Absence of an association between glucose levels and surgical site infections in patients undergoing craniotomies for brain tumors

Bacterial Meningitis Following Aneurysmal Subarachnoid Hemorrhage and Its Association with Cerebral Vasospasm

Aneurysmal subarachnoid hemorrhage (aSAH) is a critical condition with high in-hospital mortality rates. Delayed cerebral ischemia (DCI), a secondary complication associated with aSAH, can also contribute to morbidity and mortality. Although draining the hematoma from the subarachnoid space has been considered effective in preventing DCI, the placement of a drainage system could increase the risk of bacterial meningitis and ventriculitis. This study aimed to examine the association between meningitis following aSAH and the occurrence of DCI, focusing on the role of cerebral vasospasm. Patients who underwent endovascular coiling or surgical clipping for aSAH from April 2001 to March 2022 were included in this study, while those who did not undergo postoperative drainage were excluded. The patient's clinical characteristics, treatment modalities, and outcomes were then analyzed, after which logistic regression was used to assess the odds ratios (OR) for DCI. A total of 810 patients with aSAH were included in this study. Meningitis following aSAH was identified as an independent factor associated with DCI (odds ratio 5.0 [95% confidence intervals (CI) 2.3-11]). Other significant factors were female sex (odds ratio 1.5 [95% CI 0.89-2.5]) and surgical clipping (odds ratio 2.1 [95% CI 1.3-3.4]). This study demonstrated a significant association between meningitis following aSAH and the development of DCI, suggesting that the inflammatory environment associated with meningitis may contribute to cerebral vasospasm. Early recognition and treatment of meningitis in patients with aSAH could reduce the risk of DCI and improve patient outcomes.

An update on a persisting challenge: A systematic review and meta-analysis of the risk factors for surgical site infection post craniotomy

BACKGROUND

Surgical site infections (SSIs) postcraniotomy continue to impose a significant burden on health care systems and patient outcomes. It is, therefore, important to understand their risk factors in order to promote effective preventative measures. This meta-analysis aims to provide a comprehensive, up-to-date analysis of the risk factors associated with SSIs in neurosurgical procedures.

METHODS

A systematic review was conducted as per preferred reporting items for systematic reviews and meta-analysis guidelines to explore existing primary evidence on the risk factors for SSIs postcraniotomy. A comprehensive search of MEDLINE, EMBASE, and Pubmed was performed from database inception up to June 2023. 43 studies were included in the meta-analysis, encompassing a total of 68,881 patients.

RESULTS

The strongest predictor for SSIs was found to be cerebrospinal fluid (CSF) leak (OR: 8.91, CI: 4.30-18.44). Other significant factors included infratentorial surgery (OR: 0.43, CI: 0.31-0.61), emergency surgery (OR: 1.41, CI: 1.05-1.91), reintervention (OR: 3.19, CI: 1.77-5.75), prolonged operative time (mean difference: 33.25; CI: 18.83-47.67), hospital length of stay (mean difference: 0.60; CI: 0.23-0.98) and intracranial pressure monitor (ICPM) insertion (OR: 1.81; CI: 1.06-3.11). Contrarily, sex, body mass index (BMI), diabetes, antibiotic prophylaxis, immunosuppressive agents, trauma, use of artificial implants did not demonstrate statistical significance.

CONCLUSIONS

This meta-analysis provides an up-to-date and comprehensive evaluation of risk factors for SSIs postcraniotomy. It emphasizes the need for preventive strategies, particularly against CSF leaks, and calls for further research to elucidate the intricate relationships between these factors.

Association of predictive factors and neurosurgical postoperative infections: A retrospective analysis

OBJECTIVE

To identify the factors that predispose neurosurgical patients to surgical site infections (SSI) as well as assess the risk factors attached to infection by a specific microorganism.

METHODOLOGY

A retrospective case-control study was conducted at University College of Medical Sciences and G.T.B. Hospital, Delhi. Adult patients (>18 years) undergoing a neurosurgical procedure with a diagnosis of SSI in the year 2021 having a minimum follow up of 30 days postoperatively or until death if they survived less than 30 days were included. Statistical analysis was performed using the SPSS 16 software with level of significance at 0.05.

RESULTS

An incidence of 3.15% was observed at our center. Mean age of the study population was 39.2 ± 13.07 years (range 22-70 years) with a male: female ratio of 3:1. Having an underlying infection (p = 0.024), ASA score> 2 (p = 0.041), duration of surgery> 4 h (p = 0.025), diabetes (p = 0.027) and preoperative stay at the hospital (p = 0.036) were found to be statistically significant risk factors in the prediction of SSI in neurosurgical patients which were utilised to create a regression model with an accuracy of 70% and AUC of 0.833. Deep infections were found to have a significant association with positive culture on the collected samples (p = 0.035).

CONCLUSIONS

This study is a starting point to identify which factors could predict the presence of a particular organism isolated from the site of infection in neurosurgical patients, thereby minimizing AMR.

Surgical site infections after elective craniotomy for brain tumor: a study on potential risk factors and related treatments

BACKGROUND

Surgical site infection (SSI) is a common complication following craniotomy that increases morbidity, mortality, and medical expenses. The objectives of this study were to determine the relevant risk factors associated with SSI after elective craniotomy for brain tumor and analyse the treatments for SSI.

METHODS

A retrospective nested case‒control study was conducted using data from patients who underwent craniotomy for brain tumor resection at the Neurosurgical Oncology Department No. 6 of Beijing Tiantan Hospital, Capital Medical University, between January 2019 and December 2021. Risk factors for SSI were determined using multivariate logistic regression analysis. We analyzed microbiological and related treatment data for different SSI types.

RESULTS

Among 2061 patients who underwent craniotomy for brain tumor, 31 had SSI (1.50%). In the multivariate logistic regression analysis, body mass index (BMI) and operative duration were identified as independent risk factors for SSI. The most common microorganism isolated from SSIs was Staphylococcus epidermidis (22.9%), and drug sensitivity results showed that gram-positive bacteria were sensitive to linezolid, vancomycin and tigecycline, whereas gram-negative bacteria were sensitive to meropenem, cefepime and ceftazidime. Six of the seven patients who underwent bone flap removal due to osteomyelitis were infected with gram-negative bacteria.

CONCLUSIONS

BMI and operative duration were identified as independent risk factors for SSI. Diabetes mellitus, previous ratio therapy, type of incision, recurrence tumor and other risk factors were not found to be associated with the occurrence of SSI in this study.

Association of preoperative glucose concentration with mortality in patients undergoing craniotomy for brain tumor

OBJECTIVE

Hyperglycemia is associated with worse outcomes in ambulatory settings and specialized hospital settings, but there are sparse data on the importance of preoperative blood glucose measurement before brain tumor craniotomy. The authors sought to investigate the association between preoperative glucose level and 30-day mortality rate in patients undergoing brain tumor resection.

METHODS

This retrospective cohort study included patients undergoing craniotomy for brain tumors at West China Hospital, Sichuan University, from January 2011 to March 2021. Surgical mortality rates were evaluated in patients who had normal glycemia (< 5.6 mmol/L) as well as mild (5.6-6.9 mmol/L), moderate (7.0-11.0 mmol/L), and severe hyperglycemia (> 11.0 mmol/L).

RESULTS

The study included 12,281 patients who underwent tumor resection via craniotomy. The overall 30-day mortality rate was 2.0% (242/12,281), whereas the rates for normal glycemia and mild, moderate, and severe hyperglycemia were 1.5%, 2.5%, 3.8%, and 6.5%, respectively. Compared with normal glycemia, the odds of mortality at 30 days were higher in patients with mild hyperglycemia (adjusted odds ratio [OR] 1.44, 95% confidence interval [CI] 1.05-2.00), moderate hyperglycemia (OR 2.04, 95% CI 1.41-2.96), and severe hyperglycemia (OR 3.76, 95% CI 1.96-7.20; p < 0.001 for trend). When blood glucose was analyzed as a continuous variable, for each 1 mmol/L increase in blood glucose, the adjusted OR of 30-day mortality was 1.13 (95% CI 1.08-1.19). The addition of a preoperative glucose level significantly improved the area under the curve and categorical net reclassification index for prediction of mortality.

CONCLUSIONS

In patients undergoing craniotomy for brain tumors, even mild hyperglycemia was associated with an increased mortality rate, at a glucose level that was much lower than the commonly applied level.

Recursive partitioning analysis of factors determining infection after intracranial tumor surgery

OBJECTIVES

Several factors are commonly associated with the occurrence of post-operative infection after craniotomy. However, the risk factors associated with tumor surgery have been less intensively investigated. The aim of the present study was to analyze the risk factors for infection and categorize patients according to risk rate.

METHODS

In this study, we retrospectively evaluated 987 adult patients consecutively submitted to craniotomy for tumor resection. The primary outcome was the occurrence of infection within 30 days after surgery. The following independent variables were assessed: age, gender, surgery duration, length of hospital stay prior to surgery, reoperation, body mass index, serum albumin, hemoglobin, lactic dehydrogenase, smoking, diabetes, corticoid use, preoperative chemotherapy, previous irradiation, elective or urgent indication for surgery, supra or infratentorial lesion location, and tumor histology. We performed a recursive partitioning analysis to assess the relative importance of these variables in predicting infection.

RESULTS

The model returned a 3-level classification: 1. CSF-leakage (relative contribution 70%), 2. Emergency surgery indication (18%), and 3. Tumor histology (8%). Additionally, partitioning clustered together 3 risk groups: 1. CSF-leakage group (probability of infection 72.5%), 2. No CSF-leakage and urgent surgery (mean probability 18.1%); and 3. no CSF-leakage and no urgent surgery (3.4%). The misclassification rate was 4.5%, the overall specificity and sensitivity were 99.6% and 75.5%, respectively, and the area under the ROC-curve was 0.6908.

CONCLUSION

Our analysis indicates that technical and treatment-related factors are significantly more relevant than patient- or disease-related factors in determining the risk of postoperative infection.

A retrospective analysis of factors affecting surgical site infection in orthopaedic patients

Objective

To investigate the factors affecting surgical site infections (SSI) in patients undergoing orthopaedic surgery.

Methods

The electronic medical records of patients undergoing orthopaedic surgery between September 2010 and July 2018 were retrospectively retrieved and reviewed. Logistic regression analyses were used to analyse the correlation between surgery-related variables and SSI. The odds ratio (OR) and 95% confidence interval (CI) were estimated for the risk factors.

Results

Clinical data from 25 954 patients were reviewed and 804 (3.1%) were found to have become infected at the surgical site. Older age (≥60 years) was a risk factor (OR 2.218) and younger age (<18 years) was a protective factor (OR 0.258). Diabetes mellitus (OR 6.560) and hypertension (OR 3.991) were independent risk factors. Compared with type II incisions, type I incisions had a lower risk for SSI (OR 0.031), while type III incisions had a greater risk of SSI (OR 2.599). Compared with upper limbs and hands, the feet had a lower risk of infection, while surgery performed at the spine and joints did not increase the risk as compared with foot surgery.

Conclusion

Older age, hypertension, diabetes mellitus and type III incisions were risk factors for SSI following orthopaedic surgery.

Intraoperative MRI-guided Resection in Pediatric Brain Tumor Surgery: A Meta-analysis of Extent of Resection and Safety Outcomes

BACKGROUND

 The objective of this meta-analysis was to analyze the impact of intraoperative magnetic resonance imaging (iMRI) on pediatric brain tumor surgery with regard to the frequency of histopathologic entities, additional resections secondary to iMRI, rate of gross total resections (GTR) in glioma surgery, extent of resection (EoR) in supra- and infratentorial compartment, surgical site infections (SSIs), and neurologic outcome after surgery.

METHODS

 MEDLINE/PubMed Service was searched for the terms "intraoperative MRI," "pediatric," "brain," "tumor," "glioma," and "surgery." The review produced 126 potential publications; 11 fulfilled the inclusion criteria, including 584 patients treated with iMRI-guided resections. Studies reporting about patients <18 years, setup of iMRI, surgical workflow, and extent of resection of iMRI-guided glioma resections were included.

RESULTS

 IMRI-guided surgery is mainly used for pediatric low-grade gliomas. The mean rate of GTR in low- and high-grade gliomas was 78.5% (207/254; 95% confidence interval [CI]: 64.6-89.7, p < 0.001). The mean rate of GTR in iMRI-assisted low-grade glioma surgery was 74.3% (35/47; 95% CI: 61.1-85.5, p = 0.759). The rate of SSI in surgery assisted by iMRI was 1.6% (6/482; 95% CI: 0.7-2.9). New onset of transient postoperative neurologic deficits were observed in 37 (33.0%) of 112 patients.

CONCLUSION

 IMRI-guided surgery seems to improve the EoR in pediatric glioma surgery. The rate of SSI and the frequency of new neurologic deficits after IMRI-guided surgery are within the normal range of pediatric neuro-oncologic surgery.

Diabetes-associated infections: development of antimicrobial resistance and possible treatment strategies

Diabetes mellitus is associated with various types of infections notably skin, mucous membrane, soft tissue, urinary tract, respiratory tract and surgical and/or hospital-associated infections. The reason behind this frequent association with infections is an immunocompromised state of diabetic patient because uncontrolled hyperglycemia impairs overall immunity of diabetic patient via involvement of various mechanistic pathways that lead to the diabetic patient as immunocompromised. There are specific microbes that are associated with each type of infection and their presence indicates specific type of infections. For instance, E. coli and Klebsiella are the most common causative pathogens responsible for the development of urinary tract infections. Diabetic-foot infections commonly occur in diabetic patients. In this article, we have mainly focused on the association of diabetes mellitus with various types of bacterial infections and the pattern of resistance against antimicrobial agents that are frequently used for the treatment of diabetes-associated infections. Moreover, we have also summarized the possible treatment strategies against diabetes-associated infections.

Dose-response association of operative time and surgical site infection in neurosurgery patients: A systematic review and meta-analysis

BACKGROUND

The association of operative time and surgical site infection (SSI) in neurosurgery patients is unclear. We therefore, through a systematic review and meta-analysis, sought to clarify the association.

METHODS

We performed a systematic search of the PubMed and Embase databases, from January 1, 1966, to December 26, 2018, for published articles. We used random effects generalized least squares regression models to combine study-specific relative risks (RR) and 95% confidence intervals (CI), and performed a sensitivity analysis by excluding 1 study at a time to assess the stability of results and potential sources of heterogeneity. We used the Egger (from plotting to test) to assess publication bias.

RESULTS

A total of 5 articles, with 231,915 individuals and 6,726 SSI cases, were included. The summary RR for SSI after craniotomy were 1.67 (95% CI, 1.13-2.20), with high versus low operative time, and 1.34 (95% CI, 1.15-1.53), with each 1-hour increase in operative time. On sensitivity analysis, no individual study had an excessive influence on the pooled effect. We found no evidence of publication bias by the Egger test (P = .464) and Egger's plotting.

CONCLUSIONS

Prolonged operative time can increase the SSI risk for neurosurgery patients. Intensive interventions should be taken to decrease operative duration.

Risk factors for surgical site infection after craniotomy: a prospective cohort study

Background

Although surgical site infection after craniotomy (SSI-CRAN) is a serious complication, risk factors for its development have not been well defined. We aim to identify the risk factors for developing SSI-CRAN in a large prospective cohort of adult patients undergoing craniotomy.

Methods

A series of consecutive patients who underwent craniotomy at a university hospital from January 2013 to December 2015 were prospectively assessed. Demographic, epidemiological, surgical, clinical and microbiological data were collected. Patients were followed up in an active post-discharge surveillance programm e for up to one year after surgery. Multivariate analysis was carried out to identify independent risk factors for SSI-CRAN.

Results

Among the 595 patients who underwent craniotomy, 91 (15.3%) episodes of SSI-CRAN were recorded, 67 (73.6%) of which were organ/space. Baseline demographic characteristics were similar among patients who developed SSI-CRAN and those who did not. The most frequent causative Gram-positive organisms were Cutibacterium acnes (23.1%) and Staphylococcus epidermidis (23.1%), whereas Enterobacter cloacae (12.1%) was the most commonly isolated Gram-negative agent. In the univariate analysis the factors associated with SSI-CRAN were ASA score > 2 (48.4% vs. 35.5% in SSI-CRAN and no SSI-CRAN respectively, p = 0.025), extrinsic tumour (28.6% vs. 19.2%, p = 0.05), and re-intervention (4.4% vs. 1.4%, p = < 0.001). In the multivariate analysis, ASA score > 2 (AOR: 2.26, 95% CI: 1.32-3.87; p = .003) and re-intervention (OR: 8.93, 95% CI: 5.33-14.96; p < 0.001) were the only factors independently associated with SSI-CRAN.

Conclusion

The risk factors and causative agents of SSI-CRAN identified in this study should be considered in the design of preventive strategies aimed to reduce the incidence of this serious complication.

Predictors of Surgical Site Infection After Nonemergent Craniotomy: A Nationwide Readmission Database Analysis

OBJECTIVE

Surgical site infections (SSIs) carry significant patient morbidity and mortality and are a major source of readmissions after craniotomy. Because of their deleterious effects on health care outcomes and costs, identifying modifiable risk factors holds tremendous value. However, because SSIs after craniotomy are rare and most existing data comprise single-institution studies with small sample sizes, many are likely underpowered to discern for such factors. The objective of this study was to use a large hetereogenous patient sample to determine SSI incidence after nonemergent craniotomy and identify factors associated with readmission and subsequent need for wound washout.

METHODS

We used the 2010-2014 Nationwide Readmissions Database cohorts to discern for factors predictive of SSI and washout.

RESULTS

We identified 93,920 nonemergent craniotomies. There were 2079 cases of SSI (2.2%) and 835 reoperations for washout (0.89%) within 30 days of index admission and there were 2761 cases of SSI (3.6%) and 1220 reoperations for washout (1.58%) within 90 days. Several factors were predictive of SSI in multivariate analysis, including tumor operations, external ventricular drain (EVD), age, length of stay, diabetes, discharge to an intermediate-care facility, insurance type, and hospital bed size. Many of these factors were similarly implicated in reoperation for washout.

CONCLUSIONS

SSI incidence in neurosurgery is low and most readmissions occur within 30 days. Several factors predicted SSI after craniotomy, including operations for tumor, younger age, hospitalization length, diabetes, discharge to institutional care, larger hospital bed size, Medicaid insurance, and presence of an EVD. Diabetes and EVD placement may represent modifiable factors that could be explored in subsequent prospective studies for their associations with cranial SSIs.

Measurement of Hyperglycemia and Impact on Health Outcomes in People With Cancer: Challenges and Opportunities

PROBLEM IDENTIFICATION

Poor health outcomes have been associated with hyperglycemia in patients with and without diabetes. However, the impact of hyperglycemia on the health-related outcomes of patients with cancer has shown conflicting results. The purpose of this review was to explore definitions and measurement issues related to the assessment of hyperglycemia and the subsequent impact on the findings of health-related outcomes in adults with cancer.
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LITERATURE SEARCH

Four electronic databases were searched.

DATA EVALUATION

A total of 30 articles were reviewed. Quantitative articles were synthesized using integrative review strategies. 
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SYNTHESIS

Three key gaps were identified in the literature.

CONCLUSIONS

This review highlights the inconsistencies in measuring or assessing hyperglycemia and the lack of standardized guidelines in treating hyperglycemia. Failure to have a standard approach to the measurement and management of hyperglycemia impedes the ability of healthcare providers to determine the significance of its impact on health outcomes. Further research is needed to establish appropriate measurement guidelines to address hyperglycemia in people with cancer.
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IMPLICATIONS FOR PRACTICE

Evidence-based measurement and treatment guidelines are needed to inform and assist healthcare providers with clinical decision making for people with cancer who experience hyperglycemia.

Reduction of Surgical Site Infections After Cranioplasty With Perioperative Bundle

BACKGROUND

Surgical site infections (SSI) are the most common complication after cranioplasty and it is associated with poor prognosis. The aim of this study was to identify the risk factors that triggered the development of SSI after cranioplasty and establish a new perioperative bundle and monitoring system to reduce SSI.

METHODS

A retrospective review of a database that included all cranioplasty patients from 2001 to 2007 was carried out to determine the prevalence of infection. A surveillance team was set up, which assessed the clinical practice and led to the development of a new perioperative bundle and supervision system. A prospective study between 2008 and 2014 was carried out to observe whether infection rates had changed and whether an active surveillance program can change clinical practice.

RESULTS

Retrospective period included 86 adult patients. The overall rate of infection was 10.5% (9 SSI in 86 patients). Age ≥60 years (OR 1.05; 95% CI: 1.00-1.10; P = 0.04), smoking (OR 9.13; 95% CI: 1.65-50.60; P = 0.01), and duration of operation ≥180 minutes (OR1.19; 95% CI: 1.06-1.34; P < 0.01) as significant predictors of postcranioplasty SSI development. Length of preoperative stay and length of hospitalization was significantly longer among infected patients compared with uninfected patients (P < 0.01, respectively). In prospective period, the general SSI rate was reduced to 1.8% (2 SSI in 113 patients). The difference was statistically significant (P = 0.01).

CONCLUSIONS

A perioperative bundle and monitoring system may help to reduce SSI rates after cranioplasty. This work also indicates how an active surveillance program can successfully change clinical practice.

Impact of Hyperglycemia and Age on Outcomes in Patients With Acute Myeloid Leukemia

PURPOSE/OBJECTIVES

To examine the prevalence and impact of hyperglycemia on health outcomes (number of neutropenic days, infection, and hospital length of stay) in patients hospitalized for acute myeloid leukemia (AML) receiving initial induction therapy.
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DESIGN

Retrospective, descriptive study.
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SETTING

A large urban hospital in Indianapolis, Indiana.
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SAMPLE

103 patients with AML and a subset of 41 patients aged 65 years or older. 
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METHODS

Demographics and medical information were extracted from electronic health records. Serum-fasting blood glucose was used to assess glycemic status. The association of hyperglycemia with the health outcomes was analyzed. A subset of patients aged 65 years or older was also analyzed.
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MAIN RESEARCH VARIABLES

Hyperglycemia, age, and health outcomes in patients with AML.
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FINDINGS

Forty patients experienced hyperglycemia during initial induction for AML. In the larger sample, no associations were noted between hyperglycemia and health outcomes. A significant relationship (p = 0.022) was noted between hyperglycemia and infection in patients aged 65 years or older. Patients aged 65 years or older had 5.6 times the risk of developing infection as those aged younger than 65 years. Although not statistically significant, patients aged 65 years or older with hyperglycemia had 2.5 more days of neutropenia and 1.5 days longer hospital length of stay. 
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CONCLUSIONS

This study provides preliminary evidence that hyperglycemia is prevalent during initial induction for AML and may have harmful consequences, particularly for patients aged 65 years or older. More research is needed to determine clinically significant levels of hyperglycemia and their impact on health outcomes.
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IMPLICATIONS FOR NURSING

Oncology nurses can assess and proactively collaborate with members of the healthcare team to implement strategies to prevent or mitigate the harmful consequences of hyperglycemia.

Risk factors of neurosurgical site infection after craniotomy: A systematic review and meta-analysis

BACKGROUND

Neurosurgical site infection (SSI) is a complication related to craniotomy, which may lead to severe morbidity and higher hospital costs during the postoperative period.

METHODS

Retrospective cohorts, case-control studies, or prospective investigations addressing risk factors of SSI updated until January 2017 were systematically searched in 2 databases (PubMed and Embase). The Newcastle-Ottawa Scale was used to evaluate quality of the included studies, heterogeneity was assessed by I² tests, and a funnel plot and Egger test were used for the evaluation of publication bias.

RESULTS

There were 26 studies in total enrolled in this review. The results showed that the risk factors which had relation with SSI were other infection (odds ratio [OR], 5.42; 95% confidence interval [CI], 2.8-10.49), number of operations (>1) (OR, 2.352; 95% CI, 1.142-4.847), cerebrospinal fluid (CSF) leak (OR, 7.817; 95% CI, 2.573-23.751), CSF drainage (OR, 2.55; 95% CI, 1.58-4.11), duration of operation (>4 hours) (as for retrospective cohort studies) (OR, 1.766; 95% CI, 1.110-2.809), venous sinus entry (OR, 4.015; 95% CI, 1.468-10.982), American Society of Anesthesiologists score (>2) (OR, 1.398; 95% CI, 1.098-1.78), sex (male) (as for prospective investigations) (OR, 1.474; 95% CI, 1.013-2.145), and surgical reasons (nontraumatic) (OR, 2.137; 95% CI, 1.106-4.129).

CONCLUSIONS

According to the current analysis, all the factors mentioned were the risk factors for SSI after craniotomy. Patients with these risk factors should be paid more attention to prevent SSI. More evidence provided by high-quality studies is still needed to further investigate the risk factors of SSI.

Severe Intraoperative Hyperglycemia Is Independently Associated With Postoperative Composite Infection After Craniotomy: An Observational Study

BACKGROUND

Postoperative infection after craniotomy carries an increased risk of morbidity and mortality. Identification and correction of the risk factors should be prioritized. The association of intraoperative hyperglycemia with postoperative infections in patients undergoing craniotomy is inadequately studied.

METHODS

A total of 224 patients were prospectively enrolled in 2 major medical centers to assess whether severe intraoperative hyperglycemia (SIH, blood glucose ≥180 mg/dL) is associated with an increased risk of postoperative infection in patients undergoing craniotomy. Arterial blood samples were drawn and analyzed immediately after anesthetic induction and again before tracheal extubation. The new onset of any type of infection within 7 days after craniotomy was determined.

RESULTS

The incidence of new postoperative composite infection was 10% (n = 22) within the first week after craniotomy. Weight, sex, American Society of Anesthesiologists score, preoperative and/or intraoperative steroid use, and diabetes mellitus were not associated with postoperative infection. SIH was independently associated with postoperative infection (odds ratio [95% confidence interval], 4.17 [1.50-11.56], P = .006) after fitting a multiple logistic regression model to adjust for emergency surgery, length of surgery, and age ≥65 years.

CONCLUSIONS

SIH is independently associated with postoperative new-onset composite infections in patients undergoing craniotomy. Whether prevention of SIH during craniotomy results in a reduced postoperative risk of infection is unknown and needs to be appraised by further study.

Surgical Site Infection after Malignant Brain Tumor Resection: A Multicenter Study for Induction of a Basic Care Bundle

Patients with malignant brain tumors are possibly at increased risk for surgical site infections (SSIs) considering the various medical situations associated with the disease. However, the actual rate of SSI after malignant brain tumor resection has not been well established, despite the potential impact of SSI on patient outcome. To investigate the incidence of SSI following malignant brain tumor surgery, we performed a retrospective study in 3 neurosurgical units. Subsequently, aiming at the reduction of incidence of SSI, we performed a prospective study using a care bundle technique in the same units. The SSI incidence in the retrospective (n = 161) and prospective studies (n = 68) were 4.3% and 4.4%, respectively, similar to the previously reports on general craniotomies. A care bundle does not appear to enhance prevention of SSI. However, future, large studies with a new care bundle should be planned based on a zero tolerance policy.

Risk factors for meningitis after craniotomy in patients with subarachnoid hemorrhage due to anterior circulation aneurysms rupture

OBJECTIVES

Postoperative meningitis is a serious complication occurring after neurosurgical interventions. However, few investigations have focused specifically on the risk factors that predispose patients to meningitis after major craniotomy. This study identified the risk factors for postoperative meningitis after neurovascular surgery, and investigated the relationship between postoperative meningitis and clinical outcome.

PATIENTS AND METHODS

A total of 148 consecutive patients with subarachnoid hemorrhage (SAH) who underwent clipping surgery through a pterional approach within 72 h between January 2007 and September 2011 were retrospectively analyzed. The treatment strategy of our hospital for patients with SAH was based on the findings of digital subtraction angiography in the acute phase. Coil embolization was firstly considered, and clipping through craniotomy if indicated was performed as soon as possible. Prophylactic antibiotics were administered before beginning craniotomy and for at least 3 days after. Hydrocortisone was used to prevent hyponatremia if allowed by the medical condition of the patient. Intrathecal administration of nicardipine hydrochloride was given if required for vasospasm treatment. Meningitis was clinically diagnosed from the blood samplings and cerebrospinal fluid (CSF) examinations. Data were collected from the electronic and paper charts. The status of modified Rankin scale (mRS) 0-2 at discharge was defined as favorable outcome.

RESULTS

A total of 14 patients (9.5%) had meningitis during this study period. Symptomatic vasospasm was detected in 33 patients (22.3%), and 12 patients (8.1%) had permanent neurological deficits caused by vasospasm. Overall, 109 patients (73.6%) had favorable outcome. The longer duration of drainage placement, presence of CSF leakage, and intrathecal administration of vasodilatory agent showed significantly higher incidence of postoperative meningitis in univariate analysis (p=0.0093, 0.0017, and 0.0090, respectively). The proportion of favorable outcome patients at discharge (mRS 0-2) was significantly lower in patients with postoperative meningitis (35.7%) than in patients without it (77.6%) (p=0.0004). The duration of in-hospital stay was significantly longer in patients with postoperative meningitis (median 58.5, range 28-115 days) than in patients without it (median 38.5, range 19-149 days) (p<0.001). Multivariate logistic regression analysis showed that only presence of CSF leakage was associated with postoperative meningitis (p=0.0299).

CONCLUSION

Meningitis after surgery is still a serious complication that requires preventative intervention. The clinical outcome of patients with postoperative meningitis after neurovascular surgery is not still satisfactory.

Diabetes and Risk of Surgical Site Infection: A Systematic Review and Meta-analysis

OBJECTIVE To determine the independent association between diabetes and surgical site infection (SSI) across multiple surgical procedures. DESIGN Systematic review and meta-analysis. METHODS Studies indexed in PubMed published between December 1985 and through July 2015 were identified through the search terms "risk factors" or "glucose" and "surgical site infection." A total of 3,631 abstracts were identified through the initial search terms. Full texts were reviewed for 522 articles. Of these, 94 articles met the criteria for inclusion. Standardized data collection forms were used to extract study-specific estimates for diabetes, blood glucose levels, and body mass index (BMI). A random-effects meta-analysis was used to generate pooled estimates, and meta-regression was used to evaluate specific hypothesized sources of heterogeneity. RESULTS The primary outcome was SSI, as defined by the Centers for Disease Control and Prevention surveillance criteria. The overall effect size for the association between diabetes and SSI was odds ratio (OR)=1.53 (95% predictive interval [PI], 1.11-2.12; I2, 57.2%). SSI class, study design, or patient BMI did not significantly impact study results in a meta-regression model. The association was higher for cardiac surgery 2.03 (95% PI, 1.13-4.05) compared with surgeries of other types (P=.001). CONCLUSIONS These results support the consideration of diabetes as an independent risk factor for SSIs for multiple surgical procedure types. Continued efforts are needed to improve surgical outcomes for diabetic patients. Infect. Control Hosp. Epidemiol. 2015;37(1):88-99.

Preoperative steroid use and the incidence of perioperative complications in patients undergoing craniotomy for definitive resection of a malignant brain tumor

We studied the impact of preoperative steroids on 30 day morbidity and mortality of craniotomy for definitive resection of malignant brain tumors. Glucocorticoids are used to treat peritumoral edema in patients with malignant brain tumors, however, prolonged (⩾ 10 days) use of preoperative steroids as a risk factor for perioperative complications following resection of brain tumors has not been studied comprehensively. Therefore, we identified 4407 patients who underwent craniotomy to resect a malignant brain tumor between 2007 and 2012, who were reported in the National Surgical Quality Improvement Program, a prospectively collected clinical database. Metastatic brain tumors constituted 37.5% (n=1611) and primary malignant gliomas 62.5% (n=2796) of the study population. We used logistic regression to assess the association between preoperative steroid use and perioperative complications before and after 1:1 propensity score matching. Patients who received steroids constituted 22.8% of the population (n=1009). In the unmatched cohort, steroid use was associated with decreased length of hospitalization (odds ratio [OR] 0.7; 95% confidence interval [CI] 0.6-0.8), however, the risk for readmission (OR 1.5; 95% CI 1.2-1.8) was increased. In the propensity score matched cohort (n=465), steroid use was not statistically associated with any adverse outcomes. Patients who received steroids were less likely to stay hospitalized for a protracted period of time, but were more likely to be readmitted after discharge following craniotomy. As an independent risk factor, preoperative steroid use was not associated with any observed perioperative complications. The findings of this study suggest that preoperative steroids do not independently compromise the short term outcome of craniotomy for resection of malignant brain tumors.

Case-control studies in neurosurgery

OBJECT

Observational studies, such as cohort and case-control studies, are valuable instruments in evidence-based medicine. Case-control studies, in particular, are becoming increasingly popular in the neurosurgical literature due to their low cost and relative ease of execution; however, no one has yet systematically assessed these types of studies for quality in methodology and reporting.

METHODS

The authors performed a literature search using PubMed/MEDLINE to identify all studies that explicitly identified themselves as "case-control" and were published in the JNS Publishing Group journals (Journal of Neurosurgery, Journal of Neurosurgery: Pediatrics, Journal of Neurosurgery: Spine, and Neurosurgical Focus) or Neurosurgery. Each paper was evaluated for 22 descriptive variables and then categorized as having either met or missed the basic definition of a case-control study. All studies that evaluated risk factors for a well-defined outcome were considered true case-control studies. The authors sought to identify key features or phrases that were or were not predictive of a true case-control study. Those papers that satisfied the definition were further evaluated using the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) checklist.

RESULTS

The search detected 67 papers that met the inclusion criteria, of which 32 (48%) represented true case-control studies. The frequency of true case-control studies has not changed with time. Use of odds ratios (ORs) and logistic regression (LR) analysis were strong positive predictors of true case-control studies (for odds ratios, OR 15.33 and 95% CI 4.52-51.97; for logistic regression analysis, OR 8.77 and 95% CI 2.69-28.56). Conversely, negative predictors included focus on a procedure/intervention (OR 0.35, 95% CI 0.13-0.998) and use of the word "outcome" in the Results section (OR 0.23, 95% CI 0.082-0.65). After exclusion of nested case-control studies, the negative correlation between focus on a procedure/intervention and true case-control studies was strengthened (OR 0.053, 95% CI 0.0064-0.44). There was a trend toward a negative association between the use of survival analysis or Kaplan-Meier curves and true case-control studies (OR 0.13, 95% CI 0.015-1.12). True case-control studies were no more likely than their counterparts to use a potential study design "expert" (OR 1.50, 95% CI 0.57-3.95). The overall average STROBE score was 72% (range 50-86%). Examples of reporting deficiencies were reporting of bias (28%), missing data (55%), and funding (44%).

CONCLUSIONS

The results of this analysis show that the majority of studies in the neurosurgical literature that identify themselves as "case-control" studies are, in fact, labeled incorrectly. Positive and negative predictors were identified. The authors provide several recommendations that may reverse the incorrect and inappropriate use of the term "case-control" and improve the quality of design and reporting of true case-control studies in neurosurgery.

Risk factors and outcomes associated with surgical site infections after craniotomy or craniectomy

OBJECT

Many studies that have evaluated surgical site infections (SSIs) after craniotomy or craniectomy (CRANI) did not use robust methods to assess risk factors for SSIs or outcomes associated with SSIs. The authors conducted the current study to identify risk factors for SSIs after CRANI procedures and to evaluate outcomes attributed to SSIs.

METHODS

The authors performed a nested case-control study of patients undergoing CRANI procedures between 2006 and 2010 at the University of Iowa Hospitals and Clinics. They identified 104 patients with SSIs and selected 312 controls. They collected data from medical records and used multivariate analyses to identify risk factors and outcomes associated with SSIs.

RESULTS

Thirty-two percent of SSIs were caused by Staphylococcus aureus, 88% were deep incisional or organ space infections, and 70% were identified after discharge. Preoperative length of stay (LOS) ≥ 1 day was the only significant patient-related factor in the preoperative model (OR 2.1 [95% CI 1.2-3.4]) and in the overall model (OR 1.9 [95% CI 1.1-3.3]). Procedure-related risk factors that were significant in the overall model included Gliadel wafer use (OR 6.7 [95% CI 2.5-18.2]) and postoperative CSF leak (OR 3.5 [95% CI 1.4-8.5]). The preoperative SSI risk index, including body mass index, previous brain operation, chemotherapy on admission, preoperative LOS, procedure reason, and preoperative glucose level, had better predictive efficacy (c-statistic = 0.664) than the National Healthcare Safety Network risk index (c-statistic = 0.547; p = 0.004). Surgical site infections were associated with increased LOS during the initial hospitalizations (average increase of 50%) or readmissions (average increase of 100%) and with an increased risk of readmissions (OR 7.7 [95% CI 4.0-14.9]), reoperations (OR 36 [95% CI 14.9-87]), and death (OR 3.4 [95% CI 1.5-7.4]).

CONCLUSIONS

Surgeons were able to prospectively assess a patient's risk of SSI based on preoperative risk factors and they could modify some processes of care to lower the risk of SSI. Surgical site infections substantially worsened patients' outcomes. Preventing SSIs after CRANI could improve patient outcomes and decrease health care utilization.

Impact of malglycemia on clinical outcomes in hospitalized patients with cancer: a review of the literature

PURPOSE/OBJECTIVES

To examine empirical research regarding the role of malglycemia (hyperglycemia, hypoglycemia, or glycemic variability) on clinical outcomes among hospitalized patients with cancer.

DATA SOURCES

Research articles were obtained from the Ovid, PubMed, and CINAHL® databases. Key words used in the search included hyperglycemia or malglycemia and neoplasm combined with venous thromboembolism, infection, or mortality.

DATA SYNTHESIS

Eleven research articles were examined reporting the impact of malglycemia on various outcomes, including infection, mortality or survival, length of hospital stay, and toxicity.

CONCLUSIONS

Findings suggest that malglycemia may have a negative impact on outcomes for hospitalized patients with cancer. Increased rates of infection, mortality, length of stay, and toxicities, as well as decreased survival, were reported.

IMPLICATIONS FOR NURSING

Oncology nurses play an important role in the identification of patients with malglycemia. Early assessment and intervention for those patients can improve outcomes and quality of life.

Immediate titanium cranioplasty after debridement and craniectomy for postcraniotomy surgical site infection

BACKGROUND

For postcraniotomy surgical site infection (SSI) involving the bone, typical management involves craniectomy, debridement, and delayed cranioplasty. Disadvantages to delayed cranioplasty include cosmetic deformity, vulnerability of unprotected brain, and risks and costs associated with an additional operation. Many authors have attempted bone flap salvage by using various techniques.

OBJECTIVE

We evaluate our experience with immediate titanium mesh cranioplasty at the time of craniectomy and debridement.

METHODS

We retrospectively reviewed SSIs in patients that underwent craniotomy for treatment of a brain tumor. These patients were treated with craniectomy, debridement, and immediate titanium mesh cranioplasty followed by antibiotics. The primary outcome was recurrent infection.

RESULTS

Twelve patients met the inclusion criteria. Risk factors for infection included preoperative radiation therapy (33%), prior craniotomy (33%), and postoperative CSF leak (25%). Median follow-up was 14 months. Ten (83%) patients had long-term resolution without recurrent infection. One patient required additional surgical debridement for persistent infection with successful placement of new titanium mesh. Another patient developed recurrent infection but opted for hospice care because of tumor progression.

CONCLUSION

This series demonstrates the safety and feasibility of performing immediate titanium cranioplasty at the time of craniectomy and debridement in patients with postcraniotomy infections. This has been shown in patients with risk factors for poor wound healing. Immediate cranioplasty avoids the drawbacks, risks, and costs of delayed cranioplasty.

Patterns in neurosurgical adverse events: intracranial neoplasm surgery

Object

Neurosurgery is a high-risk specialty currently undertaking the pursuit of systematic approaches to measuring and improving outcomes. As part of a project to devise evidence-based safety interventions for specialty surgery, the authors sought to review current evidence in cranial tumor resection concerning the frequency of adverse events in practice, their patterns, and current methods of reducing the occurrence of these events. This review represents part of a series of papers written to consolidate information about these events and preventive measures as part of an ongoing effort to ascertain the utility of devising system-wide policies and safety tools to improve neurosurgical practice.

Methods

The authors performed a PubMed search using search terms “intracranial neoplasm,” “cerebral tumor,” “cerebral meningioma,” “glioma,” and “complications” or “adverse events.” Only papers that specifically discussed the relevant complication rates were included. Papers were chosen to maximize the range of rates of occurrence for the reported adverse events.

Results

Review of the tumor neurosurgery literature showed that documented overall complication rates ranged from 9% to 40%, with overall mortality rates of 1.5%–16%. There was a wide range of types of adverse events overall. Deep venous thromboembolism (DVT) was the most common adverse event, with a reported incidence of 3%–26%. The presence of new or worsened neurological deficit was the second most common adverse event found in this review, with reported rates ranging from 0% for the series of meningioma cases with the lowest reported rate to 20% as the highest reported rate for treatment of eloquent glioma. Benign tumor recurrence was found to be a commonly reported adverse event following surgery for intracranial neoplasms. Rates varied depending on tumor type, tumor location, patient demographics, surgical technique, the surgeon's level of experience, degree of specialization, and changes in technology, but these effects remain unmeasured. The incidence on our review ranged from 2% for convexity meningiomas to 36% for basal meningiomas. Other relatively common complications were dural closure–related complications (1%–24%), postoperative peritumoral edema (2%–10%), early postoperative seizure (1%–12%), medical complications (6%–7%), wound infection (0%–4%), surgery-related hematoma (1%–2%), and wrong-site surgery.

Strategies to minimize risk of these events were evaluated. Prophylactic techniques for DVT have been widely demonstrated and confirmed, but adherence remains unstudied. The use of image guidance, intraoperative functional mapping, and real-time intraoperative MRI guidance can allow surgeons to maximize resection while preserving neurological function. Whether the extent of resection significantly correlates with improved overall outcomes remains controversial.

Discussion

A significant proportion of adverse events in intracranial neoplasm surgery may be avoidable by use of practices to encourage use of standardized protocols for DVT, seizure, and infection prophylaxis; intraoperative navigation among other steps; improved teamwork and communication; and concentrated volume and specialization. Systematic efforts to bundle such strategies may significantly improve patient outcomes.

Infection following operations on the central nervous system: deconstructing the myth of the sterile field

Neurosurgical patients are at a high risk for infectious sequelae following operations. For neurosurgery in particular, the risk of surgical site infection has a unique implication given the proximity of the CSF and the CNS. Patient factors contribute to some degree; for example, cancer and trauma are often associated with impaired nutritional status, known risk factors for infection. Additionally, care-based factors for infection must also be considered, such as the length of surgery, the administration of steroids, and tissue devascularization (such as a craniotomy bone flap). When postoperative infection does occur, attention is commonly focused on potential lapses in surgical “sterility.” Evidence suggests that the surgical field is not free of microorganisms. The authors propose a paradigm shift in the nomenclature of the surgical field from “sterile” to “clean.” Continued efforts aimed at optimizing immune capacity and host defenses to combat potential infection are warranted.

Postoperative sepsis

PURPOSE OF REVIEW

Postoperative sepsis is a major cause of surgical associated morbidity and mortality. Our goal is to describe its incidence, pathophysiology, and contributing factors. In addition, we will review preventive measures and treatment options that may possibly reduce its healthcare burden.

RECENT FINDINGS

We review epidemiologic data and clinical tools presented in multiple current studies, which may help lower incidence and improve outcome of postoperative sepsis.

SUMMARY

The incidence of postoperative sepsis has not declined over the past years, although mortality is trending downwards. Several biochemical and genetic markers may allow early diagnosis. Prevention and prompt treatment may lower mortality.