Pooled analysis of WHO Surgical Safety Checklist use and mortality after emergency laparotomy

Background The World Health Organization (WHO) Surgical Safety Checklist has fostered safe practice for 10 years, yet its place in emergency surgery has not been assessed on a global scale. The aim of this study was to evaluate reported checklist use in emergency settings and examine the relationship with perioperative mortality in patients who had emergency laparotomy. Methods In two multinational cohort studies, adults undergoing emergency laparotomy were compared with those having elective gastrointestinal surgery. Relationships between reported checklist use and mortality were determined using multivariable logistic regression and bootstrapped simulation. Results Of 12 296 patients included from 76 countries, 4843 underwent emergency laparotomy. After adjusting for patient and disease factors, checklist use before emergency laparotomy was more common in countries with a high Human Development Index (HDI) (2455 of 2741, 89.6 per cent) compared with that in countries with a middle (753 of 1242, 60.6 per cent; odds ratio (OR) 0.17, 95 per cent c.i. 0.14 to 0.21, P <0001) or low (363 of 860, 422 per cent; OR 008, 007 to 010, P <0.001) HDI. Checklist use was less common in elective surgery than for emergency laparotomy in high-HDI countries (risk difference -94 (95 per cent c.i. -11.9 to -6.9) per cent; P <0001), but the relationship was reversed in low-HDI countries (+121 (+7.0 to +173) per cent; P <0001). In multivariable models, checklist use was associated with a lower 30-day perioperative mortality (OR 0.60, 0.50 to 073; P <0.001). The greatest absolute benefit was seen for emergency surgery in low- and middle-HDI countries. Conclusion Checklist use in emergency laparotomy was associated with a significantly lower perioperative mortality rate. Checklist use in low-HDI countries was half that in high-HDI countries.Peer reviewe

Global variation in anastomosis and end colostomy formation following left-sided colorectal resection

Background End colostomy rates following colorectal resection vary across institutions in high-income settings, being influenced by patient, disease, surgeon and system factors. This study aimed to assess global variation in end colostomy rates after left-sided colorectal resection. Methods This study comprised an analysis of GlobalSurg-1 and -2 international, prospective, observational cohort studies (2014, 2016), including consecutive adult patients undergoing elective or emergency left-sided colorectal resection within discrete 2-week windows. Countries were grouped into high-, middle- and low-income tertiles according to the United Nations Human Development Index (HDI). Factors associated with colostomy formation versus primary anastomosis were explored using a multilevel, multivariable logistic regression model. Results In total, 1635 patients from 242 hospitals in 57 countries undergoing left-sided colorectal resection were included: 113 (6·9 per cent) from low-HDI, 254 (15·5 per cent) from middle-HDI and 1268 (77·6 per cent) from high-HDI countries. There was a higher proportion of patients with perforated disease (57·5, 40·9 and 35·4 per cent; P < 0·001) and subsequent use of end colostomy (52·2, 24·8 and 18·9 per cent; P < 0·001) in low- compared with middle- and high-HDI settings. The association with colostomy use in low-HDI settings persisted (odds ratio (OR) 3·20, 95 per cent c.i. 1·35 to 7·57; P = 0·008) after risk adjustment for malignant disease (OR 2·34, 1·65 to 3·32; P < 0·001), emergency surgery (OR 4·08, 2·73 to 6·10; P < 0·001), time to operation at least 48 h (OR 1·99, 1·28 to 3·09; P = 0·002) and disease perforation (OR 4·00, 2·81 to 5·69; P < 0·001). Conclusion Global differences existed in the proportion of patients receiving end stomas after left-sided colorectal resection based on income, which went beyond case mix alone

Investigation of the MILD combustion regime via Principal Component Analysis

Moderate or Intense Low oxygen Dilution (MILD) combustion is particularly appealing for coupling very high combustion efficiencies with very low pollutant emissions. Experimental and numerical studies have been devoted to MILD combustion. However, fundamental aspects of such combustion regime are still not completely understood and this generates uncertainties, especially from the modeling perspective. A novel methodology based on Principal Component Analysis (PCA) is proposed for the investigation of the main features characterizing the MILD combustion regime. High fidelity experimental datasets of CH(4)/H(2) flames propagating into a hot and diluted co-flow are employed to this purpose. Results indicate that the proposed methodology can provide progress variables which coherently follow the modification of the flame structure experimentally observed at different levels of oxygen dilution in the co-flow. A local PCA approach is also proposed, based on the partition of the data sets into cluster, followed by the local application of PCA. Such approach ensures that the low-dimensional projection is characterized by the minimum parameterization error. Results indicate that local PCA leads to the identification of regions of the flow characterized by different physical processes, thus allowing the determination of optimal progress variables in each of them. (C) 2010 The Combustion Institute. Published by Elsevier Inc. All rights reserved

Temperature and reaction zone imaging in turbulent swirling dual-fuel flames

© 2018 The Combustion Institute. Gaseous and liquid dual-fuel flames present both a practical approach to emissions reduction and a challenge to current state-of-the-art combustion modelling. This paper uses simultaneously imaged temperature and normalised OH signal fields to investigate flame structure and provide experimental data for model validation across a range of swirl-stabilised n-heptane spray flames. These data are obtained by non-linear excitation regime two-line atomic fluorescence (NTLAF) of indium, and planar laser-induced fluorescence (OH-PLIF), respectively. Swirling gas streams are varied by flowrate (63-88% of blow-off), premixed equivalence ratio (including air-only), and by type of gaseous fuel (natural gas and hydrogen). Results are used to describe how hot combustion products interact with the fuel spray: heating and diluting the region above the apex of the spray cone at low air flowrates but drawing fuel into outer branches of the flame with increasing air flowrates. Adding natural gas to the swirling air stream, at a concentration below the lean flammability limit, gives rise to a temperature increase in the outer branches with little effect on the hot region above the apex of the spray, along the burner centreline. The size of this region is significantly reduced; however, using hydrogen. As the concentration of gaseous fuel increases towards the lean flammability limit, peak temperatures shift towards the outer branch of the flame. Exceeding the lean flammability limit, an additional reaction zone begins to form in the premixed swirling stream, adjacent to the outer branch of the swirl flame. Stable outer branches of the swirl flame, however, become less prevalent and the peak temperatures of the spray flame return to burner centreline. This study provides insight into the complex behaviour of dual-fuel flames, a complementary dataset to related, PLIF-only studies and validation data for the development of numerical modelling tools