Troy A. Markel

Steroids and poor nutrition are associated with infectious wound complications in children undergoing first stage procedures for ulcerative colitis

BACKGROUND Risk factors for postoperative infections have not been evaluated in pediatric patients with ulcerative colitis (UC). This review was undertaken to evaluate the effects of immunosuppressive therapy and other preoperative factors on infectious wound complications in children undergoing first stage surgical therapy for UC. METHODS A 10-year retrospective review of children under 18 years of age receiving first stage surgical therapy for UC at a major childrens hospital was performed. Preoperative clinical and treatment variables were identified and correlated with postoperative wound complications. RESULTS A total of 51 children were identified: 19 underwent colectomy with ileo-anal-pouch anastomosis and 32 underwent total abdominal colectomy with Hartmanns pouch. A total of 20 infectious complications were identified in 18 patients. Preoperative steroid use was associated with a greater postoperative wound infection rate. Preoperative hemoglobin less than 10 g/dL (P < .05) and albumin less than 3 g/dL (P = 0.1) were associated with greater rates of postoperative infection. Preoperative body mass index and other immunosuppressive agents did not influence postoperative infectious morbidity. CONCLUSIONS The majority of pediatric patients who require operative intervention for UC are debilitated from their disease and medication use. Children with normal serum albumin and hemoglobin who are not on steroid therapy have a low risk of postoperative infectious complications.

Hats Off: A Study of Different Operating Room Headgear Assessed by Environmental Quality Indicators

BACKGROUND The effectiveness of operating room headgear in preventing airborne contamination has been called into question. We hypothesized that bouffant style hats would be as effective in preventing bacterial and particulate contamination in the operating room compared with disposable or cloth skull caps, and bouffant style hats would have similar permeability, particle penetration, and porosity compared with skull caps. STUDY DESIGN Disposable bouffant and skull cap hats and newly laundered cloth skull caps were tested. A mock surgical procedure was used in a dynamic operating room environment. Airborne particulate and microbial contaminants were sampled. Hat fabric was tested for permeability, particle transmission, and pore sizes. RESULTS No significant differences were observed between disposable bouffant and disposable skull caps with regard to particle or actively sampled microbial contamination. However, when compared with disposable skull caps, disposable bouffant hats did have significantly higher microbial shed at the sterile field, as measured by passive settle plate analysis (p < 0.05). When compared with cloth skull caps, disposable bouffants yielded higher levels of 0.5 μm and 1.0 μm particles and significantly higher microbial shed detected with passive analysis. Fabric assessment determined that disposable bouffant hats had larger average and maximum pore sizes compared with cloth skull caps, and were significantly more permeable than either disposable or cloth skull caps. CONCLUSIONS Disposable bouffant hats had greater permeability, penetration, and greater microbial shed, as assessed by passive microbial analysis compared with disposable skull caps. When compared with cloth skull caps, disposable bouffants yielded greater permeability, greater particulate contamination, and greater passive microbial shed. Disposable style bouffant hats should not be considered superior to skull caps in preventing airborne contamination in the operating room.

Methodology for analyzing environmental quality indicators in a dynamic operating room environment.

HighlightsThis study tests air quality indicators in a dynamic operating room environment.A mock surgical procedure led by a board‐certified surgeon was used to simulate actual conditions in an operating room to provide realistic data.Levels of airborne contaminants in a health care setting can be accurately quantified using this testing protocol.Environmental quality indicators, such as number of particles, microbial contaminant load, air velocity, and temperature, provide insight to the effectiveness of heating, ventilation, and air conditioning systems. Background: Sufficient quantities of quality air and controlled, unidirectional flow are important elements in providing a safe building environment for operating rooms. Methods: To make dynamic assessments of an operating room environment, a validated method of testing the multiple factors influencing the air quality in health care settings needed to be constructed. These include the following: temperature, humidity, particle load, number of microbial contaminants, pressurization, air velocity, and air distribution. The team developed the name environmental quality indicators (EQIs) to describe the overall air quality based on the actual measurements of these properties taken during the mock surgical procedures. These indicators were measured at 3 different hospitals during mock surgical procedures to simulate actual operating room conditions. EQIs included microbial assessments at the operating table and the back instrument table and real‐time analysis of particle counts at 9 different defined locations in the operating suites. Air velocities were measured at the face of the supply diffusers, at the sterile field, at the back table, and at a return grille. Results: The testing protocol provided consistent and comparable measurements of air quality indicators between institutions. At 20 air changes per hour (ACH), and an average temperature of 66.3°F, the median of the microbial contaminants for the 3 operating room sites ranged from 3‐22 colony forming units (CFU)/m3 at the sterile field and 5‐27 CFU/m3 at the back table. At 20 ACH, the median levels of the 0.5‐&mgr;m particles at the 3 sites were 85,079, 85,325, and 912,232 in particles per cubic meter, with a predictable increase in particle load in the non–high‐efficiency particulate air‐filtered operating room site. Using a comparison with cleanroom standards, the microbial and particle counts in all 3 operating rooms were equivalent to International Organization for Standardization classifications 7 and 8 during the mock surgical procedures. Conclusions: The EQI protocol was measurable and repeatable and therefore can be safely used to evaluate air quality within the health care environment to provide guidance for operational practices and regulatory requirements.

Why wait: early enteral feeding after pediatric gastrostomy tube placement

PURPOSE Early initiation of feedings after gastrostomy tube (GT) placement may reduce associated hospital costs, but many surgeons fear complications could result from earlier feeds. We hypothesized that, irrespective of placement method, starting feedings within the first 6h following GT placement would not result in a greater number of post-operative complications. METHODS An IRB-approved retrospective review of all GTs placed between January 2012 and December 2014 at three academic institutions was undertaken. Data was stratified by placement method and whether the patient was initiated on feeds at less than 6h or after. Baseline demographics, operative variables, post-operative management and complications were analyzed. Descriptive statistics were used and P-values <0.05 were considered significant. RESULTS One thousand and forty-eight patients met inclusion criteria. GTs were inserted endoscopically (48.9%), laparoscopically (44.9%), or via an open approach (6.2%). Demographics were similar in early and late fed groups. When controlling for method of placement, those patients who were fed within the first 6h after gastrostomy placement had shorter lengths of stay compared to those fed greater than 6h after placement (P<0.05). Total post-operative outcomes were equivalent between feeding groups for all methods of placement (laparoscopic (P=0.87), PEG (P=0.94), open (P=0.81)). CONCLUSIONS Early initiation of feedings following GT placement was not associated with an increase in complications. Feeds initiated earlier may shorten hospital stays and decrease overall hospital costs. TYPE OF STUDY Multi-institutional retrospective. LEVEL OF EVIDENCE III.

Cost-benefit analysis of different air change rates in an operating room environment

HighlightsWe found low air velocity rates at back table which could lead to contamination of instruments.The levels of microbial contaminants measured led to the conclusion that higher ventilation rates do not equate to cleaner, fewer colony forming units, whereas particle data were less conclusive because of variations during Bovie use.We developed realistic estimates of the financial cost of higher operating room ventilation rates.We obtained actual air quality data during a dynamic mock surgical procedure to facilitate evidence‐based design of operating room systems. Background: Hospitals face growing pressure to meet the dual but often competing goals of providing a safe environment while controlling operating costs. Evidence‐based data are needed to provide insight for facility management practices to support these goals. Methods: The quality of the air in 3 operating rooms was measured at different ventilation rates. The energy cost to provide the heating, ventilation, and air conditioning to the rooms was estimated to provide a cost‐benefit comparison of the effectiveness of different ventilation rates currently used in the health care industry. Results: Simply increasing air change rates in the operating rooms tested did not necessarily provide an overall cleaner environment, but did substantially increase energy consumption and costs. Additionally, and unexpectedly, significant differences in microbial load and air velocity were detected between the sterile fields and back instrument tables. Conclusions: Increasing the ventilation rates in operating rooms in an effort to improve clinical outcomes and potentially reduce surgical site infections does not necessarily provide cleaner air, but does typically increase operating costs. Efficient distribution or management of the air can improve quality indicators and potentially reduce the number of air changes required. Measurable environmental quality indicators could be used in lieu of or in addition to air change rate requirements to optimize cost and quality for an operating room and other critical environments.

Loss of Angiotensin‐Converting Enzyme 2 Exacerbates Diabetic Retinopathy by Promoting Bone Marrow Dysfunction

Angiotensin‐converting enzyme 2 (ACE2) is the primary enzyme of the vasoprotective axis of the renin angiotensin system (RAS). We tested the hypothesis that loss of ACE2 would exacerbate diabetic retinopathy by promoting bone marrow dysfunction. ACE2–/y were crossed with Akita mice, a model of type 1 diabetes. When comparing the bone marrow of the ACE2–/y‐Akita mice to that of Akita mice, we observed a reduction of both short‐term and long‐term repopulating hematopoietic stem cells, a shift of hematopoiesis toward myelopoiesis, and an impairment of lineage–c‐kit+ hematopoietic stem/progenitor cell (HS/PC) migration and proliferation. Migratory and proliferative dysfunction of these cells was corrected by exposure to angiotensin‐1‐7 (Ang‐1‐7), the protective peptide generated by ACE2. Over the duration of diabetes examined, ACE2 deficiency led to progressive reduction in electrical responses assessed by electroretinography and to increases in neural infarcts observed by fundus photography. Compared with Akita mice, ACE2–/y‐Akita at 9‐months of diabetes showed an increased number of acellular capillaries indicative of more severe diabetic retinopathy. In diabetic and control human subjects, CD34+ cells, a key bone marrow HS/PC population, were assessed for changes in mRNA levels for MAS, the receptor for Ang‐1‐7. Levels were highest in CD34+ cells from diabetics without retinopathy. Higher serum Ang‐1‐7 levels predicted protection from development of retinopathy in diabetics. Treatment with Ang‐1‐7 or alamandine restored the impaired migration function of CD34+ cells from subjects with retinopathy. These data support that activation of the protective RAS within HS/PCs may represents a therapeutic strategy for prevention of diabetic retinopathy. Stem Cells 2018;36:1430–1440

Covering the instrument table decreases bacterial bioburden: An evaluation of environmental quality indicators

HighlightsCertain regulatory agencies have suggested that covering the operating room instrument table during periods of nonuse may decrease the bioburden on the table.Instrument table covers decrease bioburden on the instrument table during static and dynamic conditions.Instrument table covers should be considered for use during periods of nonuse and during active surgery to decrease bioburden near the instruments. Background Covering the instrument table during surgery may decrease contamination. We hypothesized that (1) covering the instrument table in an operating room (OR) during static periods of nonuse and dynamic periods of active use would dramatically decrease the bacterial bioburden on the table, and (2) the use of sterile plastic table covers would be equivalent to sterile impervious paper covers in reducing the bioburden in a dynamic environment. Methods Bacterial contamination of the instrument table was evaluated by settle plates in static and dynamic ORs. Airborne particulate and bacterial contaminants were sampled throughout the room. Tested groups included instrument tables covered with sterile impervious paper covers, sterile plastic covers, or no covers. Results Covering the instrument table during static and dynamic operating room conditions resulted in a significantly decreased bacterial load on the instrument table. No differences were seen between paper and plastic covers. Conclusions A significant decrease in bacterial bioburden on the instrument table when the table was covered during static and dynamic periods was observed, suggesting the utility for covering the instrument table during periods of nonuse and during active surgeries.

Wearing long sleeves while prepping a patient in the operating room decreases airborne contaminants

Background: The use of long sleeves by nonscrubbed personnel in the operating room has been called into question. We hypothesized that wearing long sleeves and gloves, compared with having bare arms without gloves, while applying the skin preparation solution would decrease particulate and microbial contamination. Methods: A mock patient skin prep was performed in 3 different operating rooms. A long‐sleeved gown and gloves, or bare arms, were used to perform the procedure. Particle counters were used to assess airborne particulate contamination, and active and passive microbial assessment was achieved through air samplers and settle plate analysis. Data were compared with Students t‐test or Mann‐Whitney U, and P < .05 was considered to be significant. Results: Operating room B demonstrated decreased 5.0‐ &mgr;m particle sizes with the use of sleeves, while operating rooms A and C showed decreased total microbes only with the use of sleeves. Despite there being no difference in the average number of total microbes for all operating rooms assessed, the use of sleeves specifically appeared to decrease the shed of Micrococcus. Conclusion: The use of long sleeves and gloves while applying the skin preparation solution decreased particulate and microbial shedding in several of the operating rooms tested. Although long sleeves may not be necessary for all operating room personnel, they may decrease airborne contamination while the skin prep is applied, which may lead to decreased surgical site infections.