Perioperative Allogeneic Blood Transfusion Is Associated With Surgical Site Infection After Abdominoperineal Resection-a Space for the Implementation of Patient Blood Management Strategies

Incidence, risk factors, and outcome of Clostridioides difficile infection following urological surgeries

PURPOSE

To assess the incidence, risk factors, and clinical outcomes associated with (Clostridioides difficile infection) CDI following urological surgery, which is the leading cause of nosocomial diarrhea and a growing public health burden.

METHODS

We queried the National Surgical Quality Improvement Program (NSQIP) to identify patients undergoing urological surgery in 2015-2016. We evaluated the 30-day incidence and factors associated with postoperative CDI and 30-day hospital readmission and length of stay as secondary outcomes. Among the subset of patients undergoing radical cystectomy with urinary diversion (surgery with highest CDI incidence) we used multivariable logistic regression analysis to evaluate independent clinical and demographic factors associated with postoperative CDI.

RESULTS

We identified 98,463 patients during the study period. The overall 30-day incidence of CDI was 0.31%, but varied considerably across surgery type. The risk of CDI was greatest following radical cystectomy with urinary diversion (2.72%) compared to all other urologic procedures (0.19%) and was associated with increased risk of hospital readmission (p < 0.0001), re-operation (p < 0.0001), and longer mean length of stay (p < 0.0001) in this cohort. Among patients undergoing radical cystectomy with urinary diversion, multivariable logistic regression revealed that preoperative renal failure (OR: 5.30, 95% CI 1.13-24.9, p = 0.035) and blood loss requiring transfusion (OR: 1.67, 95% CI 1.15-2.44, p = 0.0075) were independently associated with CDI.

CONCLUSIONS

In a nationally representative cohort, the incidence of CDI was low but varied substantially across surgery types. CDI was most common following radical cystectomy and associated with potentially modifiable factors such as blood transfusion and significantly longer length of stay.

Surgical Healthcare Workers Knowledge and Attitude on Infection Prevention and Control: A Case of Tamale Teaching Hospital, Ghana

Background

Most morbidities and mortalities related to clinical, diagnostic, and therapeutic procedures are related to infection and the solution to this is good infection prevention and control (IPC) compliance which is influenced by the right knowledge and positive attitude.

Aim

This study aimed to assess infection prevention and control (IPC) knowledge and attitude among healthcare workers at the surgical department of Tamale Teaching Hospital (TTH).

Methods

This study was conducted using a descriptive cross-sectional survey. Data entry and analysis were done using Statistical Package for the Social Sciences (SPSS) version 20 and Graph Pad Prism version 6.05. Tables, frequencies, and percentages were used for descriptive analysis and chi-square analysis for the associations.

Results

Of the 156 participants who responded, 22 (14.1%) were doctors, with 107 (68.6%) nurses, 12 (7.7%) certified registered anesthetics (CRA), and 15 (9.6%) orderlies. Approximately, 50.6% of the respondents were knowledgeable with regard to IPC and 55.1% of the respondents had a good attitude towards IPC. Factors associated with knowledge level were educational level (p ≤ 0.001), occupation (p ≤ 0.001), marital status (p=0.030), and age (p=0.030). The occupation was the only factor associated with the attitude level (p=0.048).

Conclusion

More than half of the healthcare providers reported good knowledge and attitude towards IPC. Proportionally, more nurses had good IPC knowledge and attitude as compared to other professional groups. Firming up and assimilating universal precaution with routine services by providing training, protocol, rules, and regulation are recommended.

Pelvic exenteration for colorectal and non-colorectal cancer: a comparison of perioperative and oncological outcome

BACKGROUND

Pelvic exenteration (PE) is the only option for long-term cure of advanced cancer originating from different types of tumor or recurrent disease in the lower pelvis. The aim was to show differences between colorectal and non-colorectal cancer in survival and postoperative morbidity.

METHODS

Retrospective data of 63 patients treated with total pelvic exenteration between 2013 and 2018 are reported. Pre-, intra-, and postoperative parameters, survival data, and risk factors for complications were analyzed.

RESULTS

A total of 57.2% (n = 37) of the patients had colorectal cancer, 22.3% had gynecological malignancies (vulvar (n = 6) or cervical (n = 8) cancer), 11.1% (n = 7) had anal cancer, and 9.5% had other primary tumors. A total of 30.2% (n = 19) underwent PE for a primary tumor and 69.8% (n = 44) for recurrent cancer. The 30-day in-hospital mortality was 0%. Neoadjuvant treatment was administered to 65.1% (n = 41) of the patients and correlated significantly with postoperative complications (odds ratio 4.441; 95% CI: 1.375-14.342, P > 0.05). R0, R1, R2, and Rx resections were achieved in 65.1%, 19%, 1.6%, and 14.3% of the patients, respectively. In patients undergoing R0 resection, 2-year OS and RFS were 73.2% and 52.4%, respectively. Resection status was a significant risk factor for recurrence-free and overall survival (OS) in univariate analysis. Multivariate analysis revealed age (P = 0.021), ASA ≥ 3 (P = 0.005), high blood loss (P = 0.028), low preoperative hemoglobin level (P < 0.001), nodal positivity (P < 0.001), and surgical complications (P = 0.003) as independent risk factors for OS.

CONCLUSION

Pelvic exenteration is a procedure with high morbidity rates but remains the only curative option for advanced or recurrent colorectal and non-colorectal cancer in the pelvis.

Perioperative Allogeneic Red Blood Cell Transfusion and Wound Infections: An Observational Study

BACKGROUND

It remains unclear whether the benefits of performing perioperative allogeneic red blood cell (RBC) transfusion outweigh the risks of postoperative wound infection. The aim of this study was to assess the impact of perioperative RBC transfusion as well as dose-response relationship on wound infections in surgical patients in a large cohort.

METHODS

As a retrospective observational study, the national Hospital Quality Monitoring System database was used to retrieve information about in-hospital surgical patients without limitations on surgical types in the People's Republic of China between 2013 and 2018. Patients were divided into the perioperative RBC transfusion and non-RBC transfusion groups, and wound infection rates (the primary end point) were compared. Secondary end points included in-hospital mortality, nosocomial infections, and length of hospital stay. Furthermore, patients who underwent RBC transfusion were subdivided into 6 groups based on the volume of transfused RBCs to investigate the dose-response relationship between RBC transfusions and wound infections. The association between RBC transfusion and patient outcomes were analyzed using multivariable logistic regression models adjusted for potential confounders.

RESULTS

A total of 1,896,584 patients from 29 provinces were included, among whom 76,078 (4.0%) underwent RBC transfusions; the overall wound infection rate was 0.7%. After adjusting for confounding factors, perioperative RBC transfusion was associated with higher odds of wound infection (odds ratio [OR] = 2.24, 95% confidence interval [CI], 2.09-2.40; P < .001). As the volume of transfused RBCs increased, so did the odds of wound infection with a clear dose-response relationship (OR of >0 and ≤1 U, >1 and ≤2 U, >2 and ≤4 U, >4 and ≤8 U, >8 U transfusion compared with no RBC transfusion were 1.20, 95% CI, 0.76-1.91; 1.27, 95% CI, 1.10-1.47; 1.70, 95% CI, 1.49-1.93; 2.12, 95% CI, 1.83-2.45 and 3.65, 95% CI, 3.13-4.25, respectively). RBC transfusion was also found to be associated with higher odds of in-hospital mortality, nosocomial infection, and longer hospital stay.

CONCLUSIONS

RBC transfusion was associated with an increased odd of postoperative wound infection in surgical patients, and a significant dose-related relationship was also observed. While there are still essential confounders not adjusted for and the results do not necessarily indicate a causal relationship, we still recommend to lessen perioperative blood loss and optimize blood conservation strategies.

Optimizing Blood Transfusion Practices Through Bundled Intervention Implementation in Patients With Gynecologic Cancer Undergoing Laparotomy

OBJECTIVE

To examine blood transfusion practices and develop a standardized bundle of interventions to address the high rate of perioperative red blood cell transfusion among patients with ovarian and endometrial cancer.

METHODS

This was a retrospective cohort study. Our primary aim was to determine whether an implemented bundled intervention was associated with a reduction in perioperative red blood cell transfusions among cases of laparotomy for cancer. Secondary aims included comparing perioperative demographic, surgical, complication, and cost data. Interventions included blood transfusion practice standardization using American Society of Anesthesiologists guidelines, an intraoperative hemostasis checklist, standardized intraoperative fluid status communication, and evidence-based use of tranexamic acid. Prospective data from women undergoing laparotomy for ovarian or endometrial cancer from September 28, 2015, to May 31, 2016, defined the study cohort and were compared with historical controls (September 1, 2014, to September 25, 2015). Outcomes were compared in the full unadjusted cohorts and in propensity-matched cohorts.

RESULTS

In the intervention and historical cohorts, respectively, 89 and 184 women underwent laparotomy for ovarian cancer (n=74 and 152) or advanced endometrial cancer (n=15 and 32). Tranexamic acid was administered in 54 (60.7%) patients. The perioperative transfusion rate was lower for the intervention group compared with historical controls (18.0% [16/89] vs 41.3% [76/184], P<.001), a 56.4% reduction. This improvement in the intervention group remained significant after propensity matching (16.2% [13/80] vs 36.2% [29/80], P=.004). The hospital readmission rate was also lower for the intervention group compared with historical controls (1.1% [1/89] vs 12.5% [23/184], P=.002); however, this improvement did not attain statistical significance after propensity matching (1.2% [1/80] vs 7.5% [6/80], P=.12). Cost analysis demonstrated that this intervention was cost-neutral during index hospitalization plus 30-day follow-up.

CONCLUSION

Application of a standardized bundle of evidence-based interventions was associated with reduced blood use in our gynecologic oncology practice.

Red Blood Cell Transfusion and Surgical Site Infection After Colon Resection Surgery: A Cohort Study

BACKGROUND

Surgical site infections (SSIs) after colon surgery remain a critical safety issue. Patients with an SSI have an increased risk of death, prolonged hospitalization, and increased costs of care. Red blood cell (RBC) transfusion is given during the perioperative period to increase blood oxygen delivery, but it is associated with complications, including infection. We hypothesized that RBC transfusion would be associated with increased SSI risk in patients undergoing colon resection surgery.

METHODS

A retrospective cohort study was performed using the 2014 National Surgical Quality Improvement Program participant use file. Patients who had colon resection surgery were identified using current procedural terminology codes. The association between perioperative RBC transfusion and superficial and deep incisional SSIs, organ space SSIs, and postoperative septic shock was modeled using logistic regression with propensity score analysis.

RESULTS

Of 23,388 patients who had colon resection surgery, 1845 (7.9%) received perioperative RBC transfusion. After controlling for confounders with propensity score analysis and inverse probability of treatment weighting, RBC transfusion had no apparent association with superficial incisional SSI (odds ratio [OR], 1.18; 99% confidence interval [CI], 0.48-2.88) or deep incisional SSI (OR, 1.47; 99% CI, 0.23-9.43). However, RBC transfusion appeared to be associated with increased risk of organ space SSI (OR, 2.93; 99% CI, 1.43-6.01) and septic shock (OR, 9.23; 99% CI, 3.53-24.09).

CONCLUSIONS

RBC transfusion has no apparent association with increased risk for incisional SSIs, but may be associated with increased risk for organ space SSI and septic shock after colon resection surgery.

Topical vs Intravenous Tranexamic Acid in Primary Total Hip Arthroplasty: A Double-Blind, Randomized Controlled Trial

BACKGROUND

Tranexamic acid (TXA) reduces perioperative blood loss in total hip arthroplasty (THA).

METHODS

In our randomized control trial, 139 patients were enrolled and received 2 g of either topical or intravenous (IV) TXA. Preoperative and postoperative protocols were standardized.

RESULTS

Calculated blood and Hgb loss were lower in the IV group (1195.0 ± 485.9 mL, 1442.7 ± 562.7 mL; P = .006), (160.3 [g] ± 63.8, 188.4 [g] ± 68.5; P = .014). There was a trend toward significance in transfusion reduction (11% [IV] vs 18% [topical]; P = .3). Both groups effectively reduced the transfusion rate. There was significant financial incentive for the use of TXA in THA with a savings of $314 per patient.

CONCLUSIONS

IV and topical TXA are effective tools to reduce blood loss and transfusion costs in THA, and we recommend the IV form for ease of use.