Risk factors for perioperative hypothermia and infectious outcomes in gastroschisis patients

IntroductionPrior data suggest that infants with gastroschisis are at high risk for hypothermia and infectious complications (ICs). This study evaluated the associations between perioperative hypothermia (PH) and ICs in gastroschisis using a multi-institutional cohort.MethodsRetrospective review of infants with gastroschisis who underwent abdominal closure from 2013–2017 was performed at 7 children's hospitals. Any-IC and surgical site infection (SSI) were stratified against the presence or absence of PH, and perioperative characteristics associated with PH and SSI were determined using multivariable logistic regression.ResultsOf 256 gastroschisis neonates, 42% developed PH, with 18% classified as mild hypothermia (35.5–35.9°C), 10.5% as moderate (35.0–35.4°C), and 13% severe (<35°C). There were 82 (32%) ICs with 50 (19.5%) being SSIs. No associations between PH and any-IC (p = 0.7) or SSI (p = 0.98) were found. Pulmonary comorbidities (odds ratio (OR)=3.76, 95%CI:1.42–10, p = 0.008) and primary closure (OR=0.21, 95%CI:0.12–0.39, p<0.001) were associated with PH, while silo placement (OR=2.62, 95%CI:1.1–6.3, p = 0.03) and prosthetic patch (OR=3.42, 95%CI:1.4–8.3, p = 0.007) were associated with SSI on multivariable logistic regression.ConclusionsPrimary abdominal closure and pulmonary comorbidities are associated with PH in gastroschisis, however PH was not associated with increased risk of ICs. Independent risk factors for SSI include silo placement and prosthetic patch closure.     

Postoperative outcomes in older surgical patients with preoperative cognitive impairment: A systematic review and meta-analysis

Study objectiveTo determine the effect of cognitive impairment (CI) and dementia on adverse outcomes in older surgical patients.DesignA systematic review and meta-analysis of observational studies and randomized controlled trials (RCTs). Various databases were searched from their inception dates to March 8, 2021.SettingPreoperative assessment.PatientsOlder patients (≥ 60 years) undergoing non-cardiac surgery.MeasurementsOutcomes included postoperative delirium, mortality, discharge to assisted care, 30-day readmissions, postoperative complications, and length of hospital stay. Effect sizes were calculated as Odds Ratio (OR) and Mean Difference (MD) based on random effect model analysis. The quality of included studies was assessed using the Cochrane Risk Bias Tool for RCTs and Newcastle-Ottawa Scale for observational cohort studies.ResultsFifty-three studies (196,491 patients) were included. Preoperative CI was associated with a significant risk of delirium in older patients after non-cardiac surgery (25.1% vs. 10.3%; OR: 3.84; 95%CI: 2.35, 6.26; I²: 76%; p < 0.00001). Cognitive impairment (26.2% vs. 13.2%; OR: 2.28; 95%CI: 1.39, 3.74; I²: 73%; p = 0.001) and dementia (41.6% vs. 25.5%; OR: 1.96; 95%CI: 1.34, 2.88; I²: 99%; p = 0.0006) significantly increased risk for 1-year mortality. In patients with CI, there was an increased risk of discharge to assisted care (44.7% vs. 38.3%; OR 1.74; 95%CI: 1.05, 2.89, p = 0.03), 30-day readmissions (14.3% vs. 10.8%; OR: 1.36; 95%CI: 1.00, 1.84, p = 0.05), and postoperative complications (40.7% vs. 18.8%; OR: 1.85; 95%CI: 1.37, 2.49; p < 0.0001).ConclusionsPreoperative CI in older surgical patients significantly increases risk of delirium, 1-year mortality, discharge to assisted care, 30-day readmission, and postoperative complications. Dementia increases the risk of 1-year mortality. Cognitive screening in the preoperative assessment for older surgical patients may be helpful for risk stratification so that appropriate management can be implemented to mitigate adverse postoperative outcomes.     

Tumour-infiltrating lymphocytes in non-invasive breast cancer: A systematic review and meta-analysis

BackgroundThe role of tumour infiltrating lymphocytes (TILs) as a biomarker in non-invasive breast cancer is unclear. This meta-analysis assessed the prognostic impact of TIL levels in patients with non-invasive breast cancer.MethodsSystematic literature search was performed to identify studies assessing local recurrence in patients with non-invasive breast cancer according to TIL levels (high vs. low). Subgroup analyses per local recurrence (invasive and non-invasive) were performed. Secondary objectives were the association between TIL levels and non-invasive breast cancer subtypes, age, grade and necrosis. Odds ratios (ORs) and 95% confidence intervals (CI) were extracted from each study and a pooled analysis was conducted with random-effect model.ResultsSeven studies (N = 3437) were included in the present meta-analysis. High-TILs were associated with a higher likelihood of local recurrence (invasive or non-invasive, N = 2941; OR 2.05; 95%CI, 1.03–4.08; p = 0.042), although with a lower likelihood of invasive local recurrence (N = 1722; OR 0.69; 95%CI, 0.49–0.99; p = 0.042). High-TIL levels were associated with triple-negative (OR 3.84; 95%CI, 2.23–6.61; p < 0.001) and HER2-positive (OR 6.27; 95%CI, 4.93–7.97; p < 0.001) subtypes, high grade (OR 5.15; 95%CI, 3.69–7.19; p < 0.001) and necrosis (OR 3.09; 95%CI, 2.33–4.10; p < 0.001).ConclusionsHigh-TIL levels were associated with more aggressive tumours, a higher likelihood of local recurrence (invasive or non-invasive) but a lower likelihood of invasive local recurrence in patients with non-invasive breast cancer.     

Variability in the management of adhesive small bowel obstruction in children

BackgroundThis study assessed inter-hospital variability in operative-vs-nonoperative management of pediatric adhesive small bowel obstruction (ASBO).MethodsA multi-institutional retrospective study was performed examining patients 1–21 years-of-age presenting with ASBO from 2010 to 2019 utilizing the Pediatric Health Information System. Multivariable mixed-effects logistic regression was performed assessing inter-hospital variability in operative-vs-nonoperative management of ASBO.ResultsAmong 6410 pediatric ASBO admissions identified at 46 hospitals, 3,239 (50.5%) underwent surgery during that admission. The hospital-specific rate of surgery ranged from 35.3% (95%CI: 28.5–42.6%) to 74.7% (66.3–81.6%) in the unadjusted model (p < 0.001), and from 35.1% (26.3–45.1%) to 73.9% (66.7–79.9%) in the adjusted model (p < 0.001). Factors associated with operative management for ASBO included admission to a surgical service (OR 2.8 [95%CI: 2.4–3.2], p < 0.001), congenital intestinal and/or rotational anomaly (OR 2.5 [2.1–3.1], p < 0.001), diagnostic workup including advanced abdominal imaging (OR 1.7 [1.5–1.9], p < 0.001), non-emergent admission status (OR 1.5 [1.3–1.8], p < 0.001), and increasing number of complex chronic comorbidities (OR 1.3 [1.2–1.4], p < 0.001). Factors associated with nonoperative management for ASBO included increased hospital-specific annual ASBO volume (OR 0.98 [95%CI: 0.97–0.99], p = 0.002), older age (OR 0.97 [0.96–0.98], p < 0.001), public insurance (OR 0.87 [0.78–0.96], p = 0.008), and presence of coinciding non-intestinal congenital anomalies, neurologic/neuromuscular disease, and/or medical technology dependence (OR 0.57 [95%CI: 0.47–0.68], p < 0.001).ConclusionsRates of surgical intervention for ASBO vary significantly across tertiary children's hospitals in the United States. The variability was independent of patient and hospital characteristics and is likely due to practice variation.Level of evidenceIII     

Postoperative complication rates following total shoulder arthroplasty (TSA) vs. reverse shoulder arthroplasty (RSA): A nationwide analysis

BackgroundHistorically, anatomic total shoulder arthroplasty (TSA) has been the gold-standard of care for patients with glenohumeral osteoarthritis refractory to nonoperative treatment. With expanding indications, utilization of reverse total shoulder arthroplasty (RSA) has been rapidly increasing. The purpose of this study was to use a nationwide patient database with contemporary data to identify and compare joint and systemic complication rates following primary TSA and RSA.MethodsPatients records of patients receiving TSA or RSA were queried from PearlDiver (Fort Wayne, IN), a commercially available administrative claims database, using International Classification of Diseases, Ninth Revision and Tenth Revision (ICD-9/ICD-10) and Current Procedural Technology (CPT) codes. Incidences of postoperative joint complications were measured at 90-days and 1-year post-discharge. Incidences of systemic complications were measured at 90-days post-discharge. Complication rates were compared using logistic regression. Demographic data was also compared using chi-square analysis.ResultsFrom 2007 to 2017, a total of 17,681 patients received primary total shoulder arthroplasty: 8,846 (50%) received TSA and 8,835 (50%) received RSA. A greater proportion of patients that underwent RSA were female (p < 0.001), over the age of 80 (p < 0.001), and had a higher average Charlson comorbidity index (2.49 vs. 1.99, p < 0.001). At 90-days post-discharge, patients that received RSA were more likely to have prosthetic joint infection (OR 1.66; 95% CI 1.30–2.70), periprosthetic fracture (OR 4.01; 95% CI 3.32–4.87), prosthetic dislocation (OR 2.10; 95% CI 1.57–2.85), and adjacent local scapular/acromion fractures (OR 3.58; 95% CI 2.05–6.71). At 1-year, these patients still had a higher association with periprosthetic fracture (OR 3.66; 95% CI 3.08–4.38), prosthetic dislocation (OR 1.40; 95% CI 1.12–1.75), and local fractures (OR 3.10; 95% CI 2.10–4.73). Patients that underwent TSA were more likely to have prosthetic loosening (OR 0.64; 95% CI 0.45–0.90) and prosthetic stiffness (OR 0.91; 95% CI 0.84–0.99). Additionally, patients that underwent RSA exhibited higher rates of DVT (OR 1.29; 95% CI 1.03–1.62), anemia (OR 1.42; 95% CI 1.25–1.62), acute renal failure (ARF) (OR 1.35; 95% CI 1.13–1.61), pneumonia (OR 1.23; 95% CI 1.02–1.48), and respiratory failure (OR 1.81; 95% CI 1.46–2.26).ConclusionPatients undergoing RSA exhibited higher rates of joint complications at both 90-days and 1-year post-discharge. These patients also experienced higher rates of systemic complications in the 90-day postoperative period, likely due to overall poorer health status.Level of evidenceLevel III; Treatment Study     

The effect of inpatient versus outpatient location on postoperative healthcare utilization after neonatal circumcision

Background/PurposeNeonatal circumcision is a common pediatric procedure performed in both the inpatient and outpatient setting. We aimed to determine if procedure location affected 30-day post-procedure healthcare utilization rates, inpatient length of stay (LOS), and amount charged.MethodsWe performed a retrospective cohort study comparing 30-day postoperative healthcare utilization (emergency department (ED) visits, office visits, readmissions) of full-term infants who underwent an outpatient versus inpatient (same admission as birth) circumcision from 2015 to 2020. Statistical analyses included Chi-square tests, multivariable adjusted logistic regression models when appropriate.Results3137 infants were included, 1426 (45.5%) had an outpatient circumcision, 1711 (54.5%) an inpatient. Outpatient had similar overall healthcare utilization rates as inpatients (5.7% vs. 5.6%, p = 0.933). The number of ED visits (1.5% vs 0.8%, p = 0.055), office visits (4.5% vs. 5.1%, p = 0.437), and readmissions (0.2% vs. 0.0%, p = 0.058) were not significantly different. Infants with inpatient circumcisions had longer LOS after adjusting for age, ethnicity and delivery type (Cesarean versus vaginal) with an incident rate ratio of 1.97 (95% confidence interval 1.84–2.11, p<0.001). Outpatient circumcision resulted in average charges of $372 more than inpatient.ConclusionsOutpatient circumcision has a minimal effect on healthcare utilization rates but lead to a shorter hospital stay following birth and increased charge.Study DesignRetrospectiveLevel of EvidenceIII     

Preoperative proteinuria may be a risk factor for postoperative acute kidney injury：a meta-analysis

ObjectiveTo investigate the relationship between preoperative proteinuria and postoperative acute kidney injury (AKI).MethodsWe performed a search on databases included PubMed, Embase, the Cochrane Library, and Web of Science, from December 2009 to September 2020. Data extracted from eligible studies were synthesized to calculate the odds ratio (OR) and 95% confidence interval (CI). A fixed or random effects model was applied to calculate the pooled OR based on heterogeneity through the included studies.ResultsThis meta-analysis of 11 observational studies included 203,987 participants, of whom 21,621 patients suffered from postoperative AKI and 182,366 patients did not suffer from postoperative AKI. The combined results demonstrated that preoperative proteinuria is an independent risk factor for postoperative AKI (adjusted OR = 1.65, 95%CI:1.44–1.89, p < 0.001). Subgroup analysis showed that both preoperative mild proteinuria (adjusted OR = 1.30, 95%CI:1.24–1.36, p < 0.001) and preoperative heavy proteinuria (adjusted OR = 1.93, 95%CI:1.65–2.27, p < 0.001) were independent risk factors for postoperative AKI. The heterogeneity was combined because its values were lower. Further subgroup analysis found that preoperative proteinuria measured using dipstick was an independent risk factor for postoperative AKI (adjusted OR = 1.48, 95%CI:1.37–1.60, p < 0.001). Finally, preoperative proteinuria was an independent risk factor for postoperative AKI in the non-cardiac surgery group (adjusted OR = 2.06, 95%CI:1.31–3.24, p = 0.002) and cardiac surgery group (adjusted OR = 1.69, 95%CI:1.39–2.06, p < 0.001)ConclusionPreoperative proteinuria is an independent risk factor for postoperative AKI and in instances when proteinuria is detected using dipsticks.     

Outcomes of gastrostomy placement with and without concomitant tracheostomy among ventilator dependent children

IntroductionSimultaneous gastrostomy tube (GT) and tracheostomy placement in young children offers potential benefit in limiting anesthetic exposure, but it is unknown whether combining these procedures introduces additional morbidity. This study compared outcomes after combined GT and tracheostomy placement versus GT placement alone among similar ventilator-dependent patients.MethodsVentilator-dependent children <2-years-old who underwent GT placement alone (MV-GT), simultaneous GT and tracheostomy placement (GT+T), and GT placement alone with a pre-existing tracheostomy (T-GT) were identified using 2012–2018 NSQIP-Pediatric Participant User Files. Multiple logistic regression models were used to compare outcomes while adjusting for other group differences.ResultsAmong 1100 children, 351 underwent MV-GT, 494 GT+T, and 255 T-GT. Major complications occurred in 23.6%, 17.0%, and 14.5% of the respective groups (p = 0.01). Major complications with GT+T were similar to T-GT (adjusted odds ratio [aOR]=1.19, 95%CI:0.78–1.83, p = 0.4) and lower than MV-GT (aOR=0.67, 95%CI:0.47–0.95, p = 0.02). Severe complications including mortality, cardiac arrest, and stroke were similar between the three groups (p = 0.8).ConclusionsChildren <2-years-old undergoing GT+T did not experience higher post-operative complications compared to children undergoing T-GT or MV-GT. Utilizing GT+T to limit anesthetic exposure may be reasonable within this high-risk population.Type of StudyTreatment StudyLevel of EvidenceLevel III     

Variability,outcomes and cost associated with the use of parenteral nutrition in children with complicated appendicitis: A hospital-level propensity matched analysis

Background/PurposeTo examine the influence of parenteral nutrition (PN) on clinical outcomes and cost in children with complicated appendicitis.MethodsRetrospective study of 1,073 children with complicated appendicitis from 29 hospitals participating in the NSQIP-Pediatric Appendectomy Pilot Collaborative (1/2013–6/2015). Mixed-effects regression was used to compare 30-day postoperative outcomes between high and low PN-utilizing hospitals after propensity matching on demographic characteristics, BMI and postoperative LOS as a surrogate for disease severity.ResultsOverall PN utilization was 13.6%, ranging from 0–10.3% at low utilization hospitals (n = 452) and 10.3–32.4% at high utilization hospitals (n = 621). Outcomes were similar between low and high utilization hospitals for rates of overall complications (12.3% vs. 10.5%, OR: 0.80 [0.46,1.37], p = 0.41), SSIs (11.3% vs. 8.8%, OR: 0.72 [0.40,1.32], p = 0.29) and revisits (14.7% vs. 15.9%, OR: 1.10 [0.75,1.61], p = 0.63). Adjusted mean 30-day cumulative hospital cost was 22.9% higher for patients receiving PN ($25,164 vs. $20,478, p < 0.01) after controlling for postoperative LOS.ConclusionFollowing adjustment for patient characteristics and postoperative length of stay, higher rates of PN utilization in children with complicated appendicitis were associated with higher cost but not with lower rates of overall complications, surgical site infections or revisits.Level of Evidence Level III: Treatment study - Retrospective comparative study     

Hydroxyethyl starch and acute kidney injury in high-risk patients undergoing cardiac surgery: A prospective multicenter study

BackgroundHydroxyethyl starch (HES) solutions increase the risk of acute kidney injury (AKI) in critically ill patients admitted to intensive care unit (ICU) for medical indications. We conducted a cohort study to evaluate the renal safety of modern 6% HES solutions in high-risk patients having cardiac surgery.MethodIn this multicentre prospective cohort study, we recruited 261 consecutive patients at high-risk for developing cardiac surgery-associated AKI, based on a Cleveland score ≥ 4 points, from July to December 2017th in 14 hospitals in Spain and the United Kingdom. Multivariable logistic regression modeling and propensity-score matched-pairs analysis were used to determine the adjusted association between administration of HES and AKI.ResultsOf the cohort, 95 patients (36.4%) received 6% HES 130/0.4 either intraoperatively or postoperatively. Postoperative AKI occurred in 145 patients (55.5%). The unadjusted odds of AKI was significantly higher in the HES group, when compared to those not receiving HES (OR 2.22, 95% CI 1.30–3.80, p = 0.003). In multivariable logistic regression models, modern HES was not associated with significantly increased risk of AKI (adjusted OR 0.84, 95% CI 0.41–1.71, p = 0.63). In propensity score match-pairs analysis of 188 patients, the HES group experienced similar adjusted odds of AKI (OR 1.05, CI 95% 0.87–1.27, p = 0.57) and RRT (OR 1.06, CI 95% 0.92–1.22, p = 0.36).ConclusionsThe use of modern hydroxyethyl starch 6% HES 130/0.4 was not associated with an increased risk of AKI nor dialysis in this cohort of patients at elevated risk for developing AKI after cardiac surgery.     

Risk factors for symptomatic venous thromboembolism following surgery for closed ankle fractures: A case-control study

BackgroundWe analyzed risk factors for venous thromboembolism (VTE) within 6 months after surgery for closed ankle fractures.MethodsThis was a case-control study based on data from chart review in a cohort of patients having open reduction and internal fixation (ORIF) for closed ankle fractures in two large general hospitals 2009–2011. Cases with symptomatic VTE (pulmonary embolism or deep venous thrombosis) were identified in the cohort, and additional cases of VTE were identified by computerized search of discharge diagnoses in the same hospitals in 2004–2008 and 2012–2016. In total, we identified 60 cases with VTE and compared with 240 randomly selected controls among 998 patients without VTE in the cohort. Risk factors were assessed using logistic regression analysis.ResultsAmong cases, 27 (45%) had pulmonary embolism, 33 (55%) deep venous thrombosis. Those with VTE were older, had higher BMI, had more often a family history of VTE, and more often had antibiotic prophylaxis during surgery than controls. In multivariable logistic regression analysis age/10 (OR 25.75, 95%CI 3.52–188.44, p = 0.001), (age/10)² (OR 0.77, 95%CI 0.65–0.93, p = 0.005), BMI (1.15 per kg/m², 95%CI 1.07–1.24, p < 0.001) and Charlson comorbidity index ≥2 vs.0 (OR 0.27, 95%CI 0.08–0.92, p = 0.036) and 1 vs. 0 (OR 0.27, 95%CI 0.09–0.86, p = 0.026) were associated with VTE within 6 months of surgery.ConclusionsThe odds of symptomatic VTE within 6 months of ORIF increased with increasing age and BMI, but were lower with increasing comorbidity.     

Association between use of enhanced recovery after surgery protocols and postoperative complications in colorectal surgery in Europe: The EuroPOWER international observational study

Study objectiveAssess the relationship between the Enhanced Recovery After Surgery (ERAS®) pathway and routine care and 30-day postoperative outcomes.DesignProspective cohort study.SettingEuropean centers (185 hospitals) across 21 countries.PatientsA total of 2841 adult patients undergoing elective colorectal surgery. Each hospital had a 1-month recruitment period between October 2019 and September 2020.InterventionsRoutine perioperative care.MeasurementsTwenty-four components of the ERAS pathway were assessed in all patients regardless of whether they were treated in a formal ERAS pathway. A multivariable and multilevel logistic regression model was used to adjust for baseline risk factors, ERAS elements and country-based differences.ResultsA total of 1835 patients (65%) received perioperative care at a self-declared ERAS center, 474 (16.7%) developed moderate-to-severe postoperative complications, and 63 patients died (2.2%). There was no difference in the primary outcome between patients who were or were not treated in self-declared ERAS centers (17.1% vs. 16%; OR 1.00; 95%CI, 0.79–1.27; P = 0.986). Hospital stay was shorter among patients treated in self-declared ERAS centers (6 [5–9] vs. 8 [6–10] days; OR 0.82; 95%CI, 0.78–0.87; P < 0.001). Median adherence to 24 ERAS elements was 57% [48%–65%]. Adherence to ERAS-pathway quartiles (≥65% vs. <48%) suggested that patients with the highest adherence rates experienced a lower risk of moderate-to-severe complications (15.9% vs. 17.8%; OR 0.71; 95%CI, 0.53–0.96; P = 0.027), lower risk of death (0.3% vs. 2.9%; OR 0.10; 95%CI, 0.02–0.42; P = 0.002) and shorter hospital stay (6 [4–8] vs. 7 [5–10] days; OR 0.74; 95%CI, 0.69–0.79; P < 0.001).ConclusionsTreatment in a self-declared ERAS center does not improve outcome after colorectal surgery. Increased adherence to the ERAS pathway is associated with a significant reduction in overall postoperative complications, lower risk of moderate-to-severe complications, shorter length of hospital stay and lower 30-day mortality.     

Resección transuretral en bloque vs. resección transuretral convencional para el cáncer de vejiga primario no músculo-infiltrante: metaanálisis

IntroductionWe performed a meta-analysis to evaluate the effect of en-bloc transurethral resection vs. conventional transurethral resection for primary non-muscle invasive bladder cancer.MethodsA systematic literature search up to January 2022 was done and 28 studies included 3714 primary non-muscle invasive bladder cancer subjects at the start of the study; 1870 of them were en-bloc transurethral resection, and 1844 were conventional transurethral resection for primary non-muscle invasive bladder cancer. We calculated the odds-ratio (OR) and mean-difference (MD) with 95% confidence-intervals (CIs) to evaluate the effect of en-bloc transurethral resection compared with conventional transurethral resection for primary non-muscle invasive bladder cancer by the dichotomous or continuous methods with random or fixed-effects models.ResultsEn-bloc transurethral resection had significantly lower twenty-four-month recurrence (OR: 0.63; 95%CI: 0.50-0.78; P < 0.001), catheterization-time (MD: –0.66; 95%CI: –1.02-[–0.29]; P < 0.001), length of hospital stay (MD: –0.95; 95%CI: –1.55-[–0.34]; P = 0.002), postoperative bladder irrigation duration (MD: –6.06; 95%CI: –9.45-[–2.67]; P < 0.001), obturator nerve reflex (OR: 0.08; 95%CI: 0.02-0.34; P = 0.03), and bladder perforation (OR: 0.14; 95%CI: 0.06-0.36: P < 0.001) and no significant difference in the 12-month-recurrence (OR: 0.79; 95%CI: 0.61-1.04; P = 0.09), the operation time (MD: 0.67; 95%CI: –1.92-3.25; P = 0.61), and urethral stricture (OR: 0.46; 95%CI: 0.14-1.47; P = 0.19) compared with conventional transurethral resection for primary non-muscle invasive bladder cancer subjects.ConclusionsEn-bloc transurethral resection had a significantly lower twenty-four-month recurrence, catheterization time, length of hospital stay, postoperative bladder irrigation duration, obturator nerve reflex, bladder perforation, and no significant difference in the twelve-month recurrence, operation time, and urethral stricture compared with conventional transurethral resection for primary non-muscle invasive bladder cancer subjects. Further studies are required.     

Persistent fibrinolysis shutdown is associated with increased mortality in traumatic pancreatic injury

PurposeThe features of fibrinolytic system modifications and their relationship with prognosis are still unknown in traumatic pancreatic injury. The object of this prospective cohort research was to identify fibrinolytic characteristics in patients with pancreatic trauma and to identify the correlation to mortality.MethodA prospective screening of traumatic pancreatic injury patients was done for five years. The fibrinolytic status of patients was determined by thromboelastography (TEG). The percentage reduction in clot strength 30 min (LY30) after the time of maximal clot strength was utilized to distinguish the fibrinolytic phenotype of individuals, including fibrinolytic shutdown (SD), physiologic fibrinolysis (PHYS) and hyperfibrinolysis (HF). Two cohorts, transient fibrinolytic shutdown (TSD) and persistent fibrinolytic shutdown (PSD), were divided according to whether fibrinolytic shutdown persisted within one week. Demographics, injury severity, characteristics of pancreatic injury, treatment, and outcomes were compared.ResultA total of 180 cases enrolled, aged 42(interquartile range 32–51) years, 88% males, 97% were blunt trauma. The median ISS was 19(IQR 10–25), and 76% were AAST grade III to V (high-grade). At admission, there were 159 cases of SD (88%), 15 cases of PHYS (8%) while 6 cases of HF (3%). Of these, the TSD cohort included 54 patients (34%), while the PSD cohort included 105 patients (66%). Compared with the TSD cohort, the PSD cohort had more severe injury (ISS 21[IQR 12–27] vs 16[IQR 9–22], p = 0.006) and a higher proportion of AAST high-grade (83% vs 67%, p = 0.035). Persistent fibrinolytic shutdown was associated with operative treatment (odds ratio [OR] 3.111; 95%CI 1.146–8.447; p = 0.026), associated intra-abdominal injury (OR 8.331; 95% CI 1.301–53.336; p = 0.025) and admission LY30 (OR 0.016; 95% CI 0.002 - 0.120; p < 0.001). It was an independent predictor of mortality (adjusted odds ratio [AOR] 4.674; 95% CI 1.03 to 21.14; p = 0.045).ConclusionFibrinolytic shutdown especially persistence of this phenotype is more common in traumatic pancreatic injury than PHYS and HF, which related with mortality. Risk factors including LY30 at admission, intra-abdominal injury and operative treatment were associated with the persistent fibrinolytic shutdown. Sheltered the patients from these risk factors seems to be beneficial, which need to be confirmed by further large-scale studies.     

What Goes Bump in the Night: An Evaluation of Emergency Department Visits Following Total Joint Arthroplasty

BackgroundInterest in postoperative healthcare utilization has increased following the implementation of episode-of-care funding for elective orthopedic surgery. Most efforts have focused on readmission; however, little has been reported on emergency department (ED) presentation. We analyzed elective, primary total hip or knee arthroplasty (THA and TKA) cases to determine the rate, reasons, risk factors, timing, and hospital cost associated with 30-day ED presentations.MethodsAn observational study of patients who underwent primary, elective TKA and THA between January 1, 2016, and December 31, 2017, was performed. The primary outcome was an ED visit within 30-days of the index operation. Secondary outcomes included reasons, risk factors, timing, and hospital cost of ED visits. A multivariable logistic regression was undertaken to determine patient factors associated with ED presentation.ResultsOverall, 1690 patients were included, of which 9.2% presented to the ED within 30-days of surgery. Approximately two-thirds of the visits were after-hours, and most were discharged home without readmission (81.4%). The most commonly reported reasons were wound concerns (30.1%) and pain (20.5%). Older age (OR 1.1, P = .03) and preoperative dyspnea (OR 2.1, P < .001) increased the odds of ED visits. The mean cost of an ED visit was significantly greater after-hours (P = .015).ConclusionOverall, 1 in 10 patients undergoing TKA/THA presented to the ED within 30-days of surgery, of which over 80% were not readmitted, and most occurred after-hours where cost is greatest. Our observations suggest ED visits following TKA/THA are common, and most are likely preventable. Future efforts should focus on developing interventions to reduce these visits.     

Lung protective ventilation strategy to reduce postoperative pulmonary complications (PPCs) in patients undergoing robot-assisted laparoscopic radical cystectomy for bladder cancer: A randomized double blinded clinical trial

Study objectiveTo evaluate the effects of ventilation with low tidal volume and positive end-expiratory pressure (PEEP) on postoperative pulmonary complications in patients undergoing robot-assisted laparoscopic radical cystectomy (RARC) for bladder cancer.DesignA prospective randomized double-blinded study.SettingA single center trial in a comprehensive tertiary hospital from January 2017 to January 2019.PatientsA total of 258 patients undergoing RARC for bladder cancer.InterventionsPatients were randomly assigned to receive either lung-protective ventilation (LPV group) [tidal volume 6 ml/ kg predicated body weight (PBW) + PEEP 7 cmH₂O] or nonprotective ventilation (control group) (tidal volume 9 ml/ kg PBW without PEEP) during anesthesia.MeasurementsThe primary outcome was the occurrence of postoperative pulmonary complications (PPCs) during the first 90 days after surgery. The secondary outcomes were extubation time, oxygenation index (OI) after extubation and at postoperative day 1 in blood gas.Main resultsThe incidence of PPCs at postoperative day1, 2 and 3 were lower in LPV group [26.8% vs. 47.2%, odds ratio (OR) 0.41, 95% confidence interval (CI), 0.24–0.69, P = 0.0007, 21.3% vs. 43.3%, OR 0.36, 95% CI, 0.20–0.61, P = 0.0002, 14.2% vs. 27.5%, OR0.43, 95%CI, 0.23–0.82, P = 0.0087, respectively], while no differences were observed at day 7 and 28 (3.9% vs. 9.4%, P = 0.0788, 0% vs. 1.6%, P = 0.4980, respectively). No PPCs were observed at postoperative day 90 in both groups. Furthermore, immediately after extubating and at postoperative day 1, OI was significantly higher in LPV group compared with control group [390(337–467) vs. 343(303–420), P = 0.0005, 406.7(73.0) vs. 425.5(74.7), P = 0.0440, respectively]. Patients in LPV group had a significant shorter extubation time after operation compared with control group [38(33–54) vs. 35(25–46), P = 0.0012].ConclusionLPV combining low tidal volume and PEEP during anesthesia for RARC may decrease the incidence of postoperative pulmonary complications.     

Risk factors for implant failure of intertrochanteric fractures with lateral femoral wall fracture after intramedullary nail fixation

IntroductionFew studies have specifically evaluated the comminution extent of lateral femoral wall (LFW) fracture and risk factors of implant failure in intertrochanteric fractures with LFW fracture. The aim of present study was to evaluate the influence of comminution extent of LFW fracture on implant failure and identify risk factors of implant failure in cases with LFW fracture after intramedullary fixation.MethodsThis retrospective study included 130 intertrochanteric fracture with LFW fracture treated with intramedullary fixation at a teaching hospital over a 13-year period from January 2006 to December 2018. Demographic information, cortical thickness index, the reduction quality, status of medial support, position of the screw/blade and status of lateral femoral wall were collected and compared. The logistic regression analyzes was performed to evaluate risk factors of implant failure in intertrochanteric fractures with LFW fracture after intramedullary nail fixation.Results10 patients (7.69%) suffered from mechanical failure after intramedullary fixation. Univariate analyzes showed that comminuted LFW fracture (OR, 7.625; 95%CI, 1.437~40.446; p = 0.017), poor reduction quality (OR, 49.375; 95%CI, 7.217~337.804; p < 0.001) and loss of medial support (OR, 17.818; 95%CI, 3.537~89.768; p < 0.001) were associated with implant failure. After adjustment for confounding variables, the multivariable logistic regression analyzes showed that poor reduction quality (OR, 11.318; 95%CI, 1.126~113.755; p = 0.039) and loss of medial support (OR, 7.734; 95%CI, 1.062~56.327; p = 0.043) were independent risk factors for implant failure. Whereas, comminuted LFW fracture was not associated with implant failure (p = 0.429).ConclusionsThe comminution extent of the LFW fracture might influence the stability of intertrochanteric fractures; and intramedullary fixation might be an effective treatment method. Furthermore, poor reduction quality and loss of medial support could increaze the risk of implant failure in intertrochanteric fractures with LFW fractures after intramedullary fixation. Therefore, we should pay great emphasis on fracture reduction quality in future.     

Erector spinae plane block for postoperative analgesia in breast and thoracic surgery: A systematic review and meta-analysis

Study objectiveThe erector spinae plane block (ESPB) is a newly defined regional anesthesia technique first introduced in 2016. The aim of this study is to determine its analgesic efficacy compared with non-block care and thoracic paravertebral block (TPVB).DesignWe systematically searched PubMed, Web of Science citation index, Embase, the Cochrane Library, Google Scholar, and ClinicalTrials.gov register searched up to March 2020. We conducted a meta-analysis of randomized controlled trials (RCTs) that compared an ESPB to non-block care or TPVB for postoperative analgesia in breast and thoracic surgery patients. Primary outcome was 24-hour postoperative opioid consumption. Risk of bias was assessed using Cochrane methodology.Results14 RCTs that comprised 1018 patients were included. Seven trials involved thoracic surgery patients and seven included breast surgery patients. Meta-analysis revealed that ESPB significantly reduced 24-hour opioid consumption compared with the non-block groups (−10.5 mg; 95% CI: −16.49 to −3.81; p = 0.002; I² = 99%). Similarly, the finding was consistent in subgroup analysis between the breast surgery (−7.75 mg; 95%CI −13.98 to −1.51; p = 0.01; I² = 97%) and thoracic surgery (−14.81 mg; 95%CI −21.18 to −8.44; p < 0.001; I² = 96%) subgroups. The ESPB significantly reduced pain scores at rest or movement at various time points postoperatively compared with non-block group, and reduced the rate of postoperative nausea and vomiting (OR 0.48; 95%CI 0.27 to 0.86; p = 0.01; I² = 0%). In contrast, there were no significative differences reported in any of the outcomes for ESPB versus TPVB strata.ConclusionsESPB improved analgesic efficacy in breast and thoracic surgery patients compared with non-block care. Furthermore, current literature supported the ESPB offered comparable analgesic efficacy to a TPVB.     

Perioperative intravenous S-ketamine for acute postoperative pain in adults: A systematic review and meta-analysis

Study objectiveTo evaluate the effectiveness and safety of S-ketamine for pain relief and analgesic consumption in surgical patients.DesignSystematic review and meta-analysis of randomized controlled trials (RCTs).SettingPerioperative setting.PatientsA total of 905 adult patients undergoing surgery using general anesthesia: 504 patients in the S-ketamine group and 401 patients in the placebo group.InterventionIntravenous S-ketamine as an adjuvant to general anesthesia compared with placebo.MeasurementsThe primary outcomes were resting and movement pain scores (VAS/NRS 0–10) and morphine consumption within 4, 12, 24 and 48 h after surgery. The secondary outcomes included postoperative complications such as nausea, vomiting, and psychotomimetic adverse events. We used the guidelines of the Recommendation Assessment, Development, and Evaluation (GRADE) system to evaluate the level of certainty for the main results.Main resultsA total of 12 studies were included. The types of surgery included abdominal surgery, thoracotomy, gynecologic surgery, arthroscopic anterior cruciate ligament repair, cardiac surgery, laparoscopic cholecystectomy, lumbar spinal fusion surgery, radical prostatectomy, and hemorrhoidectomy. There were significant improvements in resting pain scores at 4, 12 and 24 h with S-ketamine versus placebo [4 h: standardized mean difference (SMD) -1.11; 95% confidence interval (CI): −1.53, −0.68, p < 0.00001; GRADE = moderate; 12 h: SMD −0.88; 95%CI: −1.42, −0.34, p = 0.001; GRADE = moderate; 24 h: SMD -0.39; 95%CI: −0.73, −0.06, p = 0.02; GRADE = moderate]. The incidence of pain scores at 48 h showed no statistical difference between the two groups (SMD -0.27; 95%CI: −1.12, 0.58, p = 0.53, GRADE = moderate). The movement pain scores were not significantly different between the two groups at each time point (4 h: SMD −0.34; 95%CI: −0.73, 0.05, p = 0.09, GRADE = moderate; 12 h: SMD −0.42; 95%CI: −1.46, 0.63, p = 0.44, GRADE = low; 24 h: SMD −0.58; 95%CI: −1.25, 0.09, p = 0.09, GRADE = moderate; 48 h: SMD −0.49; 95%CI: −1.11, 0.14, p = 0.13, GRADE = low). At 4 and 12 h after surgery, the consumption of morphine was significantly reduced in the S-ketamine group (4 h: SMD −0.98; 95%CI: −1.37, −0.06, p < 0.00001, GRADE = moderate; 12 h: SMD −1.36; 95%CI: −2.26, −0.46, p = 0.003, GRADE = low). There were no significant differences in morphine use at 24 and 48 h between the two groups (24 h: SMD −0.70; 95%CI: −1.42, 0.02, p = 0.06, GRADE = low; 48 h: SMD −0.79; 95%CI: −2.26, 1.03, p = 0.39, GRADE = low). The risk for nausea [relative risk (RR) = 1.04; 95%CI: 0.83, 1.30, p = 0.73], vomiting (RR = 1.07; 95%CI: 0.84, 1.38, p = 0.57), and psychotomimetic adverse events (RR = 1.57; 95%CI: 0.82, 2.99, p = 0.17) showed no significant increase in the S-ketamine group.ConclusionsIntravenous S-ketamine as an adjunct to general anesthesia is effective for assisting analgesia and decreases the intensity of pain and opioid requirements in a short period of time after surgery, but it may increase the psychotomimetic adverse event rate. Overall, the level of certainty is moderate to low.     

Trauma surgery by general surgeons: Still an option for proximal femoral fractures?

IntroductionSurgery for proximal femoral fractures in the Netherlands is performed by trauma surgeons, general surgeons and orthopaedic surgeons. The aim of this study was to assess whether there is a difference in outcome for patients with proximal femoral fractures operated by trauma surgeons versus general surgeons. Secondly, the relation between hospital and surgeon volume and postoperative complications was explored.MethodsPatients of 18 years and older were included if operated for a proximal femoral fracture by a trauma surgeon or a general surgeon in two academic, eight teaching and two non-teaching hospitals in the Netherlands from January 2010 until December 2013. The combined endpoint was defined as reoperation or surgical site infection. Multivariate analysis was used to adjust for patient and fracture characteristics and hospital and surgeon volume. Categories for hospital volume were >170/year (high volume), 96–170/year (medium volume) and <96/year (low volume).ResultsIn 4552 included patients 2382 (52.3%) had surgery by a trauma surgeon. Postoperative complications occurred in 276 (11.6%) patients operated by a trauma surgeon and in 258 (11.9%) operated by a general surgeon (p = 0.751). When considering confounders in a multivariate analysis, surgery by trauma surgeons was associated with less postoperative complications (OR 0.746; 95%CI 0.580–0.958; p = 0.022). Surgery in high volume hospitals was also associated with less complications (OR 0.997; 95%CI 0.995–0.999; p = 0.012). Surgeon volume was not associated with complications (OR 1.008; 95%CI 0.997–1.018; p = 0.175).ConclusionSurgery by trauma surgeons and high hospital volume are associated with less reoperations and surgical site infections for patients with proximal femoral fractures.