Broad vs Narrow Spectrum Antibiotics in Common Bile Duct Stones: A Post Hoc Analysis of an Eastern Association for the Surgery of Trauma Multicenter Study.

BACKGROUND: Antimicrobial guidance for common bile duct stones during the perioperative period is limited. We sought to examine the effect of broad-spectrum (BS) vs narrow-spectrum (NS) antibiotics on surgical site infections (SSIs) in patients with common bile duct stones undergoing same-admission cholecystectomy. STUDY DESIGN: We performed a post hoc analysis of a prospective, observational, multicenter study of patients undergoing same-admission cholecystectomy for choledocholithiasis and/or acute biliary pancreatitis between 2016 and 2019. We excluded patients with cholangitis, perforated cholecystitis, and nonbiliary infections on admission. Patients were divided based on receipt of BS or NS antibiotics. Our primary outcome was the incidence of SSIs, and secondary outcomes included hospital length of stay, acute kidney injury (AKI), and 30-day readmission for SSI. RESULTS: The cohort had 891 patients: 51.7% (n= 461) received BS antibiotics and 48.3% (n = 430) received NS antibiotics. Overall antibiotic duration was longer in the BS group than in the NS group (6 vs 4 d, p = 0.01); however, there was no difference in rates of SSI (0.9% vs 0.5%, p = 0.7) or 30-day readmission for SSI (1.1% vs 1.2%, p = 1.0). Hospital length of stay was significantly longer in the BS group (p < 0.001) as were rates of AKI (5% vs 1.4%, p = 0.001). On multivariable regression, BS antibiotic use was a risk factor for AKI (adjusted odds ratio 2.8, 95% CI 1.16 to 7.82, p = 0.02). CONCLUSION: The incidence of SSI and 30-day readmission for SSI was similar between antibiotic groups. However, BS antibiotic use was associated with a longer hospitalization and greater likelihood of AKI.

Time is domain: factors affecting primary fascial closure after trauma and non-trauma damage control laparotomy (data from the EAST SLEEP-TIME multicenter registry).

PURPOSE: Damage control laparotomy (DCL) is used for both traumatic and non-traumatic indications. Failure to achieve primary fascial closure (PFC) in a timely fashion has been associated with complications including sepsis, fistula, and mortality. We sought to identify factors associated with time to PFC in a multicenter retrospective cohort. METHODS: We reviewed retrospective data from 15 centers in the EAST SLEEP-TIME registry, including age, comorbidities (Charlson Comorbidity Index [CCI]), small and large bowel resection, bowel discontinuity, vascular procedures, retained packs, number of re-laparotomies, net fluid balance after 24 h, trauma, and time to first takeback in 12-h increments to identify key factors associated with time to PFC. RESULTS: In total, 368 patients (71.2% trauma, of which 50.6% were penetrating, median ISS 25 [16, 34], with median Apache II score 15 [11, 22] in non-trauma) were in the cohort. Of these, 92.9% of patients achieved PFC at 60.8 ± 72.0 h after 1.6 ± 1.2 re-laparotomies. Each additional re-laparotomy reduced the odds of PFC by 91.5% (95%CI 88.2-93.9%, p < 0.001). Time to first re-laparotomy was highly significant (p < 0.001) in terms of odds of achieving PFC, with no difference between 12 and 24 h to first re-laparotomy (ref), and decreases in odds of PFC of 78.4% (65.8-86.4%, p < 0.001) for first re-laparotomy after 24.1-36 h, 90.8% (84.7-94.4%, p < 0.001) for 36.1-48 h, and 98.1% (96.4-99.0%, p < 0.001) for > 48 h. Trauma patients had increased likelihood of PFC in two separate analyses (p = 0.022 and 0.002). CONCLUSION: Time to re-laparotomy ≤ 24 h and minimizing number of re-laparotomies are highly predictive of rapid achievement of PFC in patients after trauma- and non-trauma DCL. LEVEL OF EVIDENCE: 2B.

Dexmedetomidine and paralytic exposure after damage control laparotomy: risk factors for delirium? Results from the EAST SLEEP-TIME multicenter trial.

PURPOSE: To evaluate factors associated with ICU delirium in patients who underwent damage control laparotomy (DCL), with the hypothesis that benzodiazepines and paralytic infusions would be associated with increased delirium risk. We also sought to evaluate the differences in sedation practices between trauma (T) and non-trauma (NT) patients. METHODS: We reviewed retrospective data from 15 centers in the EAST SLEEP-TIME registry admitted from January 1, 2017 to December 31, 2018. We included all adults undergoing DCL, regardless of diagnosis, who had completed daily Richmond Agitation Sedation Score (RASS) and Confusion Assessment Method-ICU (CAM-ICU). We excluded patients younger than 18 years, pregnant women, prisoners and patients who died before the first re-laparotomy. Data collected included age, number of re-laparotomies after DCL, duration of paralytic infusion, duration and type of sedative and opioid infusions as well as daily CAM-ICU and RASS scores to analyze risk factors associated with the proportion of delirium-free/coma-free ICU days during the first 30 days (DF/CF-ICU-30) using multivariate linear regression. RESULTS: A 353 patient subset (73.2% trauma) from the overall 567-patient cohort had complete daily RASS and CAM-ICU data. NT patients were older (58.9 ± 16.0 years vs 40.5 ± 17.0 years [p < 0.001]). Mean DF/CF-ICU-30 days was 73.7 ± 96.4% for the NT and 51.3 ± 38.7% in the T patients (p = 0.030). More T patients were exposed to Midazolam, 41.3% vs 20.3% (p = 0.002). More T patients were exposed to Propofol, 91.0% vs 71.9% (p < 0.001) with longer infusion times in T compared to NT (71.2 ± 85.9 vs 48.9 ± 69.8 h [p = 0.017]). Paralytic infusions were also used more in T compared to NT, 34.8% vs 18.2% (p < 0.001). Using linear regression, dexmedetomidine infusion and paralytic infusions were associated with decreases in DF/CF-ICU-30, (- 2.78 (95%CI [- 5.54, - 0.024], p = 0.040) and (- 7.08 ([- 13.0, - 1.10], p = 0.020) respectively. CONCLUSIONS: Although the relationship between paralytic use and delirium is well-established, the observation that dexmedetomidine exposure is independently associated with increased delirium and coma is novel and bears further study.

Trauma and nontrauma damage-control laparotomy: The difference is delirium (data from the Eastern Association for the Surgery of Trauma SLEEP-TIME multicenter trial).

BACKGROUND: Damage-control laparotomy (DCL) has been used for traumatic and nontraumatic indications. We studied factors associated with delirium and outcome in this population. METHODS: We reviewed DCL patients at 15 centers for 2 years, including demographics, Charlson Comorbidity Index (CCI), diagnosis, operations, and outcomes. We compared 30-day mortality; renal failure requiring dialysis; number of takebacks; hospital, ventilator, and intensive care unit (ICU) days; and delirium-free and coma-free proportion of the first 30 ICU days (DF/CF-ICU-30) between trauma (T) and nontrauma (NT) patients. We performed linear regression for DF/CF-ICU-30, including age, sex, CCI, achievement of primary fascial closure (PFC), small and large bowel resection, bowel discontinuity, abdominal vascular procedures, and trauma as covariates. We performed one-way analysis of variance for DF/CF-ICU-30 against traumatic brain injury severity as measured by Abbreviated Injury Scale for the head. RESULTS: Among 554 DCL patients (25.8% NT), NT patients were older (58.9 ± 15.8 vs. 39.7 ± 17.0 years, p < 0.001), more female (45.5% vs. 22.1%, p < 0.001), and had higher CCI (4.7 ± 3.3 vs. 1.1 ± 2.2, p < 0.001). The number of takebacks (1.7 ± 2.6 vs. 1.5 ± 1.2), time to first takeback (32.0 hours), duration of bowel discontinuity (47.0 hours), and time to PFC were similar (63.2 hours, achieved in 73.5%). Nontrauma and T patients had similar ventilator, ICU, and hospital days and mortality (31.0% NT, 29.8% T). Nontrauma patients had higher rates of renal failure requiring dialysis (36.6% vs. 14.1%, p < 0.001) and postoperative abdominal sepsis (40.1% vs. 17.1%, p < 0.001). Trauma and NT patients had similar number of hours of sedative (89.9 vs. 65.5 hours, p = 0.064) and opioid infusions (106.9 vs. 96.7 hours, p = 0.514), but T had lower DF/CF-ICU-30 (51.1% vs. 73.7%, p = 0.029), indicating more delirium. Linear regression analysis indicated that T was associated with a 32.1% decrease (95% CI, 14.6%-49.5%; p < 0.001) in DF/CF-ICU-30, while achieving PFC was associated with a 25.1% increase (95% CI, 10.2%-40.1%; p = 0.001) in DF/CFICU-30. Increasing Abbreviated Injury Scale for the head was associated with decreased DF/CF-ICU-30 by analysis of variance (p < 0.001). CONCLUSION: Nontrauma patients had higher incidence of postoperative abdominal sepsis and need for dialysis, while T was independently associated with increased delirium, perhaps because of traumatic brain injury. LEVEL OF EVIDENCE: Therapeutic study, level IV.

Outcomes of same admission cholecystectomy and endoscopic retrograde cholangiopancreatography for common bile duct stones: A post hoc analysis of an Eastern Association for the Surgery of Trauma multicenter study.

BACKGROUND: The optimal timing for cholecystectomy after endoscopic retrograde cholangiopancreatography (ERCP) for common bile duct (CBD) stones is unknown. We hypothesized that a delay between procedures would correlate with more biliary complications and longer hospitalizations. METHODS: We prospectively identified patients who underwent same admission cholecystectomy after ERCP for CBD stones from 2016 to 2019 at 12 US medical centers. The cohort was stratified by time between ERCP and cholecystectomy: ≤24 hours (immediate), >24 to ≤72 hours (early), and >72 hours (late). Primary outcomes included operative duration, postoperative length of stay, (LOS), and hospital LOS. Secondary outcomes included rates of open conversion, CBD explorations, biliary complications, and in-hospital complications. RESULTS: For the 349 patients comprising the study cohort, 33.8% (n = 118) were categorized as immediate, 50.4% (n = 176) as early, and 15.8% (n = 55) as late. Rates of CBD explorations were lower in the immediate group compared with the late group (0.9% vs. 9.1%, p = 0.01). Rates of open conversion were lower in the immediate group compared with the early group (0.9% vs. 10.8%, p < 0.01) and in the immediate group compared with the late group (0.9% vs. 10.9%, p < 0.001). On a mixed-model regression analysis, an immediate cholecystectomy was associated with a significant reduction in postoperative LOS (ß = 0.79; 95% confidence interval, 0.65-0.96; p = 0.02) and hospital LOS (ß = 0.68; 95% confidence interval, 0.62-0.75; p < 0.0001). CONCLUSION: An immediate cholecystectomy following ERCP correlates with a shorter postoperative LOS and hospital LOS. Rates of CBD explorations and conversion to open appear more common after 24 hours. LEVEL OF EVIDENCE: Therapeutic, level III.