Novel, digital, chest drainage system in cardiac surgery.

BACKGROUND: A new, self-contained, digital, continuous pump-driven chest drainage system is compared in a randomized control trial to a traditional wall-suction system in cardiac surgery. METHODS: One hundred and twenty adult elective cardiac patients undergoing coronary artery bypass graft and/or valve surgery were randomized to the study or control group. Both groups had similar pre/intra-operative demographics: age 67.8 vs 67.0 years, Euroscore 2.3 vs 2.2, and body surface area 1.92 vs 1.91 m2 . Additionally, a satisfaction assessment score (0-10) was performed by 52 staff members. RESULTS: Given homogenous intra-operative variables, total chest-tube drainage was comparable among groups (566 vs 640 mL; ns), but the study group showed more efficient fluid collection during the early postoperative phase due to continuous suction (P = .01). Blood, cell saver transfusions and postoperative hemoglobin values were similar in both groups. The study group experienced drain removal after 29.8 vs 38.4 hours in the control group (ns). Seven crossovers from the Study to the Control group were registered but no patient had drain-related complications. The Personnel Satisfaction Assessment scored above 5 for all questions asked. CONCLUSIONS: The new, digital, chest drainage system showed better early drainage of the chest cavity and was as reliable as conventional systems. Quicker drain removal might impact on intensive care unit (ICU) stay and reduce costs. Additional advantages are portable size, battery operation, patient mobility, noiseless function, digital indications and alarms. The satisfaction assessment of the new system by the staff revealed a higher score when compared to the traditional wall suction chest drainage system.

Fluoroscopy- vs ultrasound-guided aspiration techniques in the management of periprosthetic joint infection: which is the best?

BACKGROUND: Fluid samples obtained from an affected joint still play a central role in the diagnosis of periprosthetic joint infection (PJI). It is the only preoperative test able to discover the causative microbiological agent. In the hip, fluid aspiration can be performed through fluoroscopy, ultrasound, or, less commonly, computed tomography. However, there is still a lack of consensus on which method is preferable in terms of efficacy and costbenefit. PURPOSES: We, therefore, asked whether (1) the benefits in terms of sensitivity and specificity and (2) the costs were comparable between fluoroscopy- and ultrasound-guided joint aspirations in a suspicious of hip PJI. METHODS: Between 2013 and 2016, 52 hip aspirations were performed on 49 patients with clinical, radiological, or serological suspicion of PJI, waiting for a revision surgery. The patients were divided in two groups: fluoroscopy- (n = 26) vs ultrasound-guided hip aspiration group (n = 26). These groups were also divided in control and infected patients. The criteria of MusculoSkeletal Infection Society (MSIS) were used, as gold standard, to define PJI. RESULTS: (1) Ultrasound-guided aspiration revealed valid sensitivity (89% vs 60%) and specificity (94% vs 81%) in comparison with fluoroscopic-guided aspiration. (2) The cost analysis was also in favor of ultrasound-guided aspiration (125.30€) than fluoroscopic-guided aspiration (343.58€). CONCLUSIONS: We concluded that ultrasound-guided hip aspiration could represent a valid, safe, and less expensive diagnostic alternative to fluoroscopic-guided aspiration in hip PJI.

Factors influencing drainage setting and cost for cutaneous abscesses among pediatric patients.

OBJECTIVE: To evaluate the clinical and microbiological factors associated with skin and soft tissue infections drained in the emergency department (ED) vs operative drainage (OD) in a tertiary care children's hospital. METHODS: This was a cross-sectional study among children aged 2 months to 17 years who required incision and drainage (I&D). Demographic information, signs and symptoms, abscess size and location, and wound culture/susceptibility were recorded. Patient-specific charges were collected from the billing database. Multivariate regression analysis was used to determine factors determining setting for I&D and the effect of abscess drainage location on cost. RESULTS: Of 335 abscesses, 241 (71.9%) were drained in the ED. OD for abscesses was favored in children with prior history of abscess (odds ratio [OR], 3.18; 95% confidence interval [CI], 1.36-7.44; P = .01) and labial location (OR, 37.81; 95% CI, 8.12-176.03; P < .001). For every 1-cm increase in size, there was approximately a 26% increase in the odds of having OD (OR, 1.26; 95% CI, 1.11-1.44, P < .001). Methicillin-resistant Staphylococcus aureus was identified in 72% of the 300 abscesses cultured and 12.3% were clindamycin resistant. OD was more expensive than I&D in the ED. Per abscess that underwent I&D, OD is $3804.29 more expensive than I&D in the ED while controlling for length of stay. DISCUSSION: Clinical factors associated with OD rather than I&D in the ED included history of abscess, increased abscess length, and labial location. Microbiological factors did not differ based on I&D setting. For smaller, nonlabial abscesses, ED drainage may result in significant cost savings.

The increased total cost associated with post-operative drains in total hip and knee arthroplasty.

In a consecutive series of 536 unilateral primary total hip arthroplasties (THAs) and 598 unilateral primary total knee arthroplasties (TKAs), the use of a post-operative drain was associated with $538 additional cost per THA, and $455 for TKA. The use of a drain increased hospital length of stay (LOS) for THA, but not for TKA. In both groups, the use of a drain increased estimated blood loss (EBL) and increased the amount of allogeneic blood transfused. Over the 10-week period, drain use was associated with a total cost of $432,972 for our institution. Data from this study would favor a selective approach to the use of drains in primary joint arthroplasties.

Comparison of gravity collection versus suction collection for transfusion purposes in dogs.

Blood donation is an essential step in transfusion medicine that must take into account the donor's welfare, collection effectiveness, and blood product quality. This prospective study enrolled 13 canine blood donors, each subjected to both gravity and suction collection methods, in a randomized order. Clinical parameters, including heart rate (HR), respiratory rate (RR), systolic blood pressure (SBP), and rectal temperature (RT), were evaluated at four time points, including when the donor was on the floor and on the collection table, and before and after blood donation. The number of times the donor and needle required repositioning, the duration of the donation, the noise created by the apparatus, and the presence of a hematoma were evaluated. The weight, index of hemolysis, and hematocrit of each unit of blood were recorded. There was no significant difference between collection methods for either the clinical parameters at each time point or the prevalence of hematoma formation, the frequency of needle repositioning, the hemolysis index, or hematocrit. Collection by suction was noisier (P < 0.0001), faster (P = 0.004), and associated with significantly less donor repositioning (P = 0.007). Suction appears to be a safe and cost-effective method that should be considered to optimize blood donation.

Randomized controlled trial of pelvic calcium alginate following rectal cancer surgery.

BACKGROUND: The aim of this randomized controlled trial was to assess the possible benefit of using a new haemostatic agent (Hémoionic) in the pelvic cavity in sphincter-saving surgery for rectal cancer. METHODS: Eighty-five patients undergoing elective sphincter-saving rectal resection for cancer were randomized into Hémoionic (41 patients) and control (44) groups. In both groups, a pelvic suction drain was left in place for as long as the daily output exceeded 20 ml. The primary endpoint was volume of fluid collected by the suction drain; secondary endpoints were duration of drainage, and postoperative mortality and morbidity rates. RESULTS: The mean total drainage volume was significantly lower in the Hémoionic group (453 ml versus 758 ml in control group; P = 0.031). There was no significant difference between groups in duration of drainage and morbidity. The mortality rate was four of 41 in the Hémoioni group and one of 44 in the control group (P = 0.192). CONCLUSION: Hémoionic may reduce the drainage volume after sphincter-saving surgery for rectal cancer, but offers no clinical advantage. REGISTRATION NUMBER: ISRCTN79721331 (http://www.isrctn.org).

Cost-Effective Filtrating Suction to Evacuate Surgical Smoke in Laparoscopic and Robotic Surgery During the COVID-19 Pandemic.

The wide and fast spread of COVID-19 around the world has led to a dramatic increase in the need for protection products both for carers and for populations. Surgical team protection includes a systematic screening of patients, wearing protection devices by all the operating staff, and adequate management of aerosols. The risk of aerosol dispersal is particularly high during laparoscopic and robotic surgeries due to the interaction between circulating CO2 and surgical smoke that may contain small viral particles. To decrease the risk of virus transmission, many recommendations have been implemented including the use of integrated insufflation devices comprising smoke evacuation and filtration mode. Such devices are lacking in many centers around the world and to overcome this urgent unmet need, we designed a cost-effective filtrating suction as a more readily available alternative.

A Comparative Study of Percutaneous Aspiration with Sclerotherapy and Laparoscopic Marsupialization for Symptomatic Simple Renal Cysts.

Background: Percutaneous aspiration with sclerotherapy (PAS) and laparoscopic marsupialization (LM) are minimally invasive treatment modalities for renal cysts. We aimed to compare the efficacy and cost/effectiveness of LM and PAS for the treatment of simple symptomatic renal cysts. Methods: Data were prospectively collected from three health care institutions in which 80 patients with symptomatic simple renal cysts underwent a single session of PAS with 95% ethanol (PAS group, n = 40) or underwent LM under general anesthesia (LM group, n = 40) between March 2012 and May 2016. We compared the patient profile, duration of procedure, duration of hospital stay, radiological and symptomatic success rates, treatment costs, and incidence of complications between the two groups. Results: At the 6-month follow-up, the radiological success rate in the LM group was significantly greater than that in the PAS group (97.5% versus 60%; P < .001). The symptomatic success rate was comparable in the two groups (95% versus 90%; P = .675). The treatment failure rate did not significantly differ between the two groups (5.0% versus 17.5%, P = .154). The mean total cost in the PAS and LM groups was 1256 USD and 2343 USD, respectively (P = .001). No significant between-group difference was noted regarding the overall complication rate (P = .615). Conclusions: Both LM and PAS are effective and safe procedures for the treatment of symptomatic simple renal cysts. A single session of PAS seems to be a cost-effective method for the management of symptomatic simple renal cysts.

Closed tracheal suction systems for prevention of ventilator-associated pneumonia.

We have assessed the evidence that closed tracheal suction systems (TSS) prevent ventilator-associated pneumonia (VAP), using a meta-analysis of randomized controlled trials (RCTs). We searched PubMed and Cochrane databases to identify RCTs that compared closed with open TSS for the management of mechanically ventilated (MV) patients. Nine RCTs were included in the meta-analysis. There was no difference in the incidence of VAP between patients managed with closed and open TSS [odds ratio (OR)=0.96, 95% confidence intervals (CI) 0.72-1.28]. There was no heterogeneity among the eligible trials (I2=0, 95% CI 0-0.65). The compared groups did not differ with respect to mortality (OR=1.04, 95% CI 0.78-1.39) or intensive care unit (ICU) length of stay [two RCTs: 12.3 (sd 1.1) vs 11.5 (1.4) days and 15.6 (13.4) vs 19.9 (16.7) days]. Suctioning with closed systems was associated with longer MV duration (weighted mean differences: 0.65 days, 95% CI 0.28-1.03) and higher colonization of the respiratory tract (OR=2.88, 95% CI 1.50-5.52) than open TSS. The available evidence suggests that closed as opposed to open TSS usage did not provide any benefit on VAP incidence, mortality, or ICU stay of MV patients.

Efficacy of closed suction drainage in lower limb arterial surgery: a meta-analysis of published clinical trials.

BACKGROUND: Suction drains are widely used in vascular surgery, despite the absence of specific evidence that they confer benefit to patients. There has been no systematic review of the available evidence, though drainage has been shown to confer no benefit, or indeed harm, across a variety of surgical disciplines. Accordingly, a systematic review and meta-analysis of the current evidence base for closed suction drainage following surgical lower limb revascularization was undertaken. METHODS: Medline, Embase, trial registries, conference proceedings, and article reference lists were searched to identify randomized controlled trials of the use of surgical drains. The primary outcomes were wound infection, seroma/lymphocele formation, and hematoma formation. Pooled odds ratios were calculated for categorical outcomes. RESULTS: Four trials containing 429 groin wounds were eligible for inclusion. There was no significant effect on wound infection, seroma/lymphocele formation, or hematoma formation. CONCLUSION: Our meta-analysis suggests that no benefit is conferred by wound drainage following lower limb revascularization. The practice incurs avoidable expense and should not be routinely used.

Efficacy of TNP on lower limb wounds: a meta-analysis.

This meta-analysis of the three RCTs that have compared topical negative pressure with conventional treatment in patients with lower limb ulcers found that it significantly reduced healing times and increased the number of healed wounds.

Which way is best for stone fragments and dust extraction during percutaneous nephrolithotomy.

Percutaneous nephrolithotomy (PCNL) is a commonly used type of minimally invasive treatment in kidney stone surgeries. Surgical success is assessed according to residual stone amount after surgery. The purpose of this study is to compare the two methods' success and practicality that are applied after the fracture of the stone in the patients who applied PCNL and which enable the removal of the residual stones. Among 102 patients who underwent a single-session of PCNL at our department between June 2015 and November 2016 were evaluated. Previously identified irrigation method and our aspiration method which described used in post-operative patients divided into two groups of residual fragments was assessed by computed tomography. The results were evaluated in statistical analyses. Significant p was accepted as p < 0.05. The age and gender distribution of patients in the irrigation and aspiration groups did not differ significantly (p > 0.05). In irrigation and aspiration groups, stone size did not differ significantly (p > 0.05). The amount of residue stones and dust remaining in the irrigation group was significantly higher (p < 0.05) than the aspiration group. Although many methods have been tried before, we think that the aspiration method we have described is a cheaper, more effective and feasible option.

Cost analysis of minimally invasive surgery in a pediatric setting.

AIMS: The aims of this study was to determine whether an active policy of cost curtailment would impact on the theater cost of laparoscopic surgery in a pediatric setting; to document the extent of cost changes over time and to identify factors that adversely influence expenditure; and to investigate whether the surgeon is a significant factor in the price of the procedure. MATERIALS AND METHODS: A prospective audit of laparoscopic procedures was performed in a single unit over a 36-month period. Detailed costs of theater inventory for all procedures were compiled on a case-by-case basis and recorded on a database. The cost of six index procedures were collated and changes over the period of the study analyzed. The factors responsible for increased expenditure were flagged and appraised to enable the implementation of cost-saving measures. The prices of the laparoscopic equipment were based on invoiced figures provided by hospital managers, and no long-term outcome measures were taken into account. RESULTS: A total of 179 cases were performed by six surgeons over a 3-year period between January 1, 2003 and December 31, 2005, with no adverse intraoperative events. The procedures studied in further detail were appendicectomy (n = 50), fundoplication (n = 25), cholecystectomy (n = 12), nephrectomy (n = 10), Fowler Stevens for undescended testes (n = 10), and modified Palomo operations for varicocoele (n = 7). The mean cost of these procedures fell year by year over the period of study but was significant only in appendicectomy (P = 0.017). For this procedure, there was a significant difference in costs between the various surgeons (P = 0.007), but this trend was not noted with the other procedures. There were no major intraoperative events, although 2 patients required conversion owing to technical difficulties posed by the cases. Among the factors that influenced costs were the use of disposables, particularly for hemostasis and suctioning, and an inability to procure reuseable instruments. CONCLUSIONS: The costs of commonly performed laparoscopic procedures are falling year by year. The surgeon is a factor in the costs of some procedures. A cost-saving strategy has not been compromised of patient safety; however, some cost-saving measures, though attractive, are labor intensive and are not practical. An overall commitment to the sensible use of health care resources translates into savings for hospitals, thereby strengthening the case for laparoscopic surgery.

Role of topical negative pressure in pressure ulcer management.

The literature suggests that topical negative pressure can be an effective treatment for severe pressure ulcers. However, research is needed on its effects on variables such as dressing change frequency, quality of life, pain relief and cost-effectiveness.

Controlled Suction with Venous Catheter Irrigation in Neurosurgery: A Cost Effective Technique.

BACKGROUND: Keeping the operating field clean and visible is an important technique in neurosurgery. Continuous irrigation-suction (IS) of the surgical field is currently often done using devices available that are expensive and demand technical proficiency. We report a simple method of continuous IS using a widely available central venous catheter and a controlled suction cannula. METHODS: We used a controlled suction cannula attached to a central suction system. A single lumen central venous catheter is passed through the keyhole of a controlled suction cannula, which is connected to a continuous irrigation system. RESULTS: The operative field was clean throughout the procedure, obviating the need for an assisting surgeon to irrigate into the deep operating field and, hence, reducing the duration of surgery. CONCLUSIONS: The proposed IS system could be surgeon friendly, easily manageable, yet cost-effective and efficient.

Tracheal suction by closed system without daily change versus open system.

BACKGROUND: Tracheal suctioning costs are higher with a closed tracheal suction system (CTSS) than with an open system (OTSS), due to the need for complete daily change as recommended by the manufacturer. However, is it necessary to change the closed system daily? OBJECTIVE: To evaluate the tracheal suctioning costs and incidence of ventilator-associated pneumonia (VAP) using closed system without daily change vs OTSS. DESIGN: Prospective and randomised study. SETTING: An Intensive Care Unit in a university hospital. PATIENTS: Patients requiring mechanical ventilation. INTERVENTIONS: Patients were randomly assigned to CTSS without daily change or OTSS. We used a CTSS that allowed partial or complete change. MEASUREMENTS AND RESULTS: There were no significant differences between both groups of patients (236 with CTSS and 221 with OTSS) in gender, age, diagnosis, APACHE-II score, mortality, number of aspirations per day, percentage of patients who developed VAP (13.9 vs 14.1%) or the number of ventilator-associated pneumonia per 1000 days of mechanical ventilation (14.1 vs 14.6). There were not significant differences in tracheal suctioning costs per patient/day between CTSS vs OTSS (2.3+/-3.7 vs 2.4+/-0.5 Euros; p=0.96); however, when length of mechanical ventilation was lower than 4 days, the cost was higher with CTSS than with OTSS (7.2+/-4.7 vs 1.9+/-0.6 Euros; p<0.001); and when length of mechanical ventilation was higher than 4days, the cost was lower with CTSS than with OTSS (1.6+/-2.8 vs 2.5+/-0.5 Euros; p<0.001). CONCLUSION: CTSS without daily change is the optimal option for patients needing tracheal suction longer than 4 days.

Breast pump access in the inner city: a hospital-based initiative to provide breast pumps for low-income women.

An effective electric breast pump is an important tool for the management of breastfeeding challenges such as provision of human milk to sick or premature infants. A breast pump is also, in Western culture, critical for breastfeeding mothers who return to work. Obtaining an effective electric breast pump can be particularly difficult for uninsured or impoverished women because of the expense, complicated insurance reimbursements, and scarcity of providers that supply breast pumps to the inner-city community. To address this problem at Boston Medical Center (BMC), an inner-city hospital that serves a poor and minority urban population, members of the Breastfeeding Center worked with a local charity and local insurance companies to increase access to pumps for all women at BMC and to guarantee that every breastfeeding mother with an infant in the neonatal intensive care unit receive a double-setup electric breast pump, regardless of her insurance status or ability to pay.

An economic evaluation of the use of TNP on full-thickness wounds.

OBJECTIVE: Topical negative pressure (TNP) (vacuum therapy) is frequently used in the management of acute, traumatic, infected and chronic full-thickness wounds. This prospective clinical randomised trial compared the costs of TNP with conventional therapy (moist gauze) in the management of full-thickness wounds that required surgical closure. METHOD: The direct medical costs of the total number of resources needed to achieve a healthy, granulating wound bed that was 'ready for surgical therapy' were calculated. RESULTS: Fifty-four patients admitted to a department of plastic and reconstructive surgery were recruited into the trial. Cost analysis showed significantly higher mean material expenses for wounds treated with TNP (414euros+/-229euros [SD]) compared with conventional therapy (15euros+/-11euros; p<0.0001 ), but significantly lower mean nursing expenses (33euros+/-31 euros and 83euros+/-58euros forTNP and conventional therapy respectively; p<0.0001). Hospitalisation costs were lower in theTNP group (1788euros+/-1060euros) than in the conventional treatment group (2467euros+/-1336euros; p<0.043) due to an on average shorter duration until they were'ready for surgical therapy'. There was no significant difference in total costs per patient between the two therapies (2235euros+/-1301euros for TNP versus 2565euros+/-1384euros for conventional therapy). CONCLUSION: TNP had higher material costs. However, these were compensated by the lower number of time-consuming dressing changes and the shorter duration until they were 'ready for surgical therapy', resulting in the therapy being equally as expensive as conventional moist gauze. DECLARATION OF INTEREST: This work was partly supported by the Plastic and Reconstructive Surgery Esser Foundation, and KCI Medical, Houten,The Netherlands. The authors have no conflicts of interest.

Negative pressure wound therapy: "a rose by any other name".

Negative pressure wound therapy is one of the dominant adjunctive wound care modalities used in North America. One company has a proprietary hold on the market for this type of wound therapy and recent wound care literature has focused on the company's products rather than on the concept itself. Currently utilized standards for negative pressure wound therapy are based on a few relatively recent publications originating after 1997. However, a review of the English and Russian literature that predates this work reveals discrepancies regarding optimal duration of treatment, intensity of negative pressure, mode of application, timing of application, and intervals between treatments. A careful review of research that has rarely been cited in recent wound care literature elucidates the inconsistencies between currently held dogma and less well known negative pressure research. In order to achieve optimal outcomes of care, current practices must be re-evaluated and researched using well-established guidelines for determining treatment safety and effectiveness.

Continuous subglottic suctioning for the prevention of ventilator-associated pneumonia : potential economic implications.

STUDY OBJECTIVE: To determine the cost-effectiveness of continuous subglottic suctioning (CSS) as a strategy to decrease the incidence of ventilator-associated pneumonia (VAP). DESIGN: Decision-model analysis of the cost and efficacy of endotracheal tubes that allow CSS at preventing VAP. The primary outcome was cases of VAP averted. Model estimates were based on data from published prospective trials of CSS and other prospective studies of the incidence of VAP. SETTING AND PATIENTS: Hypothetical cohort of 100 patients requiring nonelective endotracheal intubation and management in an ICU. INTERVENTIONS: In the model, patients were managed with either traditional endotracheal tubes (ETs) or ETs capable of CSS. MEASUREMENTS AND MAIN RESULTS: The marginal cost-effectiveness of CSS was calculated as the savings resulting from cases of VAP averted minus the additional costs of CSS-ETs, and expressed as cost (or savings) per episode of VAP prevented. Sensitivity analysis of the impact of the major clinical inputs on the cost-effectiveness was performed. The base case assumed that the incidence of VAP in patients requiring > 72 h of mechanical ventilation (MV) was 25%, that CSS-ETs had no impact on patients requiring MV for < 72 h, and that CSS-ETs resulted in a relative risk reduction of VAP of 30%. Despite the higher costs of ETs capable of CSS, this tactic yielded a net savings of $4,992 per case of VAP prevented. For sensitivity analysis, model inputs were adjusted by 50% individually and then simultaneously. This demonstrated the model to be only moderately sensitive to the calculated cost of VAP. With the relative risk reduction at 50% of the base-case estimate, CSS resulted in $1,924 saved per case of VAP prevented. When all variables were skewed against CSS, total outlays were trivial (approximately $14 per patient in the cohort). CONCLUSIONS: CSS represents a strategy for the prevention of VAP that may result in savings. Further studies are warranted to confirm the efficacy of CSS.