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Rajabaleyan P, Michelsen J, Tange Holst U, Möller S, Toft P, Luxhøi J, Buyukuslu M, Bohm AM, Borly L, Sandblom G, Kobborg M, Aagaard Poulsen K, Schou Løve U, Ovesen S, Grant Sølling C, Mørch Søndergaard B, Lund Lomholt M, Ritz Møller D, Qvist N, Bremholm Ellebæk M. Vacuum-assisted closure versus on-demand relaparotomy in patients with secondary peritonitis-the VACOR trial: protocol for a randomised controlled trial. World J Emerg Surg 2022; 17:25. [PMID: 35619144 PMCID: PMC9137120 DOI: 10.1186/s13017-022-00427-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2022] [Accepted: 05/11/2022] [Indexed: 11/25/2022] Open
Abstract
Background Secondary peritonitis is a severe condition with a 20–32% reported mortality. The accepted treatment modalities are vacuum-assisted closure (VAC) or primary closure with relaparotomy on-demand (ROD). However, no randomised controlled trial has been completed to compare the two methods potential benefits and disadvantages. Methods This study will be a randomised controlled multicentre trial, including patients aged 18 years or older with purulent or faecal peritonitis confined to at least two of the four abdominal quadrants originating from the small intestine, colon, or rectum. Randomisation will be web-based to either primary closure with ROD or VAC in blocks of 2, 4, and 6. The primary endpoint is peritonitis-related complications within 30 or 90 days and one year after index operation. Secondary outcomes are comprehensive complication index (CCI) and mortality after 30 or 90 days and one year; quality of life assessment by (SF-36) after three and 12 months, the development of incisional hernia after 12 months assessed by clinical examination and CT-scanning and healthcare resource utilisation. With an estimated superiority of 15% in the primary outcome for VAC, 340 patients must be included. Hospitals in Denmark and Europe will be invited to participate. Discussion There is no robust evidence for choosing either open abdomen with VAC treatment or primary closure with relaparotomy on-demand in patients with secondary peritonitis. The present study has the potential to answer this important clinical question. Trial Registration The study protocol has been registered at clinicaltrials.gov (NCT03932461). Protocol version 1.0, 9 January 2022. Supplementary Information The online version contains supplementary material available at 10.1186/s13017-022-00427-x.
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Affiliation(s)
- Pooya Rajabaleyan
- Research Unit for Surgery, Odense University Hospital, Odense, Denmark. .,University of Southern Denmark, Odense, Denmark.
| | - Jens Michelsen
- Research Unit for Anaesthesiology, Odense University Hospital, Odense, Denmark.,University of Southern Denmark, Odense, Denmark
| | - Uffe Tange Holst
- Research Unit for Surgery, Odense University Hospital, Odense, Denmark.,University of Southern Denmark, Odense, Denmark
| | - Sören Möller
- OPEN, Open Patient Data Explorative Network, Odense University Hospital and Department of Clinical Research, University of Southern Denmark, Odense, Denmark
| | - Palle Toft
- Research Unit for Anaesthesiology, Odense University Hospital, Odense, Denmark.,University of Southern Denmark, Odense, Denmark
| | - Jan Luxhøi
- Surgical Department, Hospital of Southwest Jutland, Esbjerg, Denmark
| | - Musa Buyukuslu
- Surgical Department, Hospital of Southwest Jutland, Esbjerg, Denmark
| | | | - Lars Borly
- Surgical Department, Holbæk Hospital, Holbæk, Denmark
| | | | | | - Kristian Aagaard Poulsen
- Research Unit for Surgery, Odense University Hospital, Odense, Denmark.,University of Southern Denmark, Odense, Denmark
| | | | - Sophie Ovesen
- Surgical Department, Viborg Hospital, Viborg, Denmark
| | | | | | | | | | - Niels Qvist
- Research Unit for Surgery, Odense University Hospital, Odense, Denmark.,University of Southern Denmark, Odense, Denmark
| | - Mark Bremholm Ellebæk
- Research Unit for Surgery, Odense University Hospital, Odense, Denmark.,University of Southern Denmark, Odense, Denmark
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2
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Abstract
Secondary peritonitis accounts for 1% of urgent or emergent hospital admissions and is the second leading cause of sepsis in patients in intensive care units globally. Overall mortality is 6%, but mortality rises to 35% in patients who develop severe sepsis. Despite the dramatic growth in the availability and use of imaging and laboratory tests, the rapid diagnosis and early management of peritonitis remains a challenge for physicians in emergency medicine, surgery, and critical care. In this article, we review the pathophysiology of peritonitis and its potential progression to sepsis, discuss the utility and limitations of the physical examination and laboratory and radiographic tests, and present a paradigm for the management of secondary peritonitis.
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Affiliation(s)
- James T Ross
- Department of Surgery, University of California, San Francisco, San Francisco, CA 94143, USA
| | - Michael A Matthay
- Departments of Medicine and Anesthesia, Cardiovascular Research Institute, University of California, San Francisco, San Francisco, CA 94143, USA
| | - Hobart W Harris
- Department of Surgery, University of California, San Francisco, San Francisco, CA 94143, USA
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3
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Tridente A, Bion J, Mills GH, Gordon AC, Clarke GM, Walden A, Hutton P, Holloway PAH, Chiche JD, Stuber F, Garrard C, Hinds C. Derivation and validation of a prognostic model for postoperative risk stratification of critically ill patients with faecal peritonitis. Ann Intensive Care 2017; 7:96. [PMID: 28900902 PMCID: PMC5595707 DOI: 10.1186/s13613-017-0314-1] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2016] [Accepted: 08/18/2017] [Indexed: 01/04/2023] Open
Abstract
BACKGROUND Prognostic scores and models of illness severity are useful both clinically and for research. The aim of this study was to develop two prognostic models for the prediction of long-term (6 months) and 28-day mortality of postoperative critically ill patients with faecal peritonitis (FP). METHODS Patients admitted to intensive care units with faecal peritonitis and recruited to the European GenOSept study were divided into a derivation and a geographical validation subset; patients subsequently recruited to the UK GAinS study were used for temporal validation. Using all 50 clinical and laboratory variables available on day 1 of critical care admission, Cox proportional hazards regression was fitted to select variables for inclusion in two prognostic models, using stepwise selection and nonparametric bootstrapping sampling techniques. Using Area under the receiver operating characteristic curve (AuROC) analysis, the performance of the models was compared to SOFA and APACHE II. RESULTS Five variables (age, SOFA score, lowest temperature, highest heart rate, haematocrit) were entered into the prognostic models. The discriminatory performance of the 6-month prognostic model yielded an AuROC 0.81 (95% CI 0.76-0.86), 0.73 (95% CI 0.69-0.78) and 0.76 (95% CI 0.69-0.83) for the derivation, geographic and temporal external validation cohorts, respectively. The 28-day prognostic tool yielded an AuROC 0.82 (95% CI 0.77-0.88), 0.75 (95% CI 0.69-0.80) and 0.79 (95% CI 0.71-0.87) for the same cohorts. These AuROCs appeared consistently superior to those obtained with the SOFA and APACHE II scores alone. CONCLUSIONS The two prognostic models developed for 6-month and 28-day mortality prediction in critically ill septic patients with FP, in the postoperative phase, enhanced the day one SOFA score's predictive utility by adding a few key variables: age, lowest recorded temperature, highest recorded heart rate and haematocrit. External validation of their predictive capability in larger cohorts is needed, before introduction of the proposed scores into clinical practice to inform decision making and the design of clinical trials.
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Affiliation(s)
- Ascanio Tridente
- Whiston Hospital Prescot, Merseyside and Department of Infection, Immunity and Cardiovascular Disease, The Medical School, University of Sheffield, Sheffield, UK
| | - Julian Bion
- School of Clinical and Experimental Medicine, University of Birmingham, Birmingham, UK
| | | | | | | | - Andrew Walden
- Intensive Care Unit, Royal Berkshire Hospital, Reading, UK
| | - Paula Hutton
- Intensive Care Unit, John Radcliffe Hospital, Oxford, UK
| | | | | | - Frank Stuber
- Department of Anaesthesiology and Pain Medicine, Bern University Hospital and University of Bern, Bern, Switzerland
| | | | - Charles Hinds
- Barts and the London Queen Mary School of Medicine, London, UK
| | - On behalf of the GenOSept and GAinS Investigators
- Whiston Hospital Prescot, Merseyside and Department of Infection, Immunity and Cardiovascular Disease, The Medical School, University of Sheffield, Sheffield, UK
- School of Clinical and Experimental Medicine, University of Birmingham, Birmingham, UK
- University of Sheffield, Sheffield, UK
- Imperial College, London, UK
- The Wellcome Trust Centre for Human Genetics, University of Oxford, Oxford, UK
- Intensive Care Unit, Royal Berkshire Hospital, Reading, UK
- Intensive Care Unit, John Radcliffe Hospital, Oxford, UK
- Hospital Cochin, Paris, France
- Department of Anaesthesiology and Pain Medicine, Bern University Hospital and University of Bern, Bern, Switzerland
- Barts and the London Queen Mary School of Medicine, London, UK
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4
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Sabroe JE, Axelsen AR, Ellebæk MB, Dahler-Eriksen B, Qvist N. Intraperitoneal lactate/pyruvate ratio and the level of glucose and glycerol concentration differ between patients surgically treated for upper and lower perforations of the gastrointestinal tract: a pilot study. BMC Res Notes 2017; 10:302. [PMID: 28732549 PMCID: PMC5521133 DOI: 10.1186/s13104-017-2622-9] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2016] [Accepted: 07/13/2017] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND Secondary peritonitis is a condition associated with high morbidity and mortality. Continuous postoperative monitoring of patients to ensure timely intervention to treat complications without delay is important for survival and outcome. We aimed to (1) investigate potential differences in postoperative intraperitoneal biomarker levels between patients with upper and lower gastrointestinal tract lesion, and (2) compare postoperative biomarker levels between complicated and uncomplicated patients. METHODS We included a total of 15 consecutive patients operated for upper (n = 7) and lower (n = 8) gastrointestinal tract perforation. We registered postoperative complications during a 30 days follow up-period. Complications were defined as intraabdominal complications, septic shock, and mortality. 5 patients were complicated. A microdialysis catheter was placed intraperitoneally in each patient. Samples were collected every 4th hour for up to 7 postoperative days. Samples were analysed for concentrations of glucose, lactate, pyruvate and glycerol. RESULTS Microdialysis results showed that patients with upper gastrointestinal tract lesions had significantly higher levels of postoperative intraperitoneal glucose and glycerol concentrations, as well as lower lactate/pyruvate ratios and lactate/glucose ratios. In the group with perforation of the lower gastrointestinal tract, those patients with a complicated course showed lower levels of postoperative intraperitoneal glucose concentration and glycerol concentration and higher lactate/pyruvate ratios and lactate/glucose ratios than those patients with an uncomplicated course. CONCLUSION Patients with upper and lower gastrointestinal tract lesions showed differences in postoperative biomarker levels. A difference was also seen between patients with complicated and uncomplicated postoperative courses.
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Affiliation(s)
- Jonas E. Sabroe
- Department of Surgery, Odense University Hospital, 5000 Odense C, Denmark
| | - Anne R. Axelsen
- Department of Surgery, Odense University Hospital, 5000 Odense C, Denmark
| | - Mark B. Ellebæk
- Department of Surgery, Odense University Hospital, 5000 Odense C, Denmark
| | - Bjarne Dahler-Eriksen
- Department of Anaesthesiology and Intensive Care, Odense University Hospital, 5000 Odense C, Denmark
| | - Niels Qvist
- Department of Surgery, Odense University Hospital, 5000 Odense C, Denmark
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5
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Launey Y, Duteurtre B, Larmet R, Nesseler N, Tawa A, Mallédant Y, Seguin P. Risk factors for mortality in postoperative peritonitis in critically ill patients. World J Crit Care Med 2017; 6:48-55. [PMID: 28224107 PMCID: PMC5295169 DOI: 10.5492/wjccm.v6.i1.48] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/19/2016] [Revised: 11/02/2016] [Accepted: 12/09/2016] [Indexed: 02/06/2023] Open
Abstract
AIM To identify the risk factors for mortality in intensive care patients with postoperative peritonitis (POP).
METHODS This was a retrospective analysis using a prospective database that includes all patients hospitalized in a surgical intensive care unit for POP from September 2006 to August 2011. The data collected included demographics, comorbidities, postoperative severity parameters, bacteriological findings, adequacy of antimicrobial therapy and surgical treatments. Adequate source control was defined based on a midline laparotomy, infection source control and intraoperative peritoneal lavage. The number of reoperations needed was also recorded.
RESULTS A total of 201 patients were included. The overall mortality rate was 31%. Three independent risk factors for mortality were identified: The Simplified Acute Physiological II Score (OR = 1.03; 95%CI: 1.02-1.05, P < 0.001), postoperative medical complications (OR = 6.02; 95%CI: 1.95-18.55, P < 0.001) and the number of reoperations (OR = 2.45; 95%CI: 1.16-5.17, P = 0.015). Surgery was considered as optimal in 69% of the cases, but without any significant effect on mortality.
CONCLUSION The results from the large cohort in this study emphasize the role of the initial postoperative severity parameters in the prognosis of POP. No predefined criteria for optimal surgery were significantly associated with increased mortality, although the number of reoperations appeared as an independent risk factor of mortality.
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6
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Preoperative prognostic factors for severe diffuse secondary peritonitis: a retrospective study. Langenbecks Arch Surg 2016; 401:611-7. [PMID: 27241334 DOI: 10.1007/s00423-016-1454-8] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2016] [Accepted: 05/20/2016] [Indexed: 01/21/2023]
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7
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Shankar-Hari M, Ambler M, Mahalingasivam V, Jones A, Rowan K, Rubenfeld GD. Evidence for a causal link between sepsis and long-term mortality: a systematic review of epidemiologic studies. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2016; 20:101. [PMID: 27075205 PMCID: PMC4831092 DOI: 10.1186/s13054-016-1276-7] [Citation(s) in RCA: 71] [Impact Index Per Article: 8.9] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/04/2015] [Accepted: 03/31/2016] [Indexed: 12/29/2022]
Abstract
Background In addition to acute hospital mortality, sepsis is associated with higher risk of death following hospital discharge. We assessed the strength of epidemiological evidence supporting a causal link between sepsis and mortality after hospital discharge by systematically evaluating the available literature for strength of association, bias, and techniques to address confounding. Methods We searched Medline and Embase using the following ‘mp’ terms, MESH headings and combinations thereof - sepsis, septic shock, septicemia, outcome. Studies published since 1992 where one-year post-acute mortality in adult survivors of acute sepsis could be calculated were included. Two authors independently selected studies and extracted data using predefined criteria and data extraction forms to assess risk of bias, confounding, and causality. The difference in proportion between cumulative one-year mortality and acute mortality was defined as post-acute mortality. Meta-analysis was done by sepsis definition categories with post-acute mortality as the primary outcome. Results The literature search identified 11,156 records, of which 59 studies met our inclusion criteria and 43 studies reported post-acute mortality. In patients who survived an index sepsis admission, the post-acute mortality was 16.1 % (95 % CI 14.1, 18.1 %) with significant heterogeneity (p < 0.001), on random effects meta-analysis. In studies reporting non-sepsis control arm comparisons, sepsis was not consistently associated with a higher hazard ratio for post-acute mortality. The additional hazard associated with sepsis was greatest when compared to the general population. Older age, male sex, and presence of comorbidities were commonly reported independent predictors of post-acute mortality in sepsis survivors, challenging the causality relationship. Sensitivity analyses for post-acute mortality were consistent with primary analysis. Conclusions Epidemiologic criteria for a causal relationship between sepsis and post-acute mortality were not consistently observed. Additional epidemiologic studies with recent patient level data that address the pre-illness trajectory, confounding, and varying control groups are needed to estimate sepsis-attributable additional risk and modifiable risk factors to design interventional trials. Electronic supplementary material The online version of this article (doi:10.1186/s13054-016-1276-7) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Manu Shankar-Hari
- Guy's and St Thomas' NHS Foundation Trust, ICU support Offices, 1st Floor, East Wing, St Thomas' Hospital, London, SE1 7EH, UK. .,Division of Asthma, Allergy and Lung Biology, Kings College London, London, SE1 9RT, UK.
| | - Michael Ambler
- Guy's and St Thomas' NHS Foundation Trust, ICU support Offices, 1st Floor, East Wing, St Thomas' Hospital, London, SE1 7EH, UK
| | - Viyaasan Mahalingasivam
- Guy's and St Thomas' NHS Foundation Trust, ICU support Offices, 1st Floor, East Wing, St Thomas' Hospital, London, SE1 7EH, UK
| | - Andrew Jones
- Guy's and St Thomas' NHS Foundation Trust, ICU support Offices, 1st Floor, East Wing, St Thomas' Hospital, London, SE1 7EH, UK.,Division of Asthma, Allergy and Lung Biology, Kings College London, London, SE1 9RT, UK
| | - Kathryn Rowan
- Intensive Care National Audit & Research Centre, Napier House, 24 High Holborn, London, WC1V 6AZ, UK
| | - Gordon D Rubenfeld
- Interdepartmental Division of Critical Care Medicine, Sunnybrook Health Sciences Centre, 2075 Bayview Avenue, D5 03, Toronto, Ontario, M4N 3M5, Canada
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8
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Suarez-de-la-Rica A, Maseda E, Anillo V, Tamayo E, García-Bernedo CA, Ramasco F, Hernández-Gancedo C, López-Tofiño A, Gimenez MJ, Granizo JJ, Aguilar L, Gilsanz F. Biomarkers (Procalcitonin, C Reactive Protein, and Lactate) as Predictors of Mortality in Surgical Patients with Complicated Intra-Abdominal Infection. Surg Infect (Larchmt) 2015; 16:346-51. [DOI: 10.1089/sur.2014.178] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Affiliation(s)
| | - Emilio Maseda
- Anesthesiology and Surgical Critical Care Department, Hospital Universitario La Paz, Madrid, Spain
| | - Víctor Anillo
- Anesthesiology and Surgical Critical Care Department, Hospital Universitario La Paz, Madrid, Spain
| | - Eduardo Tamayo
- Anesthesiology and Surgical Critical Care Department, Hospital Clínico Universitario, Valladolid, Spain
| | | | - Fernando Ramasco
- Anesthesiology and Surgical Critical Care Department, Hospital Universitario La Princesa, Madrid, Spain
| | - Carmen Hernández-Gancedo
- Anesthesiology and Surgical Critical Care Department, Hospital Universitario La Paz, Madrid, Spain
| | - Araceli López-Tofiño
- Anesthesiology and Surgical Critical Care Department, Hospital Universitario La Paz, Madrid, Spain
| | | | - Juan-Jose Granizo
- Preventive Medicine Department, Hospital Infanta Cristina, Parla, Madrid, Spain
| | | | - Fernando Gilsanz
- Anesthesiology and Surgical Critical Care Department, Hospital Universitario La Paz, Madrid, Spain
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9
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Tridente A, Clarke GM, Walden A, Gordon AC, Hutton P, Chiche JD, Holloway PAH, Mills GH, Bion J, Stüber F, Garrard C, Hinds C. Association between trends in clinical variables and outcome in intensive care patients with faecal peritonitis: analysis of the GenOSept cohort. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2015; 19:210. [PMID: 25939380 PMCID: PMC4432819 DOI: 10.1186/s13054-015-0931-8] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/30/2014] [Accepted: 04/16/2015] [Indexed: 01/20/2023]
Abstract
Introduction Patients admitted to intensive care following surgery for faecal peritonitis present particular challenges in terms of clinical management and risk assessment. Collaborating surgical and intensive care teams need shared perspectives on prognosis. We aimed to determine the relationship between dynamic assessment of trends in selected variables and outcomes. Methods We analysed trends in physiological and laboratory variables during the first week of intensive care unit (ICU) stay in 977 patients at 102 centres across 16 European countries. The primary outcome was 6-month mortality. Secondary endpoints were ICU, hospital and 28-day mortality. For each trend, Cox proportional hazards (PH) regression analyses, adjusted for age and sex, were performed for each endpoint. Results Trends over the first 7 days of the ICU stay independently associated with 6-month mortality were worsening thrombocytopaenia (mortality: hazard ratio (HR) = 1.02; 95% confidence interval (CI), 1.01 to 1.03; P <0.001) and renal function (total daily urine output: HR =1.02; 95% CI, 1.01 to 1.03; P <0.001; Sequential Organ Failure Assessment (SOFA) renal subscore: HR = 0.87; 95% CI, 0.75 to 0.99; P = 0.047), maximum bilirubin level (HR = 0.99; 95% CI, 0.99 to 0.99; P = 0.02) and Glasgow Coma Scale (GCS) SOFA subscore (HR = 0.81; 95% CI, 0.68 to 0.98; P = 0.028). Changes in renal function (total daily urine output and renal component of the SOFA score), GCS component of the SOFA score, total SOFA score and worsening thrombocytopaenia were also independently associated with secondary outcomes (ICU, hospital and 28-day mortality). We detected the same pattern when we analysed trends on days 2, 3 and 5. Dynamic trends in all other measured laboratory and physiological variables, and in radiological findings, changes inrespiratory support, renal replacement therapy and inotrope and/or vasopressor requirements failed to be retained as independently associated with outcome in multivariate analysis. Conclusions Only deterioration in renal function, thrombocytopaenia and SOFA score over the first 2, 3, 5 and 7 days of the ICU stay were consistently associated with mortality at all endpoints. These findings may help to inform clinical decision making in patients with this common cause of critical illness. Electronic supplementary material The online version of this article (doi:10.1186/s13054-015-0931-8) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Ascanio Tridente
- Intensive Care Unit, Whiston Hospital, Prescot, Warrington Road, Prescot, Merseyside, L35 5DR, UK. .,Department of Infection and Immunity, The Medical School, University of Sheffield, Beech Hill Rd, Sheffield, South Yorkshire, S10 2RX, Sheffield, UK.
| | - Geraldine M Clarke
- The Wellcome Trust Centre for Human Genetics, University of Oxford, University Offices, Wellington Square, Oxford, OX1 2JD, Oxford, UK.
| | - Andrew Walden
- Intensive Care Unit, Royal Berkshire Hospital, Craven Road, RG1 5AN, Reading, UK.
| | | | - Paula Hutton
- Intensive Care Unit, John Radcliffe Hospital, Headley Way, OX3 9DU, Oxford, UK.
| | - Jean-Daniel Chiche
- Medical Intensive Care Unit, Hôpital Cochin, 27 rue du Faubourg Saint-Jacques, 75014, Paris, France.
| | | | - Gary H Mills
- Department of Infection and Immunity, The Medical School, University of Sheffield, Beech Hill Rd, Sheffield, South Yorkshire, S10 2RX, Sheffield, UK. .,Intensive Care Unit, Sheffield Teaching Hospitals NHS Trust, Northern General Hospital, Herries Road, South Yorkshire, S5 7AU, Sheffield, UK.
| | - Julian Bion
- Department of Anaesthesia and Critical Care, School of Clinical and Experimental Medicine, University of Birmingham, Office 1, Ground Floor East, old Queen Elizabeth Hospital, Edgbaston, Birmingham, B15 2TH, UK.
| | - Frank Stüber
- Department of Anaesthesiology and Pain Medicine, University Hospital Inselspital, Bern, and University of Bern, Bern, Switzerland.
| | - Christopher Garrard
- Intensive Care Unit, John Radcliffe Hospital, Headley Way, OX3 9DU, Oxford, UK.
| | - Charles Hinds
- Barts and The School of Medicine and Dentistry, Queen Mary University of London, Turner Street, London, E1 2AD, UK.
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10
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Mentula PJ, Leppäniemi AK. Applicability of the Clavien-Dindo classification to emergency surgical procedures: a retrospective cohort study on 444 consecutive patients. Patient Saf Surg 2014; 8:31. [PMID: 25075222 PMCID: PMC4114794 DOI: 10.1186/1754-9493-8-31] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2014] [Accepted: 06/18/2014] [Indexed: 02/07/2023] Open
Abstract
Background Patients undergoing emergency surgery have a high risk for surgical complications and death. The Clavien-Dindo classification has been developed and validated in elective general surgical patients, but has not been validated in emergency surgical patients. The aim of the current study was to evaluate the Clavien-Dindo classification of surgical complications in emergency surgical patients and to study preoperative factors for risk stratification that should be included into a database of surgical complications. Methods A cohort of 444 consecutive patients having emergency general surgery during a three-month period was retrospectively analyzed. Surgical complications were classified according to the Clavien-Dindo classification. Preoperative risk factors for complications were studied using logistic regression analysis. Results Preoperatively 37 (8.3%) patients had organ dysfunctions. Emergency surgical patients required a new definition for Grade IV complications (organ dysfunctions). Only new onset organ dysfunctions or complications that significantly contributed to worsening of pre-operative organ dysfunctions were classified as grade IV complications. Postoperative complications developed in 115 (25.9%) patients, and 14 (3.2%) patients developed grade IV complication. Charlson comorbidity index, preoperative organ dysfunction and the type of surgery predicted postoperative complications. Conclusions The Clavien-Dindo classification of surgical complications can be used in emergency surgical patients but preoperative organ dysfunctions should be taken into account when defining postoperative grade IV complications. For risk stratification patients’ comorbidities, preoperative organ dysfunctions and the type of surgery should be taken into consideration.
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Affiliation(s)
- Panu J Mentula
- Department of Abdominal Surgery, Helsinki University Central Hospital, P.O. Box 340, 00029 HUS Helsinki, Finland
| | - Ari K Leppäniemi
- Department of Abdominal Surgery, Helsinki University Central Hospital, P.O. Box 340, 00029 HUS Helsinki, Finland
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11
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The Systemic Inflammatory Response in Patients with Appendicitis: a Progressive Phenomenon. Indian J Surg 2014; 77:1050-6. [PMID: 27011509 DOI: 10.1007/s12262-014-1134-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2014] [Accepted: 06/24/2014] [Indexed: 02/07/2023] Open
Abstract
The systemic inflammatory response has been described in patients with appendicitis. However, its progression from onset of symptoms to diagnosis has not been characterized. The specific purpose of this study was to describe and characterize the systemic inflammatory response to appendicitis. A descriptive cross-sectional study was conducted. One hundred eighty-three patients were studied, divided into four groups from onset of symptoms to diagnosis. The primary outcome measure was to determine the systemic inflammatory response to appendicitis according to the established groups of time intervals. The secondary outcome measure was the analysis of C-reactive protein for the same purpose. The variables of the systemic inflammatory response, according to diagnostic intervals, showed non-significant differences in white blood cell count. The temperature rose constantly after 48 h, reaching its peak after 72 h (p = 0.001), and the respiratory rate rose after 73 h (p < 0.0001). After 73 h, most patients had three or four systemic inflammatory response criteria (p < 0.0001). C-reactive protein levels rose progressively, showing higher levels after 48 h (p = 0.005). The inflammatory response to appendicitis is progressive, being more marked along the timeline from onset of symptoms to diagnosis.
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12
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Abstract
Intraabdominal infections are frequent and dangerous entity in intensive care units. Mortality and morbidity are high, causes are numerous, and treatment options are variable. The intensivist is challenged to recognize and treat intraabdominal infections in a timely fashion to prevent complications and death. Diagnosis of intraabdominal infection is often complicated by confounding underlying disease or masked by overall comorbidity. Current research describes a wide heterogeneity of patient populations, making it difficult to suggest a general treatment regimen and stressing the need of an individualized approach to decision making. Early focus-oriented intervention and antibiotic coverage tailored to the individual patient and hospital is warranted.
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Affiliation(s)
| | - Mitchell Cahan
- Department of Surgery, University of Massachusetts Medical School, MA, USA
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13
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Hernández-Palazón J, Fuentes-García D, Burguillos-López S, Domenech-Asensi P, Sansano-Sánchez TV, Acosta-Villegas F. [Analysis of organ failure and mortality in sepsis due to secondary peritonitis]. Med Intensiva 2012; 37:461-7. [PMID: 23044280 DOI: 10.1016/j.medin.2012.07.010] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2012] [Revised: 06/17/2012] [Accepted: 07/27/2012] [Indexed: 01/31/2023]
Abstract
OBJECTIVES To identify the organs most susceptible to develop multiorgan dysfunction syndrome (MODS) in patients with sepsis due to secondary peritonitis, and to determine the outcome and mortality predicting utility of the SOFA (Sequential Organ Failure Assessment) system. DESIGN A prospective, observational cohort study was made. SETTING The resuscitation unit of a third-level university hospital. PATIENTS A prospective, observational cohort study was made of 102 patients with sepsis of abdominal origin and failure of at least one organ related to the infection. The demographic characteristics were documented, along with the abdominal origin of sepsis, mortality after 28 days, and the daily SOFA score. RESULTS The mortality rate after 28 days was 55%. A total of 53% of the patients presented failure of two or more organs on the first day of admission. The mean daily SOFA score was significantly higher among the patients that died after day 4 of admission. The variables showing a statistically significant correlation to increased mortality were: MODS (P=.000), central nervous system failure (P=.000) and SOFA score on day 4 of admission (P=.012). The area under the ROC curve showed the mortality predicting capacity of the SOFA score on day 4 of admission to be 0.703 (95%CI 0.538-0.853; P=.026). The maximum discriminating capacity was recorded for MODS, with an area under the ROC curve of 0.776 (95%CI 0.678-0.874; P=.000). CONCLUSIONS Organ failure outcome as predicted by the SOFA score showed high precision - the mean SOFA score on day 4 of admission being a good mortality predictor. MODS was the main cause of death, while central nervous system, renal and respiratory failure were identified as the mortality risk factors.
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Affiliation(s)
- J Hernández-Palazón
- Servicio de Anestesiología y Reanimación, Hospital Universitario Virgen de la Arrixaca, Murcia, España.
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Vincent JL, Sakr Y. SOFA so good for predicting long-term outcomes. Resuscitation 2012; 83:537-8. [PMID: 22381650 DOI: 10.1016/j.resuscitation.2012.02.024] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2012] [Accepted: 02/21/2012] [Indexed: 01/07/2023]
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Anami EH, Grion CM, Cardoso LT, Kauss IA, Thomazini MC, Zampa HB, Bonametti AM, Matsuo T. Serial evaluation of SOFA score in a Brazilian teaching hospital. Intensive Crit Care Nurs 2010; 26:75-82. [DOI: 10.1016/j.iccn.2009.10.005] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2009] [Revised: 10/21/2009] [Accepted: 10/21/2009] [Indexed: 01/31/2023]
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Perforated Duodenal Ulcer: Has Anything Changed? Eur J Trauma Emerg Surg 2010; 36:145-50. [DOI: 10.1007/s00068-010-9128-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2009] [Accepted: 11/19/2009] [Indexed: 01/29/2023]
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Chow AW, Evans GA, Nathens AB, Ball CG, Hansen G, Harding GKM, Kirkpatrick AW, Weiss K, Zhanel GG. Canadian practice guidelines for surgical intra-abdominal infections. THE CANADIAN JOURNAL OF INFECTIOUS DISEASES & MEDICAL MICROBIOLOGY = JOURNAL CANADIEN DES MALADIES INFECTIEUSES ET DE LA MICROBIOLOGIE MEDICALE 2010; 21:11-37. [PMID: 21358883 PMCID: PMC2852280 DOI: 10.1155/2010/580340] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Affiliation(s)
- Anthony W Chow
- Division of Infectious Disease, Department of Medicine, University of British Columbia and Vancouver Hospital and Health Sciences Centre, Vancouver, British Columbia
| | - Gerald A Evans
- Division of Infectious Diseases, Department of Medicine, Queen’s University, Kingston
| | - Avery B Nathens
- Department of Surgery, University of Toronto, Toronto, Ontario
| | - Chad G Ball
- Department of Surgery, University of Calgary, Calgary, Alberta
| | - Glen Hansen
- Departments of Pathology and Laboratory Medicine, University of Minnesota and Hennepin County Medical Center, Minnesota, USA
| | - Godfrey KM Harding
- Department of Medical Microbiology and Medicine, University of Manitoba, Winnipeg, Manitoba
| | | | - Karl Weiss
- Department of Infectious Diseases and Microbiology, Hôspital Maisonneuve-Rosemont, University of Montreal, Montreal, Quebec
| | - George G Zhanel
- Department of Medical Microbiology and Medicine, University of Manitoba, Winnipeg, Manitoba
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Prognostic factors in critically ill patients suffering from secondary peritonitis: a retrospective, observational, survival time analysis. World J Surg 2009; 33:34-43. [PMID: 18979129 DOI: 10.1007/s00268-008-9805-4] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
BACKGROUND Acute mortality of unselected critically ill patients has improved during the last 15 years. Whether these benefits also affect survival of critically ill patients with secondary peritonitis is unclear as is the relevance of specific prognostic factors, such as source control. METHODS We performed a retrospective analysis of data collected prospectively from March 1993 to February 2005. A cohort of 319 consecutive postoperative patients with secondary peritonitis requiring intensive care was evaluated. End points for outcome analysis were derived from daily changes of hazard rate. RESULTS Four-month survival rate after intensive care unit (ICU) admission was 31.7%. For patients who have survived for more than 4 months, the 1-year survival was 82.7%. After adjustment for relevant covariates, a high disease severity at ICU admission and during ICU stay, specific comorbidities (extended malignancies, liver cirrhosis) and sources of infection (distal esophagus, stomach), and an inadequate initial antibiotic therapy were associated with worse 4-month prognosis. Inability to obtain source control was the most important determinant of mortality, and treatment after 2002 was combined with improved prognosis. CONCLUSIONS Four-month prognosis of critically ill, surgical patients with secondary peritonitis is poor and mostly determined by the ability to obtain source control. Outcome has improved since 2002, and after successful surgical and intensive care therapy long-term survival seems to be good.
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Direct hemoperfusion with polymyxin-B-immobilized fiber columns improves septic hypotension and reduces inflammatory mediators in septic patients with colorectal perforation. Langenbecks Arch Surg 2008; 394:303-11. [PMID: 18685861 DOI: 10.1007/s00423-008-0395-2] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2008] [Accepted: 07/08/2008] [Indexed: 01/20/2023]
Abstract
PURPOSE Although some studies have reported favorable effects of direct hemoperfusion with polymyxin-B-immobilized fiber columns (PMX) for the treatment of septic shock, few studies have demonstrated the efficacy of PMX in studies with a uniform case definition and without any other blood purification techniques. MATERIALS AND METHODS Fifty-two patients with severe sepsis or septic shock secondary to colorectal perforation were treated with PMX. Hemodynamic alterations and plasma concentrations of endotoxin, interleukin (IL)-1beta, IL-1 receptor antagonist (IL-1Ra), IL-6, IL-8, and IL-10 were evaluated following PMX treatment. RESULTS We observed a significant reduction in plasma endotoxin in the nonsurvivors immediately after PMX treatment compared to before treatment. Systolic blood pressure was markedly increased and circulating levels of IL-1beta, IL-1Ra, and IL-8 were significantly reduced during a 2-h interval of PMX. CONCLUSIONS Our findings suggested that PMX treatment appears to adsorb endotoxin and also modulates circulating cytokine during a 2-h interval of direct hemoperfusion in septic patients with such condition.
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