The synergistic effect of preoperative opioid use and many associated preoperative predictors of poor outcome in the trauma patient population

OBJECTIVE

The purpose of this study is to investigate if preoperative opioid use is associated with other predictors of poor outcome and the effect of these factors on complications. We hypothesized that preoperative opioid use (POU) is associated with increased rates of postoperative complications.

DESIGN

Retrospective case control study.

SETTING

Academic level-1 trauma center.

PATIENTS/PARTICIPANTS

Patients with long bone, lower extremity fractures requiring operative fixation.

INTERVENTION

N/A.

MAIN OUTCOME MEASURES

Postoperative hospital admissions, emergency room (ER) visits, and reoperations.

RESULTS

399 patients (opioid naïve [ON] 80.2%, Age 38, 95% CI 35.9-39.6) were reviewed. Patients who had POU were older (P = 0.004), had higher BMI (P = 0.03), proportion of females (P < 0.001), tobacco use (P < 0.001), proportion of American Society of Anesthesiologist (ASA) class ≥ 3 (P < 0.001), and rates of substance use disorder (SUD) (P < 0.001). POU was associated with prolonged opiate use at 6 months (60.8%), 1 year (43.0%), higher rates of postoperative readmissions (18.1%), ER visits (17.2%), reoperations (17.5%), and complications (Odds Ratio [OR]: 2.4, P < 0.01). The risk of complication increased synergistically with the addition of other predictors: less than a high school education (OR: 4.6, P = 0.001); ASA class ≥3 (OR: 5.6, P < 0.001). All three factors combined also increased risk of complication synergistically (OR: 9.1, P = 0.003).

CONCLUSIONS

Our study demonstrates that many predictors of poor outcome frequently accompany POU. POU combined with many of these predictors synergistically increases the risk of complication. Outcomes-based payment models should reflect this expected rate of readmissions, ER visits and complications in this group. Patients with POU should be targeted with multi-disciplinary interventions aimed to modify these risk factors.

Laminar Air Flow Handling Systems in the Operating Room

BACKGROUND

Surgical site infection is associated with a substantial healthcare burden and remains one of the most challenging complications to treat. Airborne particles carrying contaminating micro-organisms are responsible for the majority of these infections.

METHODS

Various operating theater ventilatory systems have been developed to prevent direct airborne bacterial inoculation of the surgical wound. Laminar air flow uses positive pressure air currents through filtration units to direct air streams away from the operative field in order to create an ultraclean zone around the operative site.

DISCUSSION

Early studies reported lower infection rates with laminar air flow and therefore it became the accepted standard for implant-related surgery. However, more recent evidence has questioned its clinical importance. The purpose of this article is to review contemporary laminar air flow handling systems and the current evidence behind their use.

The impact of smoking on neurosurgical outcomes

Cigarette smoking is a common health risk behavior among the general adult population, and is the leading preventable cause of morbidity and mortality in the US. The surgical literature shows that active tobacco smoking is a major risk factor for perioperative morbidity and complications, and that preoperative smoking cessation is an effective measure to lower these risks associated with active smoking. However, few studies have examined the effects of smoking and perioperative complications following neurosurgical procedures. The goal of this review was to highlight the scientific data that do exist regarding the impact of smoking on neurosurgical outcomes, to promote awareness of the need for further work in the specific neurosurgical context, and to suggest ways that neurosurgeons can promote smoking cessation in their patients and lead efforts nationally to emphasize the importance of preoperative smoking cessation. This review indicates that there is limited but good evidence that smoking is associated with higher rates of perioperative complications following neurosurgical intervention. Specific research is needed to understand the effects of smoking and perioperative complications. Neurosurgeons should encourage preoperative smoking cessation as part of their clinical practice to mitigate perioperative morbidity associated with active smoking.

Prevention of infection in orthopaedic joint replacement

Infection of a prosthetic joint is a significant adverse event, affecting the patient, the surgical team, and consuming hospital resources. The patient faces multiple operations, a prolonged hospital stay and a more challenging period of rehabilitation. The surgeon must perform longer and more technically demanding revision operations in order to remove the infected prosthesis, increasing the burden on hospital resources. It has been estimated that that the cost of managing an infected total hip replacement (THR) is four times greater than for a primary procedure (Dreghorn & Hamblen 1989). The personal cost to the patient must also be emphasised.

Does the use of laminar flow and space suits reduce early deep infection after total hip and knee replacement?: the ten-year results of the New Zealand Joint Registry

We have investigated whether the use of laminar-flow theatres and space suits reduced the rate of revision for early deep infection after total hip (THR) and knee (TKR) replacement by reviewing the results of the New Zealand Joint Registry at ten years. Of the 51 485 primary THRs and 36 826 primary TKRs analysed, laminar-flow theatres were used in 35.5% and space suits in 23.5%. For THR there was a significant increase in early infection in those procedures performed with the use of a space suit compared with those without (p < 0.0001), in those carried out in a laminar-flow theatre compared with a conventional theatre (p < 0.003) and in those undertaken in a laminar-flow theatre with a space suit (p < 0.001) when compared with conventional theatres without such a suit. The results were similar for TKR with the use of a space suit (p < 0.001), in laminar-flow theatres (p < 0.019) and when space suits were used in those theatres (p < 0.001). These findings were independent of age, disease and operating time and were unchanged when the surgeons and hospital were analysed individually. The rate of revision for early deep infection has not been reduced by using laminar flow and space suits. Our results question the rationale for their increasing use in routine joint replacement, where the added cost to the health system seems to be unjustified.

Resistance of disposable drapes to bacterial penetration

PURPOSE

To test the bacterial penetrability of disposable non-woven drapes used specifically for total hip arthroplasty.

METHODS

12 round agar plates were inoculated with 107 colony-forming units/ml of coagulase-negative staphylococci (CNS) and incubated in air at 37 degrees Celsius for 18 hours to obtain a semi-confluent growth of organisms. Six brands of disposable drapes were tested; each was assigned to 2 plates. Each disposable drape was placed between a round agar plate and an inverted square agar plate filled with blood agar. After 30 and 90 minutes, the square agar plates were removed and incubated for 48 hours and inspected for growth of CNS.

RESULTS

Bacterial penetration was time dependant. Certain brands of drapes were more impenetrable than others; none was impenetrable at all time points, but most remained so or allowed passage of fewer than 100 colony-forming units at 90 minutes.

CONCLUSION

It is recommended that drapes be rigorously tested with regard to their resistance to bacterial penetration.

Hand washing rituals in trauma theatre: clean or dirty?

INTRODUCTION

The aim of this study was to investigate the degree of contamination of a surgeon's hand following use of chlorhexidine gluconate or alcohol gel as disinfectants.

MATERIALS AND METHODS

In this prospective, randomised trial, orthopaedic surgeons were allocated to one of two different hand-washing protocols using a randomisation table. The hand-washing protocol dictated that all surgeons should wash for 5 min with chlorhexidine for their first case. Thereafter, the surgeon was randomised to wash for 3 min with either alcohol gel or chlorhexidine. At the end of each procedure, the gloves of each surgeon were carefully removed and the fingertips from each hand were placed on an agar plate. The number of bacterial colonies present after 24 h and 48 h of incubation were recorded for each agar plate by a microbiologist blinded to the washing protocol used.

RESULTS

Overall, 41 procedures and 82 episodes of hand washings were included in the study. Two episodes were discarded due to contamination at the time of glove removal. Four hands (8%) were contaminated in the chlorhexidine group compared to 19 (34%) in the alcohol group. Fisher's exact test confirmed a significantly higher risk of contamination using alcohol gel compared to chlorhexidine (P = 0.002). In addition, the average bacterial colony count was substantially higher in the alcohol group (20 colony forming units) compared to the chlorhexidine group (5 colony forming units). There was no relationship between the duration of surgery and the degree of contamination (P = 1.12).

CONCLUSIONS

Alcohol gel disinfectant is not a suitable alternative to chlorhexidine when hand washing before surgery. This study has identified a higher risk of bacterial contamination of surgeons' hands washed with alcohol. This may lead to higher levels of postoperative infection in the event of glove perforation.

Survey of operating theatre ventilation facilities for minimally invasive surgery in Great Britain and Northern Ireland: current practice and considerations for the future

Increasing use of minimally invasive surgery (MIS) and other invasive procedures has raised the question of what ventilation facilities are appropriate for such procedures to prevent infection. The Hospital Infection Society (HIS) Working Party on Infection Control in Operating Theatres undertook a survey of practice in Great Britain and Northern Ireland on the ventilation facilities provided for a variety of MIS and other procedures. Five hundred and fifty questionnaires were forwarded to HIS members, and 186 (39%) replies were received. Fifty-eight percent were from district general hospitals (DGHs). Designated theatres for orthopaedic surgery (although not necessarily ultraclean ventilated theatres) were available in more than 80% of hospitals, with approximately 50% of hospitals having designated theatres for a variety of other surgical subspecialities. Approximately two-thirds of urological procedures were performed in conventionally ventilated operating theatres. Most radiological procedures were performed in non-ventilated theatres or treatment rooms. In around half of the DGHs and university/referral hospitals, orthopaedic MIS procedures such as arthroscopy were performed in ultraclean ventilated theatres. This survey revealed considerable variation in the use of conventionally ventilated theatres and ultraclean ventilated theatres. In particular, many radiological and anaesthetic procedures are performed in treatment rooms or ventilated rooms with less than 20 air changes per hour. Whilst it is not clear whether this is acceptable practice given current knowledge, large-scale clinical trials to determine what standards of ventilation are appropriate to minimize infection for these types of procedures would be difficult to conduct. Research is needed on the relative risk of airborne infection for a variety of procedures, including whether all prosthetic implant procedures should be carried out in ultraclean ventilated theatres, as infection associated with implants is often of airborne origin and of considerable clinical significance.