Todd R. Vogel

Feeding the Open Abdomen

BACKGROUND The purpose of this study was to determine if early enteral nutrition improves outcome for trauma patients with an open abdomen (OA). METHODS Retrospective review was used to identify 78 patients who required an OA for >or=4 hospital days, survived, and had available nutrition data. Demographic data and nutrition data comprising enteral nutrition initiation day and daily % target goal were collected. Patients were divided into 2 groups: early enteral feeding (EEN), initiated <or=4 days within celiotomy; and late enteral feeding (LEN; >4 days). Outcomes included infectious complications, early closure of the abdominal cavity (<8 days from original celiotomy), and fistula formation. RESULTS Fifty-three of 78 (68%) patients were men, with a mean age of 35 years; 74% had blunt trauma. Forty-three of 78 (55%) patients had EEN, whereas 35 of 78 (45%) had LEN. There was no difference with respect to demographics, injury severity, or infectious complication rates. Thirty-two of 43 (74%) patients with EEN had early closure of the abdominal cavity, whereas 17 of 35 (49%) patients with late feeding had early closure (p = .02). Four of 43 (9%) patients with EEN demonstrated fistula formation, whereas 9 of 35 (26%) patients with late feeding formed fistulae (p = .05). The EEN group had lower hospital charges (p = .04) by more than

Carotid artery stenting in the nation: the influence of hospital and physician volume on outcomes.

50,000. CONCLUSIONS EEN in the OA was associated with (1) earlier primary abdominal closure, (2) lower fistula rate, (3) lower hospital charges.

Preoperative Statins and Limb Salvage After Lower Extremity Revascularization in the Medicare Population

Objectives: To assess national outcomes of carotid artery stenting (CAS) with respect to hospital and practitioner volume. Methods: The 2005 to 2006 Nationwide Inpatient Sample (NIS) was used to assess CAS with respect to hospital volume, physician volume, and associated complications. Results: Eighteen thousand five hundred ninety-nine CAS interventions were identified. The top 25% was used to define high-volume hospitals (>60 CAS/2 years) and practitioners (>30 CAS/2 years). The stroke rate after CAS was significantly different between low- and high-volume hospitals (2.35% vs 1.78%, respectively; P = .0206). The stroke rate after CAS was also significantly different between low- and high-volume practitioners (2.19% vs 1.51%, P = .0243). Hospital resource use varied significantly between low- and high-volume hospitals (length of stay [LOS]: 1.64 ± 2.10 vs 1.45 ± 11.21, P = .0006; total charges:

Impact of infectious complications after elective surgery on hospital readmission and late deaths in the U.S. Medicare population.

32 261 ± 20 562 vs

Update and review of racial disparities in sepsis.

30 131 ± 19 592, P = .0047) and practitioners (LOS: 1.70 ± 2.14 vs 1.36 ± 1.36; P < .0001; total charges:

Infectious Complications after Vehicular Trauma in the United States

33 762 ± 21 081 vs

Use of angiotensin-converting enzyme inhibitors and freedom from amputation after lower extremity revascularization

23 957 ± 19 713; P < .0001). Conclusions: This analysis demonstrates that hospital and physician volume are associated with outcomes and utilization after CAS. High-volume hospitals and practitioners were associated with lower procedure stroke rates and decreased hospital resource utilization.

A contemporary evaluation of carotid endarterectomy outcomes in patients with chronic kidney disease in the United States

Background—Statins stabilize atherosclerotic plaque, decrease mortality after surgical procedures, and are linked to anti-inflammatory effects. The objective of this study was to evaluate preoperative administration of statins and longitudinal limb salvage after lower extremity endovascular revascularization and lower extremity open surgery. Methods and Results—Patients were selected from 2007 to 2008 Medicare claims using the International Classification of Diseases, Ninth Revision, Clinical Modification, diagnosis codes for claudication (N=8128), rest pain (N=3056), and ulceration/gangrene (N=11 770) and Current Procedural Terminology codes for endovascular revascularization (N=14 353) and open surgery (N=8601). Half (N=11 687) were identified as statin users before revascularization using Part D files. Amputations were identified using Current Procedural Terminology codes. Statin users compared with nonusers had lower amputation rates at 30 days (11.5% versus 14.4%; P<0.0001), 90 days (15.5% versus 19.3%; P<0.0001), and 1 year (20.9% versus 25.6%; P<0.0001). Survival analysis demonstrated improved limb salvage during 1 year for statin users compared with nonusers for the diagnosis of claudication (P=0.003), a similar trend for rest pain (P=0.061), and no improvement for ulceration/gangrene (P=0.65). Conclusions—Preoperative statins were associated with improved 1-year limb salvage after lower extremity revascularization. The strongest association was found for patients with the diagnosis of claudication. Statins seem to be underused among Medicare patients with peripheral artery disease. Further evaluation of the use of preoperative statins and the potential benefits for peripheral vascular interventions is warranted.

The Open Abdomen in Trauma: Do Infectious Complications Affect Primary Abdominal Closure?

BACKGROUND AND PURPOSE Whereas the negative impact of infectious complications (IC) during the index hospitalization after elective surgery is well established, the long-term ramifications of hospital-acquired post-operative infections are not well studied. This analysis evaluated the impact of a hospital-acquired IC after open abdominal vascular surgery on the readmission rate and the mortality rates 30 and 90 days after initial discharge. METHODS Data from all hospitals in the United States that performed elective open abdominal vascular operations in the Medicare population from 2005 to 2007 were extracted from the national Medicare Provider Analysis and Review database. The cohort consisted of all patients undergoing open abdominal vascular operations, including aortic, iliac, and visceral procedures. The ICs evaluated were pneumonia, urinary tract infection (UTI), postoperative sepsis (sepsis), surgical site infection (SSI), and Clostridium difficile infection (CDI). Patients were categorized as either developing an IC during their initial hospitalization (Index+INF) or not developing an IC (No INF). The rates of 30-day readmission, 30-day IC, and 30- and 90-day mortality after the initial discharge were evaluated longitudinally and compared in patients with and without an IC. RESULTS A total of 29,549 open abdominal vascular procedures were identified, and 4,016 patients (13.6%) developed an IC during their index hospitalization: Pneumonia (5.1% of the total), UTI (2.7%), sepsis (1.6%), SSI (1.4%), and CDI (0.6%). Additionally, 1.13% of patients developed pneumonia, UTI, SSI, or CDI complicated by sepsis. The hospital mortality rate during the initial hospitalization was 13.7% (Index+INF) versus 4.0% (No INF) (p<0.0002). Infectious processes (pneumonia, UTI, SSI, and CDI) complicated by sepsis had an in-hospital mortality rate significantly higher than patients having an IC alone (50.9% vs. 13.7%; p<0.002). The mortality rate 30 and 90 days after the initial discharge was significantly higher for Index+INF than for No INF (4.4% vs. 1.2% and 8.6% vs. 2.6%, respectively; p<0.0002). The highest 30-day mortality rates after discharge were found after CDI+sepsis (30%), pneumonia+sepsis (12.6%), and postoperative sepsis alone (8.6%). The same rank was found for the 90-day mortality rate: 30%, 22.5%, and 13.8%. Overall, readmission was more likely for Index+INF than for No INF (33.7% vs. 21.5%; p<0.0002). Rates of 30-day readmission after an index IC ranged from 32% to 50%. CONCLUSION For Medicare beneficiaries undergoing elective open abdominal vascular procedures, the development of any IC significantly increased not only the in-hospital mortality rate but also the mortality rates 30 and 90 days after discharge from the hospital. Index ICs also were associated with a higher 30-day readmission rate. Hospital-acquired infections have a profound late effect on outcomes after discharge. Future programs targeting high-risk patients may improve long-term survival and minimize readmissions.

Trends in Postoperative Sepsis: Are We Improving Outcomes?

BACKGROUND Sepsis is an excessive systemic inflammatory response activated by invasive infection. There has been substantial epidemiologic literature addressing perceived disparities in sepsis by demographic factors such as gender and race. There also have been multiple examinations of the disparities of sepsis with regard to environmental and socioeconomic factors. This paper reviews the current epidemiologic literature evaluating the association of race with the development of sepsis and its associated outcomes. METHODS Review of pertinent English-language literature. RESULTS Race is a marker of poverty, preexisting conditions, increased allostatic loads, and decreased access to health systems. Racial disparities and the incidence of sepsis likely are explained by a multiplicity of environmental factors that are not captured by administrative data. CONCLUSION Race is a surrogate for many intangible factors that lead to the development of sepsis and inferior outcomes.