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Enhanced recovery protocol applied to liver surgery reduced costs
SCOTTSDALE, ARIZ. – A new study shows that an Enhanced Recovery in Liver Surgery (ERLS) program reduced costs at a high-volume liver surgery center. The savings were lower in patients receiving epidurals, which is prompting the center to explore alternative methods of pain control. The program reduced costs in minor hepatectomies, but not major hepatectomies.
“It has been clearly demonstrated that patients benefit from enhanced recovery programs – they’re getting home sooner, they’re on fewer opioids, and they do better. What’s less clear is if it’s cost effective. If you can demonstrate lower costs, then all the major stakeholders involved would potentially benefit,” Michael Egger, MD, assistant professor of surgery at the University of Louisville (Ky.), said in an interview.
The study was conducted at the University of Texas MD Anderson Cancer Center, Houston. Dr. Egger presented the research at the annual meeting of the Western Surgical Association.
The liver program is similar to other enhanced recovery protocols and includes use of nonnarcotic analgesia, early ambulation, and early initiation of oral diet. Aspects unique to liver surgery include avoidance of drains and tubes placed in the operating room and limitation of intravenous fluids during and following surgery.
The researchers analyzed data from 212 patients who underwent hepatectomy between February 2012 and September 2016: 72 patients who were in an ERLS program and 140 were enrolled in a traditional recovery (TR) program. The ERLS program included patient education, narcotic-sparing anesthesia and analgesia, rapid diet advancement, restrictive fluid use, early ambulation, and avoidance of drains and tubes.
A total of 32% of patients in the ERLS group underwent major hepatectomy, compared to 64% of patients in the TR group. Forty-three percent in the ERLS group had an epidural, compared with 75% in the TR group.
The ERLS group had a shorter median length of stay (5 days vs. 6 days; P = .001) and had a 9.1% reduction in costs (P = .001). The largest cost differences were attributable to lab costs (–15.0%), room and board (–13.9%), and professional costs (–19.3%; all P less than .05).
ERLS was not associated with a statistically significant cost saving in patients undergoing major hepatectomy. In minor hepatectomy, ERLS was associated with a 17.6% reduction in overall costs (P less than .05). There was no reduction in patients who had a hospital stay over 90 days
Among patients who received patient-controlled analgesia, those in the ERLS program had a 32.0% reduction in overall costs (P less than .001), largely driven by a 34.3% reduction in lab costs, a 33.3% reduction in room and board, a 51.6% reduction in professional costs, and a 22.5% reduction in pharmacy costs (all P less than .05).
There was also no difference in cost between the two programs in patients who underwent an epidural, which suggests an avenue for improvement. “We’re looking at other regional pain blocks, such as transverse abdominis plane (TAP) block using a long-acting analgesic, and that’s our trend going forward. We’re hoping we can reduce some of those increased costs associated with the epidural, but still reap the benefits of improved pain control and reduction of narcotics use,” said Dr. Egger.
The National Institutes of Health funded the study. Dr. Egger reported having no financial disclosures.
SCOTTSDALE, ARIZ. – A new study shows that an Enhanced Recovery in Liver Surgery (ERLS) program reduced costs at a high-volume liver surgery center. The savings were lower in patients receiving epidurals, which is prompting the center to explore alternative methods of pain control. The program reduced costs in minor hepatectomies, but not major hepatectomies.
“It has been clearly demonstrated that patients benefit from enhanced recovery programs – they’re getting home sooner, they’re on fewer opioids, and they do better. What’s less clear is if it’s cost effective. If you can demonstrate lower costs, then all the major stakeholders involved would potentially benefit,” Michael Egger, MD, assistant professor of surgery at the University of Louisville (Ky.), said in an interview.
The study was conducted at the University of Texas MD Anderson Cancer Center, Houston. Dr. Egger presented the research at the annual meeting of the Western Surgical Association.
The liver program is similar to other enhanced recovery protocols and includes use of nonnarcotic analgesia, early ambulation, and early initiation of oral diet. Aspects unique to liver surgery include avoidance of drains and tubes placed in the operating room and limitation of intravenous fluids during and following surgery.
The researchers analyzed data from 212 patients who underwent hepatectomy between February 2012 and September 2016: 72 patients who were in an ERLS program and 140 were enrolled in a traditional recovery (TR) program. The ERLS program included patient education, narcotic-sparing anesthesia and analgesia, rapid diet advancement, restrictive fluid use, early ambulation, and avoidance of drains and tubes.
A total of 32% of patients in the ERLS group underwent major hepatectomy, compared to 64% of patients in the TR group. Forty-three percent in the ERLS group had an epidural, compared with 75% in the TR group.
The ERLS group had a shorter median length of stay (5 days vs. 6 days; P = .001) and had a 9.1% reduction in costs (P = .001). The largest cost differences were attributable to lab costs (–15.0%), room and board (–13.9%), and professional costs (–19.3%; all P less than .05).
ERLS was not associated with a statistically significant cost saving in patients undergoing major hepatectomy. In minor hepatectomy, ERLS was associated with a 17.6% reduction in overall costs (P less than .05). There was no reduction in patients who had a hospital stay over 90 days
Among patients who received patient-controlled analgesia, those in the ERLS program had a 32.0% reduction in overall costs (P less than .001), largely driven by a 34.3% reduction in lab costs, a 33.3% reduction in room and board, a 51.6% reduction in professional costs, and a 22.5% reduction in pharmacy costs (all P less than .05).
There was also no difference in cost between the two programs in patients who underwent an epidural, which suggests an avenue for improvement. “We’re looking at other regional pain blocks, such as transverse abdominis plane (TAP) block using a long-acting analgesic, and that’s our trend going forward. We’re hoping we can reduce some of those increased costs associated with the epidural, but still reap the benefits of improved pain control and reduction of narcotics use,” said Dr. Egger.
The National Institutes of Health funded the study. Dr. Egger reported having no financial disclosures.
SCOTTSDALE, ARIZ. – A new study shows that an Enhanced Recovery in Liver Surgery (ERLS) program reduced costs at a high-volume liver surgery center. The savings were lower in patients receiving epidurals, which is prompting the center to explore alternative methods of pain control. The program reduced costs in minor hepatectomies, but not major hepatectomies.
“It has been clearly demonstrated that patients benefit from enhanced recovery programs – they’re getting home sooner, they’re on fewer opioids, and they do better. What’s less clear is if it’s cost effective. If you can demonstrate lower costs, then all the major stakeholders involved would potentially benefit,” Michael Egger, MD, assistant professor of surgery at the University of Louisville (Ky.), said in an interview.
The study was conducted at the University of Texas MD Anderson Cancer Center, Houston. Dr. Egger presented the research at the annual meeting of the Western Surgical Association.
The liver program is similar to other enhanced recovery protocols and includes use of nonnarcotic analgesia, early ambulation, and early initiation of oral diet. Aspects unique to liver surgery include avoidance of drains and tubes placed in the operating room and limitation of intravenous fluids during and following surgery.
The researchers analyzed data from 212 patients who underwent hepatectomy between February 2012 and September 2016: 72 patients who were in an ERLS program and 140 were enrolled in a traditional recovery (TR) program. The ERLS program included patient education, narcotic-sparing anesthesia and analgesia, rapid diet advancement, restrictive fluid use, early ambulation, and avoidance of drains and tubes.
A total of 32% of patients in the ERLS group underwent major hepatectomy, compared to 64% of patients in the TR group. Forty-three percent in the ERLS group had an epidural, compared with 75% in the TR group.
The ERLS group had a shorter median length of stay (5 days vs. 6 days; P = .001) and had a 9.1% reduction in costs (P = .001). The largest cost differences were attributable to lab costs (–15.0%), room and board (–13.9%), and professional costs (–19.3%; all P less than .05).
ERLS was not associated with a statistically significant cost saving in patients undergoing major hepatectomy. In minor hepatectomy, ERLS was associated with a 17.6% reduction in overall costs (P less than .05). There was no reduction in patients who had a hospital stay over 90 days
Among patients who received patient-controlled analgesia, those in the ERLS program had a 32.0% reduction in overall costs (P less than .001), largely driven by a 34.3% reduction in lab costs, a 33.3% reduction in room and board, a 51.6% reduction in professional costs, and a 22.5% reduction in pharmacy costs (all P less than .05).
There was also no difference in cost between the two programs in patients who underwent an epidural, which suggests an avenue for improvement. “We’re looking at other regional pain blocks, such as transverse abdominis plane (TAP) block using a long-acting analgesic, and that’s our trend going forward. We’re hoping we can reduce some of those increased costs associated with the epidural, but still reap the benefits of improved pain control and reduction of narcotics use,” said Dr. Egger.
The National Institutes of Health funded the study. Dr. Egger reported having no financial disclosures.
AT WSA 2017
Key clinical point: An enhanced recovery program reduced hospital costs for livery surgery.
Major finding: The program was associated with a 9% reduction in costs, but only in minor hepatectomy procedures.
Data source: Retrospective analysis of 212 patients.
Disclosures: The National Institutes of Health funded the study. Dr. Egger reported having no financial disclosures.
High-volume centers have lower costs for some pancreatic surgeries
SCOTTSDALE, ARIZ. – Surgeons who perform five or more pancreaticoduodenectomy (PD) or Whipple operations per year had significant cost reductions, compared with lower-volume surgeons, but there was no such relationship among surgeons performing distal pancreatectomy procedures.
The finding suggests that “high volume” may need to be defined differently for the two procedures to maximize cost effectiveness.
In the age of increased pressure to reduce health care costs, and with the merit-based incentive payment system (MIPS) set to be introduced, referring pancreatic procedures to high-volume centers has the potential to increase efficiency and reduce costs, but researchers are still working to determine how high a volume is required to realize such savings. High volume has been defined by as few as two operations per year and as many as 200, according to Brooke Vuong, MD, who presented the study at at the annual meeting of the Western Surgical Association.
There have been few studies of the impact of surgeon volume on costs and outcomes, and many of those rely on databases and emphasize academic medical centers.
“There was a significant cost reduction for a low-volume threshold of five, so it raises the idea that minimum volume requirements have value,” said Dr. Vuong, who is a surgical oncology fellow at the John Wayne Cancer Institute at Providence Saint John’s Health Center, Santa Monica, Calif.
The study, which is the first to look at detailed costs and value drivers for individual surgeons performing pancreatic surgery, suggests more work needs to be done to determine a high-volume cutoff for distal pancreatectomy (DP). The study, however, also revealed another cost-saving mechanism: After participating surgeons began sharing financial data with each other, overall costs dropped by about 7%.
“The sharing of detailed financial data with [other surgeons] on a regular basis provides the opportunity to evaluate practice patterns and thereby reduce cost, and this is especially important as health care systems and individual physicians are held accountable for value-based care,” Dr. Vuong said.
That point struck a chord with one audience member. “There’s nothing like seeing your data among your peers to drive down your length-of-stay costs and make you pay real attention to complications,” one surgeon said during the Q & A period.
The researchers examined data from procedures performed at 14 hospitals in five different states. The analysis included 54 surgeons and all patients who underwent DP (n = 270) or PD (n = 526) between January 2014 and July 2017. Average length of stay (LOS), 30-day mortality, and readmission rates were collected and compared by surgeon volume. Beginning in 2016, the team conducted bimonthly video conferences to share data in a hepatobiliary clinical performance group.
High-volume surgeons had PD costs of $21,026, compared with $24,706 among low-volume surgeons (difference, $3,680; P = .005). Specific areas of savings included operating room and anesthesia (P = .005); room and board (P = .03), and ICU (P = .042). Average LOS was 9 days among high-volume surgeons, compared with 11 days among low-volume surgeons (P less than .001).
In contrast, the researchers found no significant difference in overall cost between high-volume ($14,016) and low-volume ($15,856) surgeons performing DP, though there was a lower average LOS among high-volume surgeons (6 days vs. 7 days; P = .001). High-volume surgeons also had a lower associated frequency of blood transfusions (10.2% vs. 22.6%; P = .007).
In PD surgeries, low-volume surgeons were more likely to produce a cost in the top quartile than were high-volume surgeons (odds ratio, 6.89; P less than .001). The same was true with DP surgeries (odds ratio, 5.78; P less than .001).
The researchers compared surgical costs from before and after the hepatobiliary clinical performance group was established and found a median decrease of $1,397, from $19,411 in 2014-2015 to $18,014 for 2016 (P = .013).
Readmission rates and 30-day mortality were not significantly different between high-volume and low-volume surgeons in either procedure.
The study received no outside support. Dr. Vuong reported having no financial disclosures..
SCOTTSDALE, ARIZ. – Surgeons who perform five or more pancreaticoduodenectomy (PD) or Whipple operations per year had significant cost reductions, compared with lower-volume surgeons, but there was no such relationship among surgeons performing distal pancreatectomy procedures.
The finding suggests that “high volume” may need to be defined differently for the two procedures to maximize cost effectiveness.
In the age of increased pressure to reduce health care costs, and with the merit-based incentive payment system (MIPS) set to be introduced, referring pancreatic procedures to high-volume centers has the potential to increase efficiency and reduce costs, but researchers are still working to determine how high a volume is required to realize such savings. High volume has been defined by as few as two operations per year and as many as 200, according to Brooke Vuong, MD, who presented the study at at the annual meeting of the Western Surgical Association.
There have been few studies of the impact of surgeon volume on costs and outcomes, and many of those rely on databases and emphasize academic medical centers.
“There was a significant cost reduction for a low-volume threshold of five, so it raises the idea that minimum volume requirements have value,” said Dr. Vuong, who is a surgical oncology fellow at the John Wayne Cancer Institute at Providence Saint John’s Health Center, Santa Monica, Calif.
The study, which is the first to look at detailed costs and value drivers for individual surgeons performing pancreatic surgery, suggests more work needs to be done to determine a high-volume cutoff for distal pancreatectomy (DP). The study, however, also revealed another cost-saving mechanism: After participating surgeons began sharing financial data with each other, overall costs dropped by about 7%.
“The sharing of detailed financial data with [other surgeons] on a regular basis provides the opportunity to evaluate practice patterns and thereby reduce cost, and this is especially important as health care systems and individual physicians are held accountable for value-based care,” Dr. Vuong said.
That point struck a chord with one audience member. “There’s nothing like seeing your data among your peers to drive down your length-of-stay costs and make you pay real attention to complications,” one surgeon said during the Q & A period.
The researchers examined data from procedures performed at 14 hospitals in five different states. The analysis included 54 surgeons and all patients who underwent DP (n = 270) or PD (n = 526) between January 2014 and July 2017. Average length of stay (LOS), 30-day mortality, and readmission rates were collected and compared by surgeon volume. Beginning in 2016, the team conducted bimonthly video conferences to share data in a hepatobiliary clinical performance group.
High-volume surgeons had PD costs of $21,026, compared with $24,706 among low-volume surgeons (difference, $3,680; P = .005). Specific areas of savings included operating room and anesthesia (P = .005); room and board (P = .03), and ICU (P = .042). Average LOS was 9 days among high-volume surgeons, compared with 11 days among low-volume surgeons (P less than .001).
In contrast, the researchers found no significant difference in overall cost between high-volume ($14,016) and low-volume ($15,856) surgeons performing DP, though there was a lower average LOS among high-volume surgeons (6 days vs. 7 days; P = .001). High-volume surgeons also had a lower associated frequency of blood transfusions (10.2% vs. 22.6%; P = .007).
In PD surgeries, low-volume surgeons were more likely to produce a cost in the top quartile than were high-volume surgeons (odds ratio, 6.89; P less than .001). The same was true with DP surgeries (odds ratio, 5.78; P less than .001).
The researchers compared surgical costs from before and after the hepatobiliary clinical performance group was established and found a median decrease of $1,397, from $19,411 in 2014-2015 to $18,014 for 2016 (P = .013).
Readmission rates and 30-day mortality were not significantly different between high-volume and low-volume surgeons in either procedure.
The study received no outside support. Dr. Vuong reported having no financial disclosures..
SCOTTSDALE, ARIZ. – Surgeons who perform five or more pancreaticoduodenectomy (PD) or Whipple operations per year had significant cost reductions, compared with lower-volume surgeons, but there was no such relationship among surgeons performing distal pancreatectomy procedures.
The finding suggests that “high volume” may need to be defined differently for the two procedures to maximize cost effectiveness.
In the age of increased pressure to reduce health care costs, and with the merit-based incentive payment system (MIPS) set to be introduced, referring pancreatic procedures to high-volume centers has the potential to increase efficiency and reduce costs, but researchers are still working to determine how high a volume is required to realize such savings. High volume has been defined by as few as two operations per year and as many as 200, according to Brooke Vuong, MD, who presented the study at at the annual meeting of the Western Surgical Association.
There have been few studies of the impact of surgeon volume on costs and outcomes, and many of those rely on databases and emphasize academic medical centers.
“There was a significant cost reduction for a low-volume threshold of five, so it raises the idea that minimum volume requirements have value,” said Dr. Vuong, who is a surgical oncology fellow at the John Wayne Cancer Institute at Providence Saint John’s Health Center, Santa Monica, Calif.
The study, which is the first to look at detailed costs and value drivers for individual surgeons performing pancreatic surgery, suggests more work needs to be done to determine a high-volume cutoff for distal pancreatectomy (DP). The study, however, also revealed another cost-saving mechanism: After participating surgeons began sharing financial data with each other, overall costs dropped by about 7%.
“The sharing of detailed financial data with [other surgeons] on a regular basis provides the opportunity to evaluate practice patterns and thereby reduce cost, and this is especially important as health care systems and individual physicians are held accountable for value-based care,” Dr. Vuong said.
That point struck a chord with one audience member. “There’s nothing like seeing your data among your peers to drive down your length-of-stay costs and make you pay real attention to complications,” one surgeon said during the Q & A period.
The researchers examined data from procedures performed at 14 hospitals in five different states. The analysis included 54 surgeons and all patients who underwent DP (n = 270) or PD (n = 526) between January 2014 and July 2017. Average length of stay (LOS), 30-day mortality, and readmission rates were collected and compared by surgeon volume. Beginning in 2016, the team conducted bimonthly video conferences to share data in a hepatobiliary clinical performance group.
High-volume surgeons had PD costs of $21,026, compared with $24,706 among low-volume surgeons (difference, $3,680; P = .005). Specific areas of savings included operating room and anesthesia (P = .005); room and board (P = .03), and ICU (P = .042). Average LOS was 9 days among high-volume surgeons, compared with 11 days among low-volume surgeons (P less than .001).
In contrast, the researchers found no significant difference in overall cost between high-volume ($14,016) and low-volume ($15,856) surgeons performing DP, though there was a lower average LOS among high-volume surgeons (6 days vs. 7 days; P = .001). High-volume surgeons also had a lower associated frequency of blood transfusions (10.2% vs. 22.6%; P = .007).
In PD surgeries, low-volume surgeons were more likely to produce a cost in the top quartile than were high-volume surgeons (odds ratio, 6.89; P less than .001). The same was true with DP surgeries (odds ratio, 5.78; P less than .001).
The researchers compared surgical costs from before and after the hepatobiliary clinical performance group was established and found a median decrease of $1,397, from $19,411 in 2014-2015 to $18,014 for 2016 (P = .013).
Readmission rates and 30-day mortality were not significantly different between high-volume and low-volume surgeons in either procedure.
The study received no outside support. Dr. Vuong reported having no financial disclosures..
AT WSA 2017
Key clinical point: Surgeons performing five or more pancreaticoduodenectomies annually had lower overall costs.
Major finding: Costs dropped by $3,680, but there was no significant cost difference in distal pancreatectomies.
Data source: Retrospective analysis of 796 surgeries at 14 hospitals.
Disclosures: The study received no outside support. Dr. Vuong reported having no financial disclosures.
Keep PCI patients on aspirin for noncardiac surgery
ANAHEIM, CALIF. – For every 1,000 patients with a history of percutaneous coronary intervention undergoing noncardiac surgery, perioperative aspirin would prevent 59 myocardial infarctions but cause 8 major/life-threatening bleeds, according to a substudy of the POISE-2 trial presented at the American Heart Association scientific sessions.
For patients with previous PCI undergoing noncardiac surgery, “I think aspirin will be more likely to benefit them than harm them,” so long as they are not having an operation where bleeding would be devastating.” These include “delicate neurosurgery in which, if you bleed into your spine, you end up paralyzed,” said lead investigator Michelle Graham, MD, an interventional cardiologist and professor of cardiology at the University of Alberta, Edmonton.
The original multisite POISE-2 trial (Perioperative Ischemic Evaluation 2) evaluated the effect of perioperative aspirin for noncardiac surgery. Patients were randomized to receive 200 mg aspirin or placebo within 4 hours of surgery and then 100 mg aspirin or placebo in the early postoperative period. There was no significant effect on the composite rate of death or myocardial infarction, but an increased risk of serious bleeding (N Engl J Med. 2014 Apr 17;370[16]:1494-503).
The new substudy focused on the 470 patients with previous PCIs, because such patients are known to have a higher risk for postop complications. More than half received bare-metal stents and a quarter got drug-eluting stents; in most of the rest, the stent type was not known. The median duration from PCI to noncardiac surgery was 64 months, ranging from 34 to 113 months. Patients with bare-metal stents placed within 6 weeks or drug-eluting stents within a year, were excluded.
Overall, 234 patients were randomized to the aspirin group, and 236 to placebo. Among those who came in on chronic, daily aspirin therapy – as almost all of the PCI subjects did – those who were randomized to perioperative aspirin stayed on daily 100 mg aspirin for a week postop, and then flipped back to whatever dose they were on at home. Likewise, placebo patients resumed their home aspirin after 1 week.
The results were very different from the main trial. At 30 days’ follow-up, just 6% of patients in the aspirin arm reached the primary endpoint of death or MI, versus 11.5% in the placebo group, a statistically significant 50% reduction.
This difference was driven almost entirely by a reduction in MIs. Whereas 5.1% of patients in the aspirin arm had MIs, 11% of the placebo group did, a significant 64% reduction. Meanwhile, the risk of major or life-threatening bleeding was not only similar between groups, but also to the overall trial, noted in 5.6% of aspirin and 4.2% of placebo subjects.
Over 75% of the participants were men, almost 60% were undergoing a major surgery, 30% had diabetes, and many had hypertension. Very few were on direct oral anticoagulants. The two arms were well matched, with a median age of about 68 years.
Simultaneously with Dr. Graham’s presentation, the results were published online (Ann Intern Med. 2017 Nov 14; doi: 10.7326/M17-2341)
The work was funded mostly by the Canadian Institutes of Health Research. Bayer supplied the aspirin. Dr. Graham has no industry disclosures.
ANAHEIM, CALIF. – For every 1,000 patients with a history of percutaneous coronary intervention undergoing noncardiac surgery, perioperative aspirin would prevent 59 myocardial infarctions but cause 8 major/life-threatening bleeds, according to a substudy of the POISE-2 trial presented at the American Heart Association scientific sessions.
For patients with previous PCI undergoing noncardiac surgery, “I think aspirin will be more likely to benefit them than harm them,” so long as they are not having an operation where bleeding would be devastating.” These include “delicate neurosurgery in which, if you bleed into your spine, you end up paralyzed,” said lead investigator Michelle Graham, MD, an interventional cardiologist and professor of cardiology at the University of Alberta, Edmonton.
The original multisite POISE-2 trial (Perioperative Ischemic Evaluation 2) evaluated the effect of perioperative aspirin for noncardiac surgery. Patients were randomized to receive 200 mg aspirin or placebo within 4 hours of surgery and then 100 mg aspirin or placebo in the early postoperative period. There was no significant effect on the composite rate of death or myocardial infarction, but an increased risk of serious bleeding (N Engl J Med. 2014 Apr 17;370[16]:1494-503).
The new substudy focused on the 470 patients with previous PCIs, because such patients are known to have a higher risk for postop complications. More than half received bare-metal stents and a quarter got drug-eluting stents; in most of the rest, the stent type was not known. The median duration from PCI to noncardiac surgery was 64 months, ranging from 34 to 113 months. Patients with bare-metal stents placed within 6 weeks or drug-eluting stents within a year, were excluded.
Overall, 234 patients were randomized to the aspirin group, and 236 to placebo. Among those who came in on chronic, daily aspirin therapy – as almost all of the PCI subjects did – those who were randomized to perioperative aspirin stayed on daily 100 mg aspirin for a week postop, and then flipped back to whatever dose they were on at home. Likewise, placebo patients resumed their home aspirin after 1 week.
The results were very different from the main trial. At 30 days’ follow-up, just 6% of patients in the aspirin arm reached the primary endpoint of death or MI, versus 11.5% in the placebo group, a statistically significant 50% reduction.
This difference was driven almost entirely by a reduction in MIs. Whereas 5.1% of patients in the aspirin arm had MIs, 11% of the placebo group did, a significant 64% reduction. Meanwhile, the risk of major or life-threatening bleeding was not only similar between groups, but also to the overall trial, noted in 5.6% of aspirin and 4.2% of placebo subjects.
Over 75% of the participants were men, almost 60% were undergoing a major surgery, 30% had diabetes, and many had hypertension. Very few were on direct oral anticoagulants. The two arms were well matched, with a median age of about 68 years.
Simultaneously with Dr. Graham’s presentation, the results were published online (Ann Intern Med. 2017 Nov 14; doi: 10.7326/M17-2341)
The work was funded mostly by the Canadian Institutes of Health Research. Bayer supplied the aspirin. Dr. Graham has no industry disclosures.
ANAHEIM, CALIF. – For every 1,000 patients with a history of percutaneous coronary intervention undergoing noncardiac surgery, perioperative aspirin would prevent 59 myocardial infarctions but cause 8 major/life-threatening bleeds, according to a substudy of the POISE-2 trial presented at the American Heart Association scientific sessions.
For patients with previous PCI undergoing noncardiac surgery, “I think aspirin will be more likely to benefit them than harm them,” so long as they are not having an operation where bleeding would be devastating.” These include “delicate neurosurgery in which, if you bleed into your spine, you end up paralyzed,” said lead investigator Michelle Graham, MD, an interventional cardiologist and professor of cardiology at the University of Alberta, Edmonton.
The original multisite POISE-2 trial (Perioperative Ischemic Evaluation 2) evaluated the effect of perioperative aspirin for noncardiac surgery. Patients were randomized to receive 200 mg aspirin or placebo within 4 hours of surgery and then 100 mg aspirin or placebo in the early postoperative period. There was no significant effect on the composite rate of death or myocardial infarction, but an increased risk of serious bleeding (N Engl J Med. 2014 Apr 17;370[16]:1494-503).
The new substudy focused on the 470 patients with previous PCIs, because such patients are known to have a higher risk for postop complications. More than half received bare-metal stents and a quarter got drug-eluting stents; in most of the rest, the stent type was not known. The median duration from PCI to noncardiac surgery was 64 months, ranging from 34 to 113 months. Patients with bare-metal stents placed within 6 weeks or drug-eluting stents within a year, were excluded.
Overall, 234 patients were randomized to the aspirin group, and 236 to placebo. Among those who came in on chronic, daily aspirin therapy – as almost all of the PCI subjects did – those who were randomized to perioperative aspirin stayed on daily 100 mg aspirin for a week postop, and then flipped back to whatever dose they were on at home. Likewise, placebo patients resumed their home aspirin after 1 week.
The results were very different from the main trial. At 30 days’ follow-up, just 6% of patients in the aspirin arm reached the primary endpoint of death or MI, versus 11.5% in the placebo group, a statistically significant 50% reduction.
This difference was driven almost entirely by a reduction in MIs. Whereas 5.1% of patients in the aspirin arm had MIs, 11% of the placebo group did, a significant 64% reduction. Meanwhile, the risk of major or life-threatening bleeding was not only similar between groups, but also to the overall trial, noted in 5.6% of aspirin and 4.2% of placebo subjects.
Over 75% of the participants were men, almost 60% were undergoing a major surgery, 30% had diabetes, and many had hypertension. Very few were on direct oral anticoagulants. The two arms were well matched, with a median age of about 68 years.
Simultaneously with Dr. Graham’s presentation, the results were published online (Ann Intern Med. 2017 Nov 14; doi: 10.7326/M17-2341)
The work was funded mostly by the Canadian Institutes of Health Research. Bayer supplied the aspirin. Dr. Graham has no industry disclosures.
AT THE AHA SCIENTIFIC SESSIONS
Key clinical point:
Major finding: For every 1,000 patients with a history of percutaneous coronary intervention undergoing noncardiac surgery, perioperative aspirin would prevent 59 myocardial infarctions but cause 8 major/life-threatening bleeds.
Data source: POISE-2, a randomized trial of 470 PCI patients.
Disclosures: The work was funded mostly by the Canadian Institutes of Health Research. Bayer supplied the aspirin. The lead investigator has no industry disclosures.
VIDEO: MISS 2017– Hot topics, innovations, debates
Philip R. Schauer, MD, FACS, discusses innovations, hot topics, and controversies covered in the sessions of this year’s Minimally Invasive Surgery Symposium, held in Las Vegas. In addition to highlighting what’s new this year, Dr. Schauer also spoke about plans for next year’s meeting and what makes the MISS unique and valuable to attendees.
Philip R. Schauer, MD, FACS, discusses innovations, hot topics, and controversies covered in the sessions of this year’s Minimally Invasive Surgery Symposium, held in Las Vegas. In addition to highlighting what’s new this year, Dr. Schauer also spoke about plans for next year’s meeting and what makes the MISS unique and valuable to attendees.
Philip R. Schauer, MD, FACS, discusses innovations, hot topics, and controversies covered in the sessions of this year’s Minimally Invasive Surgery Symposium, held in Las Vegas. In addition to highlighting what’s new this year, Dr. Schauer also spoke about plans for next year’s meeting and what makes the MISS unique and valuable to attendees.
VIDEO: ERAS for minimally invasive surgery
Stacy A. Brethauer, MD, FACS, discusses the role of Enhanced Recovery After Surgery (ERAS) in minimally invasive surgical procedures. The goal of the ERAS approach is to minimize surgical stress on the patient, reduce length of stay, and reduce the use of opioids in the recovery phase. Dr. Brethauer discusses a pilot program, the Energy project, which will be conducted in more than 30 institutions for a year to look at an ERAS protocol designed to work with minimally invasive surgical procedures.
The video associated with this article is no longer available on this site. Please view all of our videos on the MDedge YouTube channel
Stacy A. Brethauer, MD, FACS, discusses the role of Enhanced Recovery After Surgery (ERAS) in minimally invasive surgical procedures. The goal of the ERAS approach is to minimize surgical stress on the patient, reduce length of stay, and reduce the use of opioids in the recovery phase. Dr. Brethauer discusses a pilot program, the Energy project, which will be conducted in more than 30 institutions for a year to look at an ERAS protocol designed to work with minimally invasive surgical procedures.
The video associated with this article is no longer available on this site. Please view all of our videos on the MDedge YouTube channel
Stacy A. Brethauer, MD, FACS, discusses the role of Enhanced Recovery After Surgery (ERAS) in minimally invasive surgical procedures. The goal of the ERAS approach is to minimize surgical stress on the patient, reduce length of stay, and reduce the use of opioids in the recovery phase. Dr. Brethauer discusses a pilot program, the Energy project, which will be conducted in more than 30 institutions for a year to look at an ERAS protocol designed to work with minimally invasive surgical procedures.
The video associated with this article is no longer available on this site. Please view all of our videos on the MDedge YouTube channel
Acute cholecystitis guidelines need work
SCOTTSDALE, ARIZ. – In patients with right upper quadrant pain, the Tokyo Guidelines (TG13) failed to detect acute cholecystitis with adequate sensitivity, according to a single institution retrospective review.
Researchers at the University of Arizona, Tucson, also found that the Tokyo Guidelines’ advice to manage grade II and grade III cholecystitis patients conservatively may be unwarranted, because there were no differences in safety outcomes between grade I and grade II patients who underwent early cholecystectomy.
The Tokyo Guidelines were based on expert opinion rather than evidence, and may be limited by differences in practices in Japan and other countries. “There was no formal evaluation of the sensitivity and specificity in any other country,” Faisal Jehan, MD, a research fellow at the University of Arizona, said in an interview. Dr. Jehan presented the study at the annual meeting of the Western Surgical Association.
The study suggests there is additional work to be done before the guidelines are more generally applicable. They are being updated and the new version is slated to appear in 2018.
Cholecystectomy is one of the most common procedures in the United States, and hence represents a major source of health care expenditure. Useful guidelines will therefore be welcome to help standardize treatment, according to Dr. Riall. “I think while we’ve moved as a population toward earlier cholecystectomy, it isn’t uniformly practiced in the United States. So I think there is value in having guidelines that are relevant to our population and relevant to our practice,” she said.
But compared with the pathology report, the TG13 guidelines fared poorly in prediction of acute cholecystitis, with a sensitivity of just 53% (definitive 27%, suspected 26%, undiagnosed 53%). The underperformance of the guidelines may be due in part to recent changes in health-seeking behavior, as patients are likely to get to the hospital more quickly than in the past, and thus exhibit fewer clinical signs when first examined. “That could be decreasing the sensitivity,” said Dr. Jehan.
Suspicious that the guidelines were inadequate, the researchers analyzed their institution’s Emergency General Surgery registry, examining records from 952 patients who presented with right upper quadrant pain between 2013 and 2015. They compared diagnoses and severity assessed using the TG13 guidelines to the ensuing pathology reports, which were obtained from patient charts.
A total of 857 patients of the 952 had biliary disease. Of these, 779 patients went on to cholecystectomy, 15 had cholecystostomy-tube placement, and 63 were managed conservatively with no surgery. Among patients with biliary disease, the frequency of fever at presentation was just 4%, while 51.8% had leukocytosis. Right upper quadrant tenderness was the most sensitive predictor of acute cholecystitis (92%). Murphy’s sign occurred in 28.8% of patients and had a 72% sensitivity.
Following the TG13 guidelines resulted in classification of 414 patients as grade I, 400 as grade II, and 43 as grade III. A total of 92.5% of grade I patients underwent early cholecystectomy, as the TG-13 guidelines suggest. Nearly as many (89.3%) grade II patients also underwent early surgery, as did 50% of grade III patients. The complication rate was similar between grade I and grade II patients who underwent surgery (3.7% vs. 4.7%; P = .81). The rate of return to the operating room was also similar (0.6% vs. 0.7%; P = .95), as was mortality (0.3% vs. 0%; P = .96).
SCOTTSDALE, ARIZ. – In patients with right upper quadrant pain, the Tokyo Guidelines (TG13) failed to detect acute cholecystitis with adequate sensitivity, according to a single institution retrospective review.
Researchers at the University of Arizona, Tucson, also found that the Tokyo Guidelines’ advice to manage grade II and grade III cholecystitis patients conservatively may be unwarranted, because there were no differences in safety outcomes between grade I and grade II patients who underwent early cholecystectomy.
The Tokyo Guidelines were based on expert opinion rather than evidence, and may be limited by differences in practices in Japan and other countries. “There was no formal evaluation of the sensitivity and specificity in any other country,” Faisal Jehan, MD, a research fellow at the University of Arizona, said in an interview. Dr. Jehan presented the study at the annual meeting of the Western Surgical Association.
The study suggests there is additional work to be done before the guidelines are more generally applicable. They are being updated and the new version is slated to appear in 2018.
Cholecystectomy is one of the most common procedures in the United States, and hence represents a major source of health care expenditure. Useful guidelines will therefore be welcome to help standardize treatment, according to Dr. Riall. “I think while we’ve moved as a population toward earlier cholecystectomy, it isn’t uniformly practiced in the United States. So I think there is value in having guidelines that are relevant to our population and relevant to our practice,” she said.
But compared with the pathology report, the TG13 guidelines fared poorly in prediction of acute cholecystitis, with a sensitivity of just 53% (definitive 27%, suspected 26%, undiagnosed 53%). The underperformance of the guidelines may be due in part to recent changes in health-seeking behavior, as patients are likely to get to the hospital more quickly than in the past, and thus exhibit fewer clinical signs when first examined. “That could be decreasing the sensitivity,” said Dr. Jehan.
Suspicious that the guidelines were inadequate, the researchers analyzed their institution’s Emergency General Surgery registry, examining records from 952 patients who presented with right upper quadrant pain between 2013 and 2015. They compared diagnoses and severity assessed using the TG13 guidelines to the ensuing pathology reports, which were obtained from patient charts.
A total of 857 patients of the 952 had biliary disease. Of these, 779 patients went on to cholecystectomy, 15 had cholecystostomy-tube placement, and 63 were managed conservatively with no surgery. Among patients with biliary disease, the frequency of fever at presentation was just 4%, while 51.8% had leukocytosis. Right upper quadrant tenderness was the most sensitive predictor of acute cholecystitis (92%). Murphy’s sign occurred in 28.8% of patients and had a 72% sensitivity.
Following the TG13 guidelines resulted in classification of 414 patients as grade I, 400 as grade II, and 43 as grade III. A total of 92.5% of grade I patients underwent early cholecystectomy, as the TG-13 guidelines suggest. Nearly as many (89.3%) grade II patients also underwent early surgery, as did 50% of grade III patients. The complication rate was similar between grade I and grade II patients who underwent surgery (3.7% vs. 4.7%; P = .81). The rate of return to the operating room was also similar (0.6% vs. 0.7%; P = .95), as was mortality (0.3% vs. 0%; P = .96).
SCOTTSDALE, ARIZ. – In patients with right upper quadrant pain, the Tokyo Guidelines (TG13) failed to detect acute cholecystitis with adequate sensitivity, according to a single institution retrospective review.
Researchers at the University of Arizona, Tucson, also found that the Tokyo Guidelines’ advice to manage grade II and grade III cholecystitis patients conservatively may be unwarranted, because there were no differences in safety outcomes between grade I and grade II patients who underwent early cholecystectomy.
The Tokyo Guidelines were based on expert opinion rather than evidence, and may be limited by differences in practices in Japan and other countries. “There was no formal evaluation of the sensitivity and specificity in any other country,” Faisal Jehan, MD, a research fellow at the University of Arizona, said in an interview. Dr. Jehan presented the study at the annual meeting of the Western Surgical Association.
The study suggests there is additional work to be done before the guidelines are more generally applicable. They are being updated and the new version is slated to appear in 2018.
Cholecystectomy is one of the most common procedures in the United States, and hence represents a major source of health care expenditure. Useful guidelines will therefore be welcome to help standardize treatment, according to Dr. Riall. “I think while we’ve moved as a population toward earlier cholecystectomy, it isn’t uniformly practiced in the United States. So I think there is value in having guidelines that are relevant to our population and relevant to our practice,” she said.
But compared with the pathology report, the TG13 guidelines fared poorly in prediction of acute cholecystitis, with a sensitivity of just 53% (definitive 27%, suspected 26%, undiagnosed 53%). The underperformance of the guidelines may be due in part to recent changes in health-seeking behavior, as patients are likely to get to the hospital more quickly than in the past, and thus exhibit fewer clinical signs when first examined. “That could be decreasing the sensitivity,” said Dr. Jehan.
Suspicious that the guidelines were inadequate, the researchers analyzed their institution’s Emergency General Surgery registry, examining records from 952 patients who presented with right upper quadrant pain between 2013 and 2015. They compared diagnoses and severity assessed using the TG13 guidelines to the ensuing pathology reports, which were obtained from patient charts.
A total of 857 patients of the 952 had biliary disease. Of these, 779 patients went on to cholecystectomy, 15 had cholecystostomy-tube placement, and 63 were managed conservatively with no surgery. Among patients with biliary disease, the frequency of fever at presentation was just 4%, while 51.8% had leukocytosis. Right upper quadrant tenderness was the most sensitive predictor of acute cholecystitis (92%). Murphy’s sign occurred in 28.8% of patients and had a 72% sensitivity.
Following the TG13 guidelines resulted in classification of 414 patients as grade I, 400 as grade II, and 43 as grade III. A total of 92.5% of grade I patients underwent early cholecystectomy, as the TG-13 guidelines suggest. Nearly as many (89.3%) grade II patients also underwent early surgery, as did 50% of grade III patients. The complication rate was similar between grade I and grade II patients who underwent surgery (3.7% vs. 4.7%; P = .81). The rate of return to the operating room was also similar (0.6% vs. 0.7%; P = .95), as was mortality (0.3% vs. 0%; P = .96).
AT WSA 2017
Key clinical point: Early surgery for acute cholecystitis appears safe in well selected patients.
Major finding: TG13 guidelines predicted acute cholecystitis with a sensitivity of 53%.
Data source: Analysis of a prospectively collected data on 952 patients at a single institution.
Disclosures: The study received no outside funding. Dr. Jehan and Dr. Riall reported having no financial disclosures.
Most hyperparathyroidism cases can be considered cured after surgery
SCOTTSDALE, ARIZ. – Patients with hyperparathyroidism and single-gland disease can be considered cured if their intraoperative parathyroid hormone (PTH) level drops by 50% or more, or to normal or near-normal levels (15-65 pg/mL), and don’t require immediate follow-up for lab work, according to a retrospective review of patients who underwent parathyroidectomy at Mayo Clinic, Rochester, Minn.
These findings applied only to patients in the study whose preoperative sestamibi scans were concordant with intraoperative findings. Single-gland disease represented about 85% of cases, Melanie L. Lyden, MD, reported at the annual meeting of the Western Surgical Association.
Her team conducted a retrospective analysis of 214 patients who underwent parathyroidectomy at Mayo Clinic, Rochester, between January 2012 and March 2014. The investigators excluded patients with a history of multiple endocrine neoplasia syndrome, as well as patients with secondary or tertiary hyperparathyroidism. All patients received instructions at discharge for completing calcium testing, as well as a follow-up letter and phone call.
The overall cure rate at 6 months was 94% (202 cured, 12 not cured). In 205 of 214 cases (96%), the patients had an intraoperative drop in PTH level by 50% to normal or near-normal levels, and were therefore considered cured immediately.
The cured and not cured rate groups had no significant differences in age, gland weight, or preoperative PTH levels. Final intraoperative PTH levels were lower in patients who were cured (37 pg/mL vs. 55 pg/mL, P = .008), and the percentage decrease in PTH was greater (69% vs. 43%, P less than .0001).
A subgroup analysis found that concordant sestamibi imaging, single adenoma pathology, and an intraoperative cure combined to correlate with a 6-month cure rate of 97%.
In addition to identifying cures early, the findings suggest that patients whose PTH levels don’t drop adequately during surgery, and those with multiglandular disease should be aggressively targeted for follow-up – an important concern because many patients fail to complete calcium testing. “We were very aggressive in terms of follow-up recommendations, a follow-up letter, and a follow-up phone call, and still close to 30% of them we were not able to get to come in and get their blood checked,” said Dr. Lyden.
The study received no external funding. Dr. Lyden reported having no relevant financial disclosures.
SCOTTSDALE, ARIZ. – Patients with hyperparathyroidism and single-gland disease can be considered cured if their intraoperative parathyroid hormone (PTH) level drops by 50% or more, or to normal or near-normal levels (15-65 pg/mL), and don’t require immediate follow-up for lab work, according to a retrospective review of patients who underwent parathyroidectomy at Mayo Clinic, Rochester, Minn.
These findings applied only to patients in the study whose preoperative sestamibi scans were concordant with intraoperative findings. Single-gland disease represented about 85% of cases, Melanie L. Lyden, MD, reported at the annual meeting of the Western Surgical Association.
Her team conducted a retrospective analysis of 214 patients who underwent parathyroidectomy at Mayo Clinic, Rochester, between January 2012 and March 2014. The investigators excluded patients with a history of multiple endocrine neoplasia syndrome, as well as patients with secondary or tertiary hyperparathyroidism. All patients received instructions at discharge for completing calcium testing, as well as a follow-up letter and phone call.
The overall cure rate at 6 months was 94% (202 cured, 12 not cured). In 205 of 214 cases (96%), the patients had an intraoperative drop in PTH level by 50% to normal or near-normal levels, and were therefore considered cured immediately.
The cured and not cured rate groups had no significant differences in age, gland weight, or preoperative PTH levels. Final intraoperative PTH levels were lower in patients who were cured (37 pg/mL vs. 55 pg/mL, P = .008), and the percentage decrease in PTH was greater (69% vs. 43%, P less than .0001).
A subgroup analysis found that concordant sestamibi imaging, single adenoma pathology, and an intraoperative cure combined to correlate with a 6-month cure rate of 97%.
In addition to identifying cures early, the findings suggest that patients whose PTH levels don’t drop adequately during surgery, and those with multiglandular disease should be aggressively targeted for follow-up – an important concern because many patients fail to complete calcium testing. “We were very aggressive in terms of follow-up recommendations, a follow-up letter, and a follow-up phone call, and still close to 30% of them we were not able to get to come in and get their blood checked,” said Dr. Lyden.
The study received no external funding. Dr. Lyden reported having no relevant financial disclosures.
SCOTTSDALE, ARIZ. – Patients with hyperparathyroidism and single-gland disease can be considered cured if their intraoperative parathyroid hormone (PTH) level drops by 50% or more, or to normal or near-normal levels (15-65 pg/mL), and don’t require immediate follow-up for lab work, according to a retrospective review of patients who underwent parathyroidectomy at Mayo Clinic, Rochester, Minn.
These findings applied only to patients in the study whose preoperative sestamibi scans were concordant with intraoperative findings. Single-gland disease represented about 85% of cases, Melanie L. Lyden, MD, reported at the annual meeting of the Western Surgical Association.
Her team conducted a retrospective analysis of 214 patients who underwent parathyroidectomy at Mayo Clinic, Rochester, between January 2012 and March 2014. The investigators excluded patients with a history of multiple endocrine neoplasia syndrome, as well as patients with secondary or tertiary hyperparathyroidism. All patients received instructions at discharge for completing calcium testing, as well as a follow-up letter and phone call.
The overall cure rate at 6 months was 94% (202 cured, 12 not cured). In 205 of 214 cases (96%), the patients had an intraoperative drop in PTH level by 50% to normal or near-normal levels, and were therefore considered cured immediately.
The cured and not cured rate groups had no significant differences in age, gland weight, or preoperative PTH levels. Final intraoperative PTH levels were lower in patients who were cured (37 pg/mL vs. 55 pg/mL, P = .008), and the percentage decrease in PTH was greater (69% vs. 43%, P less than .0001).
A subgroup analysis found that concordant sestamibi imaging, single adenoma pathology, and an intraoperative cure combined to correlate with a 6-month cure rate of 97%.
In addition to identifying cures early, the findings suggest that patients whose PTH levels don’t drop adequately during surgery, and those with multiglandular disease should be aggressively targeted for follow-up – an important concern because many patients fail to complete calcium testing. “We were very aggressive in terms of follow-up recommendations, a follow-up letter, and a follow-up phone call, and still close to 30% of them we were not able to get to come in and get their blood checked,” said Dr. Lyden.
The study received no external funding. Dr. Lyden reported having no relevant financial disclosures.
AT WSA 2017
Key clinical point: The vast majority of cures could be identified during surgery, reducing the need for costly follow-up to monitor calcium levels.
Major finding: Concordant sestamibi imaging, single adenoma pathology, and an intraoperative cure combined to correlate with a 6-month cure rate of 97%.
Data source: A retrospective analysis of 214 patients at a single center.
Disclosures: The study received no external funding. Dr. Lyden reported having no relevant financial disclosures.
FDA grants 510k clearance for glucose monitoring system
OptiScan Biomedical Corporation announced Oct. 18 that the Food and Drug Administration has granted 510(k) clearance for the OptiScanner 5000 Glucose Monitoring System.
The clearance allows the device to be used for monitoring plasma glucose levels and determining dysglycemia in surgical intensive care unit (SICU) patients. It is a bedside glucose monitoring system that provides physicians with critical trending and tracking information to manage patient glucose levels in the ICU.
It is estimated that roughly 20% of ICU patients have pre-existing diabetes and an additional 40- to- 60% of ICU patients suffer from “stress hyperglycemia” or a temporary elevation of glucose levels, with all of these patients requiring accurate glucose monitoring to maintain glycemic control.
“There is a broad consensus in the medical community regarding the need for automated, continuous and highly accurate glucose monitoring in the ICU and my experience with the OptiScanner 5000 indicates that this device will play a critical role in delivering this enhanced level of care. I look forward to implementing this technology as soon as possible,” said Grant V. Bochicchio, MD, MPH, FACS, chief of acute and critical care surgery, and Harry Edison Professor of Surgery, Washington University School of Medicine, in a press release.
Read the full press release here.
OptiScan Biomedical Corporation announced Oct. 18 that the Food and Drug Administration has granted 510(k) clearance for the OptiScanner 5000 Glucose Monitoring System.
The clearance allows the device to be used for monitoring plasma glucose levels and determining dysglycemia in surgical intensive care unit (SICU) patients. It is a bedside glucose monitoring system that provides physicians with critical trending and tracking information to manage patient glucose levels in the ICU.
It is estimated that roughly 20% of ICU patients have pre-existing diabetes and an additional 40- to- 60% of ICU patients suffer from “stress hyperglycemia” or a temporary elevation of glucose levels, with all of these patients requiring accurate glucose monitoring to maintain glycemic control.
“There is a broad consensus in the medical community regarding the need for automated, continuous and highly accurate glucose monitoring in the ICU and my experience with the OptiScanner 5000 indicates that this device will play a critical role in delivering this enhanced level of care. I look forward to implementing this technology as soon as possible,” said Grant V. Bochicchio, MD, MPH, FACS, chief of acute and critical care surgery, and Harry Edison Professor of Surgery, Washington University School of Medicine, in a press release.
Read the full press release here.
OptiScan Biomedical Corporation announced Oct. 18 that the Food and Drug Administration has granted 510(k) clearance for the OptiScanner 5000 Glucose Monitoring System.
The clearance allows the device to be used for monitoring plasma glucose levels and determining dysglycemia in surgical intensive care unit (SICU) patients. It is a bedside glucose monitoring system that provides physicians with critical trending and tracking information to manage patient glucose levels in the ICU.
It is estimated that roughly 20% of ICU patients have pre-existing diabetes and an additional 40- to- 60% of ICU patients suffer from “stress hyperglycemia” or a temporary elevation of glucose levels, with all of these patients requiring accurate glucose monitoring to maintain glycemic control.
“There is a broad consensus in the medical community regarding the need for automated, continuous and highly accurate glucose monitoring in the ICU and my experience with the OptiScanner 5000 indicates that this device will play a critical role in delivering this enhanced level of care. I look forward to implementing this technology as soon as possible,” said Grant V. Bochicchio, MD, MPH, FACS, chief of acute and critical care surgery, and Harry Edison Professor of Surgery, Washington University School of Medicine, in a press release.
Read the full press release here.
Strict OR attire policy had no impact on SSI rate
SAN DIEGO – Implementation of strict operating room (OR) attire policies did not reduce the rates of superficial surgical site infections (SSIs), according to an analysis of more than 6,500 patients.
“SSIs are the most common cause of health care–associated infections in the U.S.,” study author Sandra Farach, MD, said at the annual clinical congress of the American College of Surgeons. “It’s estimated that SSIs occur in 2%-5% of patients undergoing inpatient surgery. They’re associated with significant patient morbidity and mortality and are a significant burden to the health care system, accounting for an estimated $3.5 to $10 billion in health care expenditures.”
In February 2015, the Association for periOperative Registered Nurses published recommendations on operating room attire, providing a guideline for modifying facility policies and regulatory requirements. It included stringent policies designed to minimize the exposed areas of skin and hair of operating room staff. “New attire policies were met with some criticism as there is a paucity of evidence-based data to support these recommendations,” said Dr. Farach, who helped conduct the study during her tenure as chief resident of general surgery at the University of Rochester (N.Y.) Medical Center.
A total of 6,517 patients were included in the analysis: 3,077 in the preimplementation group and 3,440 patients in the postimplementation group. The postimplementation group tended to be older and had significantly higher rates of hypertension, dialysis treatments, steroid use, and systemic inflammatory response syndrome, as well as higher American Society of Anesthesiologists classification scores. “However, they had a significantly lower BMI, incidence of smoking and COPD, and a higher incidence of clean wounds, which would theoretically leave them less exposed to SSIs,” said Dr. Farach, who is now a pediatric surgical critical care fellow at Le Bonheur Children’s Hospital in Memphis.
Overall, the rate of SSIs by wound class increased between the preimplementation and postimplementation time periods: The percent of change was 0.6%, 0.9%, 2.3%, and 3.8% in the clean, clean-contaminated, contaminated, and dirty/infected cases, respectively. When the review was limited to clean or clean-contaminated cases, SSI increased slightly, from 0.7% to 0.8% (P = .085). There were no significant differences in the complication rate, 30-day mortality, unplanned return to the OR, or length of stay between preimplementation or postimplementation at either hospital.
When Dr. Farach and her associates examined the overall infection rate, they observed no significant differences preimplementation and postimplementation in the rates of incisional SSI (0.97% vs. 0.96%, respectively; P = .949), organ space SSI (1.20% vs. 0.81%; P = .115), and total SSIs (2.11% vs. 1.77%; P = .321). Multivariate analysis showed that implementation of OR changes was not associated with an increased risk of SSIs. Factors that did predict high SSI rates included preoperative SSI (adjusted odds ratio 23.04), long operative time (AOR 3.4), preoperative open wound (AOR 2.94), contaminated/dirty wound classes (AOR 2.32), and morbid obesity (AOR 1.8).
“A hypothetical analysis revealed that a sample of over 495,000 patients would be required to demonstrate a 10% incisional SSI reduction among patients with clean or clean-contaminated wounds,” Dr. Farach noted. “Nevertheless, the study showed a numerical increase in SSI during the study period. Policies regarding OR attire were universally unpopular. As a result, OR governance is now working to repeal these new policies at both hospitals.”
“Given the rarity of SSI in the population subset which is relevant to the OR attire question (clean and clean-contaminated wounds, 0.7%), designing a study to prove effectiveness of an intervention (i.e., a 10% improvement) is totally impractical to conduct as this would require nearly a half a million cases,” said Jacob Moalem, MD, the lead author of the study who is an endocrine surgeon at the University of Rochester. At the meeting, a discussant suggested that conducting such a study is feasible; however, “I would strongly argue that putting that many people through such a study, when we know that these attire rules have a deleterious effect on surgeon comfort and OR team dynamics and morale, would not be prudent,” Dr. Moalem said. “We know that surgeon comfort, ability to focus on the task at hand, and minimizing distractions in the OR are critically important in reducing errors. In my opinion, by continuing to focus on these unfounded attire restrictions, one would be far more likely to actually cause injury to a patient than to prevent a wound infection.”
The researchers reported having no financial disclosures.
SAN DIEGO – Implementation of strict operating room (OR) attire policies did not reduce the rates of superficial surgical site infections (SSIs), according to an analysis of more than 6,500 patients.
“SSIs are the most common cause of health care–associated infections in the U.S.,” study author Sandra Farach, MD, said at the annual clinical congress of the American College of Surgeons. “It’s estimated that SSIs occur in 2%-5% of patients undergoing inpatient surgery. They’re associated with significant patient morbidity and mortality and are a significant burden to the health care system, accounting for an estimated $3.5 to $10 billion in health care expenditures.”
In February 2015, the Association for periOperative Registered Nurses published recommendations on operating room attire, providing a guideline for modifying facility policies and regulatory requirements. It included stringent policies designed to minimize the exposed areas of skin and hair of operating room staff. “New attire policies were met with some criticism as there is a paucity of evidence-based data to support these recommendations,” said Dr. Farach, who helped conduct the study during her tenure as chief resident of general surgery at the University of Rochester (N.Y.) Medical Center.
A total of 6,517 patients were included in the analysis: 3,077 in the preimplementation group and 3,440 patients in the postimplementation group. The postimplementation group tended to be older and had significantly higher rates of hypertension, dialysis treatments, steroid use, and systemic inflammatory response syndrome, as well as higher American Society of Anesthesiologists classification scores. “However, they had a significantly lower BMI, incidence of smoking and COPD, and a higher incidence of clean wounds, which would theoretically leave them less exposed to SSIs,” said Dr. Farach, who is now a pediatric surgical critical care fellow at Le Bonheur Children’s Hospital in Memphis.
Overall, the rate of SSIs by wound class increased between the preimplementation and postimplementation time periods: The percent of change was 0.6%, 0.9%, 2.3%, and 3.8% in the clean, clean-contaminated, contaminated, and dirty/infected cases, respectively. When the review was limited to clean or clean-contaminated cases, SSI increased slightly, from 0.7% to 0.8% (P = .085). There were no significant differences in the complication rate, 30-day mortality, unplanned return to the OR, or length of stay between preimplementation or postimplementation at either hospital.
When Dr. Farach and her associates examined the overall infection rate, they observed no significant differences preimplementation and postimplementation in the rates of incisional SSI (0.97% vs. 0.96%, respectively; P = .949), organ space SSI (1.20% vs. 0.81%; P = .115), and total SSIs (2.11% vs. 1.77%; P = .321). Multivariate analysis showed that implementation of OR changes was not associated with an increased risk of SSIs. Factors that did predict high SSI rates included preoperative SSI (adjusted odds ratio 23.04), long operative time (AOR 3.4), preoperative open wound (AOR 2.94), contaminated/dirty wound classes (AOR 2.32), and morbid obesity (AOR 1.8).
“A hypothetical analysis revealed that a sample of over 495,000 patients would be required to demonstrate a 10% incisional SSI reduction among patients with clean or clean-contaminated wounds,” Dr. Farach noted. “Nevertheless, the study showed a numerical increase in SSI during the study period. Policies regarding OR attire were universally unpopular. As a result, OR governance is now working to repeal these new policies at both hospitals.”
“Given the rarity of SSI in the population subset which is relevant to the OR attire question (clean and clean-contaminated wounds, 0.7%), designing a study to prove effectiveness of an intervention (i.e., a 10% improvement) is totally impractical to conduct as this would require nearly a half a million cases,” said Jacob Moalem, MD, the lead author of the study who is an endocrine surgeon at the University of Rochester. At the meeting, a discussant suggested that conducting such a study is feasible; however, “I would strongly argue that putting that many people through such a study, when we know that these attire rules have a deleterious effect on surgeon comfort and OR team dynamics and morale, would not be prudent,” Dr. Moalem said. “We know that surgeon comfort, ability to focus on the task at hand, and minimizing distractions in the OR are critically important in reducing errors. In my opinion, by continuing to focus on these unfounded attire restrictions, one would be far more likely to actually cause injury to a patient than to prevent a wound infection.”
The researchers reported having no financial disclosures.
SAN DIEGO – Implementation of strict operating room (OR) attire policies did not reduce the rates of superficial surgical site infections (SSIs), according to an analysis of more than 6,500 patients.
“SSIs are the most common cause of health care–associated infections in the U.S.,” study author Sandra Farach, MD, said at the annual clinical congress of the American College of Surgeons. “It’s estimated that SSIs occur in 2%-5% of patients undergoing inpatient surgery. They’re associated with significant patient morbidity and mortality and are a significant burden to the health care system, accounting for an estimated $3.5 to $10 billion in health care expenditures.”
In February 2015, the Association for periOperative Registered Nurses published recommendations on operating room attire, providing a guideline for modifying facility policies and regulatory requirements. It included stringent policies designed to minimize the exposed areas of skin and hair of operating room staff. “New attire policies were met with some criticism as there is a paucity of evidence-based data to support these recommendations,” said Dr. Farach, who helped conduct the study during her tenure as chief resident of general surgery at the University of Rochester (N.Y.) Medical Center.
A total of 6,517 patients were included in the analysis: 3,077 in the preimplementation group and 3,440 patients in the postimplementation group. The postimplementation group tended to be older and had significantly higher rates of hypertension, dialysis treatments, steroid use, and systemic inflammatory response syndrome, as well as higher American Society of Anesthesiologists classification scores. “However, they had a significantly lower BMI, incidence of smoking and COPD, and a higher incidence of clean wounds, which would theoretically leave them less exposed to SSIs,” said Dr. Farach, who is now a pediatric surgical critical care fellow at Le Bonheur Children’s Hospital in Memphis.
Overall, the rate of SSIs by wound class increased between the preimplementation and postimplementation time periods: The percent of change was 0.6%, 0.9%, 2.3%, and 3.8% in the clean, clean-contaminated, contaminated, and dirty/infected cases, respectively. When the review was limited to clean or clean-contaminated cases, SSI increased slightly, from 0.7% to 0.8% (P = .085). There were no significant differences in the complication rate, 30-day mortality, unplanned return to the OR, or length of stay between preimplementation or postimplementation at either hospital.
When Dr. Farach and her associates examined the overall infection rate, they observed no significant differences preimplementation and postimplementation in the rates of incisional SSI (0.97% vs. 0.96%, respectively; P = .949), organ space SSI (1.20% vs. 0.81%; P = .115), and total SSIs (2.11% vs. 1.77%; P = .321). Multivariate analysis showed that implementation of OR changes was not associated with an increased risk of SSIs. Factors that did predict high SSI rates included preoperative SSI (adjusted odds ratio 23.04), long operative time (AOR 3.4), preoperative open wound (AOR 2.94), contaminated/dirty wound classes (AOR 2.32), and morbid obesity (AOR 1.8).
“A hypothetical analysis revealed that a sample of over 495,000 patients would be required to demonstrate a 10% incisional SSI reduction among patients with clean or clean-contaminated wounds,” Dr. Farach noted. “Nevertheless, the study showed a numerical increase in SSI during the study period. Policies regarding OR attire were universally unpopular. As a result, OR governance is now working to repeal these new policies at both hospitals.”
“Given the rarity of SSI in the population subset which is relevant to the OR attire question (clean and clean-contaminated wounds, 0.7%), designing a study to prove effectiveness of an intervention (i.e., a 10% improvement) is totally impractical to conduct as this would require nearly a half a million cases,” said Jacob Moalem, MD, the lead author of the study who is an endocrine surgeon at the University of Rochester. At the meeting, a discussant suggested that conducting such a study is feasible; however, “I would strongly argue that putting that many people through such a study, when we know that these attire rules have a deleterious effect on surgeon comfort and OR team dynamics and morale, would not be prudent,” Dr. Moalem said. “We know that surgeon comfort, ability to focus on the task at hand, and minimizing distractions in the OR are critically important in reducing errors. In my opinion, by continuing to focus on these unfounded attire restrictions, one would be far more likely to actually cause injury to a patient than to prevent a wound infection.”
The researchers reported having no financial disclosures.
AT THE ACS CLINICAL CONGRESS
Key clinical point: Implementation of stringent operating room attire policies do not reduce rates superficial surgical site infections (SSIs).
Major finding: The researchers observed no significant differences preimplementation and postimplementation of OR attire policies in the rates of incisional SSI (0.97 vs. 0.96, respectively; P = .949), organ space SSI (1.20 vs 0.81; P = .115), and total SSIs (2.11 vs. 1.77; P = .321).
Study details: A study of 6,517 patients who underwent surgery at two tertiary care teaching hospitals.
Disclosures: The researchers reported having no financial disclosures.
Some measures to control HAI sound better than they perform
SAN DIEGO – Some almost universally accepted measures against hospital-acquired infections are more costly, annoying, and time consuming than they’re worth, presenters agreed during a panel discussion at the annual clinical congress of the American College of Surgeons.
Intra-abdominal antibiotic irrigation, chlorhexidine bathing, and even postsurgical antibiotic infusions have not consistently been shown to reduce infections. These measures do, however, ratchet up costs and can contribute to antibiotic resistance.
Some of these and other measures to prevent nosocomial infections may indeed reduce the risk, but the gain is small, said Charles H. Cook, MD.
“Chlorhexidine bathing, for example, is touted by many as a panacea for all the infections we’re talking about,” said Dr. Cook, a critical care surgeon at Beth Israel Deaconess Medical Center, New York. “A recent meta-analysis in critical care units did find a reduced relative risk of 0.44 for central line bloodstream infections. But you needed to bathe 360 patients to prevent one infection. It’s what I call a long run for a short slide.”
Therese Duane, MD, FACS, agreed. A surgeon at the John Peter Smith Hospital, Ft. Worth, Tex., Dr. Duane reviewed three different guidelines for the prevention of surgical site infections: the ACS and Surgical Infection Society, the World Health Organization, and the Centers for Disease Control and Prevention. In looking for similarities between the documents, she said she found several well-accepted practices that just aren’t supported by good data.
Presurgical antimicrobial infusions got a strong thumbs-up from all the groups, but only under a very specific circumstance: The medication has to be administered well in advance of surgery for it to be effective.
“Your goal is to get the appropriate concentration into the tissues by the time of incision,” Dr. Duane said. “It takes time to get there – if you give it after the incision, you have bleeding and cellular death, and the antimicrobials cannot get to that incision and do their job. If I’m starting a case and they haven’t been given, I don’t ever start them after the incision, because then you have all of the risks and none of the benefits. In my opinion, we need to move to no further antimicrobials once the incision or case is over because it serves no purpose and is inconsistent with good antibiotic stewardship.”
Adhesive drapes got a resounding “eh” from the guidelines, Dr. Duane said. “You really do not need them. They’re expensive and they’re not improving outcomes, so don’t waste your time or money. We need to think about minimizing what isn’t helpful and maximizing the things that are worthwhile. That’s the way to practice good socially responsible surgery without breaking the bank,” she said.
Antimicrobial sutures got weak recommendations, Dr. Duane said. The evidence supporting their use was not very strong, although she said she feels triclosan-coated sutures are helpful in all kinds of surgery. Preoperative showering with an antiseptic received strong support, with alcohol-containing preps superior to chlorhexidine, which is better than povidone-iodine–containing solutions.
Deep-space irrigation with aqueous iodophor also received a weak recommendation, but Dr. Duane said the evidence does not support the use of antibiotic-containing irrigation in either the abdomen or the incision. “And the guidelines came out strongly against using antimicrobial agents on the incision,” she said. None of the guidelines issued a recommendation for or against antimicrobial dressings.
Protocolized infection-control bundles are a very great help in reducing the incidence of surgical site infections, Dr. Duane added. “They increase attention to detail and decrease the rates of infection.”
Dr. Cook agreed. “Central line bundles are one of the things that work” for line-associated bloodstream infections, he said. Since their large-scale adoption, mortality from these infections has dropped significantly; it was hovering around 28,000 per year in the mid-2000s, he said. “That’s about how many men die from prostate cancer every year.”
Central line infections are very costly too, he added – around $46,000 per event. “That comes to around $2 billion in direct and indirect costs every year.”
A 2006 study demonstrated the efficacy of central line bundles in the fight against these potentially devastating infections.
The bundled intervention comprised hand washing, using full-barrier precautions during the insertion of central venous catheters, cleaning the skin with chlorhexidine, avoiding the femoral site if possible, and removing unnecessary catheters. The median rate of catheter-related bloodstream infections per 1,000 catheter-days decreased from 2.7 at baseline to 0 at 3 months after implementation of the study intervention.
Antibiotic-coated or impregnated catheters do not work as well. A 2016 Cochrane review of 57 studies determined that the devices didn’t improve sepsis, all-cause mortality, or catheter-related local infections.
The jury may still be out on coated dressings or securing devices, however. Another Cochrane review, of 22 studies, found a 40% decrease in central line–associated bloodstream infections with these items. “There was moderate evidence that tip colonization was reduced, but the authors said more research is needed.”
The evidence looks stronger for alcohol-impregnated port protectors, Dr. Cook said. Two studies in particular support their use. In an oncology unit, the rate of these infections dropped from 2.3 to 0.3 per 1,000 catheter days after the port protectors were instituted.
In the second study, infection rates declined from 1.43 to 0.69 per 1,000 line-days after the protectors came on board.
“The advantage was seen mostly in ICUs, so the recommendations are to use them there,” Dr. Cook said.
Neither Dr. Cook nor Dr. Duane had any relevant financial disclosures.
[email protected]
On Twitter @Alz Gal
SAN DIEGO – Some almost universally accepted measures against hospital-acquired infections are more costly, annoying, and time consuming than they’re worth, presenters agreed during a panel discussion at the annual clinical congress of the American College of Surgeons.
Intra-abdominal antibiotic irrigation, chlorhexidine bathing, and even postsurgical antibiotic infusions have not consistently been shown to reduce infections. These measures do, however, ratchet up costs and can contribute to antibiotic resistance.
Some of these and other measures to prevent nosocomial infections may indeed reduce the risk, but the gain is small, said Charles H. Cook, MD.
“Chlorhexidine bathing, for example, is touted by many as a panacea for all the infections we’re talking about,” said Dr. Cook, a critical care surgeon at Beth Israel Deaconess Medical Center, New York. “A recent meta-analysis in critical care units did find a reduced relative risk of 0.44 for central line bloodstream infections. But you needed to bathe 360 patients to prevent one infection. It’s what I call a long run for a short slide.”
Therese Duane, MD, FACS, agreed. A surgeon at the John Peter Smith Hospital, Ft. Worth, Tex., Dr. Duane reviewed three different guidelines for the prevention of surgical site infections: the ACS and Surgical Infection Society, the World Health Organization, and the Centers for Disease Control and Prevention. In looking for similarities between the documents, she said she found several well-accepted practices that just aren’t supported by good data.
Presurgical antimicrobial infusions got a strong thumbs-up from all the groups, but only under a very specific circumstance: The medication has to be administered well in advance of surgery for it to be effective.
“Your goal is to get the appropriate concentration into the tissues by the time of incision,” Dr. Duane said. “It takes time to get there – if you give it after the incision, you have bleeding and cellular death, and the antimicrobials cannot get to that incision and do their job. If I’m starting a case and they haven’t been given, I don’t ever start them after the incision, because then you have all of the risks and none of the benefits. In my opinion, we need to move to no further antimicrobials once the incision or case is over because it serves no purpose and is inconsistent with good antibiotic stewardship.”
Adhesive drapes got a resounding “eh” from the guidelines, Dr. Duane said. “You really do not need them. They’re expensive and they’re not improving outcomes, so don’t waste your time or money. We need to think about minimizing what isn’t helpful and maximizing the things that are worthwhile. That’s the way to practice good socially responsible surgery without breaking the bank,” she said.
Antimicrobial sutures got weak recommendations, Dr. Duane said. The evidence supporting their use was not very strong, although she said she feels triclosan-coated sutures are helpful in all kinds of surgery. Preoperative showering with an antiseptic received strong support, with alcohol-containing preps superior to chlorhexidine, which is better than povidone-iodine–containing solutions.
Deep-space irrigation with aqueous iodophor also received a weak recommendation, but Dr. Duane said the evidence does not support the use of antibiotic-containing irrigation in either the abdomen or the incision. “And the guidelines came out strongly against using antimicrobial agents on the incision,” she said. None of the guidelines issued a recommendation for or against antimicrobial dressings.
Protocolized infection-control bundles are a very great help in reducing the incidence of surgical site infections, Dr. Duane added. “They increase attention to detail and decrease the rates of infection.”
Dr. Cook agreed. “Central line bundles are one of the things that work” for line-associated bloodstream infections, he said. Since their large-scale adoption, mortality from these infections has dropped significantly; it was hovering around 28,000 per year in the mid-2000s, he said. “That’s about how many men die from prostate cancer every year.”
Central line infections are very costly too, he added – around $46,000 per event. “That comes to around $2 billion in direct and indirect costs every year.”
A 2006 study demonstrated the efficacy of central line bundles in the fight against these potentially devastating infections.
The bundled intervention comprised hand washing, using full-barrier precautions during the insertion of central venous catheters, cleaning the skin with chlorhexidine, avoiding the femoral site if possible, and removing unnecessary catheters. The median rate of catheter-related bloodstream infections per 1,000 catheter-days decreased from 2.7 at baseline to 0 at 3 months after implementation of the study intervention.
Antibiotic-coated or impregnated catheters do not work as well. A 2016 Cochrane review of 57 studies determined that the devices didn’t improve sepsis, all-cause mortality, or catheter-related local infections.
The jury may still be out on coated dressings or securing devices, however. Another Cochrane review, of 22 studies, found a 40% decrease in central line–associated bloodstream infections with these items. “There was moderate evidence that tip colonization was reduced, but the authors said more research is needed.”
The evidence looks stronger for alcohol-impregnated port protectors, Dr. Cook said. Two studies in particular support their use. In an oncology unit, the rate of these infections dropped from 2.3 to 0.3 per 1,000 catheter days after the port protectors were instituted.
In the second study, infection rates declined from 1.43 to 0.69 per 1,000 line-days after the protectors came on board.
“The advantage was seen mostly in ICUs, so the recommendations are to use them there,” Dr. Cook said.
Neither Dr. Cook nor Dr. Duane had any relevant financial disclosures.
[email protected]
On Twitter @Alz Gal
SAN DIEGO – Some almost universally accepted measures against hospital-acquired infections are more costly, annoying, and time consuming than they’re worth, presenters agreed during a panel discussion at the annual clinical congress of the American College of Surgeons.
Intra-abdominal antibiotic irrigation, chlorhexidine bathing, and even postsurgical antibiotic infusions have not consistently been shown to reduce infections. These measures do, however, ratchet up costs and can contribute to antibiotic resistance.
Some of these and other measures to prevent nosocomial infections may indeed reduce the risk, but the gain is small, said Charles H. Cook, MD.
“Chlorhexidine bathing, for example, is touted by many as a panacea for all the infections we’re talking about,” said Dr. Cook, a critical care surgeon at Beth Israel Deaconess Medical Center, New York. “A recent meta-analysis in critical care units did find a reduced relative risk of 0.44 for central line bloodstream infections. But you needed to bathe 360 patients to prevent one infection. It’s what I call a long run for a short slide.”
Therese Duane, MD, FACS, agreed. A surgeon at the John Peter Smith Hospital, Ft. Worth, Tex., Dr. Duane reviewed three different guidelines for the prevention of surgical site infections: the ACS and Surgical Infection Society, the World Health Organization, and the Centers for Disease Control and Prevention. In looking for similarities between the documents, she said she found several well-accepted practices that just aren’t supported by good data.
Presurgical antimicrobial infusions got a strong thumbs-up from all the groups, but only under a very specific circumstance: The medication has to be administered well in advance of surgery for it to be effective.
“Your goal is to get the appropriate concentration into the tissues by the time of incision,” Dr. Duane said. “It takes time to get there – if you give it after the incision, you have bleeding and cellular death, and the antimicrobials cannot get to that incision and do their job. If I’m starting a case and they haven’t been given, I don’t ever start them after the incision, because then you have all of the risks and none of the benefits. In my opinion, we need to move to no further antimicrobials once the incision or case is over because it serves no purpose and is inconsistent with good antibiotic stewardship.”
Adhesive drapes got a resounding “eh” from the guidelines, Dr. Duane said. “You really do not need them. They’re expensive and they’re not improving outcomes, so don’t waste your time or money. We need to think about minimizing what isn’t helpful and maximizing the things that are worthwhile. That’s the way to practice good socially responsible surgery without breaking the bank,” she said.
Antimicrobial sutures got weak recommendations, Dr. Duane said. The evidence supporting their use was not very strong, although she said she feels triclosan-coated sutures are helpful in all kinds of surgery. Preoperative showering with an antiseptic received strong support, with alcohol-containing preps superior to chlorhexidine, which is better than povidone-iodine–containing solutions.
Deep-space irrigation with aqueous iodophor also received a weak recommendation, but Dr. Duane said the evidence does not support the use of antibiotic-containing irrigation in either the abdomen or the incision. “And the guidelines came out strongly against using antimicrobial agents on the incision,” she said. None of the guidelines issued a recommendation for or against antimicrobial dressings.
Protocolized infection-control bundles are a very great help in reducing the incidence of surgical site infections, Dr. Duane added. “They increase attention to detail and decrease the rates of infection.”
Dr. Cook agreed. “Central line bundles are one of the things that work” for line-associated bloodstream infections, he said. Since their large-scale adoption, mortality from these infections has dropped significantly; it was hovering around 28,000 per year in the mid-2000s, he said. “That’s about how many men die from prostate cancer every year.”
Central line infections are very costly too, he added – around $46,000 per event. “That comes to around $2 billion in direct and indirect costs every year.”
A 2006 study demonstrated the efficacy of central line bundles in the fight against these potentially devastating infections.
The bundled intervention comprised hand washing, using full-barrier precautions during the insertion of central venous catheters, cleaning the skin with chlorhexidine, avoiding the femoral site if possible, and removing unnecessary catheters. The median rate of catheter-related bloodstream infections per 1,000 catheter-days decreased from 2.7 at baseline to 0 at 3 months after implementation of the study intervention.
Antibiotic-coated or impregnated catheters do not work as well. A 2016 Cochrane review of 57 studies determined that the devices didn’t improve sepsis, all-cause mortality, or catheter-related local infections.
The jury may still be out on coated dressings or securing devices, however. Another Cochrane review, of 22 studies, found a 40% decrease in central line–associated bloodstream infections with these items. “There was moderate evidence that tip colonization was reduced, but the authors said more research is needed.”
The evidence looks stronger for alcohol-impregnated port protectors, Dr. Cook said. Two studies in particular support their use. In an oncology unit, the rate of these infections dropped from 2.3 to 0.3 per 1,000 catheter days after the port protectors were instituted.
In the second study, infection rates declined from 1.43 to 0.69 per 1,000 line-days after the protectors came on board.
“The advantage was seen mostly in ICUs, so the recommendations are to use them there,” Dr. Cook said.
Neither Dr. Cook nor Dr. Duane had any relevant financial disclosures.
[email protected]
On Twitter @Alz Gal
FROM THE ACS CLINICAL CONGRESS