Philip S. Barie

Timeliness and use of antibiotic prophylaxis in selected inpatient surgical procedures

BACKGROUNDnTwenty-five percent of all nosocomial infections are wound infections. Professional guidelines support the timely use of preoperative prophylaxis for prevention of postoperative wound infections. Barriers exist in implementing this practice. IPRO, the New York State peer review organization, as part of the Health Care Financing Administrations Health Care Quality Improvement Program, sought to determine the proportion of patients receiving timely antibiotic prophylaxis for aortic grafts, hip replacements and colon resections in 44 hospitals in New York State.nnnMETHODSnIPRO conducted a retrospective medical record review of 44 hospitals through out New York State stratified for teaching, nonteaching status. A sample was drawn of 2651 patients, 2256 from Medicare and 395 from Medicaid, undergoing either abdominal aortic aneurysm repair, partial or total hip replacement or large bowel resection. The study determined the proportion of patients who had documentation of receiving antibiotics and those who received antibiotics timely, that is less than or equal to 2 hours preoperatively.nnnRESULTSnEighty-six percent of patients had documentation of receiving an antibiotic. Forty-six percent of aneurysm repairs and 60% of hip replacements had evidence of receiving timely antibiotic prophylaxis, that is within 2 hours prior to surgery. For colon resections, 73% of cases had either oral prophylaxis or timely parenteral therapy. An increased proportion of patients had received parenteral antibiotics prematurely as the surgical start time occurred later in the day. A total of 44 different antibiotics were recorded for prophylaxis.nnnCONCLUSIONSnAntibiotic prophylaxis was performed in 81% to 94% of cases, however, anywhere from 27% to 54% of all cases did not receive antibiotics in a timely fashion. By delegating implementation of ordered antibiotic prophylaxis to the anesthesia team, timing may be improved and the incidence of postoperative wound infections may decrease.

Antibiotic-resistant gram-positive cocci : Implications for surgical practice

Abstract. Gram-positive infections are causing more serious infections than ever before in surgical patients, who are increasingly aged, ill, and debilitated. Invasive procedures disrupt natural barriers to bacterial invasion, and indwelling catheters may act as conduits for infection. The use of broad-spectrum antibiotics selects for the emergence of resistant pathogens. Potential sites of nosocomial gram-positive infections include the urinary tract, surgical site (including prosthetic devices), intravascular loci, lung and pleural space, facial sinuses, and peritoneal cavity. Responsible organisms include species from the generaEnterococcus andStaphylococcus. Methicillin-resistant strains ofStaphylococcus aureus (MRSA) and Staphylococcus epidermidis (MRSE) emerged during the 1970s, leading to a marked increase in the use of vancomycin as the treatment of choice. Vancomycin use, in turn, has been implicated (along with widespread cephalosporin use) in the emergence of vancomycin-resistant enterococci (VRE) during the 1990s. Of great concern is the likely emergence of vancomycin-resistant staphylococci, which would constitute a public health emergency. Vancomycin remains the treatment of choice for infections caused by MRSA/MRSE, but rampant inappropriate use (e.g., prophylaxis in non-penicillin-allergic patients, treatment of methicillin-sensitive strains) must be curtailed. Chloramphenicol is increasingly the treatment of choice for serious VRE infections. Infection control policy must also minimize the possibility of transmission. All infected or colonized patients should be isolated and all environmental surfaces considered contaminated. Disposable gloves are mandatory for all patient contact, even incidental contact, and must be disposed of after each patient encounter. Hand-washing (the single most effective infection control measure) is mandatory after glove disposal. Gowns should be worn for direct contact with infected patients and masks used when aerosolization or splashing of secretions is likely.

A critical review of antibiotic prophylaxis in severe acute pancreatitis

The close association between infection and poor outcome in severe pancreatitis has led many investigators to hypothesize that antibiotic prophylaxis might reduce infection and thereby reduce mortality. However, despite this possible relationship, few studies of good quality have been performed in humans. Comprehensive searches using Medline and reviewing relevant published bibliographies of English-language human and experimental literature concerning acute pancreatitis or pancreatic tissue and antibiotic therapy or pharmacokinetics were conducted. Ample experimental evidence indicates that aminoglycosides penetrate pancreatic tissue poorly and that penetration of penicillins is variable, although the relevance of this is debatable, because most tissue that requires debridement in severe pancreatitis is necrotic peripancreatic retroperitoneal fat, not the pancreas itself. Although several animal studies suggest that antibiotic prophylaxis would be beneficial in severe pancreatitis, two recent randomized studies of intravenous antibiotics in humans provide conflicting data. There are insufficient data to recommend the use of selective digestive decontamination. Some justification exists for the use of intravenous antibiotic prophylaxis in severe pancreatitis, but the data are insufficient to mandate prophylaxis or to elevate it to the standard of care. If chosen, prophylaxis with the combination of a fluoroquinolone plus metronidazole, or monotherapy with a carbapenem antibiotic, would be most appropriate. Several other questions-including the minimum degree of severity that will benefit, the validity of endpoints other than mortality, and reduction of the need for surgical drainage-require additional trials.

Acute Paranasal Sinusitis in Critically Ill Patients: Guidelines for Prevention, Diagnosis, and Treatment

Nosocomial sinusitis is common in critical illness. Randomized trials indicate that radiographic sinusitis (RS) occurs in 25%-75% of all critically ill patients and that 18%-32% of endotracheally intubated patients will develop sinusitis. Variability in the estimated incidence of RS stems from the many radiographic techniques used for diagnosis. Critically ill patients with suspected sinusitis should undergo computed tomographic scanning of all paranasal sinuses. If the scans are positive (opacification, mucosal thickening, air-fluid level), aspiration is performed after meticulous nasal disinfection. Infection is confirmed if a pathogen is identified along with neutrophils. Nosocomial sinusitis is usually caused by gram-negative bacilli or is polymicrobial. Pseudomonas aeruginosa, the most common causative organism, represents 15.9% of isolates. The most common gram-positive isolate is Staphylococcus aureus (10.6%); fungi represent 8.5% of isolates. Infection is treated with aspiration and systemic antibiotics. Treatment failures are common; drainage with indwelling catheters is sometimes necessary.

Urological manifestations of acute appendicitis

The diagnosis of appendicitis may be difficult to establish even for the experienced surgeon. Considerable variability in presenting symptoms and signs, resulting in part from the numerous locations in which the appendix may be found, contributes to diagnostic insecurity. Appendicitis that mimics acute disorders of the genitourinary tract is a rare cause of diagnostic confusion. The association of appendicitis with abnormal urinary sediment or ureteral obstruction has been reported previously. We report 3 cases of proved appendicitis that presented with other symptoms suggestive of acute urological disorders (gross hematuria, acute prostatis and acute pyelonephritis). While gross hematuria caused by appendicitis has been reported previously, cases of appendicitis mimicking acute prostatitis or rupture of a renal calix with extravasation of urine following ureteral obstruction have not been described. Recognition of unusual manifestations of appendicitis is essential in current surgical practice. Appendicitis should be included in the differential diagnosis of acute urological disorders.

Resolution of refractory pancreatic ascites after continuous infusion of octreotide acetate.

SummaryThe treatment of pancreatic ascites remains a clinical challenge. Both medical and surgical management have high rates of mortality and recurrence. New methods in the treatment of pancreatic ascites are actively sought. We describe the successful use of a continuous infusion of octreotide acetate in the treatment of refractory alcoholic pancreatic ascites.

Organ-specific support in multiple organ failure: Pulmonary support

The catastrophic pulmonary failure that complicates management of patients with multiple trauma or sepsis syndrome with shock is recognizable to nearly all experienced surgeons. However, the spectrum of injury is broad, the distribution of lung injury may be heterogeneous within a single patient, and may patients will not develop acute respiratory distress syndrome (ARDS) even after a major predisposing insult. The lung responds stereotypically to many disparate insults, so a better conceptual construct of ARDS may be to consider it as one component of the multiple organ dysfunction syndrome. Support of oxygen transport with positive pressure ventilation and high levels of positive end-expiratory pressure, long the mainstay of pulmonary support, has been criticized for its predilection to cause barotrauma. Newer modes of ventilation, such as pressure-controlled, inverse-ratio ventilation and permissive hypercapnia, are under investigation but have not yet been reported with scientific rigor. However, pulmonary support extends beyond the support of gas exchange. Fluid management requires close attention so that the circulation is supported but lung water accumulation is minimized. Nosocomial pneumonia greatly increases the mortality rate in ARDS, but is difficult to diagnose and must be sought aggressively. Until recently, pharmacologic therapy has held little promise, but inhalation of very low concentrations of nitric oxide appear to decrease pulmonary vascular pressures and intrapulmonary shunt. It remains unknown whether nitric oxide is effective therapy for the underlying injury, or is simply treatment for certain manifestations.RésuméUne défaillance pulmonaire, tellement catastrophique, qui survient chez les polytraumatisés ou les patients en choc septique est facilement reconnaissable de presque tous les chirurgiens expérimentés. Cependant, la gamme de lésions est étendue, la répartition des lésions dans le poumon peut être hétérogène chez un même patient et beaucoup de patients ne développent pas obligatoirement de syndrome de détresse respiratoire de ladulte (SDRA), même en cas de cause favorisante. Le poumon répond de façon stéréotypée à des stimuli disparates si bien quil vaut peut-être mieux considérer le SDRA comme faisant partie dun syndrome de défaillance polyviscérale. La ventilation à pression positive avec oxygénothérapie poussée, longtemps considérée comme essentielle dans le traitement de ce syndrome a été récemment critiquée pour son rôle dans la création de barotraumatismes. De nouvelles techniques de ventilation à pression contrôlée, de ventilation avec rapports inversés, et dhypercapnie permissive sont actuellement en cours dinvestigation mais nont pas encore atteint un niveau scientifique rigoureux. Néanmoins, la notion de support pulmonaire dépasse celle des simples échanges de gaz. Léquilibre hydro-électrolytique est aussi important pour maintenir un état hémodynamique satisfaisant tout en évitant une surcharge hydrique au niveau des poumons. La survenue dinfection pulmonairc nosocomiale augmente la mortalité chez le patient atteint dun SDRA, mais son diagnostic est difficile et il faut la rechercher activement. Jusquà une époque récente, la pharmacologie jouait un rôle minime, mais linhalation de loxyde nitrique à de faibles doses paraît diminuer les pressions vasculaires pulmonaires et le shunt intrapulmonaire. Il reste à démontrer si loxyde nitrique est efficace sur la lésion sous-jacente, ou est simplement efficace sur ses manifestations.ResumenLa catastrófica falla pulmonar que complica el manejo de los pacientes con trauma múltiple o síndrome séptico con shock es un cuadro familiar para casi todos los circujanos experimentados. Sinembargo, el espectro de la lesión es amplio, la distribución de las alteraciones pulmonares puede ser hetereogénea en un mismo paciente y muchos no desarrollan el síndrome de dificultad respiratoria aguda (SDRA) aún después de una agresión biológica predisponente. El pulmón responde en forma estereotipada a muchas agresiones biológicas de diferente tipo, y por ello una mejor construcción conceptual del SDRA debe ser considerada como uno de los componentes del síndrome de disfunción de múltiples órganos. El soporte del transporte de oxígeno con ventilación de presión positiva y altos niveles de presión positiva al final de la espiración y un prolongado soporte de la función pulmonar general, han sido criticados por la frecuencia con que causan barotrauma. Nuevas modalidades de ventilación mecánica, tales como la presión controlada, la ventilación de relación inversa y la hipercapnia permisiva, se encuentran bajo investigación pero aún no han sido reportadas con suficiente rigor científico. Sinembargo, el sopore pulmonar debe ser llevado más allá del simple soporte del intercambio gaseoso. El manejo de los líquidos requiere una atención especial en tal forma que la circulación sea soportada al tiempo que se minimiza la acumulación pulmonar de agua. La aparición de una neumonía nosocomial aumenta enormemente la tasa de mortalidad en el SDRA, pero es difícil de diagnosticar y debe ser investigada en forma agresiva. Hasta hace poco, la terapia farmacológica aparecía muy poco promisoria, pero la inhalación de muy bajas concentraciones de óxido nítrico parece disminuir la presión vascular pulmonar y el shunt intrapulmonar. Aun no sabemos si el óxido nítrico es una modalidad terapéutica eficaz en cuanto a la lesión pulmonar subyacente, o simplemente un tratamiento para determinadas manifestaciones.

Obesity does not increase morbidity of laparoscopic cholecystectomy.

BACKGROUNDnObesity has historically been a positive predictor of surgical morbidity, especially in the morbidly obese. The purpose of our study was to compare outcomes of obese patients undergoing laparoscopic cholecystectomy (LC).nnnMETHODSnWe reviewed 1382 consecutive patients retrospectively who underwent LC for various pathologies from January 2008 to August 2011. Patients were stratified based on the World Health Organization definitions of obesity: nonobese (body mass index [BMI] < 30 kg/m(2)), obesity class I (BMI 30-34.9xa0kg/m(2)), obesity class II (BMI 35-39.9xa0kg/m(2)), and obesity class III (BMI ≥ 40xa0kg/m(2)). The primary end points were conversion rates and surgical morbidity. The secondary end point was length of stay.nnnRESULTSnThere were significantly more females in the obesity II and III groups (Pxa0=xa00.0002). American Society of Anesthesiologists scores were significantly higher in the obesity I, II, and III groups compared with the nonobese (Pxa0<xa00.05; Pxa0<xa00.01; and Pxa0<xa00.0001, respectively). Independent predictors of conversion on multivariate analysis (MVA) included age (Pxa0=xa00.01), acute cholecystitis (Pxa0=xa00.03), operative time (Pxa0<xa00.0001), blood loss (Pxa0<xa00.0001), and fellowship-trained surgeons (Pxa0<xa00.0001). Independent predictors of intraoperative complications on MVA included age (Pxa0=xa00.009), white patients (Pxa0=xa00.009), previous surgery (Pxa0=xa00.001), operative time (Pxa0<xa00.0001), and blood loss (Pxa0=xa00.01). Independent predictors of postoperative complications on MVA included American Society of Anesthesiologists score (Pxa0<xa00.0001), acute cholecystitis (Pxa0<xa00.0001), and a postoperative complication (Pxa0<xa00.0001). BMI was not a predictor of conversions or surgical morbidity. Length of stay was not significantly different between the four groups.nnnCONCLUSIONSnThis study demonstrates that overall conversion rates and surgical morbidity are relatively low following LC, even in obese and morbidly obese patients.

Epidemiology, Risk Factors, and Outcome of Multiple Organ Dysfunction Syndrome in Surgical Patients

It has been recognized for several years that organ failure is the leading cause of death in surgical patients.1 It is believed that most cases of multiple organ dysfunction syndrome (MODS) are precipitated by infection, but it is also recognized that the outcome of organ dysfunction does not correlate well with the microbiology of MODS.2 The isolated organisms are often avirulent bacterial opportunists, colonizing and sometimes invading hosts who are susceptible owing to debility. Moreover, patients who die with MODS often have no demonstrable active infection on postmortem examination.3 Indeed, some cases of organ dysfunction have been associated with histologic evidence of multiorgan inflammation in the absence of infection.4 Therefore it is possible that MODS is precipitated by an insult that causes a massive inflammatory response (systemic inflammatory response syndrome, or SIRS) or a dysregulated balance of proinflammatory and compensatory antiinflammatory responses (CARS).5.

Consequences of Failed Source Control

• Failure of source control is more important than “antibiotic failure” in defining the outcome of surgical infections in general and intra-abdominal infections in particular. • Source control of an intra-abdominal infection may fail because of a poor choice of operation, or the correct operation performed poorly or with poor timing. • Leaving the abdomen open is a viable (and often necessary) adjunct to surgical management of recurrent intra-abdominal infection. • Systemic consequences of failed source control include nosocomial infections, nutritional and metabolic disorders, and multiple organ dysfunction syndrome.