. 48, 5020 Salzburg, Austria
| | - Oliver Owen Koch
- Department of Surgery, Paracelsus Medical Private University (PMU) Salzburg, University Hospital Salzburg (SALK), Müllner Hauptstr. 48, 5020 Salzburg, Austria
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Faes S, Hübner M, Demartines N, Hahnloser D. Cytokine clearance in serum and peritoneal fluid of patients undergoing damage control surgery with abdominal negative pressure therapy for abdominal sepsis. Pleura Peritoneum 2020. [PMCID: PMC7790174 DOI: 10.1515/pp-2020-0122] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Objectives Open abdomen technique with negative pressure therapy (NPT) is widely used in patients with severe abdominal sepsis. The aim of this study was to evaluate cytokine clearance in serum and peritoneal fluid during NPT. Methods This prospective pilot study included six patients with severe abdominal sepsis requiring discontinuity resection and NPT for 48 h followed by planned reoperation. Cytokines (IL6, IL8, IL10, TNFalpha, and IL1beta) were measured in the serum and peritoneal fluid during index operation, on postoperative days 0, 1, and 2. Results Concentrations of cytokines in peritoneal fluid were higher than in serum. IL10 showed a clearance both in serum (to 16.6%, p=0.019) and peritoneal fluid (to 40.9%, p=0.014). IL6 cleared only in serum (to 24.7%, p=0.001) with persistently high levels in peritoneal fluid. IL8 remained high in both serum and peritoneal fluid. TNFalpha and IL1beta were both low in serum with wide range of high peritoneal concentrations. Only TNFalpha in peritoneal fluid showed significant differences between patients with ischemia vs. perforation (p=0.006). Conclusions The present pilot study suggests that cytokines display distinct patterns of clearance or persistence in the peritoneal fluid and serum over the first 48 h of treatment in severe abdominal sepsis with NPT.
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Affiliation(s)
- Seraina Faes
- Department of Visceral Surgery , Lausanne University Hospital CHUV, University of Lausanne (UNIL) , Lausanne , Switzerland
| | - Martin Hübner
- Department of Visceral Surgery , Lausanne University Hospital CHUV, University of Lausanne (UNIL) , Lausanne , Switzerland
| | - Nicolas Demartines
- Department of Visceral Surgery , Lausanne University Hospital CHUV, University of Lausanne (UNIL) , Lausanne , Switzerland
| | - Dieter Hahnloser
- Department of Visceral Surgery , Lausanne University Hospital CHUV, University of Lausanne (UNIL) , Lausanne , Switzerland
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Chaturvedi R, Burton BN, Trivedi S, Schmidt UH, Gabriel RA. The Association of Preoperative Hematocrit With Adverse Events Following Exploratory Laparotomy in Septic Patients: A Retrospective Analysis. J Intensive Care Med 2020; 37:46-51. [PMID: 33084472 DOI: 10.1177/0885066620967925] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND Sepsis continues to be the leading cause of death in intensive care units and surgical patients comprise almost one third of all sepsis patients. Anemia is a modifiable risk factor for worse postoperative outcomes in sepsis patients. Here we aim to evaluate the association of preoperative anemia and postoperative mortality in sepsis patients undergoing exploratory laparotomy. METHODS The National Surgical Quality Improvement Program registry was used to query for preoperative sepsis patients undergoing exploratory laparotomy between 2014 and 2016. Preoperative hematocrit was stratified into 4 categories: ≥30% to polycythemia, <21%, 21 and less than 30%, and polycythemia. The primary outcome was 30-day mortality. Multivariable logistic regression was used to evaluate the association of preoperative hematocrit with primary and secondary endpoints. The multivariable analysis included preoperative hematocrit, gender, age, BMI, smoking status, functional status, hypertension, steroid use, bleeding disorder, and sepsis. The odds ratio (OR) with associated 95% confidence interval (CI) is reported for all outcomes. A p-value of less than <0.05 was considered statistically significant. RESULTS The unadjusted 30-day death rate was the highest for patients with preoperative hematocrit <21% (p < 0.001) compared to the other hematocrit cohorts. The odds of 30-day death was significantly increased for patients with preoperative hematocrit <21% (OR 2.39 95% CI: 1.28-4.49, p = 0.006) and 21-30% (OR 1.35, 95% CI: 1.05 -1.72, p = 0.017) compared to patients with preoperative hematocrit of ≥30% and less than polycythemic ranges (reference cohort). CONCLUSION Preoperative anemia in sepsis patients undergoing surgery can lead to increased mortality, postoperative complications, and length of hospital stay. Diagnosing sepsis early in the hospital course can allow physicians more time to titrate anticoagulation medications and treat preoperative anemia.
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Affiliation(s)
- Rahul Chaturvedi
- School of Medicine, 8784University of California, San Diego, La Jolla, CA, USA
| | - Brittany N Burton
- Department of Anesthesiology and Perioperative Medicine, 8784University of California, Los Angeles, CA, USA
| | - Suraj Trivedi
- Department of Anesthesiology, 8784University of California, San Diego, La Jolla, CA, USA
| | - Ulrich H Schmidt
- Department of Anesthesiology, 8784University of California, San Diego, La Jolla, CA, USA
| | - Rodney A Gabriel
- Department of Anesthesiology, 8784University of California, San Diego, La Jolla, CA, USA
- Division of Biomedical Informatics, Department of Medicine, 8784University of California, San Diego, La Jolla, CA, USA
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Gabriel RA, Trivedi S, Schmidt UH. A Point-Based Risk Calculator Predicting Mortality in Patients That Developed Postoperative Sepsis. J Intensive Care Med 2020; 36:1443-1449. [DOI: 10.1177/0885066620960991] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Background: Predicting the mortality from post-operative sepsis remains a continuing problem. We built a statistical model using national data to predict mortality in patients who developed post-operative sepsis. Methods: This is a retrospective study using the American College of Surgeons National Quality Surgical Improvement Program database, in which we gathered data from adult patients between 2011 and 2016 who experienced postoperative sepsis. We designed a predictive model using multivariable logistic regression on a training set and validated the model on a separate test set. Results: There were 128,325 patients included in the final dataset, in which 18,499 (14.4%) died within 30-days of surgery. The model consisted of 10 covariates: American Society of Anesthesiologists Physical Status classification score, preoperative sepsis, age, chronic obstructive pulmonary disease, postoperative myocardial infarction, postoperative stroke, postoperative acute renal failure, transfusion requirement, and infection type. A point-based risk calculator was developed, which had an area under the receiver operating characteristics curve of 0.819 (95% confidence interval 0.814-0.823). Conclusion: Although further work is needed to confirm and validate our model on external datasets, our scoring system provides a novel way to measure mortality in septic post-operative patients.
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Affiliation(s)
- Rodney A. Gabriel
- Department of Anesthesiology, University of California, San Diego, CA, USA
- Division of Biomedical Informatics, University of California, San Diego, CA, USA
| | - Suraj Trivedi
- Department of Anesthesiology, University of California, San Diego, CA, USA
| | - Ulrich H. Schmidt
- Department of Anesthesiology, University of California, San Diego, CA, USA
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Utariani A, Sinaga R, Wardhani P, Hardiono H. Immature granulocyte and mean platelet volume as a predictor of 30-day postoperative mortality in patients with sepsis caused by peritonitis. BALI JOURNAL OF ANESTHESIOLOGY 2020. [DOI: 10.4103/bjoa.bjoa_114_20] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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MORPHOLOGICAL CHANGES IN RAT HEART MUSCLE IN EXPERIMENTAL PERITONITIS AGAINST THE BACKGROUND OF DIABETES MELLITUS. WORLD OF MEDICINE AND BIOLOGY 2020. [DOI: 10.26724/2079-8334-2020-2-72-156-159] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
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