Clinical Outcomes In Surgical Patients Research Articles

Association between preoperative fasting time and clinical outcomes in surgical patients in a private general hospital.

Surgical patients are routinely subjected to long periods of fasting, a practice that can exacerbate the metabolic response to trauma and impair postoperative recovery. The aim of this study was to evaluate the association between preoperative fasting time and clinical outcomes in surgical patients. An observational, prospective study with a non-probabilistic sample that included patients of both sexes, aged over 18, undergoing elective surgeries. Data were extracted from electronic medical records, and a questionnaire was applied in 48 hours after surgery. Variables related to postoperative discomfort were assessed using an 11-point numeric rating scale. The sample consisted of 372 patients, and the duration of the surgical event ranged from 30-680 minutes. The incidence of nausea (26.34%) was twice that of vomiting (13.17%) and showed an association with the surgical procedure's size (p = 0.018). A statistically significant difference was observed only between pain intensity and preoperative fasting times for liquids (p = 0.007) and postoperative fasting time (p = 0.08). The occurrence of postoperative complications showed no association with preoperative fasting time (p = 0.850). Although no association was observed between preoperative fasting time and surgical complications, it is noteworthy that both recommended and actual fasting time exceeded the proposed on clinical guidelines.

Long-term exposures to ambient particulate matter and ozone pollution with lower extremity deep vein thrombosis after surgical operations: a retrospective case-control study in Beijing, China

BackgroundLower extremity deep vein thrombosis (LEDVT) after surgical operations is a common and fatal disease leading to unfavorable outcomes including death. Nevertheless, there has been insufficient evidence on the associations between ambient air pollution and LEDVT, particularly studies from developing regions.MethodsBased on 302 LEDVT cases and 302 controls in a general hospital in Beijing, China, this unmatched retrospective case-control study investigated the associations of fine particulate matter (PM2.5), inhalable particulate matter (PM10), and ozone (O3) with odds of LEDVT.ResultsPer 10 μg/m3 increase in PM2.5, PM10, and O3 at 3-month, 6-month, and 2-year average was associated with increased LEDVT odds [odds ratios (ORs) for PM2.5: 1.10 (95%CI: 1.05, 1.14), 1.14 (95%CI: 1.09, 1.18), and 1.30 (95%CI: 1.06, 1.61); ORs for PM10: 1.06 (95%CI: 1.02, 1.10), 1.12 (95%CI: 1.08, 1.16), and 1.29 (95%CI: 1.03, 1.61); ORs for O3: 1.00 (95%CI: 0.96, 1.04), 1.16 (95%CI: 1.02, 1.31), and 2.08 (95%CI: 1.03, 4.18), respectively]. The stratified analyses, exposure-responses curves, and sensitivity analyses further highlighted the robustness of our findings.ConclusionsLong-term exposures to ambient PM2.5, PM10, and O3 may increase the risk of LEDVT in patients after surgical operations. The results may be implicated in the prevention and control of adverse clinical outcomes of surgical patients associated with ambient air pollution.

P238 The ‘Malnutrition Universal Screening Tool’ (MUST) is less effective than an IBD specific Malnutrition Inflammation Risk Tool (MIRT) in identifying malnutrition risk with hospital admissions and surgical complication

Abstract Background IBD is associated with altered body composition and micronutrient deficiencies. None of the existing validated nutritional screening tools can correctly identify nutritional deficiencies in IBD. MUST is a widely used malnutrition screening tool in the UK. However, it failed to present relevance to clinical outcomes, while a newly developed IBD-specific tool, MIRT, showed significant correlations in CD patients. Methods Two single-centred retrospective projects were conducted in IBD tertiary centre at Royal London Hospital. Study A focused on IBD inpatients during the year 2021 with hospital stays ≥7 days 69 patients (43 males and 26 females), while study B examined 49 who underwent IBD-related surgery admitted between October 2019 and March 2022. They share the same defining criteria in MUST and MIRT. Hospital length of stay (LoS) and Clavien-dindo grade (CDG) were used to assess the clinical outcomes in surgical patients (study B). Results Study A: There were significant differences between MIRT and MUST in identifying the risk of malnutrition (Chi-square statistics =1.817, df =1, p =0.178). Fisher’s exact test P=0.239. and accepted alternative hypothesis. MIRT identified a significantly higher proportion of patients with the risk of malnutrition in comparison to MUST (strengths of relationship k=0.165 [95% CI] p =0.178). An independent sample t-test was undertaken to determine the association between malnutrition -MUST ≥2 and LoS. It was found that there was no difference between the means of the two groups and the LoS. t (32) =-0.002 p=0.998 P>0.05. Similarities have been found with MIRT≥3 score and association with LoS t (67) = -0.158 p=0.875 p>0.05Study B: The MUST did not significantly correlate with CDG or LoS (ρ =0.145, P =0.322; ρ = 0.033, P =0.823); however, the MIRT score did (ρ = 0.339, P =0.017; ρ =0.399, P = 0.005). The MIRT is thus a better NST than MUST in correlating with surgical outcomes within the IBD patient population. A higher MIRT score of ≥3 was significantly associated with both CDG (P =0.009) and hospital LoS (P =0.003), while a higher MIRT score ≥2 was not significantly associated with either (P =0.272; P =0.095) shown in Table 1 Conclusion MIRT identifies a higher proportion of malnutrition in IBD patients 1 week from admission, but there is no direct correlation with complications and LoS. However, the opposite is the case in surgical patients where MIRT is a better pre-indicator for longer stays and complications. Having a disease-specific tool that correctly identifies the risk of malnutrition and predicts disease clinical outcomes in the IBD inpatient setting will improve the quality of healthcare and also will reduce healthcare costs. Further studies are needed ideally prospectively.

Recommendations From the International Consensus Conference on Anemia Management in Surgical Patients (ICCAMS).

Perioperative anemia has been associated with increased risk of red blood cell transfusion and increased morbidity and mortality after surgery. The optimal approach to the diagnosis and management of perioperative anemia is not fully established. To develop consensus recommendations for anemia management in surgical patients. An international expert panel reviewed the current evidence and developed recommendations using modified RAND Delphi methodology. The panel recommends that all patients except those undergoing minor procedures be screened for anemia before surgery. Appropriate therapy for anemia should be guided by an accurate diagnosis of the etiology. The need to proceed with surgery in some patients with anemia is expected to persist. However, early identification and effective treatment of anemia has the potential to reduce the risks associated with surgery and improve clinical outcomes. As with preoperative anemia, postoperative anemia should be treated in the perioperative period. Early identification and effective treatment of anemia has the potential to improve clinical outcomes in surgical patients.

Transcutaneous blood gas monitoring and tissue perfusion during common femoral thromboendarterectomy

Background Improving tissue perfusion can improve clinical outcomes in surgical patients, where monitoring may aid clinicians in detecting adverse conditions and guide interventions. Transcutaneous monitoring (TCM) of oxygen (tcpO2) and carbon dioxide (tcpCO2) is a well-proven technology and could potentially serve as a measure of local circulation, perfusion and metabolism, but the clinical use is not thoroughly explored. The purpose of this proof-of-concept study was to investigate whether TCM of blood gasses could detect changes in perfusion during major vascular surgery. Methods Ten patients with peripheral arterial disease scheduled for lower limb major arterial revascularization under general anaesthesia were consecutively included. TcpO2 and tcpCO2 were continuously recorded from anaesthesia induction until skin closure with a TCM monitor placed on both legs and the thorax. Peripheral oxygen saturation was kept ≥94% and mean arterial blood pressure ≥65 mmHg. The primary outcomes were changes in tcpO2 and tcpCO2 related to arterial clamping and declamping during the procedure and analyzed by paired statistics. Results Femoral artery clamping resulted in a significant decrease in tcpO2 (−2.1 kPa, IQR-4.2; −0.8), p=.017)), followed by a significant increase in response to arterial declamping (5.5 kPa, IQR 0–7.3), p=.017)). Arterial clamping resulted in a statistically significant increase in tcpCO2 (0.9 kPa, IQR 0.3–5.4), p=.008)) and a significant decrease following declamping (−0.7 kPa, IQR −2.6; −0.2), p=.011)). Conclusion Transcutaneous monitoring of oxygen and carbon dioxide is a feasible method for detection of extreme changes in tissue perfusion during arterial clamping and declamping, and its use for improving patient outcomes should be explored. Clinical Trials identifier: NCT04040478. Registered on July 31, 2019.

Healthcare Disparity Education for Surgical Residents: Progress Made, More Needed.

Healthcare disparities are an important determinant of patient outcomes yet are not standardized within surgical resident education. This study aimed to determine the prevalence and design of current healthcare disparities curricula for surgical residents and included a resident-based needs assessment at a single institution. A national survey evaluating the presence and design of healthcare disparities curricula was distributed to general surgery program directors via the Association of Program Directors in Surgery Listserv. A related survey was administered to all general surgery residents at a single academic institution. One hundred forty-six program directors completed the survey, with 68 (47%) reporting an active curriculum. The most frequently taught topic is regarding patient race as a healthcare disparity, found in 63 (93%) of existing curricula. Fifty-two (76%) of the curricula were implemented within the last 3 years. Of the 78 (53%) programs without a curriculum, 8 (10%) program directors stated that their program would not benefit from one. Thirty-four (45%) of the programs without a curriculum cited institutional support and time as the most common barriers to implementation. Of the 23 residents who completed the survey, 100% desired learning practical knowledge regarding healthcare disparities relating to how race and socioeconomic status affect the clinical outcomes of surgical patients. Less than half of general surgery training programs have implemented healthcare disparities curricula. Resident preferences for the format and content of curricula may help inform program leaders and lead to comprehensive national standards.

Perioperative pain management and outcomes in patients who -discontinued or continued pre-existing buprenorphine therapy.

This study compared opioid utilization and clinical outcomes in surgical patients receiving maintenance buprenorphine therapy who discontinued versus those who continued buprenorphine treatment perioperatively. Lack of high-quality evidence, conflicting results in previous studies, and the possible need for reinduction after discontinuing therapy present clinicians with the complicated dilemma of choosing the best strategy to control post-operative pain in patients receiving buprenorphine. A multicenter, retrospective cohort study. Hospitalized patients between January 1, 2017 and December 12, 2019 who underwent any type of surgery, had a documentation of an outpatient buprenorphine prescription or inpatient order, and received buprenorphine for 5 or more days prior to the procedure were included. The primary objective was to compare mean 24-hour morphine milligram equivalent (MME) utilization post-operatively between patients who discontinued buprenorphine preoperatively versus those who continued therapy throughout the perioperative period. Fifty-one patients met the inclusion criteria for this study. Of these, 42 patients were continued on buprenorphine through surgery, while nine patients had a documentation of discontinuation preoperatively. The 24-hour post-operative MME utilization (interquartile range) was 58.8 (18-100.8) in patients who continued therapy through surgery versus 152.6 (114.5-236) in patients who discontinued therapy preoperatively (p = 0.005). There were no significant differences in post-operative pain scores or length of stay between groups. Post-operative opioid use was significantly lower in patients who continued buprenorphine compared with those who discontinued buprenorphine preoperatively.

Perioperative Opioid Consumption and Clinical Outcomes in Surgical Patients With a Pre-existing Opioid-Based Intrathecal Drug Delivery System.

Intrathecal drug delivery systems (IDDS) have been utilized for over 3 decades for management of chronic pain and spasticity. Patients with IDDS may present for surgical procedures unrelated to the IDDS device, although data are limited regarding perioperative outcomes. This is a historical matched cohort study conducted between January 1, 2007 and December 31, 2016 of patients with an opioid-based IDDS versus matched control patients undergoing surgery excluding interventional pain procedures. Patients in the IDDS group were matched with up to 2 patients without an IDDS. Multivariable regression analyses were utilized to assess differences in the primary outcome of cumulative perioperative opioid consumption (ie, intraoperative and postanesthesia care unit [PACU] opioid consumption), and opioid consumption during the first 24 and 72 postoperative hours. Postoperative clinical outcomes were also assessed including escalating oxygen requirements, naloxone administration, pain-sedation mismatch, and perioperative pain service consultation. A total of 321 surgeries were included, 112 with IDDS and 209 controls, with median (interquartile range [IQR]) age of 57 (49-64) years. Compared to matched controls, patients with an IDDS had greater perioperative opioid consumption (median [IQR] oral morphine milligram equivalents [OME] of 110 [60-163] vs 93 [IQR, 53-142]; adjusted multiplicative increase 1.28 [95% confidence interval {CI}, 1.03-1.59]; P = .026). IDDS patients also had greater opioid consumption in the first 24 and 72 postoperative hours (multiplicative increases of 2.23 [95% CI, 1.36-3.63], P = .001, and 2.46 [95% CI, 1.41-4.32], P = .002, respectively). There were no significant differences in postoperative oxygen requirements, naloxone administration, or pain-sedation mismatch. Inpatient pain medicine consultation was more frequent in IDDS patients compared to controls (51.8% vs 6.2%; P < .001). Patients with opioid-based IDDS received more perioperative opioids and were more likely to receive postoperative pain service consultation compared to matched controls. There were no significant differences in clinical safety outcomes, suggesting tolerance for higher opioid doses. Further research is warranted to optimize perioperative outcomes in those with IDDS.

Nutritional risk screening - NRE 2017 - and clinical outcomes in surgical patients: A longitudinal study

Rationale: Malnutrition is prevalent in hospitalized surgical patients and is associated with increased mortality and worse outcomes. The aim of this study was to evaluate the performance of a nutritional screening tool Nutritional Risk Emergency-2017 (NRE– 2017) in predicting postoperative outcomes.

Fragile neutrophils in surgical patients: A phenomenon associated with critical illness.

Leukocyte viability (determined by e.g. propidium iodide [PI] staining) is automatically measured by hematology analyzers to check for delayed bench time. Incidental findings in fresh blood samples revealed the existence of leukocytes with decreased viability in critically ill surgical patients. Not much is known about these cells and their functional and/or clinical implications. Therefore, we investigated the incidence of decreased leukocyte viability, the implications for leukocyte functioning and its relation with clinical outcomes. An automated alarm was set in a routine hematology analyzer (Cell-Dyn Sapphire) for the presence of non-viable leukocytes characterized by increased fluorescence in the PI-channel (FL3:630±30nm). Patients with non-viable leukocytes were prospectively included and blood samples were drawn to investigate leukocyte viability in detail and to investigate leukocyte functioning (phagocytosis and responsiveness to a bacterial stimulus). Then, a retrospective analysis was conducted to investigate the incidence of fragile neutrophils in the circulation and clinical outcomes of surgical patients with fragile neutrophils hospitalized between 2013-2017. A high FL3 signal was either caused by 1) neutrophil autofluorescence which was considered false positive, or by 2) actual non-viable PI-positive neutrophils in the blood sample. These two causes could be distinguished using automatically generated data from the hematology analyzer. The non-viable (PI-positive) neutrophils proved to be viable (PI-negative) in non-lysed blood samples, and were therefore referred to as 'fragile neutrophils'. Overall leukocyte functioning was not impaired in patients with fragile neutrophils. Of the 11 872 retrospectively included surgical patients, 75 (0.63%) were identified to have fragile neutrophils during hospitalization. Of all patients with fragile neutrophils, 75.7% developed an infection, 70.3% were admitted to the ICU and 31.3% died during hospitalization. In conclusion, fragile neutrophils occur in the circulation of critically ill surgical patients. These cells can be automatically detected during routine blood analyses and are an indicator of critical illness.

Tissue loss syndrome as an important predictor of survival and clinical outcome in surgical patients

Tissue loss syndrome as an important predictor of survival and clinical outcome in surgical patients

The Impact of Complications and Pain on Patient Satisfaction.

To measure the association between patient-reported satisfaction and regret and clinical outcomes. Patient-reported outcomes are becoming an increasingly important marker of the quality of patient care. It is unclear however, how well patient-reported outcomes adequately reflect care quality and clinical outcomes in surgical patients. Retrospective, population-based analysis of adults ages 18 and older undergoing surgery across 38 hospitals in Michigan between January 1, 2017 and May 31, 2018. In this study, 9953 patients (mean age 56 years; 5634 women (57%)) underwent 1 of 16 procedures. 9550 (96%) patients experienced no complication, whereas 240 (2%) and 163 (2%) patients experienced Grade 1 and Grade 2-3 complications, respectively. Postoperative pain scores were: none (908 (9%) patients), mild (3863 (40%) patients), moderate (3893 (40%) patients), and severe (1075 (11%) patients). Overall, 7881 (79%) patients were highly satisfied and 8911 (91%) had absolutely no regret after surgery. Patients were less likely to be highly satisfied if they experienced a Grade 1 complication [odds ratio (OR) 0.50, 95% confidence interval (CI) 0.37-0.66], Grade 2-3 complication (OR 0.44, 95% CI 0.31-0.62), minimal pain (OR 0.80, 95% CI 0.64-0.99, moderate pain (OR 0.39, 95% CI 0.32-0.49), or severe pain (OR 0.23, 95% CI 0.18-0.29). Patients were less likely to have no regret if they experienced a Grade 1 complication (OR 0.48, 95% CI 0.33-0.70), Grade 2-3 complication (OR 0.39, 95% CI 0.25-0.60), moderate pain (OR 0.55, 95% CI 0.40-0.76), or severe pain (OR 0.22, 95% CI 0.16-0.31). The predicted probability of being highly satisfied was 79% for patients who had no complications and 88% for patients who had no pain. Patients who experienced postoperative complications and pain were less likely to be highly satisfied or have no regret. Notably, postoperative pain had a more significant effect on satisfaction and regret after surgery, suggesting focused postsurgical pain management is an opportunity to substantially improve patient experiences. More research and patient education are needed for managing expectations of postoperative pain, and use of adjuncts and regional anesthesia.

Impact of a hospital-wide sepsis pathway on improved quality of care and clinical outcomes in surgical patients at a comprehensive cancer centre.

Sepsis is a significant complication following cancer surgery. Although standardised care bundles improve sepsis outcomes in other populations, the benefits in cancer patients are unclear. The objectives of this study were to describe the epidemiology of sepsis in cancer patients post-surgery, and to evaluate the impact of a clinical sepsis pathway on management and clinical outcomes. A standardised hospital-wide sepsis pathway was developed in 2013, and all cases of sepsis at the Peter MacCallum Cancer Centre in 2014 were retrospectively evaluated. Inclusion criteria were sepsis onset during the 100-day period following a surgical procedure for cancer diagnosis. Patients were identified using ICD-10-AM sepsis discharge codes, audit documentation and the hospital's antimicrobial approval system. Sepsis episodes were classified as managed on- or off-pathway. A total of 119 sepsis episodes were identified. Of these, 71 (59.7%) were managed on the sepsis pathway. Episodes managed on-pathway resulted more frequently in administration of appropriate antibiotics compared to those off-pathway (94.4% vs. 66.7%, p<0.001), and had shorter time to first-dose antibiotics (median 85 vs. 315min, p<0.001). Pathway utilisation was associated with significant reductions in need for inotropes (7% vs. 13%, p=0.023), ventilation (3% vs. 10%, p=0.006) and length of hospitalisation (median 15 vs. 30days, p=0.008). The most frequent source of infection was organ-space surgical site infection (24.4% of instances). A dedicated hospital-wide sepsis pathway had significant impact on the quality of care and clinical outcomes of sepsis in cancer surgery patients. Cost-benefit analysis of sepsis pathways for cancer patients is required.

MALNUTRITION AND CLINICAL OUTCOMES IN SURGICAL PATIENTS WITH COLORECTAL DISEASE.

Malnutrition is a frequent condition among hospitalized patients and a factor of increased risk of postoperative complication. This study aimed to evaluate the impact of malnutrition on phase angle (PA), body water distribution and clinical outcomes in surgical patients with colorectal disease. This retrospective study was performed in a tertiary hospital with 40 patients admitted electively. In the preoperative evaluation, global subjective assessment and bioelectrical impedance analysis were performed to determine nutritional status, PA, extracellular water (ECW), intracellular water (ICW) and total body water (TBW). In postoperative evaluation, the length of hospital stay and severe complications, according to Clavien-Dindo classification, were determined. The optimal PA cutoff for malnutrition screening was determined by ROC curve analysis. Seventeen (42.5%) patients were diagnosed as malnourished and 23 (57.5%) as well-nourished according to global subjective assessment. Twelve (30.0%) patients developed severe complications. The malnourished group presented lower values of serum albumin (P=0.012), hematocrit (P=0.026) and PA (P=0.002); meanwhile, ECW/ICW (P=0.019) and ECW/TBW (P=0.047) were higher. Furthermore, 58.8% of malnourished patients developed severe postoperative complications compared to 8.7% of well-nourished. Malnutrition was independent predictor of severe postoperative complications (OR=15.00, IC: 2.63-85.68, P=0.002). The optimal PA cutoff obtained was 6.0º (AUC=0.82, P=0.001), yielding sensitivity, specificity, positive predictive value and negative predictive value of 76.5%, 87.0%, 81.3% and 83.4%, respectively. Malnutrition was an independent predictive factor for severe complications in patients underwent to elective major coloproctological surgery. Besides that, malnutrition was associated with lower PA values and greater ratio of ECW. The PA provided great accuracy in nutritional screening, implying a useful marker of malnutrition.

Meta-analysis of the influence of lifestyle changes for preoperative weight loss on surgical outcomes.

The aim was to investigate whether preoperative weight loss results in improved clinical outcomes in surgical patients with clinically significant obesity. This was a systematic review and aggregate data meta-analysis of RCTs and cohort studies. PubMed, MEDLINE, Embase and CINAHL Plus databases were searched from inception to February 2018. Eligibility criteria were: studies assessing the effect of weight loss interventions (low-energy diets with or without an exercise component) on clinical outcomes in patients undergoing any surgical procedure. Data on 30-day or all-cause in-hospital mortality were extracted and synthesized in meta-analyses. Postoperative thromboembolic complications, duration of surgery, infection and duration of hospital stay were also assessed. A total of 6060 patients in four RCTs and 12 cohort studies, all from European and North American centres, were identified. Most were in the field of bariatric surgery and all had some methodological limitations. The pooled effect estimate suggested that preoperative weight loss programmes were effective, leading to significant weight reduction compared with controls: mean difference -7·42 (95 per cent c.i. -10·09 to -4·74) kg (P < 0·001). Preoperative weight loss interventions were not associated with a reduction in perioperative mortality (odds ratio 1·41, 95 per cent c.i. 0·24 to 8·40; I2 = 0 per cent, P = 0·66) but the event rate was low. The weight loss groups had shorter hospital stay (by 27 per cent). No differences were found for morbidity. This limited preoperative weight loss has advantages but may not alter the postoperative morbidity or mortality risk.

Genetic variants in cytokine signaling pathways and clinical outcomes in early-stage lung cancer patients

ObjectivesThe purpose of this study was to explore the role of single nucleotide polymorphisms (SNPs) in cytokine signaling genes and to compare them with clinical outcomes in surgical patients with non–small cell lung cancer (NSCLC). MethodsSNPs of the cytokine signaling pathway were analyzed using peripheral blood of 722 patients who underwent resection of stage I to III NSCLC between 1995 and 2009. Cox proportional hazard analyses were performed to identify SNPs associated with overall survival (OS) and risk of recurrence. Internal validation using bootstrap analysis selected SNPs for unfavorable genotype and survival tree analysis. ResultsSeventeen and 9 SNPs were independently associated with OS and recurrence, respectively. Patients with ≥9 unfavorable genotypes experienced worse OS (median, 41 months) than patients with 7 to 8 (89 months) and ≤6 (153 months) after median follow-up of 71 months (P = 2.86 × 10−23). Patients with ≤3 unfavorable genotypes had greater time to recurrence (median not reached) than those with 4 to 6 (114 months) and ≥7 (44 months; P = 1.3 × 10−5). Survival tree analysis classified patients into 3 risk groups. Patients in the intermediate- (median OS, 82 months) and high-risk groups (43 months) had worse survival than the low-risk group (176 months; P = 5.51 × 10−20). Median time to recurrence was worse in the intermediate- (114 months) and high-risk groups (58 months) than the low-risk group (median not reached; P = 2.52 × 10−9). ConclusionsGenetic variants in cytokine signaling pathways were associated with clinical outcomes in NSCLC patients treated with surgery individually and cumulatively. Further studies are necessary to elucidate our findings and translate them into the clinical setting.

Management of 1-Lung Ventilation-Variation and Trends in Clinical Practice: A Report From the Multicenter Perioperative Outcomes Group.

Lung-protective ventilation (LPV) has been demonstrated to improve clinical outcomes in surgical patients. There are very limited data on the current use of LPV for patients undergoing 1-lung ventilation (1LV) despite evidence that 1LV may be a particularly important setting for its use. In this multicenter study, we report trends in ventilation practice for patients undergoing 1LV. The Multicenter Perioperative Outcomes Group database was used to identify patients undergoing 1LV. We retrieved and calculated median initial and overall tidal volume (VT) for the cohort and for high-risk subgroups (female sex, obesity [body mass index >30 kg/m], and short stature), percentage of patients receiving positive end-expiratory pressure (PEEP) ≥5 cm H2O, LPV during 1LV (VT ≤ 6 mL/kg predicted body weight [PBW] and PEEP ≥5 cm H2O), and ventilator driving pressure (ΔP; plateau airway pressure - PEEP). Data from 5609 patients across 4 institutions were included in the analysis. Median VT was calculated for each case and since the data were normally distributed, the mean is reported for the entire cohort and subgroups. Mean of median VT during 1LV for the cohort was 6.49 ± 1.82 mL/kg PBW. VT (mL/kg PBW) for high-risk subgroups was significantly higher; 6.86 ± 1.97 for body mass index ≥30 kg/m, 7.05 ± 1.92 for female patients, and 7.33 ± 2.01 for short stature patients. Mean of the median VT declined significantly over the study period (from 6.88 to 5.72; P < .001), and the proportion of patients receiving LPV increased significantly over the study period (from 9.1% to 54.6%; P < .001). These changes coincided with a significant decrease in ΔP during the study period, from 19.4 cm H2O during period 1 to 17.3 cm H2O in period 12 (P = .003). Despite a growing awareness of the importance of protective ventilation, a large proportion of patients undergoing 1LV continue to receive VT PEEP levels outside of recommended thresholds. Moreover, VT remains higher and LPV less common in high-risk subgroups, potentially placing them at elevated risk for iatrogenic lung injury.

Effects of perioperative supplementation with pro-/synbiotics on clinical outcomes in surgical patients: A meta-analysis with trial sequential analysis of randomized controlled trials

The Potential benefits and possible risks of perioperative supplementation with probiotics/synbiotics in surgical patients are not fully understood. Recent evidence has rapidly evolved and conveys conflicting results. Thus, we undertook a meta-analysis of randomized controlled trials (RCTs) to valuate the effectiveness, safety, cost-effectiveness and quality of life of perioperative supplementation with pro-/synbiotics. We systematically searched PubMed, Embase and the Cochrane Library through October 2015 to identify RCTs that assessed the effects of perioperative supplementation with pro-/synbiotics in surgical patients. The predefined primary efficacy outcome was surgical site infection (SSI). Random-effects model was applied to pool outcome data accounting for clinical heterogeneity. Our meta-analysis included data from 34 trials comprising 2634 participants, of whom 1300 received perioperative pro-/synbiotics intervention and 1334 received valid control treatment. Compared with the control group, patients in the pro-/synbiotics group had a lower risk of SSI (relative risk: 0.65; 95% confidence interval: 0.51, 0.84; P=0.0007). Trial sequential analysis confirmed the evidence was sufficient and conclusive. Subgroup analyses indicated the findings were consistent in all subgroup analyses except for the probiotics, enteral feeding, pre-/postoperative and live transplantation subgroups. Pro-/synbiotics also reduced the incidence of other infectious complications (including any infection, pneumonia, urinary tract infection, wound infection and sepsis); shortened antibiotic therapy, intensive care unit stay and hospital stay; and promoted earlier first defecation and first bowel movement. Pro-/synbiotics further reduced the incidence of abdominal side effects, lowered hospital costs and improved the Gastro-Intestinal Quality of Life. For surgical patients, perioperative supplementation with pro-/synbiotics is effective in preventing or controlling SSI and other infectious complications. Perioperative pro-/synbiotics might also be associated with fewer side effects, lower hospital cost and better quality of life. Current evidence indicated that perioperative synbiotics supplementation is preferred and recommended as an adjunct in surgical patients.

Impact of nutritional support that does and does not meet guideline standards on clinical outcome in surgical patients at nutritional risk: a prospective cohort study.

ObjectiveTo investigate the impact of nutritional support on clinical outcomes in patients at nutritional risk who receive nutritional support that meets guideline standards and those who do not.MethodsThis prospective cohort study enrolled hospitalized patients from the Second Affiliated Hospital of Kunming Medical University from February 2010 to June 2012. The research protocols were approved by the university’s ethics committee, and the patients signed informed consent forms. The clinical data were collected based on nutritional risk screening, administration of enteral and parenteral nutrition, surgical information, complications, and length of hospital stay.ResultsDuring the study period, 525 patients at nutritional risk were enrolled in the cohorts. Among patients who received nutritional support that met the guideline standards (Cohort 1), the incidence of infectious complications was lower than that in patients who did not meet guideline standards (Cohort 2) (17.1 % vs. 26.9 %, P = 0.01). Subgroup analysis showed that individuals who received a combination of parenteral nutrition (PN) and enteral nutrition (EN) for 7 or more days had a significantly lower incidence of infectious complications (P = 0.001) than those who received only PN for 7 or more days or those who received nutritional support for less than 7 days or at less than 10 kcal/kg/d. Binary logistic regression analysis showed that, after adjusting for confounding factors, nutritional support that met guideline standards for patients with nutritional risk was a protective factor for complications (OR: 0.870, P < 0.002).ConclusionsIn patients at nutritional risk after abdominal surgery, nutritional support that meets recommended nutrient guidelines (especially regimens involving PN + EN ≥ 7 days) might decrease the incidence of infectious complications and is worth recommending; however, well-designed trials are needed to confirm our findings. Nutritional support that does not meet the guideline standards is considered clinically undesirable.

MON-PP268: Efficacy of Intravenous Fat Emulsion Containing Omega-3 Fatty Acids on Clinical Outcomes of Surgical Patients: A Meta-Analysis of Randomized Controlled Trials

MON-PP268: Efficacy of Intravenous Fat Emulsion Containing Omega-3 Fatty Acids on Clinical Outcomes of Surgical Patients: A Meta-Analysis of Randomized Controlled Trials