Influence of the Microbiome on Anastomotic Leak

2021 ◽  
Vol 34 (06) ◽  
pp. 439-446
Author(s):  
Ashley J. Williamson ◽  
John C. Alverdy
Keyword(s):  
Anastomotic Leak ◽  
Gut Microbiome ◽  
Antibiotic Use ◽  
Hospital Length ◽  
Hospital Length Of Stay ◽  
Opioid Use ◽  
Modifiable Factor ◽  
Anastomotic Breakdown ◽  
Novel Strategy ◽  
And Behavior

AbstractDespite advances in surgical technique and the expanded use of antibiotics, anastomotic leak remains a dreaded complication leading to increased hospital length of stay, morbidity, mortality, and cost. Data continues to grow addressing the importance of a functional and diverse colonic microbiome to ensure adequate healing. Individual pathogens, such as Enterococcus faecalis and Pseudomonas aeruginosa, have been implicated in the pathogenesis of anastomotic leak. Yet how these pathogens proliferate remains unclear. It is possible that decreased microbial diversity promotes a shift to a pathologic phenotype among the remaining microbiota which may lead to anastomotic breakdown. As the microbiome is highly influenced by diet, antibiotic use, the stress of surgery, and opioid use, these factors may be modifiable at various phases of the surgical process. A large amount of data remains unknown about the composition and behavior of the “normal” gut microbiome as compared with an altered community. Therefore, targeting the gut microbiome as a modifiable factor in anastomotic healing may represent a novel strategy for the prevention of anastomotic leak.

scholarly journals Improving intravenous-to-oral antibiotic switch in children: a team-based audit and implementation approach

2021 ◽  
Vol 10 (1) ◽  
pp. e001120
Author(s):  
Brendan Joseph McMullan ◽  
Michelle Mahony ◽  
Lolita Java ◽  
Mona Mostaghim ◽  
Michael Plaister ◽  
...  
Keyword(s):  
Length Of Stay ◽  
Antibiotic Use ◽  
Hospital Length ◽  
Audit And Feedback ◽  
Hospital Length Of Stay ◽  
Oral Antibiotic ◽  
Intravenous Therapy ◽  
Paediatric Hospital ◽  
Inpatient Settings ◽  
Surgical Teams

Children in hospital are frequently prescribed intravenous antibiotics for longer than needed. Programmes to optimise timely intravenous-to-oral antibiotic switch may limit excessive in-hospital antibiotic use, minimise complications of intravenous therapy and allow children to go home faster. Here, we describe a quality improvement approach to implement a guideline, with team-based education, audit and feedback, for timely, safe switch from intravenous-to-oral antibiotics in hospitalised children. Eligibility for switch was based on evidence-based guidelines and supported by education and feedback. The project was conducted over 12 months in a tertiary paediatric hospital. Primary outcomes assessed were the proportion of eligible children admitted under paediatric and surgical teams switched within 24 hours, and switch timing prior to and after guideline launch. Secondary outcomes were hospital length of stay, recommencement of intravenous therapy or readmission. The percentage of children switched within 24 hours of eligibility significantly increased from 32/50 (64%) at baseline to 203/249 (82%) post-implementation (p=0.006). The median time to switch fell from 15 hours 42 min to 4 hours 20 min (p=0.0006). In addition, there was a 14-hour median reduction in hospital length of stay (p=0.008). Readmission to hospital and recommencement of intravenous therapy did not significantly change postimplementation. This education, audit and feedback approach improved timely intravenous-to-oral switch in children and also allowed for more timely discharge from hospital. The study demonstrates proof of concept for this implementation with a methodology that can be readily adapted to other paediatric inpatient settings.

scholarly journals Music intervention to relieve anxiety and pain in adults undergoing cardiac surgery: a systematic review and meta-analysis

Open Heart ◽  
2021 ◽  
Vol 8 (1) ◽  
pp. e001474
Author(s):  
Ellaha Kakar ◽  
Ryan J Billar ◽  
Joost van Rosmalen ◽  
Markus Klimek ◽  
Johanna J M Takkenberg ◽  
...  
Keyword(s):  
Systematic Review ◽  
Cardiac Surgery ◽  
Rating Scale ◽  
Meta Analysis ◽  
Numeric Rating Scale ◽  
Hospital Length ◽  
Hospital Length Of Stay ◽  
Music Intervention ◽  
Opioid Use ◽  
Beneficial Effects

ObjectivesPrevious studies have reported beneficial effects of perioperative music on patients’ anxiety and pain. We performed a systematic review and meta-analysis of randomised controlled trials investigating music interventions in cardiac surgery.MethodsFive electronic databases were systematically searched. Primary outcomes were patients’ postoperative anxiety and pain. Secondary outcomes were hospital length of stay, opioid use, vital parameters and time on mechanical ventilation. PRISMA guidelines were followed and PROSPERO database registration was completed (CRD42020149733). A meta-analysis was performed using random effects models and pooled standardised mean differences (SMD) with 95% confidence intervals were calculated.ResultsTwenty studies were included for qualitative analysis (1169 patients) and 16 (987 patients) for meta-analysis. The first postoperative music session was associated with significantly reduced postoperative anxiety (SMD = –0.50 (95% CI –0.67 to –0.32), p<0.01) and pain (SMD = –0.51 (95% CI –0.84 to –0.19), p<0.01). This is equal to a reduction of 4.00 points (95% CI 2.56 to 5.36) and 1.05 points (95% CI 0.67 to 1.41) on the State-Trait Anxiety Inventory and Visual Analogue Scale (VAS)/Numeric Rating Scale (NRS), respectively, for anxiety, and 1.26 points (95% CI 0.47 to 2.07) on the VAS/NRS for pain. Multiple days of music intervention reduced anxiety until 8 days postoperatively (SMD = –0.39 (95% CI –0.64 to –0.15), p<0.01).ConclusionsOffering recorded music is associated with a significant reduction in postoperative anxiety and pain in cardiac surgery. Unlike pharmacological interventions, music is without side effects so is promising in this population.

Comparative Analysis of Inpatient Costs for Obstetrics and Gynecology Surgery Patients Treated With IV Acetaminophen and IV Opioids Versus IV Opioid-only Analgesia for Postoperative Pain

2017 ◽  
Vol 51 (10) ◽  
pp. 834-839 ◽  
Author(s):  
Ryan N. Hansen ◽  
An T. Pham ◽  
Belinda Lovelace ◽  
Stela Balaban ◽  
George J. Wan
Keyword(s):  
Postoperative Pain ◽  
Postoperative Pain Management ◽  
Hospital Length ◽  
Hospital Length Of Stay ◽  
Obstetrics And Gynecology ◽  
Opioid Use ◽  
Cesarean Section Delivery ◽  
Hospitalization Costs ◽  
The Difference ◽  
Multivariable Regression Models

Background: Recovery from obstetrics and gynecology (OB/GYN) surgery, including hysterectomy and cesarean section delivery, aims to restore function while minimizing hospital length of stay (LOS) and medical expenditures. Objective: Our analyses compare OB/GYN surgery patients who received combination intravenous (IV) acetaminophen and IV opioid analgesia with those who received IV opioid-only analgesia and estimate differences in LOS, hospitalization costs, and opioid consumption. Methods: We performed a retrospective analysis of the Premier Database between January 2009 and June 2015, comparing OB/GYN surgery patients who received postoperative pain management with combination IV acetaminophen and IV opioids with those who received only IV opioids starting on the day of surgery and continuing up to the second postoperative day. We performed instrumental variable 2-stage least-squares regressions controlling for patient and hospital covariates to compare the LOS, hospitalization costs, and daily opioid doses (morphine equivalent dose) of IV acetaminophen recipients with that of opioid-only analgesia patients. Results: We identified 225 142 OB/GYN surgery patients who were eligible for our study of whom 89 568 (40%) had been managed with IV acetaminophen and opioids. Participants averaged 36 years of age and were predominantly non-Hispanic Caucasians (60%). Multivariable regression models estimated statistically significant differences in hospitalization cost and opioid use with IV acetaminophen associated with $484.4 lower total hospitalization costs (95% CI = −$760.4 to −$208.4; P = 0.0006) and 8.2 mg lower daily opioid use (95% CI = −10.0 to −6.4), whereas the difference in LOS was not significant, at −0.09 days (95% CI = −0.19 to 0.01; P = 0.07). Conclusion: Compared with IV opioid-only analgesia, managing post-OB/GYN surgery pain with the addition of IV acetaminophen is associated with decreased hospitalization costs and reduced opioid use.

PS01.212: OUTCOMES OF HYBRID VERSUS FULLY MINIMALLY INVASIVE 2-STAGE ESOPHAGECTOMY FOR CANCER OF THE DISTAL ESOPHAGUS AND GASTRO-ESOPHAGEAL JUNCTION

2018 ◽  
Vol 31 (Supplement_1) ◽  
pp. 110-110
Author(s):  
Kanatheepan Shanmuganathan ◽  
Temisanren Akitikori ◽  
Oluwasunmisola Soile ◽  
Aadil Hussain ◽  
Neda Farhangmehr ◽  
...  
Keyword(s):  
Length Of Stay ◽  
Minimally Invasive ◽  
Anastomotic Leak ◽  
Minimally Invasive Esophagectomy ◽  
Hospital Length ◽  
Leak Rate ◽  
Hospital Length Of Stay ◽  
Cardiac Complications ◽  
Invasive Esophagectomy ◽  
Anastomotic Leak Rate

Abstract Background Esophagectomy is associated with high complication rate and mortality. Numerous approaches have been introduced over the last two decades, with the ambition of reducing rate of complications, morbidity and mortality. Two-stage minimally invasive esophagectomies include hybrid (laparoscopic/thoracotomic) and fully minimally invasive and have recently gained popularity in the treatment of distal esophageal and gastro-esophageal junction cancer. We aim to compare the short-term outcomes between 2-stage hybrid and fully minimally invasive esophagectomy with intrathoracic hand-sewn anastomosis. Methods A retrospective analysis of a 4-year period prospectively collected data of 100 consecutive 2-stage minimally invasive esophagectomies was conducted. All operations were performed in a UK tertiary centre by a single surgical team between 2014 and 2018. All 3-stage and open esophagectomies were excluded from the study. A comparison of anastomotic leak rate, ITU length of stay, hospital length of stay, pulmonary complications, cardiac complications and 30 and 90-day mortality rates was made. Statistical analysis was performed using Graph-Prism 7.04. Results Seventy patients underwent hybrid and 30 underwent fully minimally invasive esophagectomy with intra-thoracic manual anastomosis. Chest infection and anastomotic leak rate were higher in the hybrid group (21.4% vs 16.8% and 10% vs 3.3%); however, cardiac complications were two times more common in fully minimally invasive compared to hybrid esophagectomies (3.3% vs 1.4%). Fully minimally invasive esophagectomies were associated with a shorter ITU stay as well as hospital length of stay compared to hybrid esophagectomies (5.5 vs 6.2 days, P = 0.47 and 10.5 vs 15.6 days P = 0.0018). Complete tumour resection (R0) rate was slightly higher in hybrid compared to fully minimally invasive esophagectomies (70.8% vs 64.3%). Thirty and 90-day mortality rate was 6.67% (1 cardiac and 1 respiratory arrest) in fully minimally invasive and 1.43% in hybrid esophagectomies. None of the mortality cases were related to surgical complications like anastomotic leak or conduit necrosis. Conclusion In our study 2-stage fully minimally invasive esophagectomy is associated with reduced post-operative complication rates compared to 2-stage hybrid oesophagectomy. Further larger studies are needed to assess the 30- and 90-day mortality risk associated with both procedures. Disclosure All authors have declared no conflicts of interest.

scholarly journals Association of prescription opioid use on mortality and hospital length of stay in the intensive care unit

PLoS ONE ◽  
2021 ◽  
Vol 16 (4) ◽  
pp. e0250320
Author(s):  
Nicole Hardy ◽  
Fatima Zeba ◽  
Anaelia Ovalle ◽  
Alicia Yanac ◽  
Christelle Nzugang-Noutonsi ◽  
...  
Keyword(s):  
Intensive Care Unit ◽  
Intensive Care ◽  
Length Of Stay ◽  
Hospital Stay ◽  
Hospital Length ◽  
Hospital Length Of Stay ◽  
Prescription Opioid ◽  
Opioid Use ◽  
Icu Admission ◽  
Prescription Opioid Use

Objective Several studies show that chronic opioid dependence leads to higher in-hospital mortality, increased risk of hospital readmissions, and worse outcomes in trauma cases. However, the association of outpatient prescription opioid use on morbidity and mortality has not been adequately evaluated in a critical care setting. The purpose of this study was to determine if there is an association between chronic opioid use and mortality after an ICU admission. Design A single-center, longitudinal retrospective cohort study of all Intensive Care Unit (ICU) patients admitted to a tertiary-care academic medical center from 2001 to 2012 using the MIMIC-III database. Setting Medical Information Mart for Intensive Care III database based in the United States. Patients Adult patients 18 years and older were included. Exclusion criteria comprised of patients who expired during their hospital stay or presented with overdose; patients with cancer, anoxic brain injury, non-prescription opioid use; or if an accurate medication reconciliation was unable to be obtained. Patients prescribed chronic opioids were compared with those who had not been prescribed opioids in the outpatient setting. Interventions None. Measurements and main results The final sample included a total of 22,385 patients, with 2,621 (11.7%) in the opioid group and 19,764 (88.3%) in the control group. After proceeding with bivariate analyses, statistically significant and clinically relevant differences were identified between opioid and non-opioid users in sex, length of hospital stay, and comorbidities. Opioid use was associated with increased mortality in both the 30-day and 1-year windows with a respective odds ratios of 1.81 (95% CI, 1.63–2.01; p<0.001) and 1.88 (95% CI, 1.77–1.99; p<0.001), respectively. Conclusions Chronic opioid usage was associated with increased hospital length of stay and increased mortality at both 30 days and 1 year after ICU admission. Knowledge of this will help providers make better choices in patient care and have a more informed risk-benefits discussion when prescribing opioids for chronic usage.

scholarly journals Acinetobacter baumannii Resistance: A Real Challenge for Clinicians

Antibiotics ◽  
2020 ◽  
Vol 9 (4) ◽  
pp. 205 ◽  
Author(s):  
Rosalino Vázquez-López ◽  
Sandra Georgina Solano-Gálvez ◽  
Juan José Juárez Vignon-Whaley ◽  
Jorge Andrés Abello Vaamonde ◽  
Luis Andrés Padró Alonzo ◽  
...  
Keyword(s):  
Antimicrobial Resistance ◽  
Acinetobacter Baumannii ◽  
Severity Of Illness ◽  
Antibiotic Use ◽  
Multidrug Resistant ◽  
Resistance Mechanisms ◽  
Hospital Length ◽  
Skin Wound ◽  
Hospital Length Of Stay ◽  
Real Challenge

Acinetobacter baumannii (named in honor of the American bacteriologists Paul and Linda Baumann) is a Gram-negative, multidrug-resistant (MDR) pathogen that causes nosocomial infections, especially in intensive care units (ICUs) and immunocompromised patients with central venous catheters. A. baumannii has developed a broad spectrum of antimicrobial resistance, associated with a higher mortality rate among infected patients compared with other non-baumannii species. In terms of clinical impact, resistant strains are associated with increases in both in-hospital length of stay and mortality. A. baumannii can cause a variety of infections; most involve the respiratory tract, especially ventilator-associated pneumonia, but bacteremia and skin wound infections have also been reported, the latter of which has been prominently observed in the context of war-related trauma. Cases of meningitis associated with A. baumannii have been documented. The most common risk factor for the acquisition of MDR A baumannii is previous antibiotic use, following by mechanical ventilation, length of ICU/hospital stay, severity of illness, and use of medical devices. Current efforts focus on addressing all the antimicrobial resistance mechanisms described in A. baumannii, with the objective of identifying the most promising therapeutic scheme. Bacteriophage- and artilysin-based therapeutic approaches have been described as effective, but further research into their clinical use is required

scholarly journals Outpatient Parenteral Antimicrobial Therapy Plus Buprenorphine for Opioid Use Disorder and Severe Injection-related Infections

2019 ◽  
Author(s):  
Laura C Fanucchi ◽  
Sharon L Walsh ◽  
Alice C Thornton ◽  
Paul A Nuzzo ◽  
Michelle R Lofwall
Keyword(s):  
Antimicrobial Therapy ◽  
Hospital Length ◽  
Opioid Use Disorder ◽  
Hospital Length Of Stay ◽  
Opioid Use ◽  
Intravenous Antibiotic ◽  
Outpatient Parenteral Antimicrobial Therapy ◽  
Model Combining ◽  
Drug Use Outcomes ◽  
Buprenorphine Treatment

Abstract In a pilot randomized trial in persons with opioid use disorder hospitalized with injection-related infections, an innovative care model combining outpatient parenteral antimicrobial therapy with buprenorphine treatment had similar clinical and drug use outcomes to usual care (inpatient intravenous antibiotic completion) and shortened hospital length of stay by 23.5 days. Clinical Trials Registration NCT03048643.

Do Lidocaine Patches Reduce Opioid Use in Acute Rib Fractures?

2020 ◽  
Vol 86 (9) ◽  
pp. 1153-1158
Author(s):  
Matthew Johnson ◽  
Lauren Strait ◽  
Ashar Ata ◽  
Ashley Bartscherer ◽  
Claire Miller ◽  
...  
Keyword(s):  
Length Of Hospital Stay ◽  
Hospital Length ◽  
Pulmonary Complications ◽  
Rib Fractures ◽  
Hospital Length Of Stay ◽  
Trauma Patients ◽  
Opioid Use ◽  
Trauma Service ◽  
Fracture Management ◽  
Multimodal Care

Background Pain control is an important aspect of rib fracture management. With a rise in multimodal care approaches, we hypothesized that transdermal lidocaine patches reduce opioid utilization in hospitalized patients with acute rib fractures not requiring continuous opioid infusion. Methods We performed a retrospective analysis of adult trauma patients with acute rib fractures admitted to the Trauma Service from January 2011 to October 2018. We compared patients who received transdermal lidocaine patches to those who did not and evaluated cumulative opioid consumption, expressed in morphine milligram equivalents (MMEs). Secondary outcomes included the rate of pulmonary complications and length of hospital stay. Results Of the 21 190 trauma admissions, 3927 (18.5%) had rib fractures. Overall, 1555 patients who received continuous opioid infusion were excluded. Of the remaining 2372 patients, 725 (30.6%) patients received lidocaine patches. The mean total MME of patients who received lidocaine patches was 55.7 MME (30.7 MME on multivariate analysis) and was lower than that of patients who did not receive lidocaine patches ( P ≤ .01). There was no difference in hospital length of stay (no lidocaine patches vs received lidocaine patches: 6.2 days vs 6.5 days, P = .34) or pulmonary complications (1.7% vs 2.8%, P = .08). Discussion In admitted trauma patients with acute rib fractures not requiring continuous intravenous opiates, lidocaine patch use was associated with a significant decrease in opiate utilization during the patients’ hospital course.

scholarly journals The Impact of NSAID Use After Lumbar Fusion Surgery on Fusion Rate and Complications: A Meta-Analysis

Neurosurgery ◽  
2019 ◽  
Vol 66 (Supplement_1) ◽  
Author(s):  
Yahya Othman ◽  
Avani Vaishnav ◽  
Steven Mcanany ◽  
Sravisht Iyer ◽  
Todd Albert ◽  
...  
Keyword(s):  
Length Of Stay ◽  
Spine Surgery ◽  
Spinal Surgery ◽  
Meta Analysis ◽  
Hospital Length ◽  
Hospital Length Of Stay ◽  
Opioid Use ◽  
Pain Scores ◽  
Patient Reported ◽  
The Impact

Abstract INTRODUCTION The purpose of this study is to compile data presented in literature regarding the efficacy of incorporating NSAIDs in the postoperative course for patients undergoing spine surgery, in particular its impact on pain levels, opioid use, complications, and hospital length of stay METHODS This is a meta-analysis and systematic review. A literature search was conducted using the backbone search [spinal surgery] [Nsaid] [complications]. Criteria for inclusion are as follows: use of NSAIDs for postoperative pain management of spinal surgery, comparison between NSAID and NSAID-free cohort, and reporting on any of pain scores, hospital opioid use, hospital length of stay, complications rate, and operative outcomes. RESULTS Out of 799 studies, 19 studies met the inclusion criteria. A total of 1522 patient were included in this analysis. The studies included randomized controlled trials, Prospective and retrospective cohorts. Operations included discectomies, laminectomies, and fusions. Most commonly regimens included the NSAID Ketorelac, as in injection given immediately postoperatively. Patients that received NSAID analgesia postoperatively had significantly lower VAS pain scores at 1 and 12 h postoperatively. This group also had a significantly lower opioid consumption and shorter hospital length of stay. A total of 7 fusion studies reported on arthrodesis, showing a significantly lower odds of fusion after NSAIDs use, however after subgrouping according to smoking, this difference proves to be no longer significant. CONCLUSION Incorporation of NSAIDs into the postoperative regimen for analgesia in patients undergoing spine surgery is an effective approach in reducing hospital length of stay, patient reported pain scores, hospital opioid use, and has no increased risk of complications. Furthermore, use of NSAIDs in the nonsmoking population does not seem to affect arthrodesis rates in patients undergoing spine surgery.

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