Postoperative Sepsis Research Articles

Surgical risks associated with winter sport tourism.

BackgroundMass tourism during winter in mountain areas may cause significant clustering of body injuries leading to increasing emergency admissions at hospital. We aimed at assessing if surgical safety and efficiency was maintained in this particular context.MethodsWe selected all emergency admissions of open surgery performed in French hospitals between 2010 and 2012. After identifying mountain areas with increasing volume of surgical stays during winter, we considered seasonal variations in surgical outcomes using a difference-in-differences study design. We computed multilevel regressions to evaluate whether significant increase in emergency cases had an effect on surgical mortality, complications and length of stay. Clustering effect of patients within hospitals was integrated in analysis and surgical outcomes were adjusted for both patient and hospital characteristics.ResultsA total of 381 hospitals had 559,052 inpatient stays related to emergency open surgery over 3 years. Compared to other geographical areas, a significant peak of activity was noted during winter in mountainous hospitals (Alps, Pyrenees, Vosges), ranging 6-77% volume increase. Peak was mainly explained by tourists’ influx (+124.5%, 4,351/3,496) and increased need for orthopaedic procedures (+36.8%, 4,731/12,873). After controlling for potential confounders, patients did not experience increased risk for postoperative death (ratio of OR 1.01, 95%CI 0.89-1.14, p = 0.891), thromboembolism (0.95, 0.77-1.17, p = 0.621) or sepsis (0.98, 0.85-1.12, p = 0.748). Length of stay was unaltered (1.00, 0.99-1.02, p = 0.716).ConclusionSurgical outcomes are not compromised during winter in French mountain areas despite a substantial influx of major emergencies.

Evaluating the effects of protective ventilation on organ-specific cytokine production in porcine experimental postoperative sepsis.

BackgroundProtective ventilation with lower tidal volume (VT) and higher positive end-expiratory pressure (PEEP) reduces the negative additive effects of mechanical ventilation during systemic inflammatory response syndrome. We hypothesised that protective ventilation during surgery would affect the organ-specific immune response in an experimental animal model of endotoxin-induced sepsis-like syndrome.Methods30 pigs were laparotomised for 2 hours (h), after which a continuous endotoxin infusion was started at 0.25 micrograms × kg−1 × h−1 for 5 h. Catheters were placed in the carotid artery, hepatic vein, portal vein and jugular bulb. Animals were randomised to two protective ventilation groups (n = 10 each): one group was ventilated with VT 6 mL × kg−1 during the whole experiment while the other group was ventilated during the surgical phase with VT of 10 mL × kg−1. In both groups PEEP was 5 cmH2O during surgery and increased to 10 cmH2O at the start of endotoxin infusion. A control group (n = 10) was ventilated with VT of 10 mL × kg−1 and PEEP 5 cm H20 throughout the experiment. In four sample locations we a) simultaneously compared cytokine levels, b) studied the effect of protective ventilation initiated before and during endotoxemia and c) evaluated protective ventilation on organ-specific cytokine levels.ResultsTNF-alpha levels were highest in the hepatic vein, IL-6 levels highest in the artery and jugular bulb and IL-10 levels lowest in the artery. Protective ventilation initiated before and during endotoxemia did not differ in organ-specific cytokine levels. Protective ventilation led to lower levels of TNF-alpha in the hepatic vein compared with the control group, whereas no significant differences were seen in the artery, portal vein or jugular bulb.ConclusionsVariation between organs in cytokine output was observed during experimental sepsis. We see no implication from cytokine levels for initiating protective ventilation before endotoxemia. However, during endotoxemia protective ventilation attenuates hepatic inflammatory cytokine output contributing to a reduced total inflammatory burden.

Improving Outcomes in Colorectal Surgery by Sequential Implementation of Multiple Standardized Care Programs

The purpose of this study was to examine the impact of the sequential implementation of the enhanced recovery program (ERP) and surgical site infection bundle (SSIB) on short-term outcomes in colorectal surgery (CRS) to determine if the presence of multiple standardized care programs provides additive benefit. Institutional ACS-NSQIP data were used to identify patients who underwent elective CRS from September 2006 to March 2013. The cohort was stratified into 3 groups relative to implementation of the ERP (February 1, 2010) and SSIB (July 1, 2011). Unadjusted characteristics and 30-day outcomes were assessed, and inverse proportional weighting was then used to determine the adjusted effect of these programs. There were 787 patients included: 337, 165, and 285 in the pre-ERP/SSIB, post-ERP/pre-SSIB, and post-ERP/SSIB periods, respectively. After inverse probability weighting (IPW) adjustment, groups were balanced with respect to patient and procedural characteristics considered. Compared with the pre-ERP/SSIB group, the post-ERP/pre-SSIB group had significantly reduced length of hospitalization (8.3 vs 6.6 days, p = 0.01) but did not differ with respect to postoperative wound complications and sepsis. Subsequent introduction of the SSIB then resulted in a significant decrease in superficial SSI (16.1% vs 6.3%, p < 0.01) and postoperative sepsis (11.2% vs 1.8%, p < 0.01). Finally, inflation-adjusted mean hospital cost for a CRS admission fell from $31,926 in 2008 to $22,044 in 2013 (p < 0.01). Sequential implementation of the ERP and SSIB provided incremental improvements in CRS outcomes while controlling hospital costs, supporting their combined use as an effective strategy toward improving the quality of patient care.

Risk of Sepsis in the Postoperative Setting [48

INTRODUCTION: Sepsis, a systemic inflammatory response syndrome (SIRS) associated with infection, can have severe complications. State reimbursement programs have instituted pay-for-performance initiatives to improve sepsis diagnosis and management. More than 75% of surgical intensive care unit patients develop SIRS; however, no data exist on the relationship between SIRS and sepsis in the routine postoperative setting. We aim to evaluate the incidence and risk factors for SIRS and sepsis postoperatively. METHODS: We conducted a prospective cohort study of adults admitted after abdominopelvic surgery at a university-affiliated county hospital. An electronic medical record query of inpatients having at least two concurrent abnormal vital signs identified those who developed SIRS postoperatively. Bivariate and regression analyses assessed factors affecting risk. RESULTS: Among 861 eligible patients, SIRS was found in 8.7%; for those with SIRS, sepsis occurred in 42.1%, severe sepsis in 6.7%, and septic shock in 4.0%. Sepsis spectrum disorders were more commonly associated with emergent than with elective surgery (7.3% compared with 2.4%, P=.001). There was a trend toward progressively increased length of stay (LOS) for patients with SIRS, sepsis alone, severe sepsis, and septic shock at 5.5, 5.7, 7.0, and 13.0 days, respectively. Only 6.5% of patients meeting medical criteria for sepsis were given an International Classification of Diseases, 9th Revision code for sepsis in their discharge summaries. CONCLUSION: Although postoperative SIRS is uncommon, more than half of the patients with SIRS will develop a sepsis spectrum disorder. We observed a strong correlation between sepsis, emergency surgery, and LOS. Future studies should evaluate the effect of risk-reducing interventions on the severity of postoperative sepsis.

Statin Use and Risk of Sepsis After Percutaneous Nephrolithotomy.

To examine the association between statin medication use and sepsis risk after percutaneous nephrolithotomy (PCNL). Using medical claims data, we identified working-age adults with urinary stone disease who were treated with PCNL. Among this cohort, we determined which patients had a prescription fill for a statin agent that encompassed their surgery date. We then fitted logistic regression models to examine for differences in rates of postoperative sepsis between statin users and nonusers. In addition, we evaluated the frequency of nonfebrile urinary tract infections (UTIs) and intensive care unit (ICU) services utilization and hospital length of stay (LOS) as a function of statin use. During the study period, at total of 2046 patients underwent PCNL, 382 (18.7%) of whom had a prescription fill for a statin agent preceding their surgery. The overall rate of sepsis in this population was 3.8%. After adjusting for patient health status and sociodemographic factors, the rate of postoperative sepsis was comparable between statin users and nonusers (5.3% vs 3.5%, respectively; P=0.105). In addition, UTI and ICU utilization rates did not relate to statin use (P>0.05 for all associations). Adjusted hospital LOS was shorter among statin users, but the difference was clinically trivial (3.6 vs 4.1 days; P=0.007). Statin use is not associated with reductions in postoperative sepsis, nonfebrile UTIs, ICU utilization, or hospital LOS after PCNL. To increase the safety of PCNL, urologists will have to consider other processes of care (e.g., clinical care pathways).

Paraplegic and quadriplegic patients undergoing emergency abdominal surgery: sicker presentations, worse outcomes.

Patients with paraplegia or quadriplegia presenting with abdominal surgical emergencies pose major clinical challenges. Difficulties in prompt diagnosis and treatment may influence patient outcomes. This is an American College of Surgeons National Surgical Quality Improvement Program study of patients undergoing an emergent abdominal operation. Patients were stratified into paraplegic (PARA), quadriplegic (QUAD), and control (CONT). PARA and QUAD groups were matched with controls by 1:2 ratio. Regression models were used to analyze the effect of paraplegia and quadriplegia on outcome. A total of 76,766 patients underwent emergent abdominal operations: 274 PARA, 132 QUAD, and 76,356 CONT patients. Lower gastrointestinal operations were the most common procedures in PARA and QUAD groups; appendectomy was the most common in the CONT group. After cohort matching, patients with cord paralysis were significantly more likely to present with severe sepsis, have "infected" wounds at operation, and have increased rates of postoperative sepsis and need for reoperation. Patients with paraplegia or quadriplegia with acute abdominal surgical emergencies are more likely to present late and have a significantly higher incidence of postoperative septic complications and longer hospital stay. Early surgical consultation and aggressive evaluation and postoperative management are warranted in these populations. Epidemiologic study, level III; therapeutic study, level IV.

MP80-04 CULTURING THE RIGHT MICROORGANISMS IN PATIENTS UNDERGOING PERCUTANEOUS NEPHROLITHOTOMY (PCNL) AND FLEXIBLE URETEROSCOPY (FURS) FOR RENAL STONES – CAN WE DO ANY MORE?

You have accessJournal of UrologyStone Disease: Evaluation II1 Apr 2015MP80-04 CULTURING THE RIGHT MICROORGANISMS IN PATIENTS UNDERGOING PERCUTANEOUS NEPHROLITHOTOMY (PCNL) AND FLEXIBLE URETEROSCOPY (FURS) FOR RENAL STONES – CAN WE DO ANY MORE? Rehan Khan, Sarah Hunt, Holly Bekarma, Alison Ramsay, and Sarath Krishna Nalagatla Rehan KhanRehan Khan More articles by this author , Sarah HuntSarah Hunt More articles by this author , Holly BekarmaHolly Bekarma More articles by this author , Alison RamsayAlison Ramsay More articles by this author , and Sarath Krishna NalagatlaSarath Krishna Nalagatla More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2015.02.2840AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES PCNL and FURS for renal stones can be a morbid procedure in view of urosepsis. Endourologists treat all positive pre-operative urine cultures with appropriate antibiotics. However, patients can still develop sepsis in the post-operative period and knowledge of the right microorganisms is not only invaluable but can also be lifesaving. Intraoperative stone cultures described as a tool to cultures the right microorganisms. Aim of this study is to assess if post op urine cultures add any information regarding culturing the right microorganisms in patients undergoing PCNL and FURS for renal stones. METHODS We prospectively collected data for patient undergoing PCNL and FURS for renal stones in our unit between August 2013 and May 2014. Demographics, details about pre-operative urine, intra- operative stone as well as post-operative urine culture were collected. Data was analysed to assess positive culture rates in each group and specifically assessed if post op urine cultures add anything to our microbiological information. RESULTS Data was collected for a total of 60 patients over the study period of 10 month period. Subsequently, only patients who had information available regarding pre-operative urine culture, intra-operative stone culture and postoperative urine cultures were included. This criteria led to exclusion of 19 patients and 41 patients were included in the final analysis. Mean age was 57 years with age range of 26 to 86 years. Pre-operative urine culture was positive in 13/41 patients (32). Intraoperative stone culture was positive in 8/41 patients (20%). Postoperative urine culture was positive in 6/41 patients (15%). One patient had exclusively postoperative urine culture and negative pre-operative urine and intraoperative stone culture and this correlated with postoperative sepsis. CONCLUSIONS Our study indicates that postoperative urine cultures add to our knowledge regarding the right microorganisms in patients undergoing PCNL and FURS for kidney stones and should be carried out routinely to allow appropriate management of postoperative urinary sepsis. © 2015 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 193Issue 4SApril 2015Page: e1020 Advertisement Copyright & Permissions© 2015 by American Urological Association Education and Research, Inc.MetricsAuthor Information Rehan Khan More articles by this author Sarah Hunt More articles by this author Holly Bekarma More articles by this author Alison Ramsay More articles by this author Sarath Krishna Nalagatla More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

PD8-06 PERIOPERATIVE BLOOD TRANSFUSIONS AS A RISK FACTOR FOR INFECTIOUS COMPLICATIONS AFTER UROLOGIC SURGERY

You have accessJournal of UrologyInfections/Inflammation of the Genitourinary Tract: Kidney & Bladder I1 Apr 2015PD8-06 PERIOPERATIVE BLOOD TRANSFUSIONS AS A RISK FACTOR FOR INFECTIOUS COMPLICATIONS AFTER UROLOGIC SURGERY Richard Matulewicz, Daniel Oberlin, Irene Helenowski, Borko Jovanovic, and Shilajit Kundu Richard MatulewiczRichard Matulewicz More articles by this author , Daniel OberlinDaniel Oberlin More articles by this author , Irene HelenowskiIrene Helenowski More articles by this author , Borko JovanovicBorko Jovanovic More articles by this author , and Shilajit KunduShilajit Kundu More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2015.02.921AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Several studies have associated perioperative blood transfusions (BT) with significantly increased postoperative infection rates. The effect of BT on infection appears to be related to the state of immunosuppression it induces. We investigated the risk of short-term post-operative infectious outcomes of urologic surgery with perioperative BT. METHODS We identified patients undergoing the thirty most common urologic surgeries captured by the ACS-NSQIP database from 2006 to 2012. The association of preoperative and intraoperative/post operative transfusions with infectious outcomes (surgical site infections (SSI), urinary tract infection (UTI), pneumonia, sepsis/septic shock) was assessed by Chi-square test with continuity correction. Multivariate logistic regression controlling for diabetes, chronic steroid use, recent chemotherapy, and operative wound classification provided odds ratios for infectious outcomes. RESULTS A total of 41,858 cases of the 30 most common urologic operations were reviewed. 30,651 (73.2%) cases met inclusion criteria for review. 0.5% (157/30651) of patients had a transfusion of at least 1 unit of packed red blood cells (pRBC) within 72 hours prior to surgery. 3.7% (1133/30651) of patients received a BT of at least 1 unit pRBC intraoperatively or within 72 hours postoperatively. Multivariate analysis, controlling for potential confounding risks factors, found that preoperative transfusion is associated with a significantly increased risk of pneumonia, UTI, and post-operative sepsis (p<0.01, Table 1). Intraoperative and post-operative transfusion is associated with both superficial and deep SSI, organ space infection, UTI, and post-operative sepsis, including septic shock (p <0.01). CONCLUSIONS Although blood transfusions are beneficial in select patients with perioperative anemia, our study shows that BT is associated with a significantly increased risk of post-operative infectious complications. We found an increase risk of SSI, pneumonia, and sepsis among transfused patients undergoing urologic surgery. Prudent use of BT can potentially mitigate infectious complications. Transfusion Timing Infectious Outcome Odds Ratio Confidence Interval (95%) p value Preoperative Pneumonia 4.0 1.4-11.0 < 0.01 UTI 2.2 1.2-4.1 0.01 Postop Sepsis 2.9 1.2-7.2 0.02 Intraoperative/Postoperative Superficial SSI 4.7 3.2-6.9 < 0.01 Deep SSI 5.4 2.5-11.5 < 0.01 Organ Space Infection 8.0 5.1-12.7 < 0.01 Pneumonia 6.7 4.6-9.8 < 0.01 UTI 1.9 1.5-2.5 < 0.01 Postop Sepsis 6.4 4.8-8.7 < 0.01 Postop Septic Shock 5.6 3.3-9.6 < 0.01 © 2015 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 193Issue 4SApril 2015Page: e192 Advertisement Copyright & Permissions© 2015 by American Urological Association Education and Research, Inc.MetricsAuthor Information Richard Matulewicz More articles by this author Daniel Oberlin More articles by this author Irene Helenowski More articles by this author Borko Jovanovic More articles by this author Shilajit Kundu More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

PD9-09 ANALYSIS OF PERIOPERATIVE OUTCOMES FOR PROCEDURES INVOLVING URINARY DIVERSION USING THE NATIONAL SURGICAL QUALITY IMPROVEMENT PROGRAM (NSQIP) DATABASE

You have accessJournal of UrologyUrinary Diversion: Bladder Reconstruction, Augmentation, Substitution, Diversion I1 Apr 2015PD9-09 ANALYSIS OF PERIOPERATIVE OUTCOMES FOR PROCEDURES INVOLVING URINARY DIVERSION USING THE NATIONAL SURGICAL QUALITY IMPROVEMENT PROGRAM (NSQIP) DATABASE Robert C. Kovell, David C. Brooks, Devin A. Haddad, Ahmed A. Aboumohamed, and Ryan P. Terlecki Robert C. KovellRobert C. Kovell More articles by this author , David C. BrooksDavid C. Brooks More articles by this author , Devin A. HaddadDevin A. Haddad More articles by this author , Ahmed A. AboumohamedAhmed A. Aboumohamed More articles by this author , and Ryan P. TerleckiRyan P. Terlecki More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2015.02.936AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Surgeries requiring urinary diversion have been associated with high rates of perioperative morbidity and mortality. Understanding factors that contribute to the risks of these surgeries is important for improving surgical outcomes and properly counseling patients. METHODS Using the National Surgical Quality Improvement Program (NSQIP) database, we identified patients undergoing urinary diversion using a bowel segment, with or without cystectomy, performed between 2010 and 2012. We compared preoperative characteristics, surgical parameters and 30-day postoperative outcomes. We stratified patients based on the continence status of the diversion, incontinent (ID) v continent (CD). Statistical significance was assessed using chi square, t-test and ANOVA. RESULTS We identified 1959 urinary diversions in the NSQIP database: 1568 IDs (80.0%) and 391 CDs (20.0%). Concomitant cystectomy was performed with 1468 (93.6%) IDs and 374 (95.7%) CDs. Among various preoperative characteristics analyzed, higher rates of COPD (4.4% v 9.1%), previous cardiac surgery (1.8% v 4.3%), HTN (47% v 63%), and metastatic cancer (2.1% v 4.7%) were associated with patients undergoing ID. Pre-operative creatinine levels were higher in patients undergoing ID (1.08 v 1.19 mg/dL). CD patients were more likely to have undergone pre-operative chemotherapy (10.5% v 5.5%). Operative time was longer for CDs (388 min v 336 min). Post-operative UTI (13.8% v 7.9%) and sepsis rates (11.5% v 7.9%) were significantly higher in CDs, whereas transfusion rates were higher with IDs (37.1% v 45.2%). No differences were observed in the rates of thromboembolic events or postoperative renal insufficiency. Thirty day readmission rates (18.2% v 15.5%), length of stay (10.2 v 10.7 days), occurrence of any NSQIP captured complication (57.5% v 60.1%) and mortality (1.5% v 2.1%) were not statistically different between CD and ID. CONCLUSIONS Surgeries involving urinary diversion continue to have significant morbidity. While continent diversion offers patients a number of long term advantages, these must be balanced against longer operative times and higher rates of post-operative infectious complications. © 2015 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 193Issue 4SApril 2015Page: e198 Advertisement Copyright & Permissions© 2015 by American Urological Association Education and Research, Inc.MetricsAuthor Information Robert C. Kovell More articles by this author David C. Brooks More articles by this author Devin A. Haddad More articles by this author Ahmed A. Aboumohamed More articles by this author Ryan P. Terlecki More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

Profile of plasma amino acids values as a predictor of sepsis in patients following living donor liver transplantation: Special reference to sarcopenia and postoperative early nutrition.

Sarcopenia is an independent predictor of mortality and sepsis after living donor liver transplantation (LDLT). However, the exact mechanisms by which sarcopenia affects poor prognosis or worse immunity against postoperative sepsis are unclear, particularly regarding muscular amino acid metabolism, and the authors aimed to identify the role of plasma amino acids in sarcopenia by retrospective study. The area of the psoas muscle in 228 recipients of LDLT was retrospectively measured by dynamic computed tomography. Additionally, plasma amino acid levels were measured both pre- and postoperatively. The impact of plasma amino acids for postoperative sepsis and the relationship between sarcopenia and early nutrition after LDLT were analyzed. Among the plasma amino acids, only leucine, isoleucine and glutamine in patients with sarcopenia were significantly lower than those without sarcopenia (each, P < 0.05). Multivariate analysis identified the lower plasma glutamine levels as a risk factor of postoperative sepsis after LDLT (odds ratio 5.371, P = 0.002). In sarcopenia patients, plasma glutamine levels after LDLT were significantly decreased compared with before LDLT in patients both with and without postoperative early nutrition. However, in non-sarcopenia patients with early nutrition, plasma glutamine levels after LDLT were comparable with those before LDLT. This is the first report to study the profile of plasma amino acid change before and after LDLT. Low preoperative glutamine values were an independent risk factor for predicting postoperative sepsis. The efficacy of postoperative early nutrition may prevent postoperative sepsis by improving glutamine levels.

Analysis of Prognostic Factors and Mortality in Children with Esophageal Atresia.

The survival rate in newborns with congenital esophageal atresia (EA) is about 85-90 %, and it raises over 95 % in the developed countries. The survival rate in developing countries is much lower and the authors describe their experience with 60 newborns. Medical records of 60 newborns (40 boys and 20 girls) with congenital EA were reviewed for the prognostic factors and mortality. The birth weight, mean Apgar score (AS) value, gestational age and birth-operative treatment time had significant influence on the mortality of treated patients (p < 0.05). Thirty five percent newborns had aspirational pneumonia at the moment of hospitalization and 86.7 % of them were operated during the first 48 h. The presence of associated anomalies considerably affected the death rate of treated patients (p < 0.05). The incidence of postoperative complications was similar to those in developed countries but the total mortality was higher (28.3 %); sepsis being the main cause of mortality. The postoperative complications and sepsis significantly influenced the mortality of patients (p < 0.05). Total mortality in newborns with EA was high; sepsis being the most frequent cause of death. The high total mortality was also caused by prematurity, delay in diagnosis, increased incidence of the aspiration pneumonia and shortage of qualified nurses.

Insights into temporal patterns of hospital patient safety from routinely collected electronic data.

BackgroundThe last two decades have seen an unprecedented growth in initiatives aimed to improve patient safety. For the most part, however, evidence of their impact remains controversial. At the same time, the healthcare industry has experienced an also unprecedented growth in the amount and variety of available electronic data.MethodsIn this paper, we provide a review of the use of routinely collected electronic data in the identification, analysis and surveillance of temporal patterns of patient safety.ResultsTwo important temporal patterns of the safety of hospitalised patients were identified and discussed: long-term trends related to changes in clinical practice and healthcare policy; and shorter term patterns related to variations in workforce and resources. We found that consistency in reporting is intrinsically related to availability of large-scale, fit-for-purpose data. Consistent reported trends of patient harms included an increase in the incidence of post-operative sepsis and a decrease in central-line associated bloodstream infections. Improvement in the treatment of specific diseases, such as cardiac conditions, has also been demonstrated. Linkage of hospital data with other datasets provides essential temporal information about errors, as well as information about unsuspected system deficiencies. It has played an important role in the measurement and analysis of the effects of off-hours hospital operation.ConclusionsMeasuring temporal patterns of patient safety is still inadequate with electronic health records not yet playing an important role. Patient safety interventions should not be implemented without a strategy for continuous monitoring of their effect.

English

AIMS AND OBJECTIVES: Maternal death is a preventable tragedy. The aim of this study is to analyze the causes of maternal mortality in a tertiary centre. MATERIAL AND METHODS: The study was conducted by reviewing the records for maternal deaths over the period of one year 1-08- 2013 to 31-07-2014 in the Department of Obstetrics and Gynecology, Guntur Medical College, Guntur. Every maternal death was scrutinized for various aspects likely to be related to death such as age, locality of residence, antenatal care, admission death interval and the cause of death. RESULTS: The maternal mortality in the present study is 788/ 1 lakh live births. There were 62 maternal deaths in the study period. Most deaths occurred in the 20-25 age group. 51.6% of deaths occurred in the first seventy two hours after admission. Hypertensive disorders (25.80%) and hemorrhage (12.5%) are the two most common direct causes of maternal death. Post-operative and post abortal sepsis, amniotic fluid embolism, pulmonary embolism and peripartum cardiomyopathy are the other direct causes. Indirect causes of maternal deaths were seen in 34.9% of the cases. Hepatitis (9.64%), severe anemia is the two leading indirect causes of maternal deaths. CONCLUSION: Most of the maternal deaths can be prevented if the high risk antenatal women are identified earlier and referred to the

Is It Safe and Effective to Lengthen a Chin With Interpositional Allogenic (Iliac) Graft?

This is a retrospective review of a consecutive series of patients undergoing chin lengthening at the time of orthognathic surgery over a 3-year timeframe. The genioplasty procedures studied included lengthening to the extent that an interpositional graft was deemed necessary (n = 19). Allogenic (iliac) corticocancellous bone was used in all cases. Each patient underwent lateral cephalometric radiography within 2 months before and 5 weeks after surgery. From the radiographs, quantitative measurements (millimeters) were made to document the vertical lengthening and horizontal advancement achieved. Chin region wound healing parameters were reviewed to document evidence of infection, sequestra, need for reoperation, and evidence of fibrous union. Inpatient hospital and outpatient office records were reviewed for any evidence of sepsis or viral transmission. The patients' mean age at operation was 35 years (range, 15 to 58 yr). Analysis of preoperative and 5-week postoperative radiographs documented a mean vertical lengthening of 7 mm (range, 4 to 10 mm). The mean horizontal advancement at the pogonion was confirmed to be 2 mm (range, 1 to 3 mm). None of the study patients sustained chin region infection graft sequestra, fibrous union, or need for reoperation. There were no cases of postoperative sepsis or viral illness to indicate systemic infectious sequelae. The study confirms the safety of allogenic (iliac) corticocancellous grafting to fill interpositional defects associated with a transverse symphyseal lengthening osteotomy.

Functional Compromise Reflected by Sarcopenia, Frailty, and Nutritional Depletion Predicts Adverse Postoperative Outcome After Colorectal Cancer Surgery

To determine the association of sarcopenia with postoperative morbidity and mortality after colorectal surgery. Functional compromise in elderly colorectal surgical patients is considered as a significant factor of impaired postoperative recovery. Therefore, the predictive value of preoperative functional compromise assessment was investigated. Sarcopenia is a hallmark of functional compromise. A total of 310 consecutive patients who underwent oncologic colorectal surgery were included in a prospective digital database. Sarcopenia was assessed using the L3 muscle index utilizing Osirix on preoperative computed tomography. Groningen Frailty Indicator and Short Nutritional Assessment Questionnaire scores were used to assess frailty and nutritional compromise. Predictors for anastomotic leakage, sepsis, and mortality were analyzed by logistic regression analysis. Age was an independent predictor of mortality [P = 0.04; odds ratio, 1.17; 95% confidence interval (CI), 1.01-1.37]. Thirty-day/in-hospital mortality rate in sarcopenic patients was 8.8% versus 0.7% in nonsarcopenic patients (P = 0.001; odds ratio, 15.5; 95% CI, 2.00-120). Sarcopenia was not predictive for anastomotic leakage or sepsis. Combination of high Short Nutritional Assessment Questionnaire score, high Groningen Frailty Indicator score, and sarcopenia strongly predicted sepsis (P = 0.001; odds ratio, 25.1; 95% CI, 5.11-123), sensitivity, 46%; specificity, 97%; positive likelihood ratio, 13 (95% CI, 4.4-38); negative likelihood ratio, 0.57 (95% CI, 0.33-0.97). Functional compromise in colorectal cancer surgery is associated with adverse postoperative outcome. Assessment of functional compromise by means of a nutritional questionnaire (Short Nutritional Assessment Questionnaire), a frailty questionnaire (Groningen Frailty Indicator), and sarcopenia measurement (L3 muscle index) can accurately predict postoperative sepsis.

Cell salvage in emergency trauma surgery

Trauma is the leading cause of death in people under the age of 45 years. Over the past 20 years, intraoperative autologous transfusions (obtained by cell salvage, also known as intraoperative blood salvage (IBS)) have been used as an alternative to blood products from other individuals during surgery because of the risk of transfusion-related infections such as hepatitis and human immunodeficiency virus (HIV). In this review, we sought to assess the effects and cost of cell salvage in individuals undergoing abdominal or thoracic surgery. To compare the effect and cost of cell salvage with those of standard care in individuals undergoing abdominal or thoracic trauma surgery. We ran the search on 25 November 2014. We searched the Cochrane Injuries Group's Specialised Register, Cochrane Central Register of Controlled Trials (CENTRAL, The Cochrane Library), Ovid MEDLINE, Ovid MEDLINE In-Process & Other Non-Indexed Citations, Ovid MEDLINE Daily and Ovid OLDMEDLINE, EMBASE Classic + EMBASE (OvidSP), PubMed, and ISI Web of Science (SCI-Expanded & CPSI-SSH). We also screened reference lists and contacted principal investigators. Randomised controlled trials comparing cell salvage with no cell salvage (standard care) in individuals undergoing abdominal or thoracic trauma surgery. Two authors independently extracted data from the trial reports. We used the standard methodological procedures expected by The Cochrane Collaboration. Only one small study (n = 44) fulfilled the inclusion criteria. Results suggested that cell salvage did not affect mortality overall (death rates were 67% (14/21 participants) in the cell salvage group and 65% (15/23) in the control group) (odds ratio (OR) 1.07, 95% confidence interval (CI) 0.31 to 3.72). For individuals with abdominal injury, mortality was also similar in both groups (OR 0.48, 95% CI 0.11 to 2.10).Less donor blood was needed for transfusion within the first 24 hours postinjury in the cell salvage group compared with the control group (mean difference (MD) -4.70 units, 95% CI -8.09 to -1.31). Adverse events, notably postoperative sepsis, did not differ between groups (OR 0.54, 95% CI 0.11 to 2.55). Cost did not notably differ between groups (MD -177.81, 95% CI -452.85 to 97.23, measured in GBP in 2002). Evidence for the use of cell salvage in individuals undergoing abdominal or thoracic trauma surgery remains equivocal. Large, multicentre, methodologically rigorous trials are needed to assess the relative efficacy, safety and cost-effectiveness of cell salvage in different surgical procedures in the emergency context.

Percutaneous nephrolithotomy for infection stones: what is the risk for postoperative sepsis? A retrospective cohort study.

The purpose of this study was to compare the postoperative course of patients with positive stone culture (SC) to patients with sterile SC, and to analyze the predictors for post percutaneous nephrolithotomy (PCNL) sepsis; and to describe the type and resistance patterns of bacteria responsible for post PCNL sepsis. From a cohort of 206 consecutive patients undergoing PCNL, we identified 45 patients with a positive SC (group A) and compared them to patients with a sterile SC (group B). Association between different groups was assessed using Chi square, two-tailed Student's t test and Mann-Whitney U test, as appropriate. Twenty-three patients had postoperative sepsis and regression analysis was performed to identify clinical variables associated with sepsis. Demographics, stone load and hospitalization time were similar in both groups. Postoperative sepsis developed in 31.1% of patients in group A compared to 5.9% in group B. In multivariate analysis, only positive SC was an independent risk factor for postoperative sepsis (OR 6.894, 95% CI 2.31-20.59, P = 0.001). All patients responded well to treatment with no septic complications. Enterococci were the prevalent organism (29.4%) in patients with a positive SC. Quinolone resistance was high in both gram negative and gram positive bacteria. Patients with an infected stone are at high risk to develop postoperative sepsis despite standard preoperative antibiotic preparation. SC is important to direct further treatment as almost half of patients with positive SC have a discordant or sterile urine culture. Determining the prevalent bacteria and resistance patterns in SC can aid the selection of empiric antibiotic therapy in high-risk patients.

Preoperative Determinants of Outcomes of Infant Heart Surgery in a Limited-Resource Setting

We studied the effect of preoperative determinants on early outcomes of 1028 consecutive infant heart operations in a limited-resource setting. Comprehensive data on pediatric heart surgery (January 2010-December 2012) were collected prospectively. Outcome measures included in-hospital mortality, prolonged ventilation (>48 hours), and bloodstream infection (BSI) after surgery. Preoperative variables that showed significant individual association with outcome measures were entered into a logistic regression model. Weight at birth was low in 224 infants (21.8%), and failure to thrive was common (mean-weight Z score at surgery was 2.72 ± 1.7). Preoperatively, 525 infants (51%) needed intensive care, 69 infants (6.7%) were ventilated, and 80 infants (7.8%) had BSI. In-hospital mortality (4.1%) was significantly associated with risk adjustment for congenital heart surgery-1 (RACHS-1) risk category (P < 0.001). Neonatal status, preoperative BSI, and requirement of preoperative intensive care and ventilation had significant individual association with adverse outcomes, whereas low birth weight, prematurity, and severe failure to thrive (weight Z score <-3) were not associated with adverse outcomes. On multivariable logistic regression analysis, preoperative sepsis (odds ratio = 2.86; 95% CI: 1.32-6.21; P = 0.008) was associated with mortality. Preoperative intensive care unit stay, ventilation, BSI, and RACHS-1 category were associated with prolonged postoperative ventilation and postoperative sepsis. Neonatal age group was additionally associated with postoperative sepsis. Although severe failure to thrive was common, it did not adversely affect outcomes. In conclusions, preoperative BSI, preoperative intensive care, and mechanical ventilation are strongly associated with adverse outcomes after infant cardiac surgery in this large single-center experience from a developing country. Failure to thrive and low birth weight do not appear to adversely affect surgical outcomes.

Audit of sepsis in neonatal surgeries at tertiary-care level hospital in India

Background: Postoperative sepsis, which has high morbidity and mortality, is a major problem affecting the outcome of neonatal surgeries. Adequate treatment and preventive measures for sepsis can decrease the morbidity and mortality in neonatal surgeries. Objective: (1) To study the incidence of sepsis in neonatal surgical patients and (2) To study the causative organisms and their sensitivity to antibiotics in such sepsis. Materials and Methods: A prospective, observational study was carried out in the tertiary-care level neonatal intensive care unit of SSG Hospital, Vadodara, Gujarat. Eighty newborns having a major surgery within the first 30 days of life were included in the study. Baseline data of the study participants were collected including antenatal and perinatal histories and evidence of postoperative sepsis. Complete examination and investigations including quantitative C-reactive protein (QCRP), WBC counts, blood culture, and treatment were also included. Conclusion: Incidence of postoperative sepsis in neonates was found to be 73.75%. We found coagulase-negative Staphylococcus aureus to be the most common organism (38%) cultured from blood, followed by Klebsiella (19%) and Acinetobactor (18.2%), which was sensitive to cefotaxime, amikacin, and piperacillin/tazobactam.

A study on positive stone culture and its association with rate of sepsis after urological procedures

Background: This prospective study is carried out to determine if there is a correlation between urine and/or stone cultures with postoperative sepsis in patients treated for renal and ureteral calculi. And to determine the correlation between different sites of urine sampling, including stones, and also ascertained which is more predictive of urosepsis. Correlation of urosepsis with prognosis and final outcome of patients of urolithiasis. Methods: This prospective study was carried out in Department of surgery, Gandhi medical collage Bhopal and associated Hamidia hospital Bhopal between July 2013 to October 2014. All patients are divided in 4 groups according to their diagnosis. Results: The incidence of renal stone was more in male (N 67) (67%) as compared with female (N 33) (33%) i.e., in the ratio of 2:1. Out of 100 patients 45 cases showed infection in preoperative urine culture, while rest 55 were sterile. Similarly 65 patients were positive for stone culture and rest 35 were sterile. 30 patients had both stone and urine culture positive. Infected urine was more common in females (66.67%). Most common bacteria isolated in urine culture were E. coli (24.44%), Klebsiella (17.77%). While correlating the result of concurrent bacteriological analysis of stones and urine culture, it is evident that same organisms from urine culture and stone culture were isolated in 8 (17.77% of positive urine culture) cases but different organisms in 26 (57.77% positive urine culture) cases. Post operatively 37% (N 37) patient show signs of SIRS out of which 17 patients had both preoperative urine and post-operative stone core culture positive. 14 Patient had only stone core culture positive, 5 pt had only urine culture positivity, and in one patient both culture were negative. Out of 37 patients who had sepsis 31 patients were positive for stone culture while 23 patients were positive for urine culture. The result was significant on chi square test (Observed P value is 0.036). Conclusions: The results of this study suggest that in patients undergoing surgery for urolithiasis, stone cultures are better predictors of urosepsis than bladder urine C and S. Positive stone culture may guide clinicians regarding selection of antibiotics, especially in cases of severe urosepsis.