Fredy Ariza, MD., MSc ., PhD(a). - PowerPoint Presentation

1. Fredy Ariza, MD., MSc., PhD(a).Servicio de Anestesiología, Reanimación y Medicina PerioperatoriaFundación Valle del Lili

2. 2012201320142015

3. 2016

4. Surgical site infection and sepsis after major surgery: a preliminary report from a prospective registry.Surgical site infection (SSI) is a concerning issue for surgical teams. It accounts for 20% of health care associated infections in the United States. The incidence of SSI is 2.9% in developing countries and 2% for the United States (1,2). It leads to increased morbidity and increased hospital length of stay (3).MethodsThis is a partial report from a prospective registry that collected data from patients aged 1 month or older who underwent major Surgery at a tertiary care hospital. Subjects who required at least 24 hours of in-hospital postoperative care between August 2015 and March 2016 were included. Main outcomes were the presence of SSI and sepsis during the first 30 postoperative days. Comparisons were done classifying the population in individuals diagnosed with SSI and those without SSI. Sociodemographic characteristics between groups were compared using Chi-square test or Mann-Whitney U test when appropriate. Statistical associations (OR, 95%CI) between risk factors and outcomes were performed using Fisher´s exact test when unadjusted and Mantel-Haenszel test when adjusted. ResultsA total of 866 patients were included. Most of them were women (62.2%), with a median age and interquantile range (IQR) of 50 and 44.8-71, respectively. ASA II status was the most prevalent (57.2%). Most frequently performed procedures were abdominal (30.7%) followed by head and neck surgeries (25.9%). The median and IQR of surgical times was 130 and 90-180 minutes respectively. After adjustment (intraoperative blood loss≥20% of total blood volume) was associated with an increased risk of SSI (OR: 3.81, 95%CI: 1.63-8.88). Similarly, we found Association between poor preoperative exercise tolerance (≤4 METs) and sepsis (OR: 3.41, 95%CI: 1.21-9.53).ConclusionsMajor bleeding and poor preoperative physical condition are independent risk factors for infectious complications in patients undergoing major surgery. Referral centers must focus on protocols for preventing significant bleeding and preoperative cardiopulmonary optimization programs.Lewis SS, Moehring RW, Chen LF, et al (2013) Assessing the relative burden of hospital-acquired infections in a network of community hospitals. Infect Control Hosp Epidemiol 34:1229–30. Weigelt JA, Lipsky BA, Tabak YP, et al (2010) Surgical site infections: Causative pathogens and associated outcomes. Am J Infect Control 38:112–120. Kirkland KB, Briggs JP, Trivette SL, et al (1999) The impact of surgical-site infections in the 1990s: attributable mortality, excess length of hospitalization, and extra costs. Infect Control Hosp Epidemiol 20:725–30. BibliografíaFredy Ariza, M.D., M.S., Andrés Felipe Beltrán, M.D., Dario Alberto Castaño, M.D., Juan Andres Cuervo, M.D., David Ramirez, M.D., Luisa Fernanda Novoa, M.D.Fundación Valle del Lili, Cali, Colombia ObjectivesThe aim of this study was to determine the incidence of SSI and identify related risk factors in patients undergoing major surgery at a Latin-American referral hospital.Introduction

5. Surgical site infection occurrence is not influenced by prophylactic use of dexamethasone against postoperative nausea and vomiting in high-risk patientsDexamethasone is frequently used as unique or combined prophylaxis against postoperative nausea and vomiting (PONV). However, whether this steroid increases the risk of surgical site infection (SSI) in high infectious risk patients such as oncologic or orthopedic patients is still debatable. MethodsA retrospective cohort study was conducted, including adult patients who underwent major oncologic or orthopedic surgeries between January-2011 and December-2012. Patients with active infection, chronic steroid use and intraoperative exposure to other steroids were excluded from analysis. Patients were divided into 2 groups, those receiving dexamethasone alone or combined to other prophylactic drugs against PONV and those who did not received dexamethasone. Main outcome for the study was any kind of SSI during the first 30 postoperative days; secondary outcome was timing of infection. Statistical comparisons were performed using Fisher´s exact test or Chi-square-test for categorical variables and Mann-Whitney U test for continuous variables. Kaplan-Meier analysis was used to evaluate SSI-free survival between groups and a multivariate Cox proportional hazards regression model to assess possible associations between dexamethasone use and other possible risk factors with SSI incidence. ResultsConclusionsKoh, In Jun, Chong Bum Chang, Jung Ha Lee, Young-Tae Jeon, and Tae Kyun Kim. "Preemptive Low-dose Dexamethasone Reduces Postoperative Emesis and Pain After TKA: A Randomized Controlled Study." Clinical Orthopaedics and Related Research® Clin Orthop Relat Res 471.9 (2013): 3010-020Adrian Cheng Kiang Lau, MBBS, FRCSE, Ghim Hoe Neo, MD, Haw Chou Lee. Risk factors of surgical site infections in hip hemiarthroplasty: a single-institution experience over nine years. Arwert, Esther N., Esther Hoste, and Fiona M. Watt. "Epithelial Stem Cells, Wound Healing and Cancer." Nature Reviews Cancer Nat Rev Cancer 12.3 (2012): 170-80. WebBibliographyF. Ariza, D. Castaño, S. Galindo , J. Valencia, J.P. Martínez, M. Herrera, L. LópezFundación Valle del Lili, Cali, Colombia ObjectivesThe aim of this study was to determine the incidence of SSI and identify related risk factors in patients undergoing major surgery at a Latin-American referral hospital.IntroductionFigure 1 . ORs adjusted by age and ASA physical status.There is no increased risk of  surgical site infection when using dexamethasone, alone or combined, in the prophylaxis of postoperative nausea and vomiting  in patients who underwent cancer or orthopedic surgery.Table 1: OutcomesTable 2: Risk Model (Odds and Hazard Ratios)1157 patients were included for analysis. Most were women (63.46%) underwent orthopedic procedures (67.56%) and ASA status system classification class II (64%). Dexamethasone alone was used in 14.9% (n=172) and combined with other drugs in 12.6% (n= 146). Dexamethasone was related with a significantly lower risk for PONV during the first 6 postoperative hours. Dexamethasone had not statistically association with SSI [OR 0.94 (95% CI: 0.48­1.88)] (Table 1). Time to SSI was not different between groups . Multivariate analysis showed a significantly higher risk of SSI in patients with COPD (Table 2)

6. Surgical site infection is not influenced by prophylactic use of dexamethasone against postoperative nausea and vomiting in high-risk patients

7. AntecedentesPONV is common in PACU30-70% during first 24 POP hoursDiscomfort and high health care costsDexametasona y Relación Hipotética con Infección de Sitio Operatorio (ISO)

8. JustificaciónInfección de Sitio OperatorioIncapacidadComplicaciones seriasAltos costos en saludFactores Rx. para ISOProcedimientos OrtopédicosProcedimientos OncológicosPrótesisPancreatectomíaBMI >= 30 kg/m2ASA III-IVRadioterapia

9. ObjetivosDeterminar una posible asociación entre ISO y el uso profiláctico de dexametasona en pacientes de cirugía oncológica y ortopédica.Características DemográficasDeterminar la Frecuencia de NVPOPValoración del Riesgo

10. Hypothesis Hipótesis NulaNo hay diferencia en el riesgo de ISO cuando se comparaban pacientes que recibían DXM con aquellos que no la recibían

11. MethodsSelection criteriaC. InclusiónExclusion criteriaAdultosUso Crónico de EsteroidesCirugía Oncológica (G.O, Cx Gral, Neurocirugía, Urología)Uso Intraoperatorio de otros EsteroidesProc.OrtopédicosInfección ActivaCohortes RetrospectivasDiseñoAnalítico Observac.Enero 2011-Dic 2012Pacientes Recolectados: 1189

12. MethodsDesenlace PrimarioPresencia de ISO en los primeros 30 días postoperatoriosDesenlace SecundarioTiempo al inicio de ISO

13. MethodsCategorical variables:Fisher's exact testChi-square testContinuous variables: Mann-Whitney U testKaplan-Meier analysisProportional regression model

14. ResultadosVariableGlobal (n=1156)DXM(n=525)No DXM(n=631)P-valueAge. N° (%)56 (43-65)53 (41-65)60 (46-70)<0.05Fémale Genre . N° (%)723 (62.5)357 (68)363 (57.5)<0.05ASA Status II/III. N° (%)740/130 (64/11.2)340/52 (64.8/9.9)339/78 (63.3/12.3)0.56COPD. N° (%)27 (2.3)11 (2.1)0 (0.0)0.62Cancer. N° (%)260 (22.5)155 (29.5)105 (16.6)<0.05Kidney failure . N° (%)13 (1.1)5 (1)8 (1.3)0.61Diabetes mellitus. N° (%)73 (6.3)27.8 (5.3)45 (7.1)0.21Congestive heart failure. N° (%)6 (0,5)4 (0.8)2 (0.3)0.29Autoinmune diseases. N° (%)30 (2.6)20 (3.8)10 (1.6)0.06Prophylactic antibiotic. N° (%)1079 (93.4)498 (94.9)582 (92.2)0.07VariableGlobal (n=1156)DXM(n=525)No DXM(n=631)P-valueType of anesthesia N° (%) <0.05 General79 (68.5)462 (88)329 (52.1)Neuroaxial187 (16.2)20 (3.9)167 (26.5)Regional89 (7.7)8 (1.5)149 (12.9)General/regional88 (7.6)35 (6.6)81 (8.4)Propofol induction. N° (%)397 (34.3)242 (46.1)155 (24.6) <0.05

15. RESULTADOSVariableGlobal (n=1156)DXM(n=525)No DXM(n=631)P-valueType of surgery. N° (%) <0.05 Orthopedic781 (67.6)285 (54.3)497 (78.7)Oncologic375 (32.4)240 (45.7)134 (21-3)Prosthetic installation. N° (%) 377 (32.6)113 (21.5)264 (41.8)0.01Nausea at PACU. N° (%) 88 (7.6)26 (5)62 (9.9)0.002Vomiting at PACU N° (%) 62 (5.4)17 (3.2)45 (7,2)0.003Nausea at 24 hours. N° (%) 15 (1.3)6 (1.1)9 (1.4)0.67Vomiting at 24 hours. N° (%) 14 (1.2)5(1)9 (1.4)0.46

16. ResultadosFactor de RiesgoOR (95% CI)P-valueHR (95% CI)P-valueDexametasona0.97 (0.46-2,1)0.950.79 (0.40-1.56)0.5Cáncer1.65 (0.68-3.99)0.271.92 (0.95-3.88)0.07Enfermedad Renal8.45 (0.52-136.77Q0.132.73 (0.37-19.9)0.32Diabetes mellitus0.79 (0.1-5.99)0.820.45 (0.06-3.26)0.43Enf. Autoinmune2.58 (0.28-24.28)0.412.38 (0.57-9.93)0.23EPOC11.97 (1.46-98.27)0.022.67 80.64-11.2)0.18Prótesis0.95(0.42-2.14)0.910.86 (0.41-1.79)0.68

17. RESULTADOSDESENLACEGlobal (n=1156)DXM(n=525)No DXM(n=631)P-valueISO. No. (%)35 (3)15 (2.9)19 (3)0.87Type of ISO. No. (%)0.81No infección1132 (97.9)513 (97.7)611 (96.8)Superficial12 (1)4 (0.8)7 (1.1)Profunda9 (0.8)3 (0.6)6 (1)Organo/cavidad12 (1.1)5 (1)7 (1.1)Dias para ISO6 (3.25-10)6 (4-10)6 (3-10)0.94

18. Análisis de Sobrevida

19. ConclusionesNo existe un incremento en el riesgo de ISO a 30 días con el uso intraoperatorio de DXM como profilaxis para NVPOPNo existen diferencias en el momento de aparición de ISOFactores de Rx.AutoinmunidadEPOCClaro BENEFICIO en la utilización de DXM para evitar riesgo de NVPOP

20.