Risk factors for postoperative neurosurgical wound infection. A case-control study

A case-control analysis was performed to evaluate the association of 15 potential risk factors with postoperative infection in neurosurgical patients. All infections that developed postoperatively on the neurosurgical service at the University of Minnesota from January, 1970, to March, 1984, were identified. Among the 9202 operations performed during that time, 101 infections occurred for a rate of 1.1%. Three risk factors showed significant association with postoperative infection: cerebrospinal fluid (CSF) leak, concurrent noncentral nervous system (CNS) infection, and perioperative antibiotic therapy. The presence of a CSF leak and a concurrent non-CNS infection increased the estimated relative risk of infection to 13:1 and 6:1, respectively. The use of perioperative antibiotics was associated with a decrease in the risk of infection to approximately 20% of the control level. Three other risk factors (paranasal sinus entry, placement of a foreign body, and use of a postoperative drain) appeared to be associated with increased risk of infection, although statistical significance was not demonstrated. None of the remaining nine risk factors studied showed any suggestion of increased risk of infection.     

Postoperative Hydrocephalus in Cranial Base Surgery

The incidence of postoperative hydrocephalus and factors relating to it were analyzed in 257 patients undergoing cranial base surgery for tumor resection. A total of 21 (8%) patients developed postoperative hydrocephalus, and all required shunting, Forty-two (17%) patients developed cerebrospinal fluid (CSF) leak that required placement of external drainage systems (ventriculostomy or lumbar drain, or both); 10 (23%) of these 42 patients eventually needed shunt placement to stop the leak because of hydrocephalus. Prior craniotomy, prior radiation therapy, and postoperative CSF infection were also associated with an increased risk of developing hydrocephalus (48% versus 6%, 19% versus 8%, and 14% versus 7%, respectively). Prior radiation and postoperative CSF infection increased the risk of CSF leak in patients with hydrocephalus (30% versus 18% and 30% versus 9%, respectively). CSF leak and hydrocephalus commonly occurred in patients who underwent resection of a glomus tumor. In conclusion, 8% of patients who underwent cranial base surgery for tumors developed de novo hydrocephalus; half of them also had CSF leak in addition to hydrocephalus; and all required shunt placement for CSF diversion.     

Postoperative hydrocephalus in cranial base surgery

The incidence of postoperative hydrocephalus and factors relating to it were analyzed in 257 patients undergoing cranial base surgery for tumor resection. A total of 21 (8%) patients developed postoperative hydrocephalus, and all required shunting, Forty-two (17%) patients developed cerebrospinal fluid (CSF) leak that required placement of external drainage systems (ventriculostomy or lumbar drain, or both); 10 (23%) of these 42 patients eventually needed shunt placement to stop the leak because of hydrocephalus. Prior craniotomy, prior radiation therapy, and postoperative CSF infection were also associated with an increased risk of developing hydrocephalus (48% versus 6%, 19% versus 8%, and 14% versus 7%, respectively). Prior radiation and postoperative CSF infection increased the risk of CSF leak in patients with hydrocephalus (30% versus 18% and 30% versus 9%, respectively). CSF leak and hydrocephalus commonly occurred in patients who underwent resection of a glomus tumor. In conclusion, 8% of patients who underwent cranial base surgery for tumors developed de novo hydrocephalus; half of them also had CSF leak in addition to hydrocephalus; and all required shunt placement for CSF diversion.     

Epidemiology and prognostic determinants of bloodstream infections in surgical intensive care

HYPOTHESIS: A set of clinical variables available at the bedside can be used to predict outcome in critically ill patients with bloodstream infection (BSI). DESIGN: A 3-year retrospective cohort study. SETTING: A surgical intensive care unit in Switzerland. PATIENTS: All patients with BSI were potentially eligible. MAIN OUTCOME MEASURES: Clinical variables, organ dysfunctions, and outcome. RESULTS: Among 4530 admissions to the surgical intensive care unit, 224 clinically significant episodes of BSI were recorded (incidence, 4.9%), with a 28-day fatality of 36%. A total of 110 patients had primary bacteremia, of which 39 (35%) were catheter related. Although gram-positive organisms were the most frequently isolated pathogens (58% [159/275]), they were associated with lower case-fatality (30%) than BSI due to gram-negative bacteria (44%). Organ dysfunctions associated with the highest risk of death were neurologic dysfunction (hazard ratio [HR], 6.9; 95% confidence interval [CI], 3.3-14.5), hepatic dysfunction (HR, 3.9; 95% CI, 2.1-7.4), and disseminated intravascular coagulation (HR, 3.0; 95% CI, 1.5-6.1). By multivariate analysis, 2 independent predictors of mortality were the APACHE II (Acute Physiology and Chronic Health Evaluation II) score at onset of BSI (HR per 1-point increase, 1.08; 95% CI, 1.04-1.12) and the number of evolving organ dysfunctions (HR, 1.4; 95% CI, 1.2-1.7). Appropriate antimicrobial therapy was associated with improved outcome (HR, 0.4; 95% CI, 0.2-0.6). CONCLUSIONS: Bloodstream infection in critically ill patients is a common and frequently fatal condition. Its outcome can be predicted by the severity of illness at onset of BSI and the number of organ dysfunctions evolving thereafter. Appropriate antimicrobial therapy is an important determinant for survival.     

Cerebrospinal fluid shunt placement for pseudotumor cerebri-associated intractable headache: predictors of treatment response and an analysis of long-term outcomes

OBJECT: Cerebrospinal fluid (CSF) shunts effectively reverse symptoms of pseudotumor cerebri postoperatively, but long-term outcome has not been investigated. Lumboperitoneal (LP) shunts are the mainstay of CSF shunts for pseudotumor cerebri; however, image-guided stereotaxy and neuroendoscopy now allow effective placement of a ventricular catheter without causing ventriculomegaly in these cases. To date it remains unknown if CSF shunts provide long-term relief from pseudotumor cerebri and whether a ventricular shunt is better than an LP shunt. The authors investigated these possibilities. METHODS: The authors reviewed the records of all shunt placement procedures that were performed for intractable headache due to pseudotumor cerebri at one institution between 1973 and 2003. Using proportional hazards regression analysis, predictors of treatment failure (continued headache despite a properly functioning shunt) were assessed, and shunt revision and complication rates were compared between LP and ventricular (ventriculoperitoneal [VP] or ventriculoatrial [VAT]) shunts. Forty-two patients underwent 115 shunt placement procedures: 79 in which an LP shunt was used and 36 in which a VP or VAT shunt was used. Forty patients (95%) experienced a significant improvement in their headaches immediately after the shunt was inserted. Severe headache recurred despite a properly functioning shunt in eight (19%) and 20 (48%) patients by 12 and 36 months, respectively, after the initial shunt placement surgery. Seventeen patients without papilledema and 19 patients in whom preoperative symptoms had occurred for longer than 2 years experienced recurrent headache, making patients with papilledema or long-term symptoms fivefold (relative risk [RR] 5.2, 95% confidence interval [CI] 1.5-17.8; p < 0.01) or 2.5-fold (RR 2.51, 95% CI 1.01-9.39; p = 0.05) more likely to experience headache recurrence, respectively. In contrast to VP or VAT shunts, LP shunts were associated with a 2.5-fold increased risk of shunt revision (RR 2.5, 95% CI 1.5-4.3; p < 0.001) due to a threefold increased risk of shunt obstruction (RR 3, 95% CI 1.5-5.7; p < 0.005), but there were similar risks between the two types of shunts for overdrainage (RR 2.3, 95% CI 0.8-7.9; p = 0.22), distal catheter migration (RR 2.1, 95% CI 0.3-19.3; p = 0.55), and shunt infection (RR 1.3, 95% CI 0.3-13.2; p = 0.75). CONCLUSIONS: Based on their 30-year experience in the treatment of these patients, the authors found that CSF shunts were extremely effective in the acute treatment of pseudotumor cerebri-associated intractable headache, providing long-term relief in the majority of patients. Lack of papilledema and long-standing symptoms were risk factors for treatment failure. The use of ventricular shunts for pseudotumor cerebri was associated with a lower risk of shunt obstruction and revision than the use of LP shunts. Using ventricular shunts in patients with papilledema or symptoms lasting less than 2 years should be considered for those with pseudotumor cerebri-associated intractable headache.     

Troponin T-values provide long-term prognosis in elderly patients undergoing non-cardiac surgery

BACKGROUND: The aim of this study was to evaluate the significance of elevated postoperative Troponin T (TnT) levels in an elderly population undergoing non-cardiac surgery. METHODS: Five hundred and forty-six consecutive patients aged 70 years or older undergoing non-cardiac surgery of >30-min duration were enrolled in this prospective, observational study. A postoperative TnT measurement was obtained on the 5th to 7th postoperative day. Troponin T values greater than 0.02 ng ml(-1) were considered positive. Patients were followed over a 1-year period, and mortality and non-fatal cardiac events (acute myocardial infarction and coronary interventions) were recorded. RESULTS: Troponin T concentrations greater than 0.02 ng ml(-1) were detected in 53 of the study subjects (9.7%). Eleven per cent of the patients with elevated TnT had electrocardiographic or clinical signs of myocardial ischemia. One year after surgery, 17 (32%) of the patients with abnormal TnT concentrations had died. In a multivariate Cox regression analysis adjusting for baseline and perioperative data, a TnT value >0.02 ng ml(-1) was an independent correlate of the mortality adjusted hazard ratio (HR): 14.9 (95% CI 3.7-60.3). Other independent predictors of death were tachycardia (HR, 14.9 95% CI 3.45-64.8), ASA 4 (HR, 8.1 95% CI 1.3-50.0), reoperation (HR, 6.4 95% CI 1.1-36.9), and use of diuretics (HR, 4.2 95% CI 1.3-13.8). CONCLUSION: We conclude that elevated TnT levels in the postoperative period confer a 15-fold increase in mortality during the first year after surgery. Our findings also provide evidence that silent myocardial ischemia is common in an elderly population. Routine perioperative surveillance for TnT might therefore be of use in detecting patients at an increased risk of mortality during the first postoperative year.     

Prognostic significance of postoperative in-hospital complications in elderly patients. I. Long-term survival

To determine the impact of in-hospital postoperative complications on long-term survival, we prospectively studied consecutive patients > or = 70 yr of age undergoing noncardiac surgery. Potential clinical risk factors were measured and evaluated for their association with the occurrence of long-term postoperative mortality. Long-term survival was determined by using the Kaplan-Meier method. Multivariate correlates of survival were analyzed with the Cox proportional hazards model. The survival of the study group was also compared with the age- and gender-matched general United States population. Five hundred seventeen patients who survived the initial hospitalization were studied. The mean follow-up duration was 28.6 +/- 12.8 mo. One hundred sixty-four of 517 patients (31.7%) were deceased at the time of follow-up. A history of cancer (hazard ratio [HR] 2.44, 95% confidence interval [CI] 1.78-3.38, P < 0.0001), ASA physical status >II (HR 2.27, 95% CI 1.61-3.21, P < 0.0001), neurologic disease (HR 1.59, 95% CI 1.13-2.24, P = 0.008), age (HR 1.42 per decade, 95% CI 1.11-1.81, P = 0.005), postoperative pulmonary complications (HR 2.41, 95% CI 1.30-4.48, P = 0.005), and renal complications (HR 6.07, 95% CI 2.23-16.52, P < 0.0001) were significant independent predictors of decreased long-term survival. Compared with the United States population, patients with complications had a greater increase in mortality risk in the first 3 mo after surgery (HR 7.3 versus general population) than those without complications (HR 2.9, P = 0.023). An effort to improve perioperative care delivery to elderly surgical patients must include measures to minimize in-hospital postoperative complications, particularly those involving the pulmonary and renal systems.     

严格控制心率是否可以提高β受体阻滞剂的作用？非心脏手术患者随机研究最新分析

背景近期的荟萃分析评估了围手术期β受体阻滞剂的有效性,但并未发现其降低手术后患者并发症发生率和死亡率的作用。有人建议严格控制心率可能会改善预后,但荟萃分析中并未考虑严格的心率控制对围手术期β受体阻滞剂有效性的影响。方法应用已发表的检索策略,我们检录了所有非心脏手术术后使用β受体阻滞剂的随机研究,共包含10项研究,2176例患者。我们利用这些研究中的数据以发现控制心率与以手术后院内心肌梗死（MI）为主要转归指标之间的相关关系。计算比值比（OR）和95％可信区间（CI）,对心率控制和心肌梗死之间的相关关系进行荟萃回归分析。结果所有研究的合并结果并未显示β受体阻滞剂有明显的心肌保护作用,各研究之间存在异质性（OR=0．76;95％CI=0．4—1．4;P=0．38;异质性：I^2=34％）。然而根据最快心率分组后显示最快心率小于100bpm组,β受体阻滞剂具有心肌保护作用（OR=0．23;95％CI=0．08～0．65;P=0．005）,最快心率大于100bpm组则不具有心肌保护作用（OR=1．17;95％CI=0．79～1．80;P=0．43）,且无组内异质性。此外,8受体阻滞剂引起的心率变化和手术后心肌梗死的logOR进行荟萃回归分析表明β受体阻滞剂对于平均心率、最大心率、心率变异性的作用与心肌梗死的OR存在线性相关（r^2=0．63;P〈0．001）,β受体阻滞剂对心率的影响越大则手术后心肌梗死的发生率越低。所有研究中β受体阻滞剂可引起手术后心率的下降（加权平均差：8．6bpm;95％CI=-9．6～-7．6;I^2=85．3％）,同时存在很大的异质性。β受体阻滞剂引起心率变化的异质性部分是由于β受体阻滞剂类型不同所致,特别是美托洛尔,也与合用钙通道阻滞剂有关。钙通道阻滞剂与美托洛尔以外的其他β受体阻滞剂合用可以有效控制心率。心率对?     

Patterns and timing of perioperative blood transfusion and association with outcomes after radical cystectomy

BackgroundPerioperative blood transfusion (PBT) has been associated with worse outcomes across tumor types, including bladder cancer. We report our institutional experience with PBT utilization in the setting of radical cystectomy (RC) for patients with bladder cancer, exploring whether timing of PBT receipt influences perioperative and oncologic outcomes.MethodsConsecutive patients with bladder cancer treated with RC were identified. PBT was defined as red blood cell transfusion during RC or the postoperative admission. Clinicopathologic and peri and/or postoperative parameters were extracted and compared between patients who did and did not receive PBT using Mann Whitney U Test, chi-square, and log-rank test. Overall (OS) and recurrence-free survival (RFS) were estimated with the Kaplan Meier method. Univariate/multivariate logistic and Cox proportional hazards regression were used to identify variables associated with postoperative and oncologic outcomes, respectively.ResultsThe cohort consisted of 747 patients (77% men; median age 67 years). Median follow-up was 61.5 months (95% CI 55.8–67.2) At least one postoperative complication (90-day morbidity) occurred in 394 (53%) patients. Median OS and RFS were 91.8 months (95% CI: 76.0–107.6) and 66.0 months (95% CI: 48.3–83.7), respectively. On multivariate analysis, intraoperative, but not postoperative, BT was independently associated with shorter OS (HR: 1.74, 95% CI: 1.32–2.29) and RFS (HR: 1.55, 95%CI: 1.20–2.01), after adjusting for relevant clinicopathologic variables. PBT (intra- or post- operative) was significantly associated with prolonged postoperative hospitalization ≥10 days.ConclusionsIntraoperative BT was associated with inferior OS and RFS, and PBT overall was associated with prolonged hospitalization following RC. Further studies are needed to validate this finding and explore potential causes for this observation.     

加速康复外科在腹腔镜肝切除术应用安全性与有效性的Meta分析

目的：评价加速康复外科（FTS）在腹腔镜肝切除围手术期应用的安全性和有效性。 方法：计算机检索1996年1月—2014年6月国内外数据库有关FTS在腹腔镜肝切除围手术期应用的随机对照试验（RCT）或临床对照试验（CCT）,采用RevMan 5.2软件进行Meta分析。 结果：最终纳入3项RCT和2项CCT,共有247例患者,其中134例采用FTS（FTS组）,113例采用传统围手术期处理（对照组）。Meta分析结果显示,与对照组比较,FTS组住院时间明显缩短（WMD=-2.19,95% CI=-2.94~-1.43,P<0.00001）,术后并发症发生率降低（RR=0.60,95% CI=0.38~0.92,P=0.02）,但两组手术时间、中转开腹发生率和住院费用无统计学差异（均P>0.05）。 结论：FTS在腹腔镜肝切除围手术期应用可有效缩短住院时间,减少术后并发症,加速患者康复。上述结果仍须更多设计严密的大样本、高质量的RCT进一步验证。     

Are Gender,Comorbidity, and Obesity Risk Factors for Postoperative Periprosthetic Fractures After Primary Total Hip Arthroplasty?

We studied the frequency and patient risk factors for postoperative periprosthetic fractures after primary total hip arthroplasty (THA). With a mean follow-up of 6.3 years, 305 postoperative periprosthetic fractures occurred in 14?065 primary THAs. In multivariable-adjusted Cox regression analyses, female gender (hazard ratio [HR], 1.48; 95% confidence interval [CI], 1.17-1.88), Deyo-Charlson comorbidity score of 2 (HR, 1.74 for score of 2; 95% CI, 1.25-2.43) or 3 or higher (HR, 1.71; 95% CI, 1.26-2.32), and American Society of Anesthesiologist class of 2 (HR, 1.84; 95% CI, 0.90-3.76) or 3 (HR, 2.45; 95% CI, 1.18-5.1) or 4 or higher (HR, 2.68; 95% CI, 0.70-10.28) were significantly associated with higher risk/hazard, and cemented implant, with lower hazard (HR, 0.68; 95% CI, 0.54-0.87) of postoperative periprosthetic fractures. Interventions targeted at optimizing comorbidity management may decrease postoperative fractures after THA.     

Uncomplicated carotid endarterectomy: factors contributing to blood pressure instability precluding safe early discharge

This study was undertaken to identify preoperative and intraoperative factors that correlate with the need for postoperative vasoactive medication (VM) use. Clinical data from 100 carotid endarterectomies (CEAs) performed in 93 patients were reviewed. Baseline comorbidities, medications, perioperative physiologic data, and operative technique were evaluated for their association with the need for postoperative VM use. Statistical analysis included univariate and multivariate logistic regression with odds ratios (ORs) and 95% confidence intervals (CIs) reported. Hemodynamic instability affected 43 patients, of whom 32 had VM started in the postanesthesia care unit (PACU). No patient who was hemodynamically stable in the PACU later required VM. The only preoperative factor associated with a need for postoperative VM was a prior stroke (OR 4.5; 95% CI 1.2-16.2; p = .02). Intraoperative factors associated with the need for postoperative VM included use of a shunt (OR 5.1; 95% CI 1.2-22.2; p = .03) and a peak intraoperative systolic blood pressure greater than 200 mm Hg (OR 5.1; 95% CI 1.2-22.2; p = .03). The number and type of preoperative blood pressure medications, preoperative hypertension, comorbidities, symptomatic presentation, and intraoperative use of VM did not correlate with postoperative VM use. There were two strokes and no deaths. Patients undergoing CEA who are hemodynamically stable in the PACU appear to be reasonable candidates for same-day discharge and warrant further prospective study.     

Glove leakage rates as a function of latex content and brand: caveat emptor

HYPOTHESIS: That water leakage rates and protection against blood-borne pathogens should not vary as a function of latex content among Food and Drug Administration-approved gloves, allowing avoidance of unnecessary latex exposure. DESIGN AND METHODS: Eighteen different glove types were purchased and tested using the American Society for Testing Methods Standard Test for Detecting Holes in medical gloves, which involves mounting the glove on a plastic tube, pouring a liter of tap water into the glove, and visually inspecting the glove initially and after 2 minutes. Half of the gloves were tested straight from the package and half after a standardized manipulation. SETTING: A university hospital. RESULTS: Eleven sterile glove types (5 high latex content, 4 low latex content, and 2 nonlatex content), and 7 nonsterile examination glove types (2 high latex content, 2 low latex content, and 3 nonlatex content) were tested (total tested, 3720 gloves). Leakage rates were greater for examination than for surgical gloves (relative risk [RR], 1.41, 95% confidence interval [CI], 1.01-1.96), for manipulated than for unused gloves (RR, 2.89, 5% CI, 1.98-4.22), and for low latex content surgical gloves (RR, 2.58, 95% CI, 1.35-4.92) or nonlatex content surgical gloves (RR, 4.93, 95% CI, 2.35-10.32) than for high latex content surgical gloves. Significant differences were observed among low latex content surgical gloves (P相似文献   

Perioperative steroid administration reduces overall complications in patients undergoing liver resection: A meta-analysis

BACKGROUNDHepatic resection (HR) results in an inflammatory response that can be modified by perioperative steroid administration. However, it remains to be determined if this response''s attenuation translates to a reduction in complications.AIMTo evaluate if perioperative administration of steroids reduces complications following HR.METHODSA systematic review of randomized controlled trials (RCTs) was conducted on PubMed, Embase, and Cochrane Central Register of Controlled Trials to evaluate the effect of perioperative steroid (compared to placebo or no intervention) use in patients undergoing HR. Clinical outcomes were extracted, and meta-analysis was performed. RESULTS8 RCTs including 590 patients were included. Perioperative steroid administration was associated with significant reduction in postoperative complications [odds ratios: 0.58; 95% confidence intervals (CI): 0.35-0.97, P = 0.04]. There was also improvement in biochemical and inflammatory markers, including serum bilirubin on postoperative day 1 [MD: -0.27; 95%CI: (-0.47, -0.06), P = 0.01], C-reactive protein on postoperative day 3 [MD: -4.89; 95%CI: (-5.83, -3.95), P < 0.001], and interleukin-6 on postoperative day 1 [MD: -54.84; 95%CI: (-63.91, -45.76), P < 0.001].CONCLUSIONPerioperative steroids administration in HR may reduce overall complications, postoperative bilirubin, and inflammation. Further studies are needed to determine the optimal dose and duration and patient selection.     

Reoperation as a quality indicator in colorectal surgery: a population-based analysis

OBJECTIVE: To describe unplanned procedures following colorectal cancer surgery that might be used as intermediate outcome measures, and to determine their association with mortality and length of stay. SUMMARY BACKGROUND: Variation in the quality of surgical care, especially for common illnesses like colorectal cancer, has received increasing attention. Nonfatal complications resulting in procedural interventions are likely to play a role in poor outcomes but have not been well explored. METHODS: Cohort analysis of 26,638 stage I to III colorectal cancer patients in the 1992 to 1996 SEER-Medicare database. Independent variables: sociodemographics, tumor characteristics, comorbidity, and acuity. Primary outcome: postoperative procedural intervention. Analysis: Logistic regression identified patient characteristics predicting postoperative procedures and the adjusted risk of 30-day mortality and prolonged hospitalization among patients with postoperative procedures. RESULTS: A total of 5.8% of patients required postoperative intervention. Patient characteristics had little impact on the frequency of postoperative procedures, except for acute medical conditions, including bowel perforation (relative risk [RR] = 3.0, 95% confidence interval [CI] = 2.5-3.6), obstruction (RR = 1.6; 95% CI = 1.4-1.8), and emergent admission (RR = 1.3; 95% CI = 1.1-1.4). After a postoperative procedure, patients were more likely to experience early mortality (RR = 2.4; 95% CI = 2.1-2.9) and prolonged hospitalization (RR = 2.2; 95% CI = 2.1-2.4). The most common interventions were performed for abdominal infection (31.7%; RR mortality = 2.9; 95% CI = 2.3-3.7), wound complications (21.1%; RR mortality = 0.7; 95% CI = 0.4-1.3), and organ injury (18.7%; RR mortality = 1.6; 95% CI = 1.1-2.3). CONCLUSIONS: Postoperative complications requiring additional procedures among colorectal cancer patients correlate with established measures of surgical quality. Prospective tracking of postoperative procedures as complication markers may facilitate outcome studies and quality improvement programs.     

Multivariable analysis of factors associated with hospital readmission after intestinal surgery

BACKGROUND: Readmission rates after major abdominal surgery have a significant impact on hospital costs and quality of care. Identification of risk factors for readmission may improve postoperative care and discharge plans. METHODS: One hundred fifty consecutive patients readmitted within 30 days of discharge after intestinal surgery (RD) were compared with matched nonreadmitted patients. Patient-related (demographic, comorbidity, medications), disease-related (diagnosis, type of surgery), and perioperative course variables were collected for logistic regression analysis. RESULTS: RD was associated with chronic obstructive pulmonary disease (odds ratio [OR] 7.12 and 95% confidence interval [CI] 1.4-37.6), worse functional capacity class (OR 2.02 and CI 1.15-3.56), previous anticoagulant therapy (OR 4.85 and CI 1.2-19.7), steroid treatment, and discharge to a facility other than home (OR 4.35 and CI 0.97-20.0, P = .055). In patients with intestinal perforation, RD rate was decreased (OR 0.3 and CI 0.1-0.9), but this was associated with a longer primary hospital stay (median 8 vs. 6 days, P = .12). RD causes included surgical site septic complications (33%), ileus and/or small-bowel obstruction (23%), medical complications (24%), and others (20%). CONCLUSIONS: Functional capacity, chronic obstructive pulmonary disease, previous anticoagulant therapy, perioperative steroids, and discharge destination are independent predictors of RD. Disease-related factors have minor impact on RD rates. Improving functional status before surgery, decreasing the adverse impact of steroids, and/or stratifying perioperative anticoagulant use may decrease unexpected readmissions in this patient population.     

Clinical application of artificial dura mater to avoid cerebrospinal fluid leaks after microvascular decompression surgery.

OBJECTIVE: Although technological advances combined with many surgical innovations have helped to minimize its occurrence, cerebrospinal fluid (CSF) leak still remains to be one of the most common postoperative complications following microvascular decompression (MVD) surgeries. The objectives of this study are 1) to detail our experience with the clinical application of artificial dura mater for the avoidance of CSF leaks in a group of 103 patients who underwent MVD surgeries and 2) to compare the results of CSF leak and deep wound infection between the group with and one without using artificial dura mater. METHODS: From July, 2002 to June, 2004 217 consecutive patients who underwent MVD surgeries for hemifacial spasm or trigeminal neuralgia in our center were enrolled into this study. Among them, 103 patients underwent the application of artificial dura mater (Neuro-patch) in the surgical closure procedure to prevent postoperative CSF leak. The handling techniques were detailed and the postoperative results were evaluated. The follow-up period was at least 6 months. RESULTS: No postoperative CSF leak occurred in the group of patients receiving artificial dura mater whereas 6 cases of CSF leak (2 otorrhea, 2 rhinorrea and 2 CSF wound leak) were found in the group not receiving artificial dura mater. There was no statistical difference of wound infection rates found between these two groups, 1.9 % vs. 2.6 %. CONCLUSIONS: The use of the artificial dura mater in the closure procedure of MVD surgery seems to be a safe and effective way to prevent CSF leaks. However, further investigations on a larger number of cases still need to be done to substantiate its validity.     

Body mass index and early outcomes following mitral valve surgery for degenerative disease

ObjectiveUsing a large national database, we sought to better define the relationship between obesity measures and early clinical outcomes following mitral valve surgery for degenerative disease.MethodsFor the outcomes of in-hospital mortality, postoperative cerebrovascular event (CVA), and deep sternal wound infection (DSWI), a retrospective cohort study was performed using data acquired from the United Kingdom National Adult Cardiac Surgery Audit. Multivariable Cox proportional hazard regression modeling was used to investigate associations with individual measures of obesity. Progressively adjusted body mass index (BMI)-specific hazard ratios (HRs) were plotted against mean BMI values in each World Health Organization category using floated variances to investigate specific shapes of association.ResultsMultivariable Cox proportional hazard modeling failed to demonstrate an association between mortality and an increase in BMI of 5 points (HR, 0.93, 95% confidence interval [CI], 0.81-1.07), a BMI quintile increase (HR, 0.98; 95% CI, 0.90-1.07), or being classed “obese” by World Health Organization standards (HR, 1.03; 95% CI, 0.74-1.42). A 5-point BMI increase was associated with an increased hazard of DSWI (HR, 1.38; 95% CI, 1.08-1.77) but was not associated with perioperative CVA (HR, 1.05; 95% CI, 0.91-1.21). The shape of association between BMI and mortality appeared approximately U-shaped. DSWI appeared linear, whereas CVA demonstrated an inverted U, or a possible hourglass.ConclusionsAlthough individual measures of obesity were not associated with an increased mortality risk on regression modeling, the U-shaped relationship between mortality and increasing BMI demonstrates lower mortality risks in lower obesity classes. Increasing BMI was associated with an increased hazard for DSWI.     

Risk factors for repeated cerebrospinal shunt failures in pediatric patients with hydrocephalus

OBJECT: Repeated cerebrospinal fluid (CSF) shunt failures in pediatric patients are common, and they are a significant cause of morbidity and, occasionally, of death. To date, the risk factors for repeated failure have not been established. By performing survival analysis for repeated events, the authors examined the effects of patient characteristics, shunt hardware, and surgical details in a large cohort of patients. METHODS: During a 10-year period all pediatric patients with hydrocephalus requiring CSF diversion procedures were included in a prospective single-institution observational study. Patient characteristics were defined as age, gender, weight, head circumference, American Society of Anesthesiology class, and cause of hydrocephalus. Surgical details included whether the procedure was performed on an emergency or nonemergency basis, use of antibiotic agents, concurrent surgical procedures, and duration of the surgical procedure. Details on shunt hardware included: the type of shunt, the valve system, whether the shunt system included multiple or complex components, the type of distal catheter, the site of the shunt, and the side on which the shunt was placed. Repeated shunt failures were assessed using multivariable time-to-event analysis (by using the Cox regression model). Conditional models (as established by Prentice, et al.) were formulated for gap times (that is, times between successive shunt failures). There were 1183 shunt failures in 839 patients. Failure time from the first shunt procedure was an important predictor for the second and third episodes of failure, thus establishing an association between the times to failure within individual patients. An age younger than 40 weeks gestation at the time of the first shunt implantation carried a hazard ratio (HR) of 2.49 (95% confidence interval [CI] 1.68-3.68) for the first failure, which remained high for subsequent episodes of failure. An age from 40 weeks gestation to 1 year (at the time of the initial surgery) also proved to be an important predictor of first shunt malfunctions (HR 1.77, 95% CI 1.29-2.44). The cause of hydrocephalus was significantly associated with the risk of initial failure and, to a lesser extent, later failures. Concurrent other surgical procedures were associated with an increased risk of failure. CONCLUSIONS: The patient's age at the time of initial shunt placement and the time interval since previous surgical revision are important predictors of repeated shunt failures in the multivariable model. Even after adjusting for age at first shunt insertion as well as the cause of hydrocephalus, there is significant association between repeated failure times for individual patients.     

Risk assessment of significant upper extremity arteriovenous graft infection in the Vascular Quality Initiative

ObjectiveInfectious complications of arteriovenous grafts (AVGs) are a major source of morbidity. Our aim was to characterize contemporary risk factors for upper extremity AVG infection.MethodsThe Vascular Quality Initiative (2011-2018) was queried for all patients undergoing upper extremity AVG creation. AVG infection was classified as an infection treated with antibiotics, incision and drainage, or graft removal. Multivariable analyses were used to evaluate risk factors for short- and long-term AVG infection.ResultsOf 1758 upper extremity AVGs, 49 (2.8%) developed significant infection within 3 months, resulting in incision and drainage in 24% and graft removal in 76% of cases. None were managed with antibiotics alone in the study sample. Patients with significant AVG infection were more likely to be white, to be insured, to have a history of coronary artery bypass graft and intravenous (IV) drug use, to be undergoing a concomitant vascular procedure, and to be discharged on an anticoagulant. In multivariable analysis, significant AVG infection within 3 months was associated with IV drug use history (odds ratio [OR], 5; 95% confidence interval [CI], 1.75-14.3; P = .003), discharge to a health care facility (OR, 2.66; 95% CI, 1.07-6.63; P = .035), discharge on an anticoagulant (OR, 2.31; 95% CI, 1.13-4.72; P = .021), white race (OR, 2.3; 95% CI, 1.21-4.34; P = .011), and female sex (OR, 2.02; 95% CI, 1.06-3.85; P = .033). Kaplan-Meier analysis showed that freedom from graft site infection at 1 year was 96.4%. Longer term graft infection at 1 year was independently associated with IV drug use history (hazard ratio [HR], 1.98; 95% CI, 1.06-3.68; P = .032), initial discharge to a health care facility (HR, 1.88; 95% CI, 1.19-2.97; P = .007), and white race (HR, 1.64; 95% CI, 1.23-2.19; P = .001).ConclusionsAlthough significant AVG infection was uncommon in the Vascular Quality Initiative, the majority were treated with graft removal. In select high-risk patients, extra care should be taken and alternative forms of arteriovenous access may be considered.