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Preoperative Patient Assessment and Management









Adverse-event rates have not declined among those hospitalized for conditions requiring surgery over the last 6 years


This study used Medicare Patient Safety Monitoring System data abstracted from medical records on 21 adverse events in patients hospitalized in the United States between 2005 and 2011 for acute myocardial infarction, congestive heart failure, pneumonia, or conditions requiring surgery. These were used to estimated trends in the rate of occurrence of adverse events for which patients were at risk, the proportion of patients with one or more adverse events, and the number of adverse events per 1000 hospitalizations. The study included 61,523 patients hospitalized for acute myocardial infarction (19%), congestive heart failure (25%), pneumonia (30%), and conditions requiring surgery (27%). From 2005 through 2011, among patients with acute myocardial infarction, the rate of occurrence of adverse events declined from 5.0% to 3.7% (difference, 1.3 percentage points; 95% confidence interval [CI], 0.7 to 1.9), the proportion of patients with one or more adverse events declined from 26.0% to 19.4% (difference, 6.6 percentage points; 95% CI, 3.3 to 10.2), and the number of adverse events per 1000 hospitalizations declined from 401.9 to 262.2 (difference, 139.7; 95% CI, 90.6 to 189.0). Among patients with congestive heart failure, the rate of occurrence of adverse events declined from 3.7% to 2.7% (difference, 1.0 percentage points; 95% CI, 0.5 to 1.4), the proportion of patients with one or more adverse events declined from 17.5% to 14.2% (difference, 3.3 percentage points; 95% CI, 1.0 to 5.5), and the number of adverse events per 1000 hospitalizations declined from 235.2 to 166.9 (difference, 68.3; 95% CI, 39.9 to 96.7). Patients with pneumonia and those with conditions requiring surgery had no significant declines in adverse-event rates.

N Engl J Med. 2014 Jan 23;370(4):341-51. doi: 10.1056/NEJMsa1300991.






No benefits of oral care with povidone-iodine to prevent ventilator-associated pneumonia after high-risk surgery


This multicenter, placebo-controlled, randomized, double-blind, two-parallel-group trial evaluate the efficacy and safety of oral care with povidone-iodine on the occurrence of ventilator-associated pneumonia in a high-risk population. Primary endpoint was the rate of ventilator-associated pneumonia. Secondary endpoint included the rates of ventilator-associated tracheobronchitis and acute respiratory distress syndrome and patient's outcome. The number of patients evaluable for the primary endpoint (preplanned modified intention-to-treat population) was 150 (78 in the povidone-iodine group, 72 in the placebo group). Ventilator-associated pneumonia occurred in 24 patients (31%) in the povidone-iodine group and 20 (28%) in the placebo group (relative risk, 1.11 [95% CI, 0.67-1.82]; p = 0.69). There was no significant difference between the two groups for ventilator-associated tracheobronchitis: eight patients (10%) in the povidone-iodine group and five patients (7%) in the placebo group (relative risk, 1.48 [95% CI, 0.51-4.31]; p = 0.47). Acute respiratory distress syndrome occurred in five patients in the povidone-iodine group but not in the placebo group (p = 0.06). There was no difference between groups for ICU and hospital lengths of stay, as well as ICU and 90-day mortality.

Crit Care Med. 2014 Jan;42(1):1-8. doi: 10.1097/CCM.0b013e3182a2770f.






High levels of anxiety are connected to increased pain sensitivity in postoperative patients


One thousand patients were used to assess genetic and other factors related to acute pain and persistent pain after treatment of breast cancer. The patients showed significant interindividual variation in heat and cold pain sensitivity and cold pain tolerance. There was a strong correlation between the experimental pain measures across the tests. Presence of chronic pain, the number of previous operations, and particularly state anxiety were related to increased pain sensitivity. Previous smoking correlated with decreased heat pain sensitivity. These factors explained 4-5% of the total variance in pain sensitivity in these tests. Oxycodone consumption during 20 h was significantly higher in patients who had axillary clearance. Oxycodone consumption had only a weak correlation with the experimental pain measures.

Anesthesiology. 2013 Dec;119(6):1410-21. doi: 10.1097/ALN.0000000000000012.









3% of postop patients continued to use opioids for more than 90 days after major elective surgery


This population study describes rates and risk factors for prolonged postoperative use of opioids in patients who had not previously used opioids and undergoing major elective surgery. Of the 39,140 patients in the entire cohort, 49.2% (n=19,256) were discharged from hospital with an opioid prescription, and 3.1% (n=1229) continued to receive opioids for more than 90 days after surgery. Following risk adjustment with multivariable logistic regression modelling, patient related factors associated with significantly higher risks of prolonged opioid use included younger age, lower household income, specific comorbidities (diabetes, heart failure, pulmonary disease), and use of specific drugs preoperatively (benzodiazepines, selective serotonin reuptake inhibitors, angiotensin converting enzyme inhibitors). The type of surgical procedure was also highly associated with prolonged opioid use. Compared with open radical prostatectomies, both open and minimally invasive thoracic procedures were associated with significantly higher risks (odds ratio 2.58, 95% confidence interval 2.03 to 3.28 and 1.95 1.36 to 2.78, respectively). Conversely, open and minimally invasive major gynaecological procedures were associated with significantly lower risks (0.73, 0.55 to 0.98 and 0.45, 0.33 to 0.62, respectively).

BMJ. 2014 Feb 11;348:g1251. doi: 10.1136/bmj.g1251.











After noncardiac surgery, myocardial injury occurs in 8% of over 45 year olds


The study's four objectives were to determine the diagnostic criteria, characteristics, predictors, and 30-day outcomes of myocardial injury after noncardiac surgery (MINS) in this international, prospective cohort study of 15,065 patients aged 45 yr or older who underwent in-patient noncardiac surgery. An elevated troponin after noncardiac surgery, irrespective of the presence of an ischemic feature, independently predicted 30-day mortality. Therefore, the authors' diagnostic criterion for MINS was a peak troponin T level of 0.03 ng/ml or greater judged due to myocardial ischemia. MINS was an independent predictor of 30-day mortality (adjusted hazard ratio, 3.87; 95% CI, 2.96-5.08) and had the highest population-attributable risk (34.0%, 95% CI, 26.6-41.5) of the perioperative complications. Twelve hundred patients (8.0%) suffered MINS, and 58.2% of these patients would not have fulfilled the universal definition of myocardial infarction. Only 15.8% of patients with MINS experienced an ischemic symptom.

Anesthesiology. 2014 Mar;120(3):564-78. doi: 10.1097/ALN.0000000000000113.









Preop statins are associated with decreased risk of major complications following noncardiac surgery


This single centre study evaluated whether the preoperative use of statins is associated with decreased postoperative major noncardiac complications in noncardiac procedures. Preoperative statin use was present in 10.5% (n = 814) of 7,777 total cases. Procedure type included general operation (n = 2,605, 33.5%), breast/endocrine (n = 739, 9.5%), colorectal (n = 1,533, 19.7%), hepatobiliary/pancreatic (n = 397, 5.1%), orthopedic (n = 205, 2.6%), skin/ear-nose- throat (145, 1.9%), thoracic (n = 53, 0.7%), upper gastrointestinal (n = 651, 8.4%), and vascular cases (1,449, 18.6%). On multivariable analysis, the use of statins was associated with decreased major, noncardiac complications (odds ratio [OR] 0.62, 95% confidence interval [95% CI] 0.49-0.92, P < .001), respiratory complications (OR 0.63, 95% CI 0.50-0.79, P = .017), VTE (OR 0.41, 95% CI 0.18-0.98, P = .044), and infectious complications (OR 0.65, 95% CI 0.45-0.94, P = .023).

Surgery. 2014 Mar;155(3):398-407. doi: 10.1016/j.surg.2013.11.008. Epub 2013 Nov 21.











Global disease burden of conditions requiring emergency surgery


This review attempted to define the population-based health burden of emergency surgical conditions (excluding trauma and obstetrics) and the status of available capacity to address this burden. In the index year of 2010, there were 896000 deaths, 20 million years of life lost and 25 million disability-adjusted life-years from 11 emergency general surgical conditions reported individually in the Global Burden of Disease Study. The most common cause of death was complicated peptic ulcer disease, followed by aortic aneurysm, bowel obstruction, biliary disease, mesenteric ischaemia, peripheral vascular disease, abscess and soft tissue infections, and appendicitis. The mortality rate was higher in high-income countries (HICs) than in low- and middle-income countries (LMICs) (24·3 versus 10·6 deaths per 100000 inhabitants respectively), primarily owing to a higher rate of vascular disease in HICs. However, because of the much larger population, 70 per cent of deaths occurred in LMICs. Deaths from vascular disease rose from 15 to 25 per cent of surgical emergency-related deaths in LMICs (from 1990 to 2010). Surgical capacity to address this burden is suboptimal in LMICs, with fewer than one operating theatre per 100000 inhabitants in many LMICs, whereas some HICs have more than 14 per 100000 inhabitants.

Br J Surg. 2014 Jan;101(1):e9-e22. doi: 10.1002/bjs.9329. Epub 2013 Nov 25.








Adjunctive simvastatin therapy do not improve day-28 survival in patients with ventilator associated pneumonia


This RCT determines whether statin therapy (simvastatin 60 mg) can decrease day-28 mortality in patients with ventilator associated pneumonia (VAP). The study was stopped for futility at the first scheduled interim analysis after enrollment of 300 patients, of whom all but 7% in the simvastatin group and 11% in the placebo group were naive to statin therapy at ICU admission. Day-28 mortality was not lower in the simvastatin group than in the placebo group. In statin-naive patients, day-28 mortality was 21.5% with simvastatin and 13.8% with placebo (P = .054). There were no significant differences regarding day-14, ICU, or hospital mortality rates; duration of mechanical ventilation; or changes in Sequential Organ Failure Assessment score.

JAMA. 2013 Oct 23;310(16):1692-700. doi: 10.1001/jama.2013.280031.







Gloves and gowns for all patient contact compared with usual care among patients ICUs did not result in a difference in the primary outcome of acquisition of MRSA or VRE


This cluster-randomised study assesses whether wearing gloves and gowns for all patient contact in the ICU decreases acquisition of methicillin-resistant Staphylococcus aureus (MRSA) or vancomycin-resistant Enterococcus (VRE) compared with usual care. From the 26,180 patients included, 92,241 swabs were collected for the primary outcome. Intervention ICUs had a decrease in the primary outcome of MRSA or VRE from 21.35 acquisitions per 1000 patient-days (95% CI, 17.57 to 25.94) in the baseline period to 16.91 acquisitions per 1000 patient-days (95% CI, 14.09 to 20.28) in the study period, whereas control ICUs had a decrease in MRSA or VRE from 19.02 acquisitions per 1000 patient-days (95% CI, 14.20 to 25.49) in the baseline period to 16.29 acquisitions per 1000 patient-days (95% CI, 13.48 to 19.68) in the study period, a difference in changes that was not statistically significant (difference, −1.71 acquisitions per 1000 person-days, 95% CI, −6.15 to 2.73; P = .57). For key secondary outcomes, there was no difference in VRE acquisition with the intervention (difference,  0.89 acquisitions per 1000 person-days; 95% CI, −4.27 to 6.04, P = .70), whereas for MRSA, there were fewer acquisitions with the intervention (difference, −2.98 acquisitions per 1000 person-days; 95% CI, −5.58 to −0.38; P = .046). Universal glove and gown use also decreased health care worker room entry (4.28 vs 5.24 entries per hour, difference, −0.96; 95% CI, −1.71 to −0.21, P = .02), increased room-exit hand hygiene compliance (78.3% vs 62.9%, difference, 15.4%; 95% CI, 8.99% to 21.8%; P = .02) and had no statistically significant effect on rates of adverse events (58.7 events per 1000 patient days vs 74.4 events per 1000 patient days; difference, −15.7; 95% CI, −40.7 to 9.2, P = .24).

JAMA. 2013 Oct 16;310(15):1571-80.







Patients in ICU is at high risk for long-term cognitive impairment


This study assessed if survivors of critical illness have a prolonged and disabling form of cognitive impairment. Of the 821 patients enrolled, 6% had cognitive impairment at baseline, and delirium developed in 74% during the hospital stay. At 3 months, 40% of the patients had global cognition scores that were 1.5 SD below the population means (similar to scores for patients with moderate traumatic brain injury), and 26% had scores 2 SD below the population means (similar to scores for patients with mild Alzheimer's disease). Deficits occurred in both older and younger patients and persisted, with 34% and 24% of all patients with assessments at 12 months that were similar to scores for patients with moderate traumatic brain injury and scores for patients with mild Alzheimer's disease, respectively. A longer duration of delirium was independently associated with worse global cognition at 3 and 12 months (P=0.001 and P=0.04, respectively) and worse executive function at 3 and 12 months (P=0.004 and P=0.007, respectively). Use of sedative or analgesic medications was not consistently associated with cognitive impairment at 3 and 12 months.

N Engl J Med. 2013 Oct 3;369(14):1306-16. doi: 10.1056/NEJMoa1301372.











Simulation-based communication training does not improve quality of communication about end-of-life care or quality of end-of-life care


This RCT assesses the effects of a communication skills intervention for internal medicine and nurse practitioner trainees on patient- and family-reported outcomes by randomising participants to an 8-session, simulation-based, communication skills intervention (N = 232) or usual education (N = 240). There were 1866 patient ratings (44% response) and 936 family ratings (68% response). The intervention was not associated with significant changes in quality of communication (QOC) or quality of end-of-life care (QEOLC). Mean values for postintervention patient QOC and QEOLC were similar to control scores. After adjustment, comparing intervention with control, there was no significant difference in the QOC score for patients or families. There was no significant difference in QEOLC score for patients or families. The intervention was associated with significantly increased depression scores among patients of postintervention trainees compared for control conditions.

JAMA. 2013 Dec 4;310(21):2271-81. doi: 10.1001/jama.2013.282081.





Goal-directed fluid therapy decreased the number of days to fascial closure in damage control surgery


The objective of this retrospective study was to determine whether resuscitation with goal-directed fluid therapy (GDT) using "dynamic" hemodynamic indices via modern pulse contour analysis devices such as the FloTrac Vigileo monitor leads to lower fluid requirements, subsequent quicker abdominal closure, and overall improved outcomes in these patients. Total fluid intake and vasopressor requirements were similar in both groups. GDT with the Vigileo allowed earlier lactate clearance and reduced the number of days until abdominal wall closure by an average of .99 days.

Am J Surg. 2013 Dec;206(6):995-1000. doi: 10.1016/j.amjsurg.2013.07.021.






Diversion rather than anastomosis should be used in patients who require vasopressor support after the initial damage control surgery


This retrospective study reviewed outcomes in patients with destructive colon injuries to identify risk factors for anastomotic failure after colon reconstruction. Of 171 identified patients, 68 had DC procedures, 41 (60%) had subsequent anastomoses performed during the same hospitalization, and 27 (40%) were diverted. The colon anastomotic leak rate in patients who underwent DC laparotomy was higher than in patients who were reconstructed at the primary operation in a non-DC setting (17% vs 6%, P = .09). The use of vasopressors after the initial DC operation more than quadrupled the leak rate to 50% (P = .02).

Am J Surg. 2013 Dec;206(6):900-3. doi: 10.1016/j.amjsurg.2013.07.034. Epub 2013 Oct 18.






Among ICU patients with hypovolemia, the use of colloids vs crystalloids did not result in a significant difference in 28-day mortality


This multicentre RCT tests whether use of colloids (n = 1414) compared with crystalloids (n = 1443) for fluid resuscitation alters mortality in patients admitted to the intensive care unit (ICU) with hypovolemic shock (CRISTAL trial). Within 28 days, there were 359 deaths (25.4%) in colloids group vs 390 deaths (27.0%) in crystalloids group (P = .26). Within 90 days, there were 434 deaths (30.7%) in colloids group vs 493 deaths (34.2%) in crystalloids group (P = .03). Renal replacement therapy was used in 156 (11.0%) in colloids group vs 181 (12.5%) in crystalloids group (P = .19). There were more days alive without mechanical ventilation in the colloids group vs the crystalloids group by 7 days (P = .01) and by 28 days (P = .01) and alive without vasopressor therapy by 7 days (P = .04) and by 28 days (P = .03).

JAMA. 2013 Nov 6;310(17):1809-17. doi: 10.1001/jama.2013.280502.













Walking speed can predict postop complications and 1-year mortality across surgical specialties

The purpose of this study was to determine the relationship between the ‘Timed Up and Go’ test and postoperative morbidity and 1-year mortality and to compare the Timed Up and Go to the standard-of-care surgical risk calculators for prediction of postoperative complications. The Timed Up and Go test starts with the subject standing from a chair, walking 10 feet, returning to the chair, and ends after the subject sits. Results were grouped as fast ≤ 10 seconds, intermediate = 11-14 seconds, and slow ≥ 15 seconds. This study included 272 subjects (mean age of 74 ± 6 years). Slower Timed Up and Go was associated with increased postoperative complications after colorectal  and cardiac operations. Slower Timed Up and Go was associated with increased 1-year mortality following both colorectal and cardiac.

Ann Surg. 2013 Oct;258(4):582-90. doi: 10.1097/SLA.0b013e3182a4e96c.





Enhanced recovery pathway for oesophagectomy was associated with cost savings

The aim of this study was to investigate the impact of an enhanced recovery pathway (ERP) on medical costs for oesophagectomy. A total of 106 patients were included (47 traditional care, 59 ERP). There were no differences in patient, pathological and operative characteristics between the groups. Median length of hospital stay (LOS) was lower in the ERP group (8 (interquartile range 7-18) days versus 10 (9-18) days with traditional care). There was no difference in 30-day complication rates and the 30-day or in-hospital mortality rate was low. Costs in the on-course and minor-deviation groups were significantly lower after implementation of the ERP. The pathway-dependent cost saving per patient was €1055 and the overall cost saving per patient was €2013.

Br J Surg. 2013 Sep;100(10):1326-34. doi: 10.1002/bjs.9224.





Edoxaban was similar to warfarin therapy in VTE with less bleeding

In a randomized, double-blind, noninferiority study, the investigators randomly assigned patients with acute venous thromboembolism, who had initially received heparin, to receive edoxaban at a dose of 60 mg once daily, or 30 mg once daily in  4921 patients presented with deep-vein thrombosis, and 3319 with a pulmonary embolism. Edoxaban was noninferior to warfarin with respect to the primary efficacy outcome, which occurred in 130 patients in the edoxaban group (3.2%) and 146 patients in the warfarin group (3.5%). The safety outcome occurred in 349 patients (8.5%) in the edoxaban group and 423 patients (10.3%) in the warfarin group. The rates of other adverse events were similar in the two groups.

N Engl J Med 2013; 369:1406-1415October 10, 2013DOI: 10.1056/NEJMoa1306638











Perioperative increase in global blood flow to explicit defined goals and outcomes after surgery

The use of perioperative cardiac output monitoring as a means of maximising oxygen delivery and potentially improving patient outcome remains a grey area for anaesthetists. NICE currently recommend consideration for the use of the Cardio-Q-ODM in patients undergoing major or high risk surgery where invasive cardiovascular monitoring would be used (NICE Medical Technologies Guidance 3, March 2011) and compliance with intraoperative fluid management using systems consistent with NTAC guidance has formed a part of CQUIN payment as of March 2013. However, in spite of such incentives, widespread adoption of this technology has not been seen, as strong evidence supporting these guidelines is actually lacking. Grocott and colleagues performed a meta-analysis of 31 randomised controlled trials in adults undergoing cardiac output monitoring to guide fluid and vasoactive drug therapy. A total of 5292 patients were covered by this well performed systematic review. There was no significant difference in mortality between the two groups; 8.9% in treatment group vs 10.8% in the control group (RR 0.89, 95% CI 0.76-1.05; p=0.18). Morbidity was reduced, however, in the treatment arms with reduced rates of renal failure, respiratory failure and wound infections. No differences in cardiovascular complications were seen. Length of hospital stay was reduced by 1.16 days (95% CI: 0.43-1.89; p=0.002). Importantly, a large number of studies included in this systematic review were over 10 years old and so may not now represent what is accepted as best current practice.

Br J Anaesth. 2013 111: 535-548






Mortality in high-risk emergency general surgical admissions

The aim of this study was to quantify and explore variability in mortality amongst high-risk emergency general surgery admissions to English NHS hospital Trusts. 367 796 patients admitted to 145 hospital Trusts were included in the study; the 30-day mortality rate was 15·6 per cent (institutional range 9·2-18·2 per cent). Intensive care and high-dependency bed resources, as well as greater institutional use of computed tomography (CT), were independent predictors of reduced mortality (P < 0·001). Low-mortality outlying Trusts had significantly more intensive care beds per 1000 hospital beds (20·8 versus 14·0; P = 0·017) and made significantly greater use of CT (24·6 versus 17·2 scans per bed per year; P < 0·001) and ultrasonography (42·5 versus 30·2 scans per bed per year; P < 0·001).

Br J Surg, 2013;100(10):1318-25.








Haloperidol should not be administered to reduce the duration of delirium in critically ill patients

The presence of delirium is known to be associated with worse outcome in the critically ill patient population (it can be considered to be another organ failure – brain). Haloperidol is frequently used to treat patients with delirium, usually to assist in their management, but whether this modifies duration of delirium was unknown prior to this study. This placebo-controlled randomised trial of 142 patients requiring mechanical ventilation was conducted in a general ICU environment. Patients were randomised to either receive 2.5mg haloperidol IV or 0.9% saline placebo every 8 hours for up to 14 days. 71 patients received haloperidol and 70 0.9% saline. Patients receiving haloperidol spent the same amount of time with delirium as the placebo group (median 5 days [IQR 0-10] vs 6 days [IQR 0-11] days; p=0.53). No serious adverse events related to the study drug occurred. This study thus suggests that haloperidol should not be administered to reduce the duration of delirium in critically ill patients, but can still safely be used to manage acute agitation in the short term.

The Lancet Respiratory Medicine 2013 doi:10.1016/S2213-2600(13)70166-8.




Tracheostomy within 4 days of critical care admission was not associated with an improvement in 30-day mortality

The aim of this open multicentered randomized clinical trial to test whether early vs late tracheostomy would be associated with lower mortality in adult patients requiring mechanical ventilation in critical care units. Of the 455 patients assigned to early tracheostomy, 91.9% received a tracheostomy and of 454 assigned to late tracheostomy, 44.9% received a tracheostomy. All-cause mortality 30 days after randomization was 30.8% in the early and 31.5% in the late group. Two-year mortality was 51.0% in the early and 53.7% in the late group (P = .74). Median critical care unit length of stay in survivors was 13.0 days in the early and 13.1 days in the late group (P = .74).





Cardiorespiratory fitness is an independent predictor of mortality and length of hospital stay following surgery

This study aimed to define the relationship between cardiorespiratory fitness and age in the context of postsurgery mortality and morbidity in older people.  An unselected consecutive group of 389 adults with a mean age of 66 years (range 26-86 years) underwent cardiorespiratory exercise testing before major hepatobiliary surgery at a single center. Anaerobic threshold was the most significant independent predictor for postoperative mortality (P = 0.003) in 18 of 389 (4.6%) patients who died during their in-hospital stay. Age was not a significant predictor in this model. Older people with normal cardiorespiratory fitness spent the same number of days in the hospital or critical care unit as younger people with similar cardiorespiratory fitness. Patients older than 75 years with low cardiorespiratory fitness spent a median of 11 days longer in hospital (23 vs 12; P < 0.0001) and 2 days longer in critical care (2.9 vs 0.9; P < 0.0001) when compared with patients with adequate cardiorespiratory fitness.

Annals of Surgery, 2013;257:999–1004





Intermittent pneumatic compression is associated with lower #VTE in critically ill patients

This prospective cohort study of 798 medical and surgical patients admitted over an 18-month period to a single ICU showed that there was a significant reduction in the occurrence of venous thromboembolism (PE and DVT) when intermittent pneumatic compression (IPC) were used (propensity scores adjusted hazard ratio, 0.45; 95% CI 0.22-0.95; P=0.04) when compared with no mechanical thromboprophylaxis. Interestingly, no significant reduction was seen in VTE incidence when graduated compression stockings (TEDS) were used, however (aHR 1.24; 95%CI 0.66-2.34; P=0.5). This association was independent of the type of prophylactic heparin used. Although not a randomised-controlled trial, propensity scores were used in this study to reduce the effect of confounders. Importantly, prior to this publication there was very little evidence to suggest which form of mechanical VTE prophylaxis is most efficacious when used in conjunction with heparin prophylaxis. It would seem reasonable that IPC should now be used as an adjunct to pharmacological VTE prophylaxis in critically ill patients.

Chest, 2013;doi: 10.1378/chest.12-2028




Ventilator-associated pneumonia is highest rates for surgery patients

This review estimates the attributable mortality using the individual original patient data of published randomised trials of ventilator-associated pneumonia prevention. Individual patient data were available for 6284 patients from 24 trials. The overall attributable mortality was 13%, with higher mortality rates in surgical patients and patients with mid-range severity scores at admission (ie, acute physiology and chronic health evaluation score [APACHE] 20—29 and simplified acute physiology score [SAPS 2] 35—58). Attributable mortality was close to zero in trauma, medical patients, and patients with low or high severity of illness scores. Competing risk analyses could be done for 5162 patients from 19 studies, and the overall daily hazard for intensive care unit (ICU) mortality after ventilator-associated pneumonia was 1·13 (95% CI 0·98—1·31). The overall daily risk of discharge after ventilator-associated pneumonia was 0·74 (0·68—0·80), leading to an overall cumulative risk for dying in the ICU of 2·20 (1·91—2·54). Highest cumulative risks for dying from ventilator-associated pneumonia were noted for surgical patients.

Lancet Infectious Diseases, 2013;13(8):665-671





Use of hydroxyethyl starch and acute kidney injury in critically ill patients and sepsis

Several important, well-conducted, clinical trials have demonstrated a strong association between the use of hydroxyethyl starch and acute kidney injury in critically ill patients. There may also be an increase in mortality associated with their use. This sparked considerable debate in editorials questioning whether these synthetic fluids should be used at all in any patient population. The European Medicines Agency has recently recommended the cessation of marketing authorisations for such fluids and the MHRA is imminently about to produce its own statement on the matter.



Perner, A. et al. Hydroxyethyl starch 130/0.42 versus Ringer’s acetate in severe sepsis. N Engl J Med,  2012;367(2):124-13

Myburgh, J.A. et al. Hydroxyethyl starch or saline for fluid resuscitation in intensive care. N Engl J Med, 2012;367(20):1901-1911

Bayer O et al. Effects of fluid resuscitation with synthetic colloids or crystalloids alone on shock reversal, fluid balance, and patient outcomes in patients with severe sepsis: a prospective sequential analysis. Crit Care Med, 2012;40(9):2543-51





Nasogastric feeding not inferior to nasojejunal feeding in acute pancreatitis

This small meta-analysis of 3 RCTs published in Critical Care, which included 157 patients in total, aimed to demonstrate any difference in safety and efficacy between nasogastric and nasojejunal feeding in patients with severe acute pancreatitis. There was no significant difference in mortality nor exacerbation of pain, as may have been predicted. There were also no significant differences in meeting energy balance nor in the incidence of aspiration pneumonitis. Given that NJ tube insertion can be difficult and less well tolerated than NG tube insertion, NG feeding appears to be as safe as NJ feeding. The total sample size in this study was very small, however, and the authors acknowledge that further large scale randomised controlled trials are needed to make the use of NG feeding over NJ routine practice.

Chang et al. Nasogastric or nasojejunal feeding in predicted severe acute pancreatitis: a meta-analysis. Critical Care, 2013;17:R118.




Clinical Anesthesia, 6th Edition, edited by Paul Barash, Bruce Cullen, Robert Stoelting, Michael Cahalan, and Christine Stock. Podcast of the chapter on Preoperative Patient Assessment and Management.




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