Use of Epidural Analgesia as an Adjunct in Elective Abdominal Wall Reconstruction: A Review of 4983 Cases.

CONTEXT: Use of epidural analgesia in patients undergoing elective abdominal wall reconstruction is common. OBJECTIVE: To assess the impact of epidural analgesia in patients undergoing abdominal wall reconstruction. DESIGN: All patients who underwent elective ventral hernia repair from 2005 to 2014 were retrospectively identified. Patients were divided into two groups by the postoperative use of epidural analgesics as an adjunct analgesic method. Preoperative comorbidities, American Society of Anesthesiologists status, operative findings, postoperative pain management, and venothromboembolic prophylaxis were extracted from the database. Logistic regressions were performed to assess the impact of epidural use. MAIN OUTCOME MEASURES: Severity of pain on postoperative days 1 and 2. RESULTS: During the study period, 4983 patients were identified. Of those, 237 patients (4.8%) had an epidural analgesic placed. After adjustment for differences between groups, use of epidural analgesia was associated with significantly lower rates of 30-day presentation to the Emergency Department (adjusted odds ratio [AOR] = 0.53, 95% confidence interval [CI] = 0.32-0.87, adjusted p = 0.01). Use of epidural analgesia resulted in higher odds of abscess development (AOR = 5.89, CI = 2.00-17.34, adjusted p < 0.01) and transfusion requirement (AOR = 2.92, CI = 1.34-6.40, adjusted p < 0.01). Use of epidural analgesia resulted in a significantly lower pain score on postoperative day 1 (3 vs 4, adjusted p < 0.01). CONCLUSION: Use of epidural analgesia in patients undergoing abdominal wall reconstruction may result in longer hospital stay and higher incidence of complications while having no measurable positive clinical impact on pain control.

Association of Unplanned Reintubation with Higher Mortality in Old, Frail Patients: A National Surgical Quality-Improvement Program Analysis.

BACKGROUND: Unplanned postoperative reintubation increases the risk of mortality, but associated factors are unclear. OBJECTIVE: To elucidate factors associated with increased mortality risk in patients with unplanned postoperative reintubation. DESIGN: Retrospective study. Patients older than 40 years who underwent unplanned reintubation from 2005 to 2010 were identified using the American College of Surgeons National Surgical Quality Improvement Program database. Multiple regression models were used to examine the impact on mortality of factors that included the modified frailty index (mFI) we developed, American Society of Anesthesiologists (ASA) score, age decile, and days to reintubation. MAIN OUTCOME MEASURE: Mortality. RESULTS: A total of 17,051 postoperative reintubations in adults were analyzed. Overall mortality was 29.4% (n = 5009). On postoperative day 1, 4434 patients were reintubated and 878 (19.8%) died. On postoperative day 7 and beyond, 6329 patients were reintubated and 2215 (35.0%) died. Increasing mFI resulted in increasing incidence of mortality (mFl of 0 = 20.5% mortality vs mFl of 0.37-0.45 = 41.7% mortality). As ASA score increased from 1 to 5, reintubation was associated with a mortality of 12.1% to 41.6%, respectively. Similarly, increasing age decile was associated with increasing incidence of mortality (40-49 years, 17.9% vs 80-89 years, 42.1%). After adjustment for confounding factors, mFI, ASA score, age decile, and increasing number of days to reintubation were independently and significantly associated with increased mortality in the study population. CONCLUSION: Among patients who underwent unplanned reintubation, older and more frail patients had an increased risk of mortality.

Predictors of Clavien 4 Complications and Mortality After Necrosectomy: Analysis of the NSQIP Database.

BACKGROUND: Acute severe pancreatitis is one of the most common gastrointestinal reasons for admission to hospitals in the USA. Up to 20 % of these patients will progress to necrotizing pancreatitis requiring intervention. The aim of this study is to identify specific preoperative factors for the development of Clavien 4 complications and mortality in patients undergoing pancreatic necrosectomy. METHODS: The American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) participant use files were reviewed from 2007 to 2012 to identify patients who underwent a pancreatic necrosectomy. Postoperative complications were stratified into Clavien 4 (ICU level complications) and Clavien 5 (mortality). Univariate and multivariate analyses were performed. RESULTS: A total of 1156 patients underwent a pancreatic necrosectomy from 2007 to 2012. Overall, 42 % of patients experienced a Clavien 4 complication. Mortality rate was 9.5 %. Nonindependent functional status and ASA class were highly significant (p < 0.001) in univariate analysis. Frailty and emergency surgery status (p < 0.001), as well as increased blood urea nitrogen (BUN) and alkaline phosphatase and decreased albumin (p < 0.05) demonstrated independent significance of Clavien 4 complications and mortality in multivariate analysis. CONCLUSION: This study identified specific preoperative variables that place patients at increased risk of Clavien 4 complications and mortality after necrosectomy. Identification of high-risk patients can aid in selection of appropriate treatment strategies and allow for informed preoperative discussion regarding surgical risk.

Are the frail destined to fail? Frailty index as predictor of surgical morbidity and mortality in the elderly.

BACKGROUND: America's aging population has led to an increase in the number of elderly patients necessitating emergency general surgery. Previous studies have demonstrated that increased frailty is a predictor of outcomes in medicine and surgical patients. We hypothesized that use of a modification of the Canadian Study of Health and Aging Frailty Index would be a predictor of morbidity and mortality in patients older than 60 years undergoing emergency general surgery. METHODS: Data were obtained from the National Surgical Quality Improvement Program Participant Use Files database in compliance with the National Surgical Quality Improvement Program Data Use Agreement. We selected all emergency cases in patients older than 60 years performed by general surgeons from 2005 to 2009. The effect of increasing frailty on multiple outcomes including wound infection, wound occurrence, any infection, any occurrence, and mortality was then evaluated. RESULTS: Total sample size was 35,334 patients. As the modified frailty index increased, associated increases occurred in wound infection, wound occurrence, any infection, any occurrence, and mortality. Logistic regression of multiple variables demonstrated that the frailty index was associated with increased mortality with an odds ratio of 11.70 (p < 0.001). CONCLUSION: Frailty index is an important predictive variable in emergency general surgery patients older than 60 years. The modified frailty index can be used to evaluate risk of both morbidity and mortality in these patients. Frailty index will be a valuable preoperative risk assessment tool for the acute care surgeon. LEVEL OF EVIDENCE: Prognostic study, level II.

Developing an experimental model for surgical drainage investigations: an initial report.

BACKGROUND: We sought to pilot and initiate validation of a surgical drainage model. METHODS: We designed a laboratory model to compare Jackson-Pratt surgical drains using 3 soups to emulate body fluids of serous, purulent, and necrotic debris. Each drain was trialed with each of the 3 fluids. Time and completeness of drainage were recorded. A survey of surgical residents and faculty was performed for convenience sampling. RESULTS: Under serous conditions, the round Jackson-Pratt drained the cavity quicker, but left a larger residual volume of fluid. Under purulent conditions, the round Jackson-Pratt was slower and drained less fluid. With debris fluid, the round Jackson-Pratt was quicker with less residual fluid whereas the flat type clogged each time. Survey results showed adequate concordance with surgeons in agreement on soup choice. CONCLUSIONS: The Jackson-Pratt drains perform differently depending on the drainage situation. The surgical community requires improved drain data to drive practice patterns.

Laparoscopic colectomy significantly decreases length of stay compared with open operation.

INTRODUCTION: Current literature tends not to adjust for biases in patient selection attributable to comorbidities that could provide alternate explanations for length of stay differences in laparoscopic versus open colectomy. We hypothesized that utilizing the National Surgical Quality Improvement Program (NSQIP) dataset and acuity adjustment methods would demonstrate an independent improvement in length of stay for laparoscopic colectomy. METHODS: We used CPT coding to select all colectomies in NSQIP public use files from 2005-2009. Outlier status for surgical length of stay (SLOS) was defined as >75th percentile. Logistic regression analysis was used to predict this outlier status and linear regression to directly predict SLOS. Acuity adjustment was performed by using the most prevalent variables from multiple NSQIP annual reports. This work was done under the approval of our institutional review board and the data use agreement of the American College of Surgeons. Data were analyzed by using SPSS(®). RESULTS: A total of 45,645 colectomies were reviewed, of which 12,455 (27.3%) were laparoscopic. The 75th percentile for SLOS was 11 days. This implied that 9,249 (27.9%) of the open colectomies were outliers, whereas only 1,152 (9.2%) of laparoscopic colectomies were outliers (p < 0.001). When optimizing a simple linear regression to predict SLOS, using common acuity adjustors (i.e., age, functional status, wound category, etc.), the variable marking open procedures consistently had a coefficient of 1.8, implying that open procedures increased SLOS by 1.8 days (p < 0.001). Utilizing logistic regression to predict outlier status, open colectomies were associated with an odds ratio of 3.79 for outlier status (p < 0.001), thus implying an independent effect on SLOS. CONCLUSIONS: These results indicate that laparoscopic colectomy independently decreases SLOS compared with open colectomy. This study is unique in using statistical methods to control for selection bias of patients who might be more "surgically fit."

What ring tone should be used for patient safety? Early results with a Blackberry-based telementoring safety solution.

OBJECTIVE: Technology currently exists for the application of remote guidance in the laparoscopic operating suite. However, these solutions are costly and require extensive preparation and reconfiguration of current hardware. We propose a solution from existing technology, to send video of laparoscopic cholecystectomy to the Blackberry Pearl device (RIM Waterloo, ON, Canada) for remote guidance purposes. This technology is time- and cost-efficient, as well as reliable. METHODS: After identification of the critical maneuver during a laparoscopic cholecystectomy as the division of the cystic duct, we captured a segment of video before it's transection. Video was captured using the laparoscopic camera input sent via DVI2USB Solo Frame Grabber (Epiphan Ottawa, Canada) to a video recording application on a laptop. Seven- to 40-second video clips were recorded. The video clip was then converted to an .mp4 file and was uploaded to our server and a link was then sent to the consultant via e-mail. The consultant accessed the file via Blackberry for viewing. After reviewing the video, the consultant was able to confidently comment on the operation. RESULTS: Approximately 7 to 40 seconds of 10 laparoscopic cholecystectomies were recorded and transferred to the consultant using our method. All 10 video clips were reviewed and deemed adequate for decision making. CONCLUSION: Remote guidance for laparoscopic cholecystectomy with existing technology can be accomplished with relatively low cost and minimal setup. Additional evaluation of our methods will aim to identify reliability, validity, and accuracy. Using our method, other forms of remote guidance may be feasible, such as other laparoscopic procedures, diagnostic ultrasonography, and remote intensive care unit monitoring. In addition, this method of remote guidance may be extended to centers with smaller budgets, allowing ubiquitous use of neighboring consultants and improved safety for our patients.

Acute renal failure in cardiothoracic surgery patients: what is the best definition of this common and potent predictor of increased morbidity and mortality.

BACKGROUND: Universal agreement on criteria for acute renal failure (ARF) is lacking. The purpose of the current study was to determine which of 6 definitions for ARF best predicted clinical outcomes in postoperative cardiothoracic surgery (CTS) patients. METHODS: Criteria for ARF were retrospectively applied to 1,085 CTS patients. General linear models analyzed length of stay (LOS) and ventilator days with logistic regression for mortality. RESULTS: Thirty-seven percent of patients met at least 1 of 6 definitions of ARF. For each 1-mg/dL increase from the initial creatinine, LOS increased by 6.96 days, ventilator days increased by 3.58 days, and mortality increased by 2.23 times (P < .0001). CONCLUSIONS: One definition that best predicted ARF was not found. ARF was a significant independent predictor of increased mortality, LOS, and ventilator days. Even small increases in creatinine correlate with clinically significant worsening of expected outcomes.

The impact of mild renal dysfunction on postoperative mortality in the surgical intensive care unit.

The negative impact of mild to moderate renal dysfunction on patient outcome is often under-estimated. Any amount of renal dysfunction is deleterious in the surgical intensive care unit (SICU). We evaluated all surgery patients admitted to our SICU. We identified two groups of patients: no renal failure and acute renal failure. A total of 5152 patients were included in this study. There were 1259 patients in the acute renal failure group. The average number of ventilator days increased by 2.2 for every increase of creatinine by 1.0. Patients who required dialysis stayed an average of 11 days longer than patients who did not have any renal failure. For every increase of creatinine by 1.0, average cost increased by $23,048. Only 7 per cent of the patients with acute renal failure required dialysis (n = 85). The odds ratio for mortality compared with those patients without renal failure was 7.06 (confidence interval, 3.91-12.76) regardless of the definition of renal failure. This study demonstrates that even mild to moderate renal failure increases mortality. Moreover, we demonstrated that even a mild decline in renal function increases length of stay, ventilator days, and cost in patients in the SICU. Aggressive vigilance in the prevention of any loss of renal function is warranted in the SICU.

Renal dysfunction in trauma: even a little costs a lot.

BACKGROUND: Acute renal failure (ARF) is a devastating complication in critically ill patients. There is a paucity of data that describes the impact of ARF on the outcome of trauma patients admitted to the intensive care unit. METHODS: We studied trauma patients admitted to the surgical intensive care unit to determine the effect of increases in serum creatinine on the number of ventilator days, length of stay, mortality, and cost. We used the administrative database of the hospital and the trauma registry. Renal failure (RF) was defined as one or more of the following: creatinine >1.5 mg/dL, increase in creatinine of >50%, or increase of creatinine by 0.5 mg/dL. RESULTS: We obtained data on 1,033 patients. Two hundred and forty-six (23.8%) patients met at least one criterion for RF. Only 25 of these patients had one or more episodes of renal replacement therapy. The RF group had mortality of 24.4% compared with 2.3% in the no renal failure group (p < 0.0001). For each 1 mg/dL increase from the initial creatinine, length of stay increased by 2.21 days, ventilator days increased by 1.09 days, and the mortality risk increased by 1.83 times (CI, 1.47-2.29; p < 0.0001). For any diagnosis of renal dysfunction, the average cost increase was $3,088.00 and increased mortality risk was 7.19 times (CI, 4.11-12.58). CONCLUSION: Vigilance in preventing creatinine increases and ameliorating or removing potential causes should occur as soon as creatinine begins to rise to avoid worsening renal function, to reduce cost, and to improve patient outcome.

Open Roux-en-Y gastric bypass in 925 patients without mortality.

BACKGROUND: Open Roux-en-Y gastric bypass has become the gold standard for bariatric surgery. Safety has always been a concern with this elective surgery, especially among the general public. With increasing numbers of bariatric surgeries being performed, the public eye is once again focused on safety and outcomes for these patients. METHODS: Nine hundred twenty-five consecutive open Roux-en-Y gastric bypass patients were reviewed. Charts were retrospectively reviewed for early complications, late complications, and resolution of medical comorbidities. RESULTS: There were no deaths in this study group. The average body mass index (BMI) was 51. Eight leaks at the anastomosis occurred with no reoperations. Hypertension resolved in 70% and diabetes mellitus resolved in 58% of patients. CONCLUSIONS: Open Roux-en-Y gastric bypass is a safe operation, even with increasing numbers of surgeries being performed. Major complications are low and improvement of medical comorbidities is significant. A multidisciplinary team approach helps to improve care and clinical outcomes.