Surgery News
Insurance Coverage Is Associated with Mortality after Gunshot Trauma
An article in this months American College of Surgeons hypothesized that insurance coverage is also associated with mortality after gunshot trauma and found that Despite similar injury severity, uninsured trauma patients were more likely to die after gunshot injury than insured patients. The in-hospital mortality rate was significantly higher for uninsured patients than for insured patients (9% vs 6%, p = 0.02). After controlling for age, gender, race, and injury severity by logistic regression analysis, the odds ratio for death of uninsured patients was 2.2 (95% CI 1.1 to 4.5).
Therapeutic role of water-soluble contrast agent in adhesive small bowel obstruction
A meta-analysis out of the British Journal of Surgery assessed the diagnostic and therapeutic role of water-soluble contrast agent (WSCA) in adhesive small bowel obstruction (SBO). The appearance of contrast in the colon within 4-24 h after administration had a sensitivity of 96 per cent and specificity of 98 per cent in predicting resolution of SBO. It concluded that water-soluble contrast was effective in predicting the need for surgery in patients with adhesive SBO. In addition, it reduced the need for operation and shortened hospital stay.
Risk Factors for Treatment Failure in Patients Receiving Vancomycin for Hospital-Acquired Methicillin-Resistant Staphylococcus aureus Pneumonia
The rate of vancomycin failure in patients with hospital-acquired pneumonia (HAP) caused by methicillin-resistant Staphylococcus aureus (MRSA) has exceeded 40% in several studies. This observation was attributed initially to the lack of weight-based dosing and targeting of lower trough concentrations. However, a subsequent study demonstrated no additional benefit in patients who achieved trough vancomycin concentrations >15mg/L compared with patients with concentrations between 5 and 15mg/L. A study out of Surgical Infections sought to identify contributors to vancomycin failure in patients with MRSA HAP and found data suggest that patients who have recent exposure to vancomycin are at high risk for vancomycin failure and may benefit from an appropriate alternative when a diagnosis of MRSA HAP is made.
Benefits shown with early versus delayed laparoscopic cholecystectomy for acute cholecystitis
In many countries laparoscopic cholecystectomy for acute cholecystitis is mainly performed after the acute episode has settled because of the anticipated increased risk of morbidity and higher conversion rate from laparoscopic to open cholecystectomy.A systematic review was performed with meta-analysis of randomized clinical trials of early laparoscopic cholecystectomy (ELC; performed within 1 week of onset of symptoms) versus delayed laparoscopic cholecystectomy (performed at least 6 weeks after symptoms settled) for acute cholecystitis. Five trials with 451 patients were included. There was no significant difference between the two groups in terms of bile duct injury or conversion to open cholecystectomy. The total hospital stay was shorter by 4 days for ELC.
Study suggests use of anitbiotic lavage in peritonitis increases survival
Morbidity and mortality associated with bacterial peritonitis remain a challenge for contemporary surgery. Despite great surgical improvements, death rates have not improved. A secondary debate concerns the volume and nature of peritoneal lavage or washout - what volume, what carrier and what, if any, antibiotic or antiseptic? In an experimental peritonitis setting a mortality rate of 48·9 per cent was found for saline lavage compared with 16·4 per cent for antibiotic lavage.
Chlorhexidine–Alcohol versus Povidone–Iodine for Surgical-Site Antisepsis
A new study from the New England Journal of Medicine hypothesized that preoperative skin cleansing with chlorhexidine–alcohol is more protective against infection than is povidone–iodine. The primary outcome was any surgical-site infection within 30 days after surgery. Secondary outcomes included individual types of surgical-site infections. The overall rate of surgical-site infection was significantly lower in the chlorhexidine–alcohol group than in the povidone–iodine group. Chlorhexidine–alcohol was significantly more protective than povidone–iodine against both superficial incisional infections and deep incisional infections.
Predicting Death in Necrotizing Soft Tissue Infections: A Clinical Score
Necrotizing soft tissue infections (NSTIs) are associated with a high mortality rate; however, there is no uniform way to categorize the severity of this disease early in its course. The goal of this study was to develop a clinical score based on data available at the time of initial assessment to aid in stratifying patients according to their risk of death.
Six admission parameters independently predicted death: Age>50 years, heart rate>110 beats/min, temperature <36°C, white blood cell count>40,000/mcL, serum creatinine concentration>1.5mg/dL, and hematocrit>50%. The accuracy of this model was 86.8%; the area under the receiver-operating characteristic curve was 0.81, and the Hosmer-Lemeshow statistic was 11.8.
Fondaparinux appears to offer protection against VTE in high-risk trauma patients
Journal of the American College of Surgeons
Venous thromboembolic events (VTE) remain a major cause of morbidity and mortality after trauma. Fondaparinux, a synthetic, nonheparin drug, has shown promise in reducing VTE in orthopaedic patients, but has not previously been studied in trauma patients. The goal of this study was to determine the safety and efficacy of fondaparinux when incorporated into our VTE prevention protocol.Overall incidence of DVT among the 87 enrolled patients was 4.6%. DVT developed in only 1 of 80 patients who received fondaparinux (1.2%).
Insulin Resistance Heralds Positive Cultures after Severe Injury
Surgical Infections
Insulin resistance and hyperglycemia are common in acutely injured patients, and associated with poor outcomes. In the era of tight glucose control, measures of insulin responsiveness (IR) may provide a better indicator of patient status than does the serum glucose concentration. It was hypothesized that measures of IR during tight glycemic control protocols are associated with infection and may be more predictive than the serum glucose concentration. During the six-month study period, 356 patients were placed on the tight glycemic control protocol. Of these, 101 patients had 192 positive cultures. Patients with positive cultures required significantly more hourly insulin than those without a positive culture . A greater insulin requirement suggesting resistance may be used as a marker of a higher risk of nosocomial infection.
Pulmonary Embolism May Not Result from Deep Venous Thrombosis in Trauma
Archives of Surgery Abstract
The rationale for the study is the fact that, as documented by several other investigators, many patients with PE have no DVT. This study showed that among 247 trauma patients undergoing CTPA/CTV, PE was diagnosed in 46 (19%) and DVT in 18 (7%). Few patients with PE have DVT of the pelvic or proximal lower extremity veins. Pulmonary embolism may not originate from these veins, as commonly believed, but instead may occur de novo in the lungs. These findings have implications for thromboprophylaxis and, particularly, the value of vena cava filters.
Positive Serum Ethanol Level Decreases Mortality in Moderate to Severe Traumatic Brain Injury
Archives of Surgery
A Retrospective database review was conducted A total of 38 019 patients with severe traumatic brain injuries were evaluated. Thirty-eight percent tested positive for ethanol. Ethanol-positive patients were younger, had a lower Injury Severity Score, and a lower Glasgow Coma Scale score compared with their ethanol-negative counterparts. After logistic regression analysis, ethanol was associated with reduced mortality and higher complications.
Randomized clinical trial of folate supplementation in patients with peripheral arterial disease
British Journal of Surgery
The aim was to determine whether folate supplementation improved arterial function in patients with peripheral arterial disease (PAD). Individuals with PAD were randomly assigned to receive 400 µg folic acid (45 patients) or 5-methyltetrahydrofolate (5-MTHF) (48) daily, or placebo (40) for 16 weeks. Primary endpoints were changes in plasma total homocysteine (tHcy), ankle : brachial pressure index (ABPI) and pulse wave velocity (PWV). Folate administration reduced plasma homocysteine, and slightly improved ABPI and bk-PWV.
Hospital variation in transfusion and infection after cardiac surgery
Transfusion practices in hospitalised patients are being re-evaluated, in part due to studies indicating adverse effects in patients receiving large quantities of stored blood. Concomitant with this re-examination have been reports showing variability in the use of specific blood components. This investigation was designed to assess hospital variation in blood use and outcomes in cardiac surgery patients.
Intravenous lidocaine decrease postsurgical ileus and shorten hospital stay in elective bowel surgery
The American Journal of Surgery
This study examined whether systemic infusion of lidocaine, a local anesthetic with anti-inflammatory properties, can decrease surgical pain, length of postsurgical ileus, and hospital stay. The return of bowel movement after surgery was considered significant (lidocaine 88.3 ± 6.08 hours vs placebo group 116 ± 10.1 hours; P = .0286). The lidocaine group was discharged by mean day 3.76 ± .24 versus placebo at mean day 4.93 ± .42; P = .0277
Diagnostic value of hyperbilirubinemia as a predictive factor for appendiceal perforation in acute appendicitis
The American Journal of Surgery Abstract
Patients with hyperbilirubinemia and clinical symptoms of appendicitis should be identified as having a higher probability of appendiceal perforation than those with normal bilirubin levels.
