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Predicting MDR Gram-negative infection mortality risk
Source control, defined as location and elimination of the source of the infection, was critical for patient survival in the case of multidrug resistant bacterial infection, according to the results of a case-control study of 62 critically ill surgical patients who were assessed between 2011 and 2014.
Researchers examined the characteristics of infected patients surviving to hospital discharge compared with those of nonsurvivors to look for predictive factors. Demographically, patients had an overall mean age of 62 years; 30.6% were women; 69.4% were white. The first culture obtained during a surgical ICU admission that grew a carbapenem-resistant Enterobacteriaceae (CRE), MDR Pseudomonas aeruginosa, or MDR Acinetobacter spp. was defined as the index culture.
“In this study, 33.9% [21/62] of critically ill surgical patients with a culture positive for MDR Gram-negative bacteria died prior to hospital discharge,” according to Andrew S. Jarrell, PharmD, of the Johns Hopkins Hospital, Baltimore, and his colleagues.
With multivariate logistic regression, achievement of source control was the only variable associated with decreased in-hospital mortality (odds ratio 0.04, 95% confidence interval, 0.003-0.52); P = .01).
“Source control status was predictive of in-hospital mortality after controlling for other factors. Specifically, the odds of in-hospital mortality were 97% lower when source control was achieved as compared to when source control was not achieved,” the authors stated (J Crit Care. 2018;43:321-6).
Scenarios in which source control was not applicable (pneumonia and urinary tract infection) were also similarly distributed between survivors and nonsurvivors, they reported.
Other than source control, the only significant risk factors for mortality, as seen in univariate analysis, all occurred prior to index culture. They were: vasopressor use (46.3% of survivors, vs. 76.2% of nonsurvivors, P = .03); mechanical ventilation (63.4% vs. 100%, P = .001); and median ICU length of stay (10 days vs. 18 days, P = .001).
“Achievement of source control stands out as a critical factor for patient survival. Clinicians should take this, along with prior ICU LOS, vasopressor use, and mechanical ventilation status, into consideration when evaluating patient prognosis,” Dr. Jarrell and his colleagues concluded.
The authors reported that they had no conflicts or source of funding.
Source: Jarrell, A.S., et al. J Crit Care. 2018;43:321-6.
Source control, defined as location and elimination of the source of the infection, was critical for patient survival in the case of multidrug resistant bacterial infection, according to the results of a case-control study of 62 critically ill surgical patients who were assessed between 2011 and 2014.
Researchers examined the characteristics of infected patients surviving to hospital discharge compared with those of nonsurvivors to look for predictive factors. Demographically, patients had an overall mean age of 62 years; 30.6% were women; 69.4% were white. The first culture obtained during a surgical ICU admission that grew a carbapenem-resistant Enterobacteriaceae (CRE), MDR Pseudomonas aeruginosa, or MDR Acinetobacter spp. was defined as the index culture.
“In this study, 33.9% [21/62] of critically ill surgical patients with a culture positive for MDR Gram-negative bacteria died prior to hospital discharge,” according to Andrew S. Jarrell, PharmD, of the Johns Hopkins Hospital, Baltimore, and his colleagues.
With multivariate logistic regression, achievement of source control was the only variable associated with decreased in-hospital mortality (odds ratio 0.04, 95% confidence interval, 0.003-0.52); P = .01).
“Source control status was predictive of in-hospital mortality after controlling for other factors. Specifically, the odds of in-hospital mortality were 97% lower when source control was achieved as compared to when source control was not achieved,” the authors stated (J Crit Care. 2018;43:321-6).
Scenarios in which source control was not applicable (pneumonia and urinary tract infection) were also similarly distributed between survivors and nonsurvivors, they reported.
Other than source control, the only significant risk factors for mortality, as seen in univariate analysis, all occurred prior to index culture. They were: vasopressor use (46.3% of survivors, vs. 76.2% of nonsurvivors, P = .03); mechanical ventilation (63.4% vs. 100%, P = .001); and median ICU length of stay (10 days vs. 18 days, P = .001).
“Achievement of source control stands out as a critical factor for patient survival. Clinicians should take this, along with prior ICU LOS, vasopressor use, and mechanical ventilation status, into consideration when evaluating patient prognosis,” Dr. Jarrell and his colleagues concluded.
The authors reported that they had no conflicts or source of funding.
Source: Jarrell, A.S., et al. J Crit Care. 2018;43:321-6.
Source control, defined as location and elimination of the source of the infection, was critical for patient survival in the case of multidrug resistant bacterial infection, according to the results of a case-control study of 62 critically ill surgical patients who were assessed between 2011 and 2014.
Researchers examined the characteristics of infected patients surviving to hospital discharge compared with those of nonsurvivors to look for predictive factors. Demographically, patients had an overall mean age of 62 years; 30.6% were women; 69.4% were white. The first culture obtained during a surgical ICU admission that grew a carbapenem-resistant Enterobacteriaceae (CRE), MDR Pseudomonas aeruginosa, or MDR Acinetobacter spp. was defined as the index culture.
“In this study, 33.9% [21/62] of critically ill surgical patients with a culture positive for MDR Gram-negative bacteria died prior to hospital discharge,” according to Andrew S. Jarrell, PharmD, of the Johns Hopkins Hospital, Baltimore, and his colleagues.
With multivariate logistic regression, achievement of source control was the only variable associated with decreased in-hospital mortality (odds ratio 0.04, 95% confidence interval, 0.003-0.52); P = .01).
“Source control status was predictive of in-hospital mortality after controlling for other factors. Specifically, the odds of in-hospital mortality were 97% lower when source control was achieved as compared to when source control was not achieved,” the authors stated (J Crit Care. 2018;43:321-6).
Scenarios in which source control was not applicable (pneumonia and urinary tract infection) were also similarly distributed between survivors and nonsurvivors, they reported.
Other than source control, the only significant risk factors for mortality, as seen in univariate analysis, all occurred prior to index culture. They were: vasopressor use (46.3% of survivors, vs. 76.2% of nonsurvivors, P = .03); mechanical ventilation (63.4% vs. 100%, P = .001); and median ICU length of stay (10 days vs. 18 days, P = .001).
“Achievement of source control stands out as a critical factor for patient survival. Clinicians should take this, along with prior ICU LOS, vasopressor use, and mechanical ventilation status, into consideration when evaluating patient prognosis,” Dr. Jarrell and his colleagues concluded.
The authors reported that they had no conflicts or source of funding.
Source: Jarrell, A.S., et al. J Crit Care. 2018;43:321-6.
FROM THE JOURNAL OF CRITICAL CARE
Key clinical point: Source control was the most important predictor of MDR Gram-negative infection mortality in hospitalized patients.
Major finding: The odds of in-hospital mortality were 97% lower when source control was achieved.
Study details: Case-control study of 62 critically ill surgical patients from 2011 to 2014 who had an MDR infection.
Disclosures: The authors reported that they had no conflicts or source of funding.
Source: Jarrell, A.S., et al. J Crit Care. 2018;43:321-6.
Clinical Trial: The Checklist to Prevent MRSA Surgical Site Infections
who are undergoing or have undergone cardiac surgery or total joint arthroplasty.
The Department of Veteran Affairs has previously implemented the VA MRSA Prevention Initiative, which successfully reduced patient-to-patient MRSA transmission; however, this initiative does not prevent most MRSA surgical site infections, which are spread differently. The VA has developed a new checklist which will be tested in this study aimed at reducing MRSA surgical site infections (SSIs), and will be implemented at 10 VA medical centers.
The primary outcome measure is superficial and deep/organ space MRSA infections within 90 days of operation. Secondary outcome measures include superficial and deep/organ space MRSA infections within 1 year of operation, presurgical bundle and individual bundle components compliance for 30 days prior to operation, length of postoperative stay, all-cause mortality 1 year after surgery, readmission within 90 days of surgery, and mupirocin and chlorhexidine resistance 30 days presurgery to 90 days postsurgery.
The study will end in April 2019. More than 10,000 people are expected to be included in the final analysis.
Find more information on the study page at Clinicaltrials.gov.
who are undergoing or have undergone cardiac surgery or total joint arthroplasty.
The Department of Veteran Affairs has previously implemented the VA MRSA Prevention Initiative, which successfully reduced patient-to-patient MRSA transmission; however, this initiative does not prevent most MRSA surgical site infections, which are spread differently. The VA has developed a new checklist which will be tested in this study aimed at reducing MRSA surgical site infections (SSIs), and will be implemented at 10 VA medical centers.
The primary outcome measure is superficial and deep/organ space MRSA infections within 90 days of operation. Secondary outcome measures include superficial and deep/organ space MRSA infections within 1 year of operation, presurgical bundle and individual bundle components compliance for 30 days prior to operation, length of postoperative stay, all-cause mortality 1 year after surgery, readmission within 90 days of surgery, and mupirocin and chlorhexidine resistance 30 days presurgery to 90 days postsurgery.
The study will end in April 2019. More than 10,000 people are expected to be included in the final analysis.
Find more information on the study page at Clinicaltrials.gov.
who are undergoing or have undergone cardiac surgery or total joint arthroplasty.
The Department of Veteran Affairs has previously implemented the VA MRSA Prevention Initiative, which successfully reduced patient-to-patient MRSA transmission; however, this initiative does not prevent most MRSA surgical site infections, which are spread differently. The VA has developed a new checklist which will be tested in this study aimed at reducing MRSA surgical site infections (SSIs), and will be implemented at 10 VA medical centers.
The primary outcome measure is superficial and deep/organ space MRSA infections within 90 days of operation. Secondary outcome measures include superficial and deep/organ space MRSA infections within 1 year of operation, presurgical bundle and individual bundle components compliance for 30 days prior to operation, length of postoperative stay, all-cause mortality 1 year after surgery, readmission within 90 days of surgery, and mupirocin and chlorhexidine resistance 30 days presurgery to 90 days postsurgery.
The study will end in April 2019. More than 10,000 people are expected to be included in the final analysis.
Find more information on the study page at Clinicaltrials.gov.
FROM CLINICALTRIALS.GOV
MSQC quality recommendations improve SSI in colectomy patients
The rate of patients decreased as hospitals implemented three specific care measures promoted by the Michigan Surgical Quality Collaborative, according to a study funded by the Blue Cross Blue Shield of Michigan.
With surgical site infections (SSIs) after colectomy associated with high morbidity as the second leading hospital acquired infection, and costing the health care system approximately $315 million annually, investment in this quality improvement program could ease a tremendous burden, according to Joceline V. Vu, MD, general surgery resident at the University of Michigan, Ann Arbor, and fellow investigators. The study was published in the Journal of the American College of Surgeons (2018 Jan;226[1]:91-99).
The study cohort included 5,742 colectomy patients at 1 of 52 hospitals associated with the Michigan Surgical Quality Collaborative (MSQC) between 2012 and 2016. Investigators assessed the use of the MSQC-recommended care bundle – cefazolin/metronidazole, oral antibiotics with mechanical bowel preparation, and postoperative day-1 glucose less than or equal to 140 mg/dL – and the impact of the bundle components on surgical site infection (SSI).
Patients were also split into groups based on the use of perioperative treatments previously found to be associated with SSI improvement, which included the three treatments in the care bundle as well as postoperative normothermia, minimally invasive surgery, and operative duration defined as either less than or greater than 100 minutes.
Those who had received these perioperative measures were given one point for each measure received.
Of the total, 8.1% of patients received 0-1 point, 22.2% received 2 points, 31.7% received 3 points, 27.2% received 4 points, and 10.7% received 5-6 points.
Patients were split relatively evenly between male and female, and the majority of patients were white across all six SSI perioperative groups.
Patients with 0-1 point were more likely to be older than 65 years (56.4%), while those who received 5-6 points were more likely to be between 45 and 64 years old (45.6% [P less than .001]).
Hospitals increased the use of three of the promoted processes (cefazolin/metronidazole, oral antibiotics with mechanical bowel preparation, and normoglycemia) during 2012-2016, and average use scores for patients went from 1.1 to 1.5 (P less than .001), according to investigators. As the rate of cefazolin/metronidazole and oral antibiotics with mechanical bowel preparation use rose from 18.6% and 42.9%, respectively, to 32.3% and 62.0% (P less than .001), SSI rates fell from 6.7% to 3.9% (P = .012) during the same period. The change in the normoglycemia rate (48.9% to 57.7%) was not significant (P = .112).
Hospitals that used all six recommended items saw a slightly decreased rate of SSI (r = –.39) between 2012 and 2016, according to Dr. Vu and her colleagues. Patients who received more measures had lower rates of complications, with SSI rates at 5.7% for those with 0-1 point, compared with 1.1% in those with 5-6 (P less than .001).
Rates of sepsis, pneumonia, emergency department visits, readmission, reoperation, and morbidity were also significantly lower.
“The MSQC and other collaborative quality improvement organizations represent a step toward this vision [of a learning health care system],” according to Dr. Vu and her colleagues. “Collaborating organizations can identify problems in care, adopt practice changes, and analyze the effect of those changes in a timely fashion.”
The findings of this study may be limited by a selection bias of how many bundle procedures a patient received based on comorbidities such as chronic obstructive pulmonary disease, hypertension, and obesity, which were all higher among those with fewer points. Investigators were also unable to discern causality of certain results because of the observational nature of the study. Hospitals included in the cohort volunteered to use the MSQC infrastructure, which may have limited the generalizability of the study,
Investigators reported no relevant financial disclosures. The study was funded by the Blue Cross Blue Shield of Michigan.
SOURCE: Vu, J V et al. J Am Coll Surg. 2018 Jan;226(1):91-9.
The rate of patients decreased as hospitals implemented three specific care measures promoted by the Michigan Surgical Quality Collaborative, according to a study funded by the Blue Cross Blue Shield of Michigan.
With surgical site infections (SSIs) after colectomy associated with high morbidity as the second leading hospital acquired infection, and costing the health care system approximately $315 million annually, investment in this quality improvement program could ease a tremendous burden, according to Joceline V. Vu, MD, general surgery resident at the University of Michigan, Ann Arbor, and fellow investigators. The study was published in the Journal of the American College of Surgeons (2018 Jan;226[1]:91-99).
The study cohort included 5,742 colectomy patients at 1 of 52 hospitals associated with the Michigan Surgical Quality Collaborative (MSQC) between 2012 and 2016. Investigators assessed the use of the MSQC-recommended care bundle – cefazolin/metronidazole, oral antibiotics with mechanical bowel preparation, and postoperative day-1 glucose less than or equal to 140 mg/dL – and the impact of the bundle components on surgical site infection (SSI).
Patients were also split into groups based on the use of perioperative treatments previously found to be associated with SSI improvement, which included the three treatments in the care bundle as well as postoperative normothermia, minimally invasive surgery, and operative duration defined as either less than or greater than 100 minutes.
Those who had received these perioperative measures were given one point for each measure received.
Of the total, 8.1% of patients received 0-1 point, 22.2% received 2 points, 31.7% received 3 points, 27.2% received 4 points, and 10.7% received 5-6 points.
Patients were split relatively evenly between male and female, and the majority of patients were white across all six SSI perioperative groups.
Patients with 0-1 point were more likely to be older than 65 years (56.4%), while those who received 5-6 points were more likely to be between 45 and 64 years old (45.6% [P less than .001]).
Hospitals increased the use of three of the promoted processes (cefazolin/metronidazole, oral antibiotics with mechanical bowel preparation, and normoglycemia) during 2012-2016, and average use scores for patients went from 1.1 to 1.5 (P less than .001), according to investigators. As the rate of cefazolin/metronidazole and oral antibiotics with mechanical bowel preparation use rose from 18.6% and 42.9%, respectively, to 32.3% and 62.0% (P less than .001), SSI rates fell from 6.7% to 3.9% (P = .012) during the same period. The change in the normoglycemia rate (48.9% to 57.7%) was not significant (P = .112).
Hospitals that used all six recommended items saw a slightly decreased rate of SSI (r = –.39) between 2012 and 2016, according to Dr. Vu and her colleagues. Patients who received more measures had lower rates of complications, with SSI rates at 5.7% for those with 0-1 point, compared with 1.1% in those with 5-6 (P less than .001).
Rates of sepsis, pneumonia, emergency department visits, readmission, reoperation, and morbidity were also significantly lower.
“The MSQC and other collaborative quality improvement organizations represent a step toward this vision [of a learning health care system],” according to Dr. Vu and her colleagues. “Collaborating organizations can identify problems in care, adopt practice changes, and analyze the effect of those changes in a timely fashion.”
The findings of this study may be limited by a selection bias of how many bundle procedures a patient received based on comorbidities such as chronic obstructive pulmonary disease, hypertension, and obesity, which were all higher among those with fewer points. Investigators were also unable to discern causality of certain results because of the observational nature of the study. Hospitals included in the cohort volunteered to use the MSQC infrastructure, which may have limited the generalizability of the study,
Investigators reported no relevant financial disclosures. The study was funded by the Blue Cross Blue Shield of Michigan.
SOURCE: Vu, J V et al. J Am Coll Surg. 2018 Jan;226(1):91-9.
The rate of patients decreased as hospitals implemented three specific care measures promoted by the Michigan Surgical Quality Collaborative, according to a study funded by the Blue Cross Blue Shield of Michigan.
With surgical site infections (SSIs) after colectomy associated with high morbidity as the second leading hospital acquired infection, and costing the health care system approximately $315 million annually, investment in this quality improvement program could ease a tremendous burden, according to Joceline V. Vu, MD, general surgery resident at the University of Michigan, Ann Arbor, and fellow investigators. The study was published in the Journal of the American College of Surgeons (2018 Jan;226[1]:91-99).
The study cohort included 5,742 colectomy patients at 1 of 52 hospitals associated with the Michigan Surgical Quality Collaborative (MSQC) between 2012 and 2016. Investigators assessed the use of the MSQC-recommended care bundle – cefazolin/metronidazole, oral antibiotics with mechanical bowel preparation, and postoperative day-1 glucose less than or equal to 140 mg/dL – and the impact of the bundle components on surgical site infection (SSI).
Patients were also split into groups based on the use of perioperative treatments previously found to be associated with SSI improvement, which included the three treatments in the care bundle as well as postoperative normothermia, minimally invasive surgery, and operative duration defined as either less than or greater than 100 minutes.
Those who had received these perioperative measures were given one point for each measure received.
Of the total, 8.1% of patients received 0-1 point, 22.2% received 2 points, 31.7% received 3 points, 27.2% received 4 points, and 10.7% received 5-6 points.
Patients were split relatively evenly between male and female, and the majority of patients were white across all six SSI perioperative groups.
Patients with 0-1 point were more likely to be older than 65 years (56.4%), while those who received 5-6 points were more likely to be between 45 and 64 years old (45.6% [P less than .001]).
Hospitals increased the use of three of the promoted processes (cefazolin/metronidazole, oral antibiotics with mechanical bowel preparation, and normoglycemia) during 2012-2016, and average use scores for patients went from 1.1 to 1.5 (P less than .001), according to investigators. As the rate of cefazolin/metronidazole and oral antibiotics with mechanical bowel preparation use rose from 18.6% and 42.9%, respectively, to 32.3% and 62.0% (P less than .001), SSI rates fell from 6.7% to 3.9% (P = .012) during the same period. The change in the normoglycemia rate (48.9% to 57.7%) was not significant (P = .112).
Hospitals that used all six recommended items saw a slightly decreased rate of SSI (r = –.39) between 2012 and 2016, according to Dr. Vu and her colleagues. Patients who received more measures had lower rates of complications, with SSI rates at 5.7% for those with 0-1 point, compared with 1.1% in those with 5-6 (P less than .001).
Rates of sepsis, pneumonia, emergency department visits, readmission, reoperation, and morbidity were also significantly lower.
“The MSQC and other collaborative quality improvement organizations represent a step toward this vision [of a learning health care system],” according to Dr. Vu and her colleagues. “Collaborating organizations can identify problems in care, adopt practice changes, and analyze the effect of those changes in a timely fashion.”
The findings of this study may be limited by a selection bias of how many bundle procedures a patient received based on comorbidities such as chronic obstructive pulmonary disease, hypertension, and obesity, which were all higher among those with fewer points. Investigators were also unable to discern causality of certain results because of the observational nature of the study. Hospitals included in the cohort volunteered to use the MSQC infrastructure, which may have limited the generalizability of the study,
Investigators reported no relevant financial disclosures. The study was funded by the Blue Cross Blue Shield of Michigan.
SOURCE: Vu, J V et al. J Am Coll Surg. 2018 Jan;226(1):91-9.
Key clinical point: Promotion of quality improvement bundled process measures by regional programs is associated with lower SSI in colectomy patients.
Major finding: As use of bundled care processes increased, surgical site infections (SSI) decreased from 6.7% to 3.9% (P = .012) across 52 hospitals.
Study details: Observational study of 5,742 colectomy patients at 1 of 52 hospitals in the Michigan Surgical Quality Collaborative system between 2012 and 2016.
Disclosures: Investigators reported no relevant financial disclosures. The study was funded by the Blue Cross Blue Shield of Michigan.
Source: Vu, J V et al. J Am Coll Surg. 2018 Jan;226(1):91-99.
Gastrointestinal complications are a key risk factor for death after AEF repair
Aortoenteric fistulas (AEFs) are an uncommon but lethal form of aortic graft infection with morbidity and mortality rates reported in the literature to range from 14% to 75%. Over a 20-year period, researchers found that nearly half of their patients undergoing repair of their aortoenteric fistulas died within 60 days. The presence of gastrointestinal complications increased the risk of mortality more than threefold, according to the results of a single-center retrospective review of consecutive AEF repairs.
The researchers assessed 50 patients who presented with AEF and had repair during 1995-2014. Sixty percent of the patients were men, and the overall median age was 70 years. The median follow-up for the entire cohort was 14 months. The duodenum was the most common location of the enteric defect, found in 80% of the infections. Overall, 23 patients (46%) died by day 60, according to the report published in the July Journal of the American College of Surgeons.
Univariate analysis showed that advanced age, chronic renal insufficiency, any complications, and GI complications in particular (occurring in 26% of patients) were all associated with an increase in overall mortality (P less than .05). But upon multivariate analysis, gastrointestinal complications (hazard ratio, 3.23; P = .015) and advanced age (HR, 1.07; P = .01) were the only independent predictors of mortality, Atish Chopra, MD, of the division of vascular surgery, Oregon Health & Science University, Portland, and his colleagues wrote.
The institution changed operative procedures in 2007, based upon an earlier assessment of the importance of GI complications performed by the researchers, with greater emphasis placed on ensuring a viable GI reconstruction, and early intervention for mesenteric ischemia. In addition, they surmised that, after 2007, there was improved adherence to achieving wide debridement of nonviable and infected tissue, and to creating a tension-free anastomosis to healthy tissue edges while optimizing nutritional, medical, and antibiotic therapy, according to the researchers.
“When comparing the patients undergoing repair before 2007 with those compared after 2007 [38 and 12 AEF patients, respectively], we found that in-hospitality mortality decreased from 37% to 8% (P = .08), 60-day mortality decreased from 53% to 8% (P less than .01), and mortality at last follow-up decreased from 55% to 17% (P = .02). Dr. Chopra and his colleagues also found that mortality after GI complications decreased from 90% for those operated on before 2007 to 33% in those operated on after 2007 (P = .01).
“Methods to decrease and improvement management of GI complications may prove most effective at improving mortality rates for this lethal pathology,” the researchers concluded.
The authors reported that they had nothing to disclose.
SOURCE: Chopra A et al. J Am Coll Surg 2017 Jul;225(1):9-18.
While secondary aortoenteric fistulas fortunately are a rare occurrence after open aortic repair (less than 1%), the reported results of treatment are disappointing (up to 75% mortality). The authors have demonstrated significant improvement in overall mortality in their series by paying more attention to the GI component of the procedure and postoperative management of the patient.
When we published our institutions experience with AEFs from 1991 to 2004, the study included 29 patients with one-third of patients presenting in shock. Extra-anatomic repair was performed in 86% (68% single stage). Mortality was 24%, with shock, blood transfusions, and suprarenal clamping associated with a worse outcome. Our 5-year survival was 61% and freedom from recurrent infection or amputation was 86% and 88% respectively. While our experience favors an extra-anatomic reconstruction, there has been increased utilization of in-situ repair in recent years. The current authors have extensive experience with the Neoaortoiliac System (NAIS) procedure and have had minimal complications associated with the extensive vein harvest necessary for NAIS; however, this is not universal. Wound complications, compartment syndrome, and chronic venous insufficiency are not uncommon complications. Improved results using cryopreserved aortoiliac allografts (CAA) were reported by The Vascular Low-Frequency Disease Consortium. In a 2014 publication on 220 patients receiving CAA for aortic reconstruction for aortic graft infection, freedom from graft-related complications, graft explant, and limb loss was 80%, 88%, and 97%, respectively, at 5 years. This compares favorably with extra-anatomic reconstruction and other techniques. In suprarenal reconstructions, allografts have been favored since the natural branches can be used to simplify multiple vessel reconstruction. In cases of low-grade infection (Staphylococcus epidermidis), excellent results have been demonstrated with wide debridement, in-situ replacement with rifampin-bonded grafts and omental coverage.
AEF can also occur after endovascular abdominal aortic aneurysm (AAA) repair and a management strategy for removing the endograft should be considered in the planning of these cases. The authors describe their technique, which involves constraining the endograft using an umbilical tape. Another technique that I prefer uses a 20-cc syringe with the tip cut off. The endograft is constrained by advancing the syringe proximally over the endograft. The syringe collapses the device and can be used to constrain the proximal fixation stents of a suprarenal graft, simplifying removal of the stent graft. Infected EVAR will likely become more common as an etiology as we continue to expand EVAR utilization for AAA repair. Another Low-Frequency Consortium paper reviewed the treatment and outcome of EVAR infection. In that report of 206 infected EVAR (endovascular aneurysm repair) and TEVAR (thoracic endovascular aortic repair) patients, 90% had in situ replacement with a 30-day mortality of 11% and morbidity of 35%.
As in previous reports on AEF, the authors highlight the importance of high clinical suspicion in making an expeditious diagnosis. Many imaging modalities can be used, but often operative exploration is required for a definitive diagnosis. Complete graft excision and wide debridement are critical to minimize the risk of recurrent infection. Optimal revascularization techniques should be determined by the experience of the operator, current experience demonstrating nearly equivalent outcomes with extra-anatomic and in situ replacement. Careful GI reconstruction and post-operative nutrition, culture-specific antibiotics, and ICU care are likely more important than the mode of reconstruction. Lifelong surveillance to detect recurrent infections also is recommended.
Murray L. Shames, MD , is professor of surgery and radiology and chief of the division of vascular surgery at the University of South Florida, Tampa, and director of the Tampa General Hospital aortic program.
While secondary aortoenteric fistulas fortunately are a rare occurrence after open aortic repair (less than 1%), the reported results of treatment are disappointing (up to 75% mortality). The authors have demonstrated significant improvement in overall mortality in their series by paying more attention to the GI component of the procedure and postoperative management of the patient.
When we published our institutions experience with AEFs from 1991 to 2004, the study included 29 patients with one-third of patients presenting in shock. Extra-anatomic repair was performed in 86% (68% single stage). Mortality was 24%, with shock, blood transfusions, and suprarenal clamping associated with a worse outcome. Our 5-year survival was 61% and freedom from recurrent infection or amputation was 86% and 88% respectively. While our experience favors an extra-anatomic reconstruction, there has been increased utilization of in-situ repair in recent years. The current authors have extensive experience with the Neoaortoiliac System (NAIS) procedure and have had minimal complications associated with the extensive vein harvest necessary for NAIS; however, this is not universal. Wound complications, compartment syndrome, and chronic venous insufficiency are not uncommon complications. Improved results using cryopreserved aortoiliac allografts (CAA) were reported by The Vascular Low-Frequency Disease Consortium. In a 2014 publication on 220 patients receiving CAA for aortic reconstruction for aortic graft infection, freedom from graft-related complications, graft explant, and limb loss was 80%, 88%, and 97%, respectively, at 5 years. This compares favorably with extra-anatomic reconstruction and other techniques. In suprarenal reconstructions, allografts have been favored since the natural branches can be used to simplify multiple vessel reconstruction. In cases of low-grade infection (Staphylococcus epidermidis), excellent results have been demonstrated with wide debridement, in-situ replacement with rifampin-bonded grafts and omental coverage.
AEF can also occur after endovascular abdominal aortic aneurysm (AAA) repair and a management strategy for removing the endograft should be considered in the planning of these cases. The authors describe their technique, which involves constraining the endograft using an umbilical tape. Another technique that I prefer uses a 20-cc syringe with the tip cut off. The endograft is constrained by advancing the syringe proximally over the endograft. The syringe collapses the device and can be used to constrain the proximal fixation stents of a suprarenal graft, simplifying removal of the stent graft. Infected EVAR will likely become more common as an etiology as we continue to expand EVAR utilization for AAA repair. Another Low-Frequency Consortium paper reviewed the treatment and outcome of EVAR infection. In that report of 206 infected EVAR (endovascular aneurysm repair) and TEVAR (thoracic endovascular aortic repair) patients, 90% had in situ replacement with a 30-day mortality of 11% and morbidity of 35%.
As in previous reports on AEF, the authors highlight the importance of high clinical suspicion in making an expeditious diagnosis. Many imaging modalities can be used, but often operative exploration is required for a definitive diagnosis. Complete graft excision and wide debridement are critical to minimize the risk of recurrent infection. Optimal revascularization techniques should be determined by the experience of the operator, current experience demonstrating nearly equivalent outcomes with extra-anatomic and in situ replacement. Careful GI reconstruction and post-operative nutrition, culture-specific antibiotics, and ICU care are likely more important than the mode of reconstruction. Lifelong surveillance to detect recurrent infections also is recommended.
Murray L. Shames, MD , is professor of surgery and radiology and chief of the division of vascular surgery at the University of South Florida, Tampa, and director of the Tampa General Hospital aortic program.
While secondary aortoenteric fistulas fortunately are a rare occurrence after open aortic repair (less than 1%), the reported results of treatment are disappointing (up to 75% mortality). The authors have demonstrated significant improvement in overall mortality in their series by paying more attention to the GI component of the procedure and postoperative management of the patient.
When we published our institutions experience with AEFs from 1991 to 2004, the study included 29 patients with one-third of patients presenting in shock. Extra-anatomic repair was performed in 86% (68% single stage). Mortality was 24%, with shock, blood transfusions, and suprarenal clamping associated with a worse outcome. Our 5-year survival was 61% and freedom from recurrent infection or amputation was 86% and 88% respectively. While our experience favors an extra-anatomic reconstruction, there has been increased utilization of in-situ repair in recent years. The current authors have extensive experience with the Neoaortoiliac System (NAIS) procedure and have had minimal complications associated with the extensive vein harvest necessary for NAIS; however, this is not universal. Wound complications, compartment syndrome, and chronic venous insufficiency are not uncommon complications. Improved results using cryopreserved aortoiliac allografts (CAA) were reported by The Vascular Low-Frequency Disease Consortium. In a 2014 publication on 220 patients receiving CAA for aortic reconstruction for aortic graft infection, freedom from graft-related complications, graft explant, and limb loss was 80%, 88%, and 97%, respectively, at 5 years. This compares favorably with extra-anatomic reconstruction and other techniques. In suprarenal reconstructions, allografts have been favored since the natural branches can be used to simplify multiple vessel reconstruction. In cases of low-grade infection (Staphylococcus epidermidis), excellent results have been demonstrated with wide debridement, in-situ replacement with rifampin-bonded grafts and omental coverage.
AEF can also occur after endovascular abdominal aortic aneurysm (AAA) repair and a management strategy for removing the endograft should be considered in the planning of these cases. The authors describe their technique, which involves constraining the endograft using an umbilical tape. Another technique that I prefer uses a 20-cc syringe with the tip cut off. The endograft is constrained by advancing the syringe proximally over the endograft. The syringe collapses the device and can be used to constrain the proximal fixation stents of a suprarenal graft, simplifying removal of the stent graft. Infected EVAR will likely become more common as an etiology as we continue to expand EVAR utilization for AAA repair. Another Low-Frequency Consortium paper reviewed the treatment and outcome of EVAR infection. In that report of 206 infected EVAR (endovascular aneurysm repair) and TEVAR (thoracic endovascular aortic repair) patients, 90% had in situ replacement with a 30-day mortality of 11% and morbidity of 35%.
As in previous reports on AEF, the authors highlight the importance of high clinical suspicion in making an expeditious diagnosis. Many imaging modalities can be used, but often operative exploration is required for a definitive diagnosis. Complete graft excision and wide debridement are critical to minimize the risk of recurrent infection. Optimal revascularization techniques should be determined by the experience of the operator, current experience demonstrating nearly equivalent outcomes with extra-anatomic and in situ replacement. Careful GI reconstruction and post-operative nutrition, culture-specific antibiotics, and ICU care are likely more important than the mode of reconstruction. Lifelong surveillance to detect recurrent infections also is recommended.
Murray L. Shames, MD , is professor of surgery and radiology and chief of the division of vascular surgery at the University of South Florida, Tampa, and director of the Tampa General Hospital aortic program.
Aortoenteric fistulas (AEFs) are an uncommon but lethal form of aortic graft infection with morbidity and mortality rates reported in the literature to range from 14% to 75%. Over a 20-year period, researchers found that nearly half of their patients undergoing repair of their aortoenteric fistulas died within 60 days. The presence of gastrointestinal complications increased the risk of mortality more than threefold, according to the results of a single-center retrospective review of consecutive AEF repairs.
The researchers assessed 50 patients who presented with AEF and had repair during 1995-2014. Sixty percent of the patients were men, and the overall median age was 70 years. The median follow-up for the entire cohort was 14 months. The duodenum was the most common location of the enteric defect, found in 80% of the infections. Overall, 23 patients (46%) died by day 60, according to the report published in the July Journal of the American College of Surgeons.
Univariate analysis showed that advanced age, chronic renal insufficiency, any complications, and GI complications in particular (occurring in 26% of patients) were all associated with an increase in overall mortality (P less than .05). But upon multivariate analysis, gastrointestinal complications (hazard ratio, 3.23; P = .015) and advanced age (HR, 1.07; P = .01) were the only independent predictors of mortality, Atish Chopra, MD, of the division of vascular surgery, Oregon Health & Science University, Portland, and his colleagues wrote.
The institution changed operative procedures in 2007, based upon an earlier assessment of the importance of GI complications performed by the researchers, with greater emphasis placed on ensuring a viable GI reconstruction, and early intervention for mesenteric ischemia. In addition, they surmised that, after 2007, there was improved adherence to achieving wide debridement of nonviable and infected tissue, and to creating a tension-free anastomosis to healthy tissue edges while optimizing nutritional, medical, and antibiotic therapy, according to the researchers.
“When comparing the patients undergoing repair before 2007 with those compared after 2007 [38 and 12 AEF patients, respectively], we found that in-hospitality mortality decreased from 37% to 8% (P = .08), 60-day mortality decreased from 53% to 8% (P less than .01), and mortality at last follow-up decreased from 55% to 17% (P = .02). Dr. Chopra and his colleagues also found that mortality after GI complications decreased from 90% for those operated on before 2007 to 33% in those operated on after 2007 (P = .01).
“Methods to decrease and improvement management of GI complications may prove most effective at improving mortality rates for this lethal pathology,” the researchers concluded.
The authors reported that they had nothing to disclose.
SOURCE: Chopra A et al. J Am Coll Surg 2017 Jul;225(1):9-18.
Aortoenteric fistulas (AEFs) are an uncommon but lethal form of aortic graft infection with morbidity and mortality rates reported in the literature to range from 14% to 75%. Over a 20-year period, researchers found that nearly half of their patients undergoing repair of their aortoenteric fistulas died within 60 days. The presence of gastrointestinal complications increased the risk of mortality more than threefold, according to the results of a single-center retrospective review of consecutive AEF repairs.
The researchers assessed 50 patients who presented with AEF and had repair during 1995-2014. Sixty percent of the patients were men, and the overall median age was 70 years. The median follow-up for the entire cohort was 14 months. The duodenum was the most common location of the enteric defect, found in 80% of the infections. Overall, 23 patients (46%) died by day 60, according to the report published in the July Journal of the American College of Surgeons.
Univariate analysis showed that advanced age, chronic renal insufficiency, any complications, and GI complications in particular (occurring in 26% of patients) were all associated with an increase in overall mortality (P less than .05). But upon multivariate analysis, gastrointestinal complications (hazard ratio, 3.23; P = .015) and advanced age (HR, 1.07; P = .01) were the only independent predictors of mortality, Atish Chopra, MD, of the division of vascular surgery, Oregon Health & Science University, Portland, and his colleagues wrote.
The institution changed operative procedures in 2007, based upon an earlier assessment of the importance of GI complications performed by the researchers, with greater emphasis placed on ensuring a viable GI reconstruction, and early intervention for mesenteric ischemia. In addition, they surmised that, after 2007, there was improved adherence to achieving wide debridement of nonviable and infected tissue, and to creating a tension-free anastomosis to healthy tissue edges while optimizing nutritional, medical, and antibiotic therapy, according to the researchers.
“When comparing the patients undergoing repair before 2007 with those compared after 2007 [38 and 12 AEF patients, respectively], we found that in-hospitality mortality decreased from 37% to 8% (P = .08), 60-day mortality decreased from 53% to 8% (P less than .01), and mortality at last follow-up decreased from 55% to 17% (P = .02). Dr. Chopra and his colleagues also found that mortality after GI complications decreased from 90% for those operated on before 2007 to 33% in those operated on after 2007 (P = .01).
“Methods to decrease and improvement management of GI complications may prove most effective at improving mortality rates for this lethal pathology,” the researchers concluded.
The authors reported that they had nothing to disclose.
SOURCE: Chopra A et al. J Am Coll Surg 2017 Jul;225(1):9-18.
FROM THE JOURNAL OF THE AMERICAN COLLEGE OF SURGEONS
Key clinical point: Nearly half of patients undergoing aortoenteric fistula repair died within 60 days.
Major finding: The presence of gastrointestinal complications increased the risk of mortality for AEF repair more than threefold.
Study details: A single center, retrospective review of 50 consecutive patients with AEF repairs during 1995-2014.
Disclosures: The authors reported that they had nothing to disclose.
Source: Chopra A et al. J Am Coll Surg. 2017 Jul;225:9-18.
Potential postthyroidectomy quality improvement metrics arise from study
of U.S. hospitals, suggesting to the authors that these measures could be used for quality improvement metrics.
In the study, published Nov. 29 in JAMA Surgery, hospitals with significantly lower rates of hypocalcemia were more likely to conduct postoperative parathyroid hormone level measurement as well as to prescribe vitamin D, calcium supplements, or both. Hospitals with lower RLN injury rates more frequently used energy devices and intraoperative nerve monitoring.
“Causation cannot be proven by this, but the confidence that these practice parameters are important is high,” senior author Bruce Hall, MD, PhD, vice president and chief quality officer at BJC Healthcare, and professor of surgery at Washington University, St. Louis, said in an interview. Dr. Hall is consulting director for the American College of Surgeon’s National Surgical Quality Improvement Program (NSQIP), which provided data for the analysis (JAMA Surg. 2017 Nov 29. doi: 10.1001/jamasurg.2017.4593).
The researchers examined data from 14,540 patients who underwent thyroidectomies at 98 hospitals between Jan. 1, 2013, and Dec. 31, 2015. These included 13,242 operations at 96 hospitals with complete hypocalcemia data, 13,144 operations at 95 hospitals with complete RLN data, and 13,197 operations at 95 hospitals with complete hematoma data. The primary outcome was the 30-day incidence of hypocalcemia, RLN, and hematoma. The researchers also measured 30-day mortality, surgical site infections, and hospital readmissions.
A total of 3.3% of patients experienced clinically severe hypocalcemia (0.6% after partial thyroidectomy, 4.7% after total or subtotal thyroidectomy). Another 5.7% experienced RLN (4.2% after partial, 6.6% after total or subtotal). Hematoma occurred in 1.3% of cases, but there were no significant variations in rates of hematoma across participating institutions.
For hypocalcemia and RLN injury, there were hospital outliers both on the low end of complication rates and on the high end of complication rates, defined by odds ratios with 95% confidence ratios that were greater than 1 for high outliers, or lower than 1 for low outliers. There were no outliers with respect to hematoma, suggesting that it may not be a useful barometer of hospital performance.
With respect to hypocalcemia rates, four hospitals were low outliers, and seven were high. Eight hospitals were low outliers with respect to RLN injury, and 14 were high outliers.
In the analysis of postoperative hypocalcemia, both low and high outliers measured postoperative calcium with similar frequency (68.4% vs. 71.0%; P =.09). However, high performance outliers were more likely to prescribe postoperative calcium, vitamin D, or both (76.6% vs. 66.8%; P less than .001).
Among RLN outliers, intraoperative nerve monitoring was more common in the top performing hospitals (55.7% vs. 37.7%; P less than .001), as was the use of energy devices (69.1% vs. 55.2%; P less than .001).
There was one high outlier when it came to surgical site infections, and one high and one low outlier with respect to morbidity outcomes. There were no hospital readmission outliers.
No source of funding was disclosed. Dr. Liu and Dr. Hall reported having no financial disclosures.
of U.S. hospitals, suggesting to the authors that these measures could be used for quality improvement metrics.
In the study, published Nov. 29 in JAMA Surgery, hospitals with significantly lower rates of hypocalcemia were more likely to conduct postoperative parathyroid hormone level measurement as well as to prescribe vitamin D, calcium supplements, or both. Hospitals with lower RLN injury rates more frequently used energy devices and intraoperative nerve monitoring.
“Causation cannot be proven by this, but the confidence that these practice parameters are important is high,” senior author Bruce Hall, MD, PhD, vice president and chief quality officer at BJC Healthcare, and professor of surgery at Washington University, St. Louis, said in an interview. Dr. Hall is consulting director for the American College of Surgeon’s National Surgical Quality Improvement Program (NSQIP), which provided data for the analysis (JAMA Surg. 2017 Nov 29. doi: 10.1001/jamasurg.2017.4593).
The researchers examined data from 14,540 patients who underwent thyroidectomies at 98 hospitals between Jan. 1, 2013, and Dec. 31, 2015. These included 13,242 operations at 96 hospitals with complete hypocalcemia data, 13,144 operations at 95 hospitals with complete RLN data, and 13,197 operations at 95 hospitals with complete hematoma data. The primary outcome was the 30-day incidence of hypocalcemia, RLN, and hematoma. The researchers also measured 30-day mortality, surgical site infections, and hospital readmissions.
A total of 3.3% of patients experienced clinically severe hypocalcemia (0.6% after partial thyroidectomy, 4.7% after total or subtotal thyroidectomy). Another 5.7% experienced RLN (4.2% after partial, 6.6% after total or subtotal). Hematoma occurred in 1.3% of cases, but there were no significant variations in rates of hematoma across participating institutions.
For hypocalcemia and RLN injury, there were hospital outliers both on the low end of complication rates and on the high end of complication rates, defined by odds ratios with 95% confidence ratios that were greater than 1 for high outliers, or lower than 1 for low outliers. There were no outliers with respect to hematoma, suggesting that it may not be a useful barometer of hospital performance.
With respect to hypocalcemia rates, four hospitals were low outliers, and seven were high. Eight hospitals were low outliers with respect to RLN injury, and 14 were high outliers.
In the analysis of postoperative hypocalcemia, both low and high outliers measured postoperative calcium with similar frequency (68.4% vs. 71.0%; P =.09). However, high performance outliers were more likely to prescribe postoperative calcium, vitamin D, or both (76.6% vs. 66.8%; P less than .001).
Among RLN outliers, intraoperative nerve monitoring was more common in the top performing hospitals (55.7% vs. 37.7%; P less than .001), as was the use of energy devices (69.1% vs. 55.2%; P less than .001).
There was one high outlier when it came to surgical site infections, and one high and one low outlier with respect to morbidity outcomes. There were no hospital readmission outliers.
No source of funding was disclosed. Dr. Liu and Dr. Hall reported having no financial disclosures.
of U.S. hospitals, suggesting to the authors that these measures could be used for quality improvement metrics.
In the study, published Nov. 29 in JAMA Surgery, hospitals with significantly lower rates of hypocalcemia were more likely to conduct postoperative parathyroid hormone level measurement as well as to prescribe vitamin D, calcium supplements, or both. Hospitals with lower RLN injury rates more frequently used energy devices and intraoperative nerve monitoring.
“Causation cannot be proven by this, but the confidence that these practice parameters are important is high,” senior author Bruce Hall, MD, PhD, vice president and chief quality officer at BJC Healthcare, and professor of surgery at Washington University, St. Louis, said in an interview. Dr. Hall is consulting director for the American College of Surgeon’s National Surgical Quality Improvement Program (NSQIP), which provided data for the analysis (JAMA Surg. 2017 Nov 29. doi: 10.1001/jamasurg.2017.4593).
The researchers examined data from 14,540 patients who underwent thyroidectomies at 98 hospitals between Jan. 1, 2013, and Dec. 31, 2015. These included 13,242 operations at 96 hospitals with complete hypocalcemia data, 13,144 operations at 95 hospitals with complete RLN data, and 13,197 operations at 95 hospitals with complete hematoma data. The primary outcome was the 30-day incidence of hypocalcemia, RLN, and hematoma. The researchers also measured 30-day mortality, surgical site infections, and hospital readmissions.
A total of 3.3% of patients experienced clinically severe hypocalcemia (0.6% after partial thyroidectomy, 4.7% after total or subtotal thyroidectomy). Another 5.7% experienced RLN (4.2% after partial, 6.6% after total or subtotal). Hematoma occurred in 1.3% of cases, but there were no significant variations in rates of hematoma across participating institutions.
For hypocalcemia and RLN injury, there were hospital outliers both on the low end of complication rates and on the high end of complication rates, defined by odds ratios with 95% confidence ratios that were greater than 1 for high outliers, or lower than 1 for low outliers. There were no outliers with respect to hematoma, suggesting that it may not be a useful barometer of hospital performance.
With respect to hypocalcemia rates, four hospitals were low outliers, and seven were high. Eight hospitals were low outliers with respect to RLN injury, and 14 were high outliers.
In the analysis of postoperative hypocalcemia, both low and high outliers measured postoperative calcium with similar frequency (68.4% vs. 71.0%; P =.09). However, high performance outliers were more likely to prescribe postoperative calcium, vitamin D, or both (76.6% vs. 66.8%; P less than .001).
Among RLN outliers, intraoperative nerve monitoring was more common in the top performing hospitals (55.7% vs. 37.7%; P less than .001), as was the use of energy devices (69.1% vs. 55.2%; P less than .001).
There was one high outlier when it came to surgical site infections, and one high and one low outlier with respect to morbidity outcomes. There were no hospital readmission outliers.
No source of funding was disclosed. Dr. Liu and Dr. Hall reported having no financial disclosures.
FROM JAMA SURGERY
Key clinical point: Prescription of postoperative calcium, vitamin D, or both, and greater use of intraoperative nerve monitoring may lead to fewer adverse events after thyroidectomy.
Major finding: Both low and high outliers on 30-day rates of postoperative hypocalcemia measured postoperative calcium with similar frequency (68.4% vs. 71.0%; P =.09). However, high performance outliers were more likely to prescribe postoperative calcium, vitamin D, or both (76.6% vs. 66.8%; P less than .001).
Data source: Retrospective analysis of 14,540 patients at 98 hospitals in the American College of Surgeon’s National Surgical Quality Improvement Program.
Disclosures: No source of funding was disclosed. Dr. Liu and Dr. Hall reported having no financial disclosures.
Single-port laparoscopy has few complications but BMI matters
NATIONAL HARBOR, MD. – Single-port laparoscopy is both safe and feasible, and has the potential to decrease surgical complications and increase efficiency, according to findings presented at the AAGL Global Congress.
Ahmed N. Al-Niaimi, MD, of the University of Wisconsin–Madison, and his colleagues, conducted a retrospective cohort study analyzing 587 consecutive patients who underwent single-port laparoscopy from March 2012 to December 2016. Of the 587 patients, there were 27 clinically-relevant complications among 18 patients (3%). The complications included intensive care unit admission, reoperation, end organ damage, organ space surgical site infection, and readmission. 
“Those factors leading to those complications are similar to the factors that cause complications in any other surgery,” Dr. Al-Niaimi said in an interview before the meeting.
Body mass index was found to be a primary contributor to surgical complications. Patients with a BMI of more than 30 kg/m2 experienced a 1% increase in the risk of surgical complications per unit value increase of BMI. This is significant because the median BMI of the patient population in the study was 33.9 kg/m2 and 57% of the study participants were considered obese or morbidly obese.
“The heavier the patient, the higher the complication rate,” Dr. Al-Niaimi said.
Surgeons who are learning single-port laparoscopy should choose patients with lower BMIs to gain efficiency in using the new technique, Dr. Al-Niaimi suggested. This will allow patients to decrease their risk of surgical complications while allowing surgeons to hone their abilities in a new surgical technique, he said.
The other prime contributor to surgical complications is the length of surgical time. The average time of surgery during the study was 156 minutes. Dr. Al-Niaimi and his colleagues found that for each 10-minute increase in surgical time, the risk of complications increased by 2%.
While the results of the study demonstrate safety in the single-port approach, Dr. Al-Niaimi said a randomized controlled trial is needed to validate the findings and determine whether single-port laparoscopy is more effective than multi-port laparoscopy.
Dr. Al-Niaimi reported having no financial disclosures.
NATIONAL HARBOR, MD. – Single-port laparoscopy is both safe and feasible, and has the potential to decrease surgical complications and increase efficiency, according to findings presented at the AAGL Global Congress.
Ahmed N. Al-Niaimi, MD, of the University of Wisconsin–Madison, and his colleagues, conducted a retrospective cohort study analyzing 587 consecutive patients who underwent single-port laparoscopy from March 2012 to December 2016. Of the 587 patients, there were 27 clinically-relevant complications among 18 patients (3%). The complications included intensive care unit admission, reoperation, end organ damage, organ space surgical site infection, and readmission.
“Those factors leading to those complications are similar to the factors that cause complications in any other surgery,” Dr. Al-Niaimi said in an interview before the meeting.
Body mass index was found to be a primary contributor to surgical complications. Patients with a BMI of more than 30 kg/m2 experienced a 1% increase in the risk of surgical complications per unit value increase of BMI. This is significant because the median BMI of the patient population in the study was 33.9 kg/m2 and 57% of the study participants were considered obese or morbidly obese.
“The heavier the patient, the higher the complication rate,” Dr. Al-Niaimi said.
Surgeons who are learning single-port laparoscopy should choose patients with lower BMIs to gain efficiency in using the new technique, Dr. Al-Niaimi suggested. This will allow patients to decrease their risk of surgical complications while allowing surgeons to hone their abilities in a new surgical technique, he said.
The other prime contributor to surgical complications is the length of surgical time. The average time of surgery during the study was 156 minutes. Dr. Al-Niaimi and his colleagues found that for each 10-minute increase in surgical time, the risk of complications increased by 2%.
While the results of the study demonstrate safety in the single-port approach, Dr. Al-Niaimi said a randomized controlled trial is needed to validate the findings and determine whether single-port laparoscopy is more effective than multi-port laparoscopy.
Dr. Al-Niaimi reported having no financial disclosures.
NATIONAL HARBOR, MD. – Single-port laparoscopy is both safe and feasible, and has the potential to decrease surgical complications and increase efficiency, according to findings presented at the AAGL Global Congress.
Ahmed N. Al-Niaimi, MD, of the University of Wisconsin–Madison, and his colleagues, conducted a retrospective cohort study analyzing 587 consecutive patients who underwent single-port laparoscopy from March 2012 to December 2016. Of the 587 patients, there were 27 clinically-relevant complications among 18 patients (3%). The complications included intensive care unit admission, reoperation, end organ damage, organ space surgical site infection, and readmission.
“Those factors leading to those complications are similar to the factors that cause complications in any other surgery,” Dr. Al-Niaimi said in an interview before the meeting.
Body mass index was found to be a primary contributor to surgical complications. Patients with a BMI of more than 30 kg/m2 experienced a 1% increase in the risk of surgical complications per unit value increase of BMI. This is significant because the median BMI of the patient population in the study was 33.9 kg/m2 and 57% of the study participants were considered obese or morbidly obese.
“The heavier the patient, the higher the complication rate,” Dr. Al-Niaimi said.
Surgeons who are learning single-port laparoscopy should choose patients with lower BMIs to gain efficiency in using the new technique, Dr. Al-Niaimi suggested. This will allow patients to decrease their risk of surgical complications while allowing surgeons to hone their abilities in a new surgical technique, he said.
The other prime contributor to surgical complications is the length of surgical time. The average time of surgery during the study was 156 minutes. Dr. Al-Niaimi and his colleagues found that for each 10-minute increase in surgical time, the risk of complications increased by 2%.
While the results of the study demonstrate safety in the single-port approach, Dr. Al-Niaimi said a randomized controlled trial is needed to validate the findings and determine whether single-port laparoscopy is more effective than multi-port laparoscopy.
Dr. Al-Niaimi reported having no financial disclosures.
AT AAGL 2017
Key clinical point:
Major finding: Obese patients experienced a 1% increase in risk of surgical complications per unit value increase of BMI.
Data source: Retrospective cohort study of 587 consecutive patients undergoing single-port laparoscopy at a single academic institution.
Disclosures: Dr. Al-Niaimi reported having no financial disclosures.
Type of headwear worn during surgery had no impact on SSI rates
SAN DIEGO – Surgeon preference for bouffant versus skull caps does not significantly impact superficial surgical site infection rates after accounting for surgical procedure type, results from a an analysis of a previously randomized, prospective trial showed.
“We are all aware of the current battle that is taking place over operating room attire based on the differences between the AORN [Association of periOperative Nurses] recommendations and ACS guidelines,” lead study author Shanu N. Kothari, MD, FACS, said at the annual clinical congress of the American College of Surgeons.
In 2016, Dr. Kothari, director of minimally invasive bariatric surgery at Gundersen Health System, La Crosse, Wisc., and his associates published results from a prospective, randomized non-inferiority trial on the impact of hair removal on surgical site infection rates (J Am Coll Surg 2016;223[5]:704-11). Patients were grouped by the attending surgeons’ preferred cap choice into either bouffant or skull cap groups. Their analysis concluded that hair left on the abdomen had no impact on surgical site infection rates. “What is unique about this study is that two independent certified research nurses independently assessed every wound in that trial,” he said.
For the current study, the researchers re-examined the data by conducting a multivariate analysis to determine the influence of surgical cap choice on SSIs. Overall, 1,543 patients were included in the trial. Attending surgeons wore bouffant caps and skull caps in 39% and 61% of cases, respectively. Bouffant caps were used in 71% of colon/intestine, 42% of hernia/other, 40% of biliary cases and only 1% of foregut cases. Overall, SSIs occurred in 8% and 5% of cases in which attending surgeons wore a bouffant and skull cap, respectively (P = .016), with 6% vs. 4% classified as superficial (P = .041), 0.8% vs. 0.2% deep (P = .120), and 1% vs. 0.9% organ space (P = .790). However, when the researchers adjusted for the type of surgery and surgical approach (laparoscopic vs. open), they observed no difference in SSI rates for skull cap, compared with bouffant cap.
“Surgeon preference should dictate the choice of headwear in the operating room,” Dr. Kothari commented. “What I would encourage is perhaps a summit between thought leaders in the ACS and the AORN, [to conduct] a true review of evidence and come up with a universal guideline. There are many other issues we need to be focusing on in surgery, and this probably doesn’t have to be one of them.”
“In general, there is a complete and utter absence of any scientific evidence whatsoever for most of the things we are told to do in terms of wearing what we do in the OR,” said invited discussant E. Patchen Dellinger, MD, FACS, FIDSA, professor of surgery at the University of Washington, Seattle. “In fact, there are prospective randomized trials showing that wearing a [face] mask does not reduce surgical site infection, although I’ve been wearing a mask in the OR for approximately 48 years.”
Dr. Kothari reported having no relevant financial disclosures.
SAN DIEGO – Surgeon preference for bouffant versus skull caps does not significantly impact superficial surgical site infection rates after accounting for surgical procedure type, results from a an analysis of a previously randomized, prospective trial showed.
“We are all aware of the current battle that is taking place over operating room attire based on the differences between the AORN [Association of periOperative Nurses] recommendations and ACS guidelines,” lead study author Shanu N. Kothari, MD, FACS, said at the annual clinical congress of the American College of Surgeons.
In 2016, Dr. Kothari, director of minimally invasive bariatric surgery at Gundersen Health System, La Crosse, Wisc., and his associates published results from a prospective, randomized non-inferiority trial on the impact of hair removal on surgical site infection rates (J Am Coll Surg 2016;223[5]:704-11). Patients were grouped by the attending surgeons’ preferred cap choice into either bouffant or skull cap groups. Their analysis concluded that hair left on the abdomen had no impact on surgical site infection rates. “What is unique about this study is that two independent certified research nurses independently assessed every wound in that trial,” he said.
For the current study, the researchers re-examined the data by conducting a multivariate analysis to determine the influence of surgical cap choice on SSIs. Overall, 1,543 patients were included in the trial. Attending surgeons wore bouffant caps and skull caps in 39% and 61% of cases, respectively. Bouffant caps were used in 71% of colon/intestine, 42% of hernia/other, 40% of biliary cases and only 1% of foregut cases. Overall, SSIs occurred in 8% and 5% of cases in which attending surgeons wore a bouffant and skull cap, respectively (P = .016), with 6% vs. 4% classified as superficial (P = .041), 0.8% vs. 0.2% deep (P = .120), and 1% vs. 0.9% organ space (P = .790). However, when the researchers adjusted for the type of surgery and surgical approach (laparoscopic vs. open), they observed no difference in SSI rates for skull cap, compared with bouffant cap.
“Surgeon preference should dictate the choice of headwear in the operating room,” Dr. Kothari commented. “What I would encourage is perhaps a summit between thought leaders in the ACS and the AORN, [to conduct] a true review of evidence and come up with a universal guideline. There are many other issues we need to be focusing on in surgery, and this probably doesn’t have to be one of them.”
“In general, there is a complete and utter absence of any scientific evidence whatsoever for most of the things we are told to do in terms of wearing what we do in the OR,” said invited discussant E. Patchen Dellinger, MD, FACS, FIDSA, professor of surgery at the University of Washington, Seattle. “In fact, there are prospective randomized trials showing that wearing a [face] mask does not reduce surgical site infection, although I’ve been wearing a mask in the OR for approximately 48 years.”
Dr. Kothari reported having no relevant financial disclosures.
SAN DIEGO – Surgeon preference for bouffant versus skull caps does not significantly impact superficial surgical site infection rates after accounting for surgical procedure type, results from a an analysis of a previously randomized, prospective trial showed.
“We are all aware of the current battle that is taking place over operating room attire based on the differences between the AORN [Association of periOperative Nurses] recommendations and ACS guidelines,” lead study author Shanu N. Kothari, MD, FACS, said at the annual clinical congress of the American College of Surgeons.
In 2016, Dr. Kothari, director of minimally invasive bariatric surgery at Gundersen Health System, La Crosse, Wisc., and his associates published results from a prospective, randomized non-inferiority trial on the impact of hair removal on surgical site infection rates (J Am Coll Surg 2016;223[5]:704-11). Patients were grouped by the attending surgeons’ preferred cap choice into either bouffant or skull cap groups. Their analysis concluded that hair left on the abdomen had no impact on surgical site infection rates. “What is unique about this study is that two independent certified research nurses independently assessed every wound in that trial,” he said.
For the current study, the researchers re-examined the data by conducting a multivariate analysis to determine the influence of surgical cap choice on SSIs. Overall, 1,543 patients were included in the trial. Attending surgeons wore bouffant caps and skull caps in 39% and 61% of cases, respectively. Bouffant caps were used in 71% of colon/intestine, 42% of hernia/other, 40% of biliary cases and only 1% of foregut cases. Overall, SSIs occurred in 8% and 5% of cases in which attending surgeons wore a bouffant and skull cap, respectively (P = .016), with 6% vs. 4% classified as superficial (P = .041), 0.8% vs. 0.2% deep (P = .120), and 1% vs. 0.9% organ space (P = .790). However, when the researchers adjusted for the type of surgery and surgical approach (laparoscopic vs. open), they observed no difference in SSI rates for skull cap, compared with bouffant cap.
“Surgeon preference should dictate the choice of headwear in the operating room,” Dr. Kothari commented. “What I would encourage is perhaps a summit between thought leaders in the ACS and the AORN, [to conduct] a true review of evidence and come up with a universal guideline. There are many other issues we need to be focusing on in surgery, and this probably doesn’t have to be one of them.”
“In general, there is a complete and utter absence of any scientific evidence whatsoever for most of the things we are told to do in terms of wearing what we do in the OR,” said invited discussant E. Patchen Dellinger, MD, FACS, FIDSA, professor of surgery at the University of Washington, Seattle. “In fact, there are prospective randomized trials showing that wearing a [face] mask does not reduce surgical site infection, although I’ve been wearing a mask in the OR for approximately 48 years.”
Dr. Kothari reported having no relevant financial disclosures.
AT THE ACS CLINICAL CONGRESS
Key clinical point: Surgeon preference should dictate choice of headwear in the OR.
Major finding: There was no significant difference in the rate of SSI, regardless of whether a skull cap or a bouffant cap was used during surgery.
Study details: Re-examination of a prospective, randomized non-inferiority trial of 1,543 patients, on the impact of hair removal on surgical site infection rates.
Disclosures: Dr. Kothari reporting having no relevant disclosures.
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
VIDEO: Researchers beginning to explore microbiome’s effect on surgical outcomes
SAN DIEGO – Surgery seems to stimulate abrupt changes in both the skin and gut microbiome, which in some patients may increase the risk of surgical-site infections and anastomotic leaks. With that knowledge, researchers are exploring the very first steps toward a presurgical microbiome optimization protocol, Heidi Nelson, MD, FACS, said at the annual clinical congress of the American College of Surgeons.
It’s very early in the journey, said Dr. Nelson, the Fred C. Andersen Professor of Surgery at Mayo Clinic, Rochester, Minn. The path is not straightforward because the human microbiome appears to be nearly as individually unique as the human fingerprint, so presurgical protocols might have to be individually tailored to each patient.
Dr. Nelson comoderated a session exploring this topic with John Alverdy, MD, FACS, of the University of Chicago. The panel discussed human and animal studies suggesting that the stress of surgery, when combined with subclinical ischemia and any baseline physiologic stress (chronic illness or radiation, for example), can cause some commensals to begin producing collagenase – a change that endangers even surgically sound anastomoses. The skin microbiome is altered as well, with areas around abdominal incisions beginning to express gut flora, which increase the risk of a surgical-site infection.
Through diet or other presurgical interventions, Dr. Nelson said in a video interview, it might be possible to optimize the microbiome and reduce the chances of some of these occurrences.
She had no financial disclosures.
On Twitter @Alz_Gal
SAN DIEGO – Surgery seems to stimulate abrupt changes in both the skin and gut microbiome, which in some patients may increase the risk of surgical-site infections and anastomotic leaks. With that knowledge, researchers are exploring the very first steps toward a presurgical microbiome optimization protocol, Heidi Nelson, MD, FACS, said at the annual clinical congress of the American College of Surgeons.
It’s very early in the journey, said Dr. Nelson, the Fred C. Andersen Professor of Surgery at Mayo Clinic, Rochester, Minn. The path is not straightforward because the human microbiome appears to be nearly as individually unique as the human fingerprint, so presurgical protocols might have to be individually tailored to each patient.
Dr. Nelson comoderated a session exploring this topic with John Alverdy, MD, FACS, of the University of Chicago. The panel discussed human and animal studies suggesting that the stress of surgery, when combined with subclinical ischemia and any baseline physiologic stress (chronic illness or radiation, for example), can cause some commensals to begin producing collagenase – a change that endangers even surgically sound anastomoses. The skin microbiome is altered as well, with areas around abdominal incisions beginning to express gut flora, which increase the risk of a surgical-site infection.
Through diet or other presurgical interventions, Dr. Nelson said in a video interview, it might be possible to optimize the microbiome and reduce the chances of some of these occurrences.
She had no financial disclosures.
On Twitter @Alz_Gal
SAN DIEGO – Surgery seems to stimulate abrupt changes in both the skin and gut microbiome, which in some patients may increase the risk of surgical-site infections and anastomotic leaks. With that knowledge, researchers are exploring the very first steps toward a presurgical microbiome optimization protocol, Heidi Nelson, MD, FACS, said at the annual clinical congress of the American College of Surgeons.
It’s very early in the journey, said Dr. Nelson, the Fred C. Andersen Professor of Surgery at Mayo Clinic, Rochester, Minn. The path is not straightforward because the human microbiome appears to be nearly as individually unique as the human fingerprint, so presurgical protocols might have to be individually tailored to each patient.
Dr. Nelson comoderated a session exploring this topic with John Alverdy, MD, FACS, of the University of Chicago. The panel discussed human and animal studies suggesting that the stress of surgery, when combined with subclinical ischemia and any baseline physiologic stress (chronic illness or radiation, for example), can cause some commensals to begin producing collagenase – a change that endangers even surgically sound anastomoses. The skin microbiome is altered as well, with areas around abdominal incisions beginning to express gut flora, which increase the risk of a surgical-site infection.
Through diet or other presurgical interventions, Dr. Nelson said in a video interview, it might be possible to optimize the microbiome and reduce the chances of some of these occurrences.
She had no financial disclosures.
On Twitter @Alz_Gal
AT THE ACS CLINICAL CONGRESS
