In the Absence of a Mechanical Bowel Prep, Does the Addition of Pre-Operative Oral Antibiotics to Parental Antibiotics Decrease the Incidence of Surgical Site Infection after Elective Segmental Colectomy?

BACKGROUND: Pre-operative oral antibiotics administered the day prior to elective colectomy have been shown to decrease the incidence of surgical site infections (SSI) if a mechanical bowel prep (MBP) is used. Recently, the role for mechanical bowel prep has been challenged as being unnecessary and potentially harmful. We hypothesize that if MBP is omitted, oral antibiotics do not alter the incidence of SSI following colectomy. METHODS: We selected patients who underwent an elective segmental colectomy from the 2012 and 2013 National Surgical Quality Improvement Program colectomy procedure targeted database. Indications for surgery included colon cancer, diverticulitis, inflammatory bowel disease, or benign polyp. Patients who received mechanical bowel prep were excluded. The primary outcome measured was surgical site infection, defined as the presence of superficial, deep or, organ space infection within 30 d from surgery. RESULTS: A total of 6,399 patients underwent elective segmental colectomy without MBP. The incidence of SSI differed substantially between patients who received oral antibiotics, versus those who did not (9.7% vs. 13.7%, p=0.01). Multivariate analysis indicated that age, smoking status, operative time, perioperative transfusions, oral antibiotics, and surgical approach were associated with post-operative SSI. When controlling for confounding factors, the use of pre-operative oral antibiotics decreased the incidence of surgical site infection (odds ratio=0.66, 95% confidence interval=0.48-0.90, p=0.01). CONCLUSION: Even in the absence of mechanical bowel prep, pre-operative oral antibiotics appear to reduce the incidence of surgical site infection following elective colectomy.

Whence Resistance?

BACKGROUND: Antimicrobial resistance results from a complex interaction between pathogenic and non-pathogenic bacteria, antimicrobial pressure, and genes, which together comprise the total body of potential resistance elements. The purpose of this study is to review and evaluate the importance of antimicrobial pressure on the development of resistance in a single surgical intensive care unit. METHODS: We reviewed a prospectively collected dataset of all intensive care unit (ICU)-acquired infections in surgical and trauma patients over a 6-y period at a single hospital. Resistant gram-negative pathogens (rGNR) included those resistant to all aminoglycosides, quinolones, penicillins, cephalosporins, or carbapenems; resistant gram-positive infections (rGPC) included methicillin-resistant Staphylococcus aureus (MRSA) or vancomycin-resistant enterococci (VRE). Each resistant infection was evaluated for prior or concomitant antibiotic use, previous treatment for the same (non-resistant) organism, and concurrent infection with the same organism (genus and species, although not necessarily resistant) in another ICU patient. RESULTS: Three hundred and thirty resistant infections were identified: 237 rGNR and 93 rGPC. Infections with rGNR occurred frequently while receiving antibiotic therapy (65%), including the sensitive form of the subsequent resistant pathogen (42.2%). Infections with rGPC were also likely to occur on antimicrobial therapy (50.6%). Treatment of a different patient for an infection with the same resistant pathogen in the ICU at the time of diagnosis, implying potential patient-to-patient transmission occurred more frequently with rGNR infections (38.8%). CONCLUSION: Antimicrobial pressure exerts a substantial effect on the development of subsequent infection. Our data demonstrate a high estimated rate of de novo emergence of resistance after treatment, which appears to be more common than patient-to-patient transmission. These data support the concept that efforts to limit antimicrobial usage will be more efficacious than enhanced isolation procedures when trying to reduce antimicrobial resistance.

Hypocaloric compared with eucaloric nutritional support and its effect on infection rates in a surgical intensive care unit: a randomized controlled trial.

BACKGROUND: Proper caloric intake goals in critically ill surgical patients are unclear. It is possible that overnutrition can lead to hyperglycemia and an increased risk of infection. OBJECTIVE: This study was conducted to determine whether surgical infection outcomes in the intensive care unit (ICU) could be improved with the use of hypocaloric nutritional support. DESIGN: Eighty-three critically ill patients were randomly allocated to receive either the standard calculated daily caloric requirement of 25-30 kcal · kg(-1) · d(-1) (eucaloric) or 50% of that value (hypocaloric) via enteral tube feeds or parenteral nutrition, with an equal protein allocation in each group (1.5 g · kg(-1) · d(-1)). RESULTS: There were 82 infections in the hypocaloric group and 66 in the eucaloric group, with no significant difference in the mean (± SE) number of infections per patient (2.0 ± 0.6 and 1.6 ± 0.2, respectively; P = 0.50), percentage of patients acquiring infection [70.7% (29 of 41) and 76.2% (32 of 42), respectively; P = 0.57], mean ICU length of stay (16.7 ± 2.7 and 13.5 ± 1.1 d, respectively; P = 0.28), mean hospital length of stay (35.2 ± 4.9 and 31.0 ± 2.5 d, respectively; P = 0.45), mean 0600 glucose concentration (132 ± 2.9 and 135 ± 3.1 mg/dL, respectively; P = 0.63), or number of mortalities [3 (7.3%) and 4 (9.5%), respectively; P = 0.72]. Further analyses revealed no differences when analyzed by sex, admission diagnosis, site of infection, or causative organism. CONCLUSIONS: Among critically ill surgical patients, caloric provision across a wide acceptable range does not appear to be associated with major outcomes, including infectious complications. The optimum target for caloric provision remains elusive.

Characteristics of surgical patients receiving inappropriate empiric antimicrobial therapy.

BACKGROUND: Inappropriate antibiotics have been observed to result in an increased duration of antibiotic treatment and hospital length of stay, development of multidrug-resistant organisms, and mortality rate compared with appropriate antibiotic treatment. Few studies have evaluated independent risk factors associated with inappropriateness. The purpose of this study was to identify independent predictors of inappropriate, empiric antimicrobial therapy for the treatment of severe sepsis. METHODS: This was a retrospective analysis of a prospectively maintained database of all surgical/trauma patients admitted to a tertiary care center from 1996 to 2007 and treated for sepsis. "Appropriate" empiric antibiotic treatment was determined by sensitivity testing. Demographics and comorbidities, infection sites, infection organisms, and outcomes between strata were compared. Differences in outcome were estimated using relative risk and 95% confidence intervals for correlated data. RESULTS: A total of 2,855 patients (7,158 infections) were identified. Independent predictors of inappropriate, empiric antimicrobial therapy for the treatment of severe sepsis included site of infection and organism type. Severity of illness, age, medical conditions, and community versus health care-associated infections were not associated with inappropriate therapy. Although inappropriate empiric therapy was associated with a longer length of stay and duration of antimicrobial use, it did not result in higher mortality. CONCLUSION: Our study observed that inappropriate empiric antibiotic selection is related to site of infection and pathogen. Other clinical variables do not appear to predict inappropriateness of antibiotic treatment. Efforts should be focused on early broad-spectrum therapy and more rapid microbiologic methods. LEVEL OF EVIDENCE: Therapeutic/care management study, level II.

Does it Matter if we get it right? Impact of appropriateness of empiric antimicrobial therapy among surgical patients.

Previous studies have shown conflicting evidence regarding the impact of inappropriate, initial antibiotic therapy. The purpose of this study was to evaluate the impact of inappropriate empiric antimicrobial therapy for the treatment of infection among surgical patients. We hypothesized that inappropriate empiric antimicrobial therapy would predict increased mortality risk compared with appropriate therapy. This was a retrospective analysis of a prospectively maintained database of all surgical patients admitted to a tertiary care center from 1996 to 2007 and treated for sepsis. "Appropriate" empiric antibiotic treatment was determined by sensitivity testing. Demographics and comorbidities, infection sites, infection organisms, and outcomes were compared between inappropriately and appropriately treated groups. Multivariable log-binomial regression was performed. There were 2,855 patients (7,158 infectious episodes) identified by culture analysis as either appropriately or inappropriately treated. Three hundred seventeen (15%) inappropriately treated infectious episodes resulted in death compared with 718 (14%) of the appropriately treated infectious episodes. After adjusting for statistically significant variables, inappropriately treated episodes of infection were not found to be associated with an increased risk for mortality compared with appropriately treated episodes of infection (relative risk, 1.0; 95% confidence interval, 0.99 - 1.02; P = 0.36). Our study observed no difference in mortality between appropriately and inappropriately treated infections within a surgical population.

Sex- and diagnosis-dependent differences in mortality and admission cytokine levels among patients admitted for intensive care.

OBJECTIVES: To investigate the role of sex on cytokine expression and mortality in critically ill patients. DESIGN: A cohort of patients admitted to were enrolled and followed over a 5-year period. SETTING: Two university-affiliated hospital surgical and trauma ICUs. PATIENTS: Patients 18 years old and older admitted for at least 48 hours to the surgical or trauma ICU. INTERVENTIONS: Observation only. MEASUREMENTS AND MAIN RESULTS: Major outcomes included admission cytokine levels, prevalence of ICU-acquired infection, and mortality during hospitalization conditioned on trauma status and sex. The final cohort included 2,291 patients (1,407 trauma and 884 nontrauma). The prevalence of ICU-acquired infection was similar for men (46.5%) and women (44.5%). All-cause in-hospital mortality was 12.7% for trauma male patient and 9.1% for trauma female patient (p = 0.065) and 22.9% for nontrauma male patients and 20.6% for nontrauma female patients (p = 0.40). Among trauma patients, logistic regression analysis identified female sex as protective for all-cause mortality (odds ratio, 0.57). Among trauma patients, men had significantly higher admission serum levels of interleukin-2, interleukin-12, interferon-γ, and tumor necrosis factor-α, and among nontrauma patients, men had higher admission levels of interleukin-8 and tumor necrosis factor-α. CONCLUSIONS: The relationship between sex and outcomes in critically ill patients is complex and depends on underlying illness. Women appear to be better adapted to survive traumatic events, while sex may be less important in other forms of critical illness. The mechanisms accounting for this gender dimorphism may, in part, involve differential cytokine responses to injury, with men expressing a more robust proinflammatory profile.

Continuous intraoperative temperature measurement and surgical site infection risk: analysis of anesthesia information system data in 1008 colorectal procedures.

OBJECTIVES: To investigate the association between intraoperative temperature and surgical site infection (SSI) in colorectal surgery with anesthesia information system data. METHODS: Continuously measured intraoperative anesthesia information system temperature data for adult abdominal colorectal surgery procedures at a large tertiary center for 1 year were linked to 30-day American College of Surgeons National Surgical Quality Improvement Program SSI outcomes. Univariable and multivariable analyses of SSI to descriptive temperature statistics, absolute and relative temperature threshold times, and other clinically relevant variables were performed. RESULTS: Overall, 1008 patients (48% female, median age: 53 years) underwent major colorectal procedures (7% emergent, 72% open, 173 ± 95 minutes mean procedure time) with median intraoperative temperature 36.0°C, using active rewarming in 92% and 1-hour presurgical antibiotic administration in 91%. Thirty-day overall and organ/space infection rates were 17.4% (175) and 8.5% (86). Maximum, minimum, ending, and median temperatures were similar for those with or without SSI (36.6°C vs 36.5°C, 34.9°C vs 35.0°C, 36.4°C vs 36.2°C, and 36.1°C vs 36.0°C, P = not significant) and percent minutes using incremental cutoffs failed to correlate SSI with temperature. Absolute minutes for higher temperature cutoffs correlated with SSI because of longer procedure times. On multivariable analysis, factors associated with SSI were preoperative diabetes [odds ratio: 1.81 (1.07-3.07), P = 0.022] and blood loss of more than 500 mL [odds ratio: 1.61 (1.01-2.58), P = 0.047]. CONCLUSIONS: Although active rewarming remains an accepted and valid process measure, highly granular anesthesia information system temperature data did not demonstrate a correlation between temperature measures and SSI. SSI prevention efforts should focus on more efficacious interventions as opposed to currently mandated publicly reported normothermia measures.

Model for End-stage Liver Disease (MELD) in predicting postoperative mortality of patients undergoing colorectal surgery.

The Model for End-stage Liver Disease (MELD) score was previously shown to predict perioperative mortality in patients with cirrhosis undergoing a variety of nontransplant surgical procedures. We sought to determine its usefulness in predicting postoperative mortality in patients undergoing colorectal procedures. National Surgical Quality Improvement Program data were gathered for adult patients undergoing elective and emergent colorectal procedures (Current Procedural Terminology codes 44005 through 45563 excluding appendectomy) during 2005 and 2006 at participating centers. The preoperative MELD score was calculated for all patients and assessed using logistic regression modeling. A total of 10,033 patients met study inclusion criteria. Overall 30-day mortality was 6.6 per cent. In all patients undergoing colorectal surgery, MELD was an independent predictor of mortality (2.95 [2.27 to 3.84]). Other independent predictors included age, functional status, American Society of Anesthesiologists classification, ascites, esophageal varices, disseminated cancer, chronic steroid use, cardiac disease, renal failure, malnutrition, sepsis, emergency, and ventilator dependence. The MELD score is an independent predictor of mortality in patients undergoing colorectal procedures. These data can be used to assign risk and assist in clinical decision-making.

Mortality factors in geriatric blunt trauma patients: creation of a highly predictive statistical model for mortality using 50,765 consecutive elderly trauma admissions from the National Sample Project.

Elderly patients are at high risk for mortality after injury. We hypothesized that trauma benchmarking efforts would benefit from development of a geriatric-specific model for risk-adjusted analyses of trauma center outcomes. A total of 57,973 records of elderly patients (age older than 65 years), which met our selection criteria, were submitted to the National Trauma Database and included within the National Sample Project between 2003 and 2006. These cases were used to construct a multivariable logistic regression model, which was compared with the American College of Surgeons Committee on Trauma's Trauma Quality Improvement Project's (TQIP) existing model. Additional spline regression analyses were performed to further objectively quantify the physiologic differences between geriatric patients and their younger counterparts. The geriatric-specific and TQIP mortality models shared several covariates: age, Injury Severity Score, motor component of the Glasgow Coma Scale, and systolic blood pressure. Our model additionally used temperature and the presence of mechanical ventilation. Our geriatric-specific regression mode generated a superior c-statistic as compared with the TQIP approximation (0.85 vs 0.77; P = 0.048). Spline analyses demonstrated that elderly patients appear to be less likely to tolerate relative hypotension with higher observed mortality at initial systolic blood pressures of 90 to 130 mmHg. Although the TQIP model includes a single age component, these data suggest that each variable needs to be adjusted for age to more accurately predict mortality in the elderly. Clearly, a separate geriatric model for predicting outcomes is not only warranted, but necessary.

Aggressive versus conservative initiation of antimicrobial treatment in critically ill surgical patients with suspected intensive-care-unit-acquired infection: a quasi-experimental, before and after observational cohort study.

BACKGROUND: Antimicrobial treatment in critically ill patients can either be started as soon as infection is suspected or after objective data confirm an infection. We postulated that delaying antimicrobial treatment of patients with suspected infections in the surgical intensive care unit (SICU) until objective evidence of infection had been obtained would not worsen patient mortality. METHODS: We did a 2-year, quasi-experimental, before and after observational cohort study of patients aged 18 years or older who were admitted to the SICU of the University of Virginia (Charlottesville, VA, USA). From Sept 1, 2008, to Aug 31, 2009, aggressive treatment was used: patients suspected of having an infection on the basis of clinical grounds had blood cultures sent and antimicrobial treatment started. From Sept 1, 2009, to Aug 31, 2010, a conservative strategy was used, with antimicrobial treatment started only after objective findings confirmed an infection. Our primary outcome was in-hospital mortality. Analyses were by intention to treat. FINDINGS: Admissions to the SICU for the first and second years were 762 and 721, respectively, with 101 patients with SICU-acquired infections during the aggressive year and 100 patients during the conservative year. Compared with the aggressive approach, the conservative approach was associated with lower all-cause mortality (13/100 [13%] vs 27/101 [27%]; p=0·015), more initially appropriate therapy (158/214 [74%] vs 144/231 [62%]; p=0·0095), and a shorter mean duration of therapy (12·5 days [SD 10·7] vs 17·7 [28·1]; p=0·0080). After adjusting for age, sex, trauma involvement, acute physiology and chronic health evaluation (APACHE) II score, and site of infection, the odds ratio for the risk of mortality in the aggressive therapy group compared with the conservative therapy group was 2·5 (95% CI 1·5-4·0). INTERPRETATION: Waiting for objective data to diagnose infection before treatment with antimicrobial drugs for suspected SICU-acquired infections does not worsen mortality and might be associated with better outcomes and use of antimicrobial drugs. FUNDING: National Institutes of Health.

Colonic volvulus: presentation and management in metropolitan Minnesota, United States.

BACKGROUND: Management approaches for colonic volvulus are infrequently described in the literature in the United States, and many studies only report operative cases. OBJECTIVE: The aim of this study was to define the demographics, diagnostic and treatment approaches, and outcomes for patients with this disorder in the United States. DESIGN: This study is a retrospective review. SETTINGS: The study was conducted at a 7-hospital health system. PATIENTS: All patients diagnosed with colonic volvulus by International Classification of Diseases, Ninth Revision code were included. MAIN OUTCOME MEASURES: The primary outcomes measured were recurrence, complications, and mortality. RESULTS: One hundred three cases of volvulus (50 sigmoid, 53 cecal) were identified in 92 patients. Compared with cecal volvulus, sigmoid volvulus was more common in men, patients with neurologic diagnoses, and residents of skilled nursing home. Eighty-five percent of the cases presented were acutely obstructed. The diagnosis was established by abdominal x-ray (17%), contrast enema study (27%), CT scan (35%), or laparotomy (17%). Abdominal x-rays were insufficient for definitive diagnosis in 85% of cecal and 49% of sigmoid cases (p = 0.002). All patients with cecal volvulus were treated surgically. Seventy-nine percent of patients with sigmoid volvulus underwent successful nonoperative reduction, of whom 38% had subsequent surgery. Fifty-eight percent of patients with sigmoid volvulus were treated operatively. Resection with primary anastomosis was chosen in most cases (78%). Resection with end ostomy (10%), reduction and pexy (7%), and reduction alone (4%) were other approaches. The mortality rate was 5% (cecal 0%, sigmoid 10%; p = 0.012). There were no readmissions for recurrent cecal volvulus. Nonoperative treatment for sigmoid volvulus often failed (48%). Complication rates were higher in sigmoid volvulus cases (cecal 17%, sigmoid 34%; p = 0.047). LIMITATIONS: This study was limited by its retrospective, nonexperimental design. CONCLUSIONS: Although incidences of cecal and sigmoid volvulus are similar in the present series, sigmoid volvuli are more common in men, individuals with neurologic disease, and residents of nursing homes. Plain radiograph is insufficient to confirm cecal volvulus. The diagnosis is most often made with CT scans. The nonoperative management of sigmoid volvulus is associated with a high recurrence rate.

Severe traumatic head injury affects systemic cytokine expression.

BACKGROUND: The neuroimmunologic effect of traumatic head injury remains ill-defined. This study aimed to characterize systemic cytokine profiles among traumatically injured patients to assess the effect of traumatic head injury on the systemic inflammatory response. STUDY DESIGN: For 5 years, 1,022 patients were evaluated from a multi-institutional Trauma Immunomodulatory Database. Patients were stratified by presence of severe head injury (SHI; head Injury Severity Score ≥4, n = 335) vs nonsevere head injury (NHI; head Injury Severity Score ≤3, n = 687). Systemic cytokine expression was quantified by ELISA within 72 hours of admission. Patient factors, outcomes, and cytokine profiles were compared by univariate analyses. RESULTS: SHI patients were more severely injured with higher mortality, despite similar ICU infection and ventilator-associated pneumonia rates. Expression of early proinflammatory cytokines, interleukin-6 (p < 0.001) and tumor necrosis factor-α (p = 0.02), was higher among NHI patients, and expression of immunomodulatory cytokines, interferon-γ (p = 0.01) and interleukin-12 (p = 0.003), was higher in SHI patients. High tumor necrosis factor-α levels in NHI patients were associated with mortality (p = 0.01), increased mechanical ventilation (p = 0.02), and development of ventilator-associated pneumonia (p = 0.01). Alternatively, among SHI patients, high interleukin-2 levels were associated with survival, decreased mechanical ventilation, and absence of ventilator-associated pneumonia. CONCLUSIONS: The presence of severe traumatic head injury significantly alters systemic cytokine expression and exerts an immunomodulatory effect. Early recognition of these profiles can allow for targeted intervention to reduce patient morbidity and mortality.

Thirty-day outcomes in patients treated with en bloc colectomy and pancreatectomy for locally advanced carcinoma of the colon.

OBJECTIVE: The aim of this was to define 30-day outcomes of patients treated with colectomy and en bloc pancreatectomy for invasive colon cancer. METHODS: ACS NSQIP was used to identify patients who underwent colectomy and pancreatectomy concomitantly (n = 65) for colon carcinoma. Patients with en bloc pancreatectomy were compared to a propensity score-matched control group for 30-day outcomes. RESULTS: Sixteen patients underwent a pancreaticoduodenectomy with colectomy and 49 patients underwent a distal pancreatectomy with colectomy. There were 195 matched control patients. En bloc pancreatectomy (Whipple vs. distal pancreatectomy vs. control) patients had longer OR times (390 vs. 265 vs.137 min) and length of postoperative stay (12 vs. 10 vs. 6 days). The frequency of pulmonary complications (31.3% vs. 36.7% vs. 3.6%), blood transfusions (2.9 vs. 1.7 vs. 0.3 U), wound dehiscence, (18.8% vs. 6.12% vs.0.5%) and surgical site infection (43.5% vs. 34.7% vs.14.9%) were substantially higher in the pancreatectomy group (p < 0.05). There were no statistically significant differences in 30-day mortality between the pancreatectomy group and the control group (6.3% vs. 0% vs. 1.5% p = 0.25) CONCLUSIONS: Perioperative outcomes with en bloc pancreatectomy and colectomy include increased pulmonary complications, blood transfusions, wound complications, and length of stay compared to patients treated with colectomy alone for colon cancer.

Effective cohorting and "superisolation" in a single intensive care unit in response to an outbreak of diverse multi-drug-resistant organisms.

BACKGROUND: Cohorting patients in dedicated hospital wards or wings during infection outbreaks reduces transmission of organisms, yet frequently, this may not be feasible because of inadequate capacity, especially in the intensive care unit (ICU). We hypothesized that cohorting isolation patients in one geographic location in a single ICU and using enhanced isolation procedures ("superisolation") can prevent the further spread of highly multi-drug-resistant organisms (MDRO). METHODS: Six patients dispersed throughout our Surgical Trauma Burn ICU had infections with carbapenem-resistant, non-clonal gram-negative MDRO, namely Klebsiella pneumoniae, Citrobacter freundii, Stenotrophomonas maltophilia, Aeromonas hydrophilia, Proteus mirabilis, Pseudomonas aeruginosa, and Providencia rettgeri. Five of the six patients also had simultaneous isolation of vancomycin-resistant enterococci (VRE). Under threat of unit closure and after all standard isolation procedures had been enacted, these six patients were moved to the front six beds of the unit, the front entrance was closed, and all traffic was redirected through the back entrance. Nursing staff were assigned to either two isolation or two non-isolation patients. In accordance with the practice of Semmelweis, rounds were conducted so as to end at the rooms of the patients with the most highly-resistant bacterial infections. RESULTS: A few months after these interventions, all six patients had been discharged from the ICU (three alive and three dead), and no new cases of infection with any of their pathogens (based on species and antibiogram) or VRE occurred. The mean ICU stay and overall hospital length of stay for these six patients were 78.3 days and 117.2 days respectively, with a mortality rate of 50%. CONCLUSION: Cohorting patients to one area and altering work routines to minimize contact with patients with MDRO (essentially designating a "high-risk" zone) may be beneficial in stopping patient-to-patient spread of highly resistant bacteria without the need for a dedicated isolation unit.

The impact of coronary artery endarterectomy on outcomes during coronary artery bypass grafting.

BACKGROUND: The impact of coronary artery endarterectomy during coronary artery bypass grafting (CABG) has been debated. We examined the early and late outcomes of CABG with endarterectomy (CE) compared to CABG alone. METHODS: Patients undergoing isolated CABG operations from 2003 to 2008 were retrospectively reviewed. We identified 99 patients who underwent CE and 3:1 propensity matched them to 297 CABG-alone patients based upon clinical factors: Society of Thoracic Surgeons (STS) predicted risk of mortality, age, gender, year of surgery, and ejection fraction. Patient risk factors as well as short- and long-term outcomes were compared by univariate and Kaplan-Meier analysis. RESULTS: Preoperative risk factors were similar between patients undergoing CE or CABG alone. Cross-clamp times (95.6 vs. 71.8 minutes, p = 0.0001) and perfusion times (121.8 vs. 92.7 minutes, p = 0.0001) were longer in patients undergoing CE. Operative mortality (4.0% vs. 1.3%, p = 0.112) and postoperative complications were not significantly different between groups. Patients undergoing coronary endarterectomy incurred longer ICU (75.06 vs. 48.64 hours, p = 0.001) and hospital stays (9.01 vs. 7.7 days, p = 0.034). Long-term mortality (mean follow-up = 27.7 ± 17.7 months) was equivalent despite revascularization technique (p = 0.13); however, patients undergoing CE encountered worse overall freedom from myocardial infarction (MI) (p = 0.03). CONCLUSION: Patients undergoing CABG with coronary CE required longer ventilatory support and ICU stay yet have comparable operative mortality, major complication rates, and long-term survival to isolated CABG. Coronary endarterectomy should be considered an acceptable adjunct to CABG for patients with extensive coronary artery disease to achieve complete revascularization.

Donor age is associated with chronic allograft vasculopathy after adult heart transplantation: implications for donor allocation.

BACKGROUND: Chronic allograft vasculopathy (CAV) is a major cause of long-term complications and mortality after heart transplantation. Although recipient factors have been implicated, little is known of the role of donor factors in CAV development. We sought to identify donor factors associated with development of CAV after heart transplantation. METHODS: We reviewed the United Network for Organ Sharing heart transplant database from August 1987 to May 2008. Univariate and multivariate analyses were performed to assess the association between donor variables and the onset of CAV for adult recipients. Donor age was matched to recipient age and analyzed with respect to development of CAV. RESULTS: Of the 39,704 recipients, a total of 11,714 (29.5%) experienced CAV. Multivariate analysis demonstrated seven donor factors as independent predictors of CAV: age, ethnicity, sex, weight, history of diabetes, hypertension, and tobacco use. When matching young donors (0 to 19.9 years) and old donors (> or =50 years) to each recipient age group, older donors (> or =50 years) conferred a higher risk of developing CAV. Further modeling demonstrated that for each recipient group, older donor age (> or =50 years) conferred a higher risk of CAV development compared with younger donor age (0 to 19.9 years; p < 0.0001). CONCLUSIONS: Donor factors including sex, hypertension, diabetes, and tobacco use are independently associated with recipient CAV. Older donor age confers a greater risk of CAV development regardless of the age of the recipient. A heightened awareness for the development of CAV is warranted when using older donors in adult cardiac transplantation, in particular with recipients 40 years of age or older.

Intravenous lidocaine is as effective as epidural bupivacaine in reducing ileus duration, hospital stay, and pain after open colon resection: a randomized clinical trial.

BACKGROUND: Both postoperative epidural analgesia and intravenous (IV) infusion of local anesthetic have been shown to shorten ileus duration and hospital stay after colon surgery when compared with the use of systemic narcotics alone. However, they have not been compared directly with each other. METHODS: Prospective, randomized clinical trial was conducted comparing the 2 treatments in open colon surgery patients. Before induction of general anesthesia, patients were randomized either to epidural analgesia (bupivacaine 0.125% and hydromorphone 6 microg/mL were started at 10 mL/hr within 1 hr of the end of surgery) or IV lidocaine (1 mg/min in patients < 70 kg, 2 mg/min in patients > or = 70 kg). Markers of return of bowel function, length of stay, postoperative pain scores, systemic analgesic requirements, and adverse events were recorded and compared between the 2 groups in an intent-to-treat analysis. RESULTS: Study enrollment took place from April 2005 to July 2006. Twenty-two patients were randomized to IV lidocaine therapy and 20 patients to epidural therapy. No statistically significant differences were found between groups in time to return of bowel function or hospital length of stay. The median pain score difference was not statistically significant. No statistically significant differences were found in pain scores for any specific postoperative day or in analgesic consumption. CONCLUSIONS: No differences were observed between groups in terms of return of bowel function, duration of hospital stay, and postoperative pain control, suggesting that IV infusion of local anesthetic may be an effective alternative to epidural therapy in patients in whom epidural anesthesia is contraindicated or not desired.