Adipose-Derived Inflammatory and Coagulant Mediators in Patients With Sepsis.

ABSTRACT: Results from preclinical sepsis studies using rodents are often criticized as not being reproducible in humans. Using a murine model, we previously reported that visceral adipose tissues (VAT) are highly active during the acute inflammatory response, serving as a major source of inflammatory and coagulant mediators. The purpose of this study was to determine whether these findings are recapitulated in patients with sepsis and to evaluate their clinical significance. VAT and plasma were obtained from patients undergoing intra-abdominal operations with noninflammatory conditions (control), local inflammation, or sepsis. In mesenteric and epiploic VAT, gene expression of pro-inflammatory (TNFα, IL-6, IL-1α, IL-1ß) and pro-coagulant (PAI-1, PAI-2, TSP-1, TF) mediators was increased in sepsis compared with control and local inflammation groups. In the omentum, increased expression was limited to IL-1ß, PAI-1, and PAI-2, showing a depot-specific regulation. Histological analyses showed little correlation between cellular infiltration and gene expression, indicating a resident source of these mediators. Notably, a strong correlation between PAI-1 expression in VAT and circulating protein levels was observed, both being positively associated with markers of acute kidney injury (AKI). In another cohort of septic patients stratified by incidence of AKI, circulating PAI-1 levels were higher in those with versus without AKI, thus extending these findings beyond intra-abdominal cases. This study is the first to translate upregulation of VAT mediators in sepsis from mouse to human. Collectively, the data suggest that development of AKI in septic patients is associated with high plasma levels of PAI-1, likely derived from resident cells within VAT.

Implementation of Opioid-Free Thyroid and Parathyroid Procedures: A Single Center Experience.

BACKGROUND: Initial opioid exposure for most individuals with substance use disorder comes from the healthcare system, and overprescription of opioids in ambulatory operations is common. This report describes an academic medical center's experience implementing opioid-free thyroid and parathyroid operations. MATERIALS AND METHODS: This is a retrospective chart review of patients undergoing a thyroid or parathyroid operation before and after implementation of an opioid-free analgesia protocol. The primary endpoint was new postoperative opioid prescription. Secondary endpoints included prescription characteristics and predictors of new opioid prescription. RESULTS: A total of 515 patients were enrolled in the study: 240 in the control or "pre-intervention" cohort (May through October 2017) and 275 in the intervention or "post" cohort (May through October 2018). Patients in the intervention cohort were significantly less likely to receive an opioid prescription (12.0% versus 59.6%, P < 0.001). When opioids were prescribed, they were used for shorter durations and at lower doses in the intervention cohort. Among the patients prescribed opioids in the intervention cohort (N = 33), the only significant predictor of postoperative opioid use was preoperative opioid use (P = 0.001). CONCLUSIONS: Opioids may not be required after thyroidectomy and parathyroidectomy, especially for opioid-naïve patients. Future research should examine patient satisfaction with opioid-sparing analgesia.

Opioid use in the acute setting: A survey of providers at an academic medical center.

OBJECTIVE: To examine attitudes, beliefs, and influencing factors of inpatient healthcare providers regarding prescription of opioid analgesics. DESIGN: Electronic cross-sectional survey. SETTING: Academic medical center. PARTICIPANTS: Physicians, advanced practice providers, and pharmacists from a single academic medical center in the southeast United States. MAIN OUTCOME MEASURES: Respondents completed survey items addressing: (1) their practice demographics, (2) their opinions regarding overall use, safety, and efficacy of opioids compared to other analgesics, (3) specific clinical scenarios, (4) main pressures to prescribe opioids, and (5) confidence/comfort prescribing opioids or nonopioids in select situations. RESULTS: The majority of the sample (n = 363) were physicians (60.4 percent), with 69.4 percent of physicians being attendings. Most respondents believed that opioids were overused at our institution (61.7 percent); nearly half thought opioids had similar efficacy to other analgesics (44.1 percent), and almost all believed opioids were more dangerous than other analgesics (88.1 percent). Many respondents indicated that they would modify a chronic regimen for a high-risk patient, and use of nonopioids in specific scenarios was high. However, this use was often in combination with opioids. Respondents identified patients (64 percent) and staff (43.1 percent) as the most significant sources of pressure to prescribe opioids during an admission; the most common sources of pressure to prescribe opioids on discharge were to facilitate discharge (44.8 percent) and to reduce follow-up requests, calls, or visits (36.3 percent). Resident physicians appear to experience more pressure to prescribe opioids than other providers. Managing pain in patients with substance use disorders and effectively using nonopioid analgesics were the most common educational needs identified by respondents. CONCLUSION: Most individuals believe opioid analgesics are overused in our specific setting, commonly to satisfy patient requests. In general, providers feel uncomfortable prescribing nonopioid analgesics to patients.

Minimizing opioid use after acute major trauma.

PURPOSE: Results of an initiative at an academic medical center to reduce prescription opioid use in patients with acute traumatic injuries are reported. METHODS: In 2014, the University of Kentucky Hospital trauma service implemented a pain management strategy consisting of patient and provider education emphasizing the use of nonopioid analgesics to minimize opioid use without compromising analgesia effectiveness. To assess the impact of the initiative, a retrospective analysis of data on cohorts of patients admitted with acute trauma before (n = 489) and after (n = 424) project implementation was conducted. The primary endpoint was opioid use (prescribed daily milligram morphine equivalents [MME]) at discharge. Secondary endpoints included inpatient opioid and alternative analgesic use, pain control, ileus development, length of stay, and discharge disposition. RESULTS: Compared with the preintervention cohort, the postintervention cohort had a lower median daily discharge MME overall (45 MME versus 90 MME, p < 0.001); after stratification of MME data by baseline opioid use, this finding held true only for patients with no opioid prescription at admission. Although utilization of gabapentinoids, skeletal muscle relaxants, and clonidine increased during the postintervention period, inpatient opioid use did not differ significantly in the 2 cohorts. Utilization of both nonsteroidal antiinflammatory drugs and acetaminophen was lower in the postintervention cohort versus the preintervention cohort. CONCLUSION: Targeted provider and patient education on minimizing opioid use was associated with a reduction in MME on discharge from the hospital after traumatic injury.

Procalcitonin: Usefulness in Acute Care Surgery and Trauma.

BACKGROUND: Procalcitonin (PCT) is a serum biomarker currently suggested by the Surviving Sepsis Campaign to aid in determination of the appropriate duration of therapy in sepsis patients. We review the use of procalcitonin in patients after trauma or acute care surgery. METHOD: A MEDLINE search via PubMed was performed using the combination of "procalcitonin" and "humans" and "injuries, trauma," "wounds and injuries," or "wounds." Studies of burn patients, children, other biomarkers, and non-acute care surgery were excluded. RESULTS: Procalcitonin may be useful in identifying infection in trauma and post-operative acute care surgery. However, heterogenity exists among patients, and surgery and trauma alone elevate PCT even in the absence of infection. CONCLUSIONS: Although trends in PCT concentrations may offer insight, no standard approach can be recommended currently.

Antibiotics vs. Appendectomy for Acute Uncomplicated Appendicitis in Adults: Review of the Evidence and Future Directions.

BACKGROUND: Acute appendicitis is the most common abdominal surgical emergency in the United States, with a lifetime risk of 7%-8%. The treatment paradigm for complicated appendicitis has evolved over the past decade, and many cases now are managed by broad-spectrum antibiotics. We determined the role of non-operative and operative management in adult patients with uncomplicated appendicitis. METHODS: Several meta-analyses have attempted to clarify the debate. Arguably the most influential is the Appendicitis Acuta (APPAC) Trial. RESULTS: According to the non-inferiority analysis and a pre-specified non-inferiority margin of -24%, the APPAC did not demonstrate non-inferiority of antibiotics vs. appendectomy. Significantly, however, the operations were nearly always open, whereas the majority of appendectomies in the United States are done laparoscopically; and laparoscopic and open appendectomies are not equivalent operations. Treatment with antibiotics is efficacious more than 70% of the time. However, a switch to an antimicrobial-only approach may result in a greater probability of antimicrobial-associated collateral damage, both to the host patient and to antibiotic susceptibility patterns. A surgery-only approach would result in a reduction in antibiotic exposure, a consideration in these days of focus on antimicrobial stewardship. CONCLUSION: Future studies should focus on isolating the characteristics of appendicitis most susceptible to antibiotics, using laparoscopic operations as controls and identifying long-term side effects such as antibiotic resistance or Clostridium difficile colitis.

The Surgical Infection Society Revised Guidelines on the Management of Intra-Abdominal Infection.

BACKGROUND: Previous evidence-based guidelines on the management of intra-abdominal infection (IAI) were published by the Surgical Infection Society (SIS) in 1992, 2002, and 2010. At the time the most recent guideline was released, the plan was to update the guideline every five years to ensure the timeliness and appropriateness of the recommendations. METHODS: Based on the previous guidelines, the task force outlined a number of topics related to the treatment of patients with IAI and then developed key questions on these various topics. All questions were approached using general and specific literature searches, focusing on articles and other information published since 2008. These publications and additional materials published before 2008 were reviewed by the task force as a whole or by individual subgroups as to relevance to individual questions. Recommendations were developed by a process of iterative consensus, with all task force members voting to accept or reject each recommendation. Grading was based on the GRADE (Grades of Recommendation Assessment, Development, and Evaluation) system; the quality of the evidence was graded as high, moderate, or weak, and the strength of the recommendation was graded as strong or weak. Review of the document was performed by members of the SIS who were not on the task force. After responses were made to all critiques, the document was approved as an official guideline of the SIS by the Executive Council. RESULTS: This guideline summarizes the current recommendations developed by the task force on the treatment of patients who have IAI. Evidence-based recommendations have been made regarding risk assessment in individual patients; source control; the timing, selection, and duration of antimicrobial therapy; and suggested approaches to patients who fail initial therapy. Additional recommendations related to the treatment of pediatric patients with IAI have been included. SUMMARY: The current recommendations of the SIS regarding the treatment of patients with IAI are provided in this guideline.

Emergency department repair of blunt right atrial rupture utilizing cardiopulmonary bypass.

Blunt cardiac injury (BCI) with free wall rupture carries a high risk of pre-hospital death. Cardiopulmonary bypass (CPB) has been utilized as a bridge to repair of cardiac lesions in select patients. We present an interesting case of emergency department repair of right atrial rupture with cardiopulmonary bypass.

Retained surgical sponges: findings from incident reports and a cost-benefit analysis of radiofrequency technology.

BACKGROUND: Retained surgical items (RSIs) are serious events with a high potential to harm patients. It is estimated that as many as 1 in 5,500 operations result in an RSI, and sponges are most commonly involved. The adverse outcomes, additional medical care needed, and medico-legal costs associated with these events are substantial. The objective of this analysis was to advance our understanding of the occurrence of RSIs, the methods of prevention, and the costs involved. STUDY DESIGN: Incident reports entered into the University HealthSystem Consortium (UHC) Safety Intelligence database on incorrect surgical counts and RSIs were analyzed. Reported cases of retained surgical sponges at organizations that use radiofrequency (RF) technology and those that do not were compared. A cost-benefit analysis on adopting RF technology was conducted. RESULTS: Five organizations that implemented RF technology between 2008 and 2012 collectively demonstrated a 93% reduction in the rate of reported retained surgical sponges. By comparison, there was a 77% reduction in the rate of retained sponges at 5 organizations that do not use RF technology. The UHC cost-benefit analysis showed that the savings in x-rays and time spent in the operating room and in the medical and legal costs that were avoided outweighed the expenses involved in using RF technology. CONCLUSIONS: Current standards for manual counting of sponges and the use of radiographs are not sufficient to prevent the occurrence of retained surgical sponges; our data support the use of adjunct technology. We recommend that hospitals evaluate and consider the use of an adjunct technology.

A prospective, controlled evaluation of the abdominal reapproximation anchor abdominal wall closure system in combination with VAC therapy compared with VAC alone in the management of an open abdomen.

Dramatic increases in damage control and decompressive laparotomies and a significant increase in patients with open abdominal cavities have resulted in numerous techniques to facilitate fascial closure. We hypothesized addition of the abdominal reapproximation anchor system (ABRA) to the KCI Abdominal Wound Vac™ (VAC) or KCI ABThera™ would increase successful primary closure rates and reduce operative costs. Fourteen patients with open abdomens were prospectively randomized into a control group using VAC alone (control) or a study group using VAC plus ABRA (VAC-ABRA). All patients underwent regular VAC changes; patients receiving VAC-ABRA also underwent concomitant daily elastomer adjustment of the ABRA system. Primary end points included abdominal closure, number of operating room (OR) visits, and OR time use. Eight patients were included in the VAC-ABRA group and six patients in the control group. Primary closure rates between groups were not statistically different; however, the number of trips to the OR and OR time use were different. Despite higher Acute Physiology and Chronic Health Evaluation II scores, larger starting wound size, and higher rates of abdominal compartment syndrome, closure rates in the VAC-ABRA group were similar to VAC alone. Importantly, however, fewer OR trips and less OR time were required for the VAC-ABRA group.

Influence of in-house attending presence on trauma outcomes and hospital efficiency.

BACKGROUND: The influence of in-house (IH) attendings on trauma patient survival and efficiency measures, such as emergency department length of stay (LOS), ICU LOS, and hospital LOS, has been debated for more than 20 years. No study has definitively shown improved outcomes with IH vs home-call attendings. This study examines trauma outcomes in a single, Level I trauma center before and after the institution of IH attending call. STUDY DESIGN: Patient data were collected from the University of Kentucky's trauma registry. Based on the Trauma-Related Injury Severity Score, survival rates were compared between the IH and home-call groups. To evaluate efficiency, emergency department LOS, ICU LOS, and hospital LOS were compared. A separate subanalysis for the most severely injured patients (trauma alert red) was also performed. RESULTS: The home-call group (n = 4,804) was younger (p = 0.018) and had a higher Injury Severity Score (p = 0.003) than the IH group (n = 5259), but there was no difference in Trauma-Related Injury Severity Score (p = 0.205) between groups. In-house attending presence did not reduce mortality. Emergency department LOS, ICU LOS, and hospital LOS were shorter during the IH period. Emergency department to operating room time was not different. There was no change in trauma alert red mortality with an attending present (20.7% vs 18.2%, p = 0.198). CONCLUSIONS: In-house attending presence does not improve trauma patient survival. For the most severely injured patients, attendings presence does not reduce mortality. In-house coverage can improve hospital efficiency by decreasing emergency department LOS, hospital LOS, and ICU LOS.

Intraoperative transfusion of 1 U to 2 U packed red blood cells is associated with increased 30-day mortality, surgical-site infection, pneumonia, and sepsis in general surgery patients.

BACKGROUND: Transfusion of packed red blood cells (PRBCs) increases morbidity and mortality in select surgical specialty patients. The impact of low-volume, leukoreduced RBC transfusion on general surgery patients is less well understood. STUDY DESIGN: The American College of Surgeons National Surgical Quality Improvement Program participant use file was queried for general surgery patients recorded in 2005 to 2006 (n = 125,223). Thirty-day morbidity (21 uniformly defined complications) and mortality, demographic, preoperative, and intraoperative risk variables were obtained. Infectious complications and composite morbidity and mortality were stratified across intraoperative PRBCs units received. Multivariable logistic regression was used to assess influence of transfusion on outcomes, while adjusting for transfusion propensity, procedure type, wound class, operative duration, and 30+ patient risk factors. RESULTS: After adjustment for transfusion propensity, procedure group, wound class, operative duration, and all other important risk variables, 1 U PRBCs significantly (p < 0.05) increased risk of 30-day mortality (odds ratio [OR] = 1.32), composite morbidity (OR = 1.23), pneumonia (OR = 1.24), and sepsis/shock (OR = 1.29). Transfusion of 2 U additionally increased risk for these outcomes (OR = 1.38, 1.40, 1.25, 1.53, respectively; p

A new complication from a new technology: what a general surgeon should know about wireless capsule endoscopy.

Wireless capsule endoscopy has revolutionized the diagnostic evaluation of the small intestine and is increasingly used by gastroenterologists. However, complications can occur with this seemingly safe procedure. We report two cases of Crohn's disease in which capsule endoscopy was performed with retention of the capsules. Both patients were taken to the operating room electively after careful preoperative planning to address both the surgical aspect of Crohn's disease and the retained capsule. We reviewed the literature on the use of wireless capsule endoscopy in patients with Crohn's disease and discuss the approach to a new surgical complication.