-
Annals of Vascular Surgery Sep 2023Perioperative glycemic control plays a pivotal role in improving postsurgical outcomes. Hyperglycemia occurs frequently in surgical patients and has been associated with...
BACKGROUND
Perioperative glycemic control plays a pivotal role in improving postsurgical outcomes. Hyperglycemia occurs frequently in surgical patients and has been associated with higher rates of mortality and postoperative complications. However, no current guidelines exist regarding intraoperative glycemic monitoring of patients undergoing peripheral vascular procedures and postoperative surveillance is often restricted to diabetic patients. We sought to characterize the current practices around glycemic monitoring and efficacy of perioperative glycemic control at our institution. We also examined the impact of hyperglycemia in our surgical population.
METHODS
This was a retrospective cohort study performed at the McGill University Health Centre and Jewish General Hospital in Montreal, Canada. Patients undergoing elective open lower extremity revascularization or major amputation between 2019 and 2022 were included. Data collected from the electronic medical record included standard demographics, clinical, and surgical characteristics. Glycemic measurements and perioperative insulin use were recorded. Outcomes included 30-day mortality and postoperative complications.
RESULTS
A total of 303 patients were included in the study. Overall, 38.9% of patients experienced perioperative hyperglycemia defined as glucose ≥180 mg/dL (10 mmol/L) during their hospital admission. Only 12 (3.9%) patients within the cohort underwent any intraoperative glycemic surveillance, while 141 patients (46.5%) had an insulin sliding scale prescribed postoperatively. Despite these efforts, 51 (16.8%) patients remained hyperglycemic for at least 40% of their measurements during their hospitalization. Hyperglycemia in our cohort was significantly associated with an increased risk of 30-day acute kidney injury (11.9% vs. 5.4%, P = 0.042), major adverse cardiac events (16.1% vs. 8.6%, P = 0.048), major adverse limb events (13.6% vs. 6.5%, P = 0.038), any infection (30.5% vs. 20.5%, P = 0.049), intensive care unit admission (11% vs. 3.2%, P = 0.006) and reintervention (22.9% vs. 12.4%, P = 0.017) on univariate analysis. Furthermore, multivariable logistic regression including the covariates of age, sex, hypertension, smoking status, diabetic status, presence of chronic kidney disease, dialysis, Rutherford stage, coronary artery disease and perioperative hyperglycemia demonstrated a significant relationship between perioperative hyperglycemia and 30-day mortality (odds ratio [OR]: 25.00, 95% confidence interval [CI]: 2.469-250.00, P = 0.006), major adverse cardiac events (OR: 2.08, 95% CI: 1.008-4.292, P = 0.048), major adverse limb events (OR: 2.24, 95% CI: 1.020-4.950, P = 0.045), acute kidney injury (OR: 7.58, 95% CI: 3.021-19.231, P < 0.001), reintervention (OR: 2.06, 95% CI: 1.117-3.802, P = 0.021), and intensive care unit admission (OR: 3.38, 95% CI: 1.225-9.345, P = 0.019).
CONCLUSIONS
Perioperative hyperglycemia was associated with 30-day mortality and complications in our study. Despite this, intraoperative glycemic surveillance occurred rarely in our cohort and current postoperative glycemic control protocols and management failed to achieve optimal control in a significant percentage of patients. Standardized glycemic monitoring and stricter control in the intraoperative and postoperative period therefore represent an area of opportunity for reducing patient mortality and complications following lower extremity vascular surgery.
Topics: Humans; Risk Factors; Retrospective Studies; Peripheral Arterial Disease; Treatment Outcome; Diabetes Mellitus; Hyperglycemia; Insulin; Postoperative Complications; Postoperative Period; Blood Glucose
PubMed: 37003358
DOI: 10.1016/j.avsg.2023.03.009 -
International Orthopaedics Sep 2023To identify clinical and laboratory predictors for low- and high-grade prosthetic joint infection (PJI) within the first postoperative days following primary total...
PURPOSE
To identify clinical and laboratory predictors for low- and high-grade prosthetic joint infection (PJI) within the first postoperative days following primary total hip/knee arthroplasty (THA/TKA).
METHODS
Institutional bone and joint infection registry of a single osteoarticular infection referral centre was reviewed to identify all osteoarticular infections treated between 2011 and 2021. Among them were 152 consecutive PJI (63 acute high-grade PJI, 57 chronic high-grade PJI, and 32 low-grade PJI) who also had primary THA/TKA performed at the same institution, which were retrospectively analyzed with multivariate logistic regression and covariables.
RESULTS
For each additional day of wound discharge, persistent wound drainage (PWD) predicted PJI in the acute high-grade PJI group with odds ratio (OR) 39.4 (p = 0.000, 95%CI 1.171-1.661), in the low-grade PJI group with OR 26.0 (p = 0.045, 95%CI 1.005-1.579), but not in the chronic high-grade PJI group (OR 16.6, p = 0.142, 95%CI 0.950-1.432). The leukocyte count product of pre-surgery and POD2 >100 predicted PJI in the acute high-grade PJI group (OR 2.1, p = 0.025, 95%CI 1.003-1.039) and in the chronic high-grade PJI group (OR 2.0, p = 0.018, 95%CI 1.003-1.036). Similar trend was also seen in the low-grade PJI group, but was not statistically significant (OR 2.3, p = 0.061, 95%CI 0.999-1.048).
CONCLUSIONS
The most optimal threshold value for predicting PJI was observed only in the acute high-grade PJI group, where PWD >three days after index surgery yielded 62.9% sensitivity and 90.6% specificity, whereby the leukocyte count product of pre-surgery and POD2 >100 showed 96.9% specificity. Glucose, erythrocytes, hemoglobin, thrombocytes, and CRP showed no significant value in this regard.
Topics: Humans; Arthroplasty, Replacement, Knee; Retrospective Studies; Prosthesis-Related Infections; Arthroplasty, Replacement, Hip; Arthritis, Infectious
PubMed: 37421426
DOI: 10.1007/s00264-023-05891-x -
Plastic and Reconstructive Surgery Oct 2023Frontofacial surgery (FFS) creates a communication between the cranial and nasal cavities and is associated with significant infection risk. After a cluster of...
BACKGROUND
Frontofacial surgery (FFS) creates a communication between the cranial and nasal cavities and is associated with significant infection risk. After a cluster of infections affecting patients undergoing FFS, a root cause analysis of index cases was undertaken, but no specifically remedial causes were identified. Basic principles incorporating known risk factors for the prevention of surgical-site infection were then applied to the creation of a perioperative management protocol. This study analyzes infection rates before and after its implementation.
METHODS
The protocol was designed around the needs of patients undergoing FFS and consists of three checklists covering their preoperative, intraoperative, and postoperative care. Compliance required the completion of each checklist. All patients undergoing FFS between 1999 and 2019 were studied retrospectively, and infections occurring before and after the implementation of the protocol were analyzed.
RESULTS
One hundred three patients underwent FFS (60 monobloc and 36 facial bipartition) before the implementation of the protocol in August of 2013, and 30 patients underwent FFS after its implementation. Compliance with the protocol was 95%. After implementation, there was a statistically significant reduction in infections from 41.7% to 13.3% ( P = 0.005).
CONCLUSIONS
Although no specific cause for a cluster of postoperative infection had been identified, the implementation of a bespoke protocol consisting of preoperative, perioperative, and postoperative checklists covering measures known to reduce infection risk was associated with a significant reduction in postoperative infections in patients undergoing FFS.
CLINICAL QUESTION/LEVEL OF EVIDENCE
Therapeutic, III.
Topics: Humans; Retrospective Studies; Surgical Wound Infection; Skull; Face
PubMed: 36940153
DOI: 10.1097/PRS.0000000000010442 -
La Revue Du Praticien Nov 2023INFECTION AFTER SOLID-ORGAN-TRANSPLANTATION. Infections is one the most cause for hospitalization after solid-organ-transplantation. We distinguish donor-derived...
INFECTION AFTER SOLID-ORGAN-TRANSPLANTATION. Infections is one the most cause for hospitalization after solid-organ-transplantation. We distinguish donor-derived infections, reactivation of latent infection in recipients, nosocomial infections and community infections. The first three types are observed mainly in the early period post-transplantation, while community infections can occur at any time after transplantation. Opportunistic infections and some specific infections should be assessed systematically and rapidly. This often requires invasive diagnostic procedures. Prevention altered the incidence and severity of post-transplant infections. It included vaccination, use of universal prophylaxis, systematic monitoring of some agents after transplantation and safer living.
Topics: Humans; Cross Infection; Hospitalization; Postoperative Complications; Tissue Donors; Organ Transplantation
PubMed: 38294445
DOI: No ID Found -
Oral and Maxillofacial Surgery Jun 2024To clarify reasons for infections, surgical techniques, and occurrence of postoperative surgical site complications in infected mandibular fractures.
PURPOSE
To clarify reasons for infections, surgical techniques, and occurrence of postoperative surgical site complications in infected mandibular fractures.
METHODS
Patients with clinically infected mandibular fracture of the dentate part without preceding surgery were studied retrospectively. Clinical infection was defined to occur if pus, abscess, or a fistula in the fracture area was present. Patient-, fracture-, and surgery-related variables were evaluated, and predictors for postoperative complications were analysed.
RESULTS
Of 908 patients with surgically treated fracture in the dentate part of the mandible, 41 had infected fracture at the time of surgery (4.5%). Of these patients, 46.3% were alcohol or drug abusers. Median delay from injury to surgery was 9 days. Patient-related factors were the most common cause for delayed surgery (n = 30, 73.2%), followed by missed diagnosis by a health care professional (n = 8, 19.5%). Twenty-two fractures were treated via extraoral approach (53.7%) and the remaining 19 intraorally (46.3%). Postoperative surgical site complications were found in 13 patients (31.7%), with recurrent surgical site infections predominating. Notable differences between total complication rates between intraoral and extraoral approaches were not detected. Secondary osteosynthesis for non-union was conducted for one patient treated intraorally.
CONCLUSIONS
Postoperative surgical site complications are common after treatment of infected mandibular fractures, and these occur despite the chosen surgical approach. Infected mandibular fractures heal mainly without bone grafting, and non-union is a rare complication. Due to the high complication rate, careful perioperative and postoperative care is required for these patients.
Topics: Humans; Mandibular Fractures; Adult; Male; Female; Surgical Wound Infection; Middle Aged; Retrospective Studies; Adolescent; Aged; Young Adult; Fracture Fixation, Internal; Postoperative Complications; Time-to-Treatment; Substance-Related Disorders; Delayed Diagnosis
PubMed: 38286958
DOI: 10.1007/s10006-024-01213-6 -
Surgical Infections May 2024Improvements in liver transplant (LT) outcomes are attributed to advances in surgical techniques, use of potent immunosuppressants, and rigorous pre-LT testing. Despite... (Review)
Review
Improvements in liver transplant (LT) outcomes are attributed to advances in surgical techniques, use of potent immunosuppressants, and rigorous pre-LT testing. Despite these improvements, post-LT infections remain the most common complication in this population. Bacteria constitute the most common infectious agents, while fungal and viral infections are also frequently encountered. Multi-drug-resistant bacterial infections develop because of polymicrobial overuse and prolonged hospital stays. Immediate post-LT infections are commonly caused by viruses. Appropriate vaccination, screening of both donor and recipients before LT and antiviral prophylaxis in high-risk individuals are recommended. Antimicrobial drug resistance is common in high-risk LT and associated with poor outcomes; epidemiology and management of these cases is discussed. Additionally, we also discuss the effect of coronavirus disease 2019 (COVID-19) infection and monkeypox in the LT population.
Topics: Humans; Liver Transplantation; Transplant Recipients; COVID-19; Bacterial Infections; Postoperative Complications; SARS-CoV-2; Mycoses; Virus Diseases
PubMed: 38700753
DOI: 10.1089/sur.2023.346 -
Ocular Immunology and Inflammation Aug 2023To report outcomes in cases of endogenous endophthalmitis (EE) following COVID-19 infection. (Review)
Review
PURPOSE
To report outcomes in cases of endogenous endophthalmitis (EE) following COVID-19 infection.
MATERIAL AND METHODS
In a retrospective study, patients with EE, who had a recent history of COVID-19 infection requiring hospital admission were recruited. Necessary demographic details, details of ocular examination, and microbiological details were collected.
RESULTS
Six patients (10 eyes), with a mean age of 48 + 19.80 years were included. The mean duration of onset of ocular symptoms from the time of diagnosis of COVID was 28.16 + 16.15 days. 8 eyes required surgical intervention, whereas 2 eyes were managed conservatively. Three patients were positive for , two patients were positive for , and one patient was a presumed bacterial EE. The majority of the eyes had favorable functional and anatomical outcomes during the post-operative period.
CONCLUSION
High-dose corticosteroid therapy in the management of moderate and severe COVID-19 infection may be associated with EE, predominantly fungal.
Topics: Humans; Adult; Middle Aged; Aged; Eye Infections, Fungal; Retrospective Studies; COVID-19; Endophthalmitis; Bacteria; Vitrectomy
PubMed: 37043623
DOI: 10.1080/09273948.2023.2192273 -
The Journal of Hospital Infection Aug 2023For patients undergoing total joint arthroplasty (TJA), pre-admission meticillin-resistant Staphylococcus aureus (MRSA) nasal screening has been widely adopted to...
BACKGROUND
For patients undergoing total joint arthroplasty (TJA), pre-admission meticillin-resistant Staphylococcus aureus (MRSA) nasal screening has been widely adopted to prevent postoperative joint infection. However, screening cost-effectiveness and clinical utility have not been adequately evaluated.
AIM
To assess the MRSA infection rate, associated costs, and costs of screening at our institution, before and after screening implementation.
METHODS
This was a retrospective cohort study examining patients who underwent TJA at a health system in New York State, between 2005 and 2016. Patients were divided into the 'no-screening' group if the operation occurred prior to adoption of the MRSA screening protocol in 2011 and the 'screening' group if afterwards. The number of MRSA joint infections, cost of each infection, and costs associated with preoperative screening were recorded. Fisher's exact test and cost comparison analysis were performed.
FINDINGS
The no-screening group had four MRSA infections in 6088 patients over a seven-year period, whereas the screening group had two in 5177 patients over five years. Fisher's exact test showed no significant association between screening and MRSA infection rate (P = 0.694). The cost of postoperative MRSA joint infection treatment was US$40,919.13 per patient, whereas annual nasal screening was US$103,999.97.
CONCLUSION
At our institution, MRSA screening had little impact on infection rates and led to increased costs, with 2.5 MRSA infections required annually to meet the costs of screening. Therefore, the screening protocol may be best suited for high-risk populations, rather than the average TJA patient. The authors recommend a similar clinical utility and cost-effectiveness analysis at other institutions implementing MRSA screening programmes.
Topics: Humans; Methicillin-Resistant Staphylococcus aureus; Arthroplasty, Replacement, Knee; Retrospective Studies; Cost-Benefit Analysis; Arthroplasty, Replacement, Hip; Staphylococcal Infections; Surgical Wound Infection; Postoperative Complications; Mass Screening
PubMed: 37277014
DOI: 10.1016/j.jhin.2023.05.012 -
Neurosurgery Oct 2023Surgical site infections (SSIs) account for one of the most common causes of nosocomial infections. Bundle approaches for infection prevention and control do not capture... (Observational Study)
Observational Study
BACKGROUND
Surgical site infections (SSIs) account for one of the most common causes of nosocomial infections. Bundle approaches for infection prevention and control do not capture the full complexity of neurosurgical interventions.
OBJECTIVE
To study the efficacy of an interdisciplinary infection prevention and control bundle (IPCB) in neurosurgery.
METHODS
This was a prospective, single-center, observational study, analyzing 3 periods: before (2014), during (2017), and after (2019) full implementation of IPCB. IPCB included the following infection prevention measures: preoperative decolonization, patient engagement, operating room (OR) hygiene protocol, and pre-, peri-, and postoperative standard operating procedures (SOPs) while infection control measures included intraoperative sonication, blood culture inoculation, and interdisciplinary SSI management. All neurosurgical patients being readmitted to the hospital for SSIs within 90 days after receiving index surgery were included in the trial (403/9305).
RESULTS
Implementation of IPCB resulted in more frequently succeeded pathogen isolation in patients with SSI (2014: 138 isolates in 105 (83%) patients with SSI, 2017: 169 isolates in 124 (91%) patients with SSI, and 2019: 199 isolates in 136 (97%) patients with SSI; P < .001). Proportion of gram-positive SSI and virulence was declining ( P = .041, P = .007). The number of repeated revision surgeries decreased from 26 (20%) in 2014 and 31 (23%) in 2017 to 18 (13%) in 2019 ( P = .085). Significantly, fewer patients experienced sepsis in response to SSI (2014: 12%, 2017: 10%, and 2019: 3.6%, P = .035). In-hospital mortality rate was declining from 12 (9.4%) in 2014 to 9 (6.6%) in 2017 to 5 (3.6%) in 2019 ( P = .148).
CONCLUSION
Introducing an interdisciplinary IPCB in neurosurgery leads to a significant reduction of sepsis and decreased in-hospital mortality while a pathogen switch toward gram-negative bacteria was observed. Minimizing diagnostic gap of pathogen detection toward a more efficient anti-infective treatment may be the main reason for the substantial decrease in morbidity and mortality.
Topics: Humans; Prospective Studies; Neurosurgical Procedures; Anti-Infective Agents; Neurosurgery; Surgical Wound Infection; Risk Factors; Sepsis
PubMed: 37125801
DOI: 10.1227/neu.0000000000002507 -
Orthopedics 2023In 2018, periprosthetic joint infection (PJI) criteria were revised to include a new category labeled "inconclusive." The purpose of this study was to characterize and... (Review)
Review
In 2018, periprosthetic joint infection (PJI) criteria were revised to include a new category labeled "inconclusive." The purpose of this study was to characterize and describe the fate of the inconclusive PJI workup and to analyze preoperative factors associated with outcomes. We reviewed all PJI workups at our institution during a 3-year period (426 patients). Patients were labeled "infected," "not infected," or "inconclusive" according to 2018 PJI preoperative criteria. In addition to standard diagnostic variables, the presence or absence of clinical elements that increase the pretest probability of infection were collected. Patients with any missing preoperative diagnostic test results and those with clinical follow-up less than 30 days were excluded. Logistic regression was used to identify the factors associated with infection. Two hundred ninety-six workups remained after exclusion criteria were applied, consisting of 66 (22.2%) with a preoperative score of 6 or greater defined as infected, 52 (17.6%) inconclusive (score 2-5), and 178 (60.1%) not infected (score 0-1). Postoperative re-scoring of the inconclusive group based on intraoperative findings as per the 2018 criteria identified 6 of 52 (11.5%) as infected, 12 (23.1%) inconclusive, and 34 (65.4%) not infected. Among those preoperatively scored as inconclusive, variables statistically correlated with the presence of infection included history of PJI, factors that increase skin barrier penetration (eg, psoriasis and venous stasis), and presence of comorbidities predisposing to infection. For patients labeled inconclusive, clinical elements of the pretest probability for infection (eg, history of prior PJI) were as reliable as any diagnostic test, including alpha-defensin, in the diagnosis of PJI. [. 2023;46(5):e291-e297.].
Topics: Humans; Sensitivity and Specificity; Prosthesis-Related Infections; Reproducibility of Results; Arthritis, Infectious; Probability; Synovial Fluid; Retrospective Studies; Arthroplasty, Replacement, Hip
PubMed: 36921226
DOI: 10.3928/01477447-20230310-08