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Accurate risk stratification for development of organ/space surgical site infections after emergent trauma laparotomy.

ABSTRACT: BACKGROUND:Organ/space surgical site infection (OS-SSI) develops frequently after trauma laparotomies and is associated with significant morbidity. No valid model exists to accurately risk-stratify the probability of OS-SSI development after emergent laparotomy. Risk stratification for OS-SSI in these patients could guide promising, but unproven, interventions for OS-SSI prevention, such as more frequent dosing of intraoperative antibiotics or direct peritoneal resuscitation. We hypothesize that in trauma patients who undergo emergent laparotomy, probability of OS-SSI can be accurately estimated using patient data available during the index operation. METHODS:Retrospective review was performed on a prospectively maintained database of emergent trauma laparotomies from 2011 to 2016. Patient demographics and risk factors for OS-SSI were collected. We performed Bayesian multilevel logistic regression to develop the model based on a 70% training sample. Evaluation of model fit using area under the curve was performed on a 30% test sample. The Bayesian approach allowed the model to address clustering of patients within physician while implementing regularization to improve predictive performance on test data. RESULTS:One hundred seventy-two (15%) of 1,171 patients who underwent laparotomy developed OS-SSI. Variables thought to affect development of surgical site infections and were available to the surgeon near the conclusion of the trauma laparotomy were included in the model. Two variables that contributed most to OS-SSIs were damage-control laparotomy and colon resection. The area under the curve of the predictive model validated on the test sample was 0.78 (95% confidence interval, 0.71-0.85). CONCLUSION:Using a combination of factors available to surgeons before the end of an emergent laparotomy, the probability of OS-SSI could be accurately estimated using this retrospective cohort. A Web-based calculator is under design to allow the real-time estimation of probability of OS-SSI intraoperatively. Prospective validation of its generalizability to other trauma cohorts and of its utility at the point of care is required. LEVEL OF EVIDENCE:Prognostic study, level IV.

SUBMITTER: Wei S

PROVIDER: S-EPMC7004798 | biostudies-literature | 2019 Feb

REPOSITORIES: biostudies-literature

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Accurate risk stratification for development of organ/space surgical site infections after emergent trauma laparotomy.

Wei Shuyan S Green Charles C Kao Lillian S LS Padilla-Jones Brandy B BB Truong Van Thi Thanh VTT Wade Charles E CE Harvin John A JA

The journal of trauma and acute care surgery 20190201 2

<h4>Background</h4>Organ/space surgical site infection (OS-SSI) develops frequently after trauma laparotomies and is associated with significant morbidity. No valid model exists to accurately risk-stratify the probability of OS-SSI development after emergent laparotomy. Risk stratification for OS-SSI in these patients could guide promising, but unproven, interventions for OS-SSI prevention, such as more frequent dosing of intraoperative antibiotics or direct peritoneal resuscitation. We hypothes ...[more]

PMID: 30531329

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Project description:BackgroundOrgan/space surgical site infection (organ/space SSI) is a serious postoperative complication, closely related to a poor prognosis. Few studies have attempted to stratify the risk of organ/space SSI for patients with advanced digestive system cancer. This study aimed to identify a simple risk stratification for these patients based on perioperative factors.MethodsThe study was based on two randomized controlled trials (RCT) (NCT02715076, ChiCTR-IPR-17011099), including 839 patients undergoing elective radical resection of advanced digestive system cancer. The primary outcome was organ/space SSI within 30 days after surgery. Multivariable logistic regression model was used to identify risk factors. The risk of organ/space SSI stratified over those risk factors was compared using chi-square tests and the relative risk (RR) was estimated.ResultsAmong the 839 patients, 51 developed organ/space SSI (6.1%) within 30 days after surgery. According to the multivariable logistic regression model, 3 procedure types, including gastrectomy (OR=8.22, 95% CI: 2.71-24.87, P<0.001), colorectal resection (OR=8.65, 95% CI: 3.13-23.85, P<0.001) and pancreatoduodenectomy (OR=7.72, 95% CI: 2.95-20.21, P<0.001), as well as anaesthesia time > 4 h (OR=2.38, 95% CI: 1.08-5.27, P=0.032) and prolonged ICU stay (OR=4.10, 95% CI: 1.67-10.10, P=0.002), were risk factors for postoperative organ/space SSI. The number of risk factors was significantly associated with an increased risk of organ/space SSI (P<0.001), which was 2.8% in patients with 0-1 risk factor (RR=0.20, 95% CI: 0.11-0.35), 13.0% in patients with 2 risk factors (RR=3.64, 95% CI: 2.14-6.20) and 35.7% in patients with 3 risk factors (RR=6.41, 95% CI: 3.01-13.65).ConclusionThis study is a preliminary exploratory and provides a simple risk stratification to identify the risk of postoperative organ/space SSI for patients with advanced digestive system cancer. Further research is needed to validate and generalize the results in a wider population.Clinical trial registrationClinicalTrials.gov, identifier NCT02715076; Chinese Clinical Trial Registry [https://www.chictr.org.cn/enindex.aspx], identifier ChiCTR-IPR-17011099.

Project description:BACKGROUND:To standardize care and promote early fascial closure among patients undergoing emergent laparotomy and temporary abdominal closure (TAC), we developed a protocol addressing patient selection, operative technique, resuscitation strategies, and critical care provisions. We hypothesized that primary fascial closure rates would increase following protocol implementation with no difference in complication rates. STUDY DESIGN:We performed a retrospective cohort analysis of 138 adult trauma and emergency general surgery patients who underwent emergent laparotomy and TAC, comparing protocol patients (n = 60) to recent historic controls (n = 78) who would have met protocol inclusion criteria. The protocol includes low-volume 3% hypertonic saline resuscitation, judicious wound vacuum fluid replacement, and early relaparotomy with sequential fascial closure. Demographics, baseline characteristics, illness severity, resuscitation course, operative management, and outcomes were compared. The primary outcome was fascial closure. RESULTS:Baseline characteristics, including age, American Society of Anesthesiologists class, and postoperative lactate levels, were similar between groups. Within 48 hours of initial laparotomy and TAC, protocol patients received significantly lower total intravenous fluid resuscitation volumes (9.7 vs. 11.4 L, p = 0.044) and exhibited higher serum osmolarity (303 vs. 293 mOsm/kg, p = 0.001). The interval between abdominal operations was significantly shorter following protocol implementation (28.2 vs. 32.2 hours, p = 0.027). The incidence of primary fascial closure was significantly higher in the protocol group (93% vs. 81%, p = 0.045, number needed to treat = 8.3). Complication rates were similar between groups. CONCLUSIONS:Protocol implementation was associated with lower crystalloid resuscitation volumes, a transient hyperosmolar state, shorter intervals between operations, and higher fascial closure rates with no difference in complications. LEVEL OF EVIDENCE:Therapeutic study, level IV.

Project description:BackgroundOur objective was to establish the safety of 3% hypertonic saline (HTS) resuscitation for trauma and acute care surgery patients undergoing emergent laparotomy and temporary abdominal closure (TAC) with the hypothesis that HTS administration would be associated with hyperosmolar hypercholoremic acidosis, lower resuscitation volumes, and higher fascial closure rates, without adversely affecting renal function.MethodsWe performed a retrospective cohort analysis of 189 trauma and acute care surgery patients who underwent emergent laparotomy and TAC, comparing patients with normal baseline renal function who received 3% HTS at 30 mL/h (n = 36) to patients with standard resuscitation (n = 153) by baseline characteristics, resuscitation parameters, and outcomes including primary fascial closure and Kidney Disease: Improving Global Outcomes stages of acute kidney injury.ResultsThe HTS and standard resuscitation groups had similar baseline illness severity and organ dysfunction, though HTS patients had lower serum creatinine at initial laparotomy (1.2 mg/dL vs. 1.4 mg/dL; p = 0.078). Forty-eight hours after TAC, HTS patients had significantly higher serum sodium (145.8 mEq/L vs. 142.2 mEq/L, p < 0.001), chloride (111.8 mEq/L vs. 106.6 mEq/L, p < 0.001), and osmolarity (305.8 mOsm/kg vs. 299.4 mOsm/kg; p = 0.006), and significantly lower arterial pH (7.34 vs. 7.38; p = 0.011). The HTS patients had lower intravenous fluid (IVF) volumes within 48 hours of TAC (8.5 L vs. 11.8 L; p = 0.004). Serum creatinine, urine output, and kidney injury were similar between groups. Fascial closure was achieved for 92% of all HTS patients and 77% of all standard resuscitation patients (p = 0.063). Considering all 189 patients, higher IVF resuscitation volumes within 48 hours of TAC were associated with decreased odds of fascial closure (odds ratio, 0.90; 95% confidence interval, 0.83-0.97; p = 0.003).ConclusionHypertonic saline resuscitation was associated with the development of a hypernatremic, hyperchloremic, hyperosmolar acidosis, and lower total IVF resuscitation volumes, without adversely affecting renal function. These findings may not be generalizable to patients with baseline renal dysfunction and susceptibility to hyperchloremic acidosis-induced kidney injury.Level of evidencePrognostic study, level II.

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Accurate risk stratification for development of organ/space surgical site infections after emergent trauma laparotomy.

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Accurate risk stratification for development of organ/space surgical site infections after emergent trauma laparotomy.

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