Nathan Schmoekel

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.

Nonoperative Damage Control: The Use of Extracorporeal Membrane Oxygenation in Traumatic Bronchial Avulsion as a Bridge to Definitive Operation.

The conventional treatment for an avulsed bronchus is emergent thoracotomy and repair or lobectomy. The principles of damage control thoracic operations include initial hemorrhage control with delayed definite repair after physiologic resuscitation. We report a multiply injured patient with avulsion of the left lower lobe bronchus. Profound acidosis, hypercarbia, and hypoxia precluded an emergent operation, and venovenous extracorporeal membrane oxygenation (V-V ECMO) was used for organ support during physiologic resuscitation. After the achievement of physiologic repletion, a thoracotomy and lobectomy were performed while the patient was supported by V-V ECMO.

Scoring Systems are Essential in Prediction of SSI Development After Hernia Repair: Reply

Dr. Resanovic et al., Thank you for your kind words for our recent publication at the Word Journal of Surgery regarding the creation of a scoring system in patients undergoing elective abdominal wall reconstruction that would predict the risk of developing surgical site infections (SSIs) [1]. We agree with the authors in terms of the importance of scoring systems. A scoring system can provide an objective way to risk stratify patients. This is extremely important in the modern era where outcomes are not only reportable, but also dictate compensation and provide a way of assuring quality for the patients. We read your letter with interest and we agree with your comments. We did not include laparoscopic hernia repair for several reasons. Multiple studies have shown that laparoscopic surgery is associated with a decreased incidence of surgical site infections. We felt that the mechanism of injury is different from that associated with open hernia repair. We agree with the comments that open hernia repair may result in more vascular compromise of the soft tissue and as a result higher probability of SSIs postoperatively. In order to ensure more homogeneity of the group in our study, we opted to omit laparoscopic repair. BMI and COPD have traditionally been associated with higher risk of infection in various abdominal surgeries including abdominal wall reconstruction. The location of the hernia requiring reconstruction was not available in the database. Even though research derived from large databases has the advantage of large number of subjects, one of the major disadvantages is missing information that could potentially be helpful. We do agree that the fascial defect is an important factor. It is our anecdotal experience that large fascial defects are more prone to developing postoperative complications, including but not limited to SSIs. Even though the exact defect was not available in the database, several surrogate markers such as extensive lysis of adhesions and need to leave drains were included in the system. Drains are foreign bodies, often in close proximity to a mesh, that provide a tract of entry from bacteria from the skin in deeper tissues. The present study did show an association between the presence of drains and development of SSIs. The surgeon needs to find a balance between avoiding a seroma formation by placing drains and increasing the risk of SSIs by increasing the amount of time the drains are left in place. The duration of drains is an important factor that needs to be further studied in the future. Several questions remain unanswered optimal duration of drains if deemed necessary, need for prophylactic antibiotics while patient has the drains in place, choice of antibiotic if deemed necessary. Finally, the use of perioperative antibiotics is an extremely important topic. Over use of antibiotics has resulted in multi-drug-resistant bacteria that may lead to significant morbidity and mortality in the future. Furthermore, the rising incidence of clostridium difficile-associated infection (CDAI) oftentimes resulting from a single dose of antibiotics may suggest that antibiotics should not be so liberally used in the perioperative period. In the database, the vast majority of the patient received prophylactic preoperative antibiotics and as such any meaningful conclusions could not be made. We are currently working on a prospective study, stratifying patients into groups according to the aforementioned scoring system and randomizing & Efstathios Karamanos ef.karamanos@gmail.com