Management of penetrating vascular injuries

Universitatea din Tartu, Facultatea de Medicină, Departamentul de Chirurgie, Tartu, Estonia, Al XII-lea Congres al Asociației Chirurgilor „Nicolae Anestiadi” din Republica Moldova cu participare internațională 23-25 septembrie 2015Introducere: Managementul leziunilor vasculare (LV) a suportat schimbări semnificative pe parcursul ultimilor decenii. Resuscitarea hipotensivă, utilizarea turnichetelor în leziunile extremităţilor, înlocuirea angiografiei prin cateter cu CT-angiografie (CTA) şi „damage control” sunt doar câteva componente ale evoluţiei recente. Traumatismele penetrante reprezintă peste 36- 50% din totalul LV traumatice. Diagnosticul: Recunoaşterea LV periferice se bazează pe examenul clinic cu stratificarea manifestărilor în „semne majore”, „semne minore” sau „semne absente”. În prezenţa semnelor majore repararea vasculară este necesară în aproape 100% cazuri. Aproximativ 1-8% dintre bolnavii cu semne minore pot avea LV ce necesită intervenţie, fapt ce dictează necesitatea examenului imagistic. Recent investigaţia de elecţie s-a schimbat de la angiografie prin cateter spre CTA şi sonografie duplex. În absenţa semnelor LV investigaţiile ulterioare nu sunt indicate. Managementul chirurgical: Recoltarea grefei venoase la nivelul extremităţilor inferioare întotdeauna necesită condiții sterile. După realizarea controlului proximal şi distal, vasul lezat este debridat în limita ţesuturilor sănătoase. Cu ajutorul cateterului Fogarty se curăţă vasele aferente şi eferente şi se aplică heparinizarea locală. Leziunile arteriale se repară prin sutura pr imară sau prin interpoziţia unui grefon autolog sau din PTFE. Leziunile venoase se ligaturează conform tuturor scenariilor de „damage control”, deşi în condiţii controlate şi cazuri selectate poate fi aplicată sutura laterală a venei. Venele: mezenterica superioară, portă, cava supra-renală şi venele jugulare interne bilateral se ligaturează numai în situaţii cu pericol pentru viaţă, manevra fiind insoţită de o morbiditate semnificativă. Pentru „damage control” utilizăm şunturi cu diametru maximal aplicabil leziunilor arteriale. Majoritatea absolută a şunturilor va rămâne patentă timp de 24 ore. Venele majore sau de importanţă vitală la fel pot fi şuntate. Evaluarea rezultatelor: Mortalitatea generală în LV civile constituie circa 29%, iar rata amputaţiilor alcătuieşte 8%. Perspective: Au fost bine stabilite opţiunile de tratament endovascular în leziunile trunchiului arterial. În acealaşi timp patenţa leziunilor tratate endovascular la nivelul extremităţilor rămâne până în prezent nedefinită.Introduction: The management of vascular injuries (VI) has experienced significant changes in recent decades. Hypotensive resuscitation, utilization of tourniquets in extremity injuries, shift from catheter-based angiography to CT-angiography (CTA) and damage control are a few components of the recent evolution. Penetrating trauma results in more than 36-50% of all traumatic VI. Making the diagnosis: The diagnosis of peripheral VI is based on clinical examination stratifying injuries into “hard signs”, “soft signs” or “no signs”. When hard signs are present close to 100% require vascular repair. About 1-8% of patients with soft signs of VI harbor a lesion requiring repair and thus imaging are advocated. Recently the investigation of choice has shifted from catheter based angiography to CTA or Duplex ultrasound. With no sign of VI, no further evaluation is indicated. Operative management: Always include the lower extremities for conduit harvest in the sterile field. After obtaining proximal and distal vascular control, the injured vessel is debrided to the healthy tissue. A Fogarty catheter sweep clears the vascular inflow-outflow and regional heparinization is provided. The arterial injury is repaired primarily or utilizing autologous or PTFE interposition graft. Venous injuries are ligated in all damage control scenarios; however, in controlled settings in selected patients lateral venous repair can be performed. The superior mesenteric, portal, supra-renal cava, and bilateral internal jugular veins are ligated only in life-threatening settings with a significant morbidity. In damage control, we utilize the largest diameter shunt applicable for arterial injuries. The vast majority of shunts stay patent for 24 hours. Large and vital veins can likewise be shunted. Outcome measures: Overall mortality in VI in civilian setting is about 29% and overall amputation rate is at 8%. Future perspectives: Endovascular treatment options for truncal arterial injuries have been established. However, the patency of lesions managed by endovascular interventions in extremity injuries remains undefined

Emergency general surgery: a time for a new surgical specialty?

Universitatea din Tartu, Facultatea de Medicină, Departamentul de Chirurgie, Tartu, Estonia, Al XII-lea Congres al Asociației Chirurgilor „Nicolae Anestiadi” din Republica Moldova cu participare internațională 23-25 septembrie 2015Introducere: În ultimele decenii societăţile chirurgicale din Europa şi America de Nord au aprobat separarea specialităţii de chirurgie programată de la cea de urgenţă. La baza acestor tendinţe au stat: rezultatele nesatisfăcătoare ale spitalizărilor urgente, coordonarea inadecvată a serviciului, lipsa literaturii şi a training-urilor specializate, alocarea limitată a resurselor şi complexitatea înaltă caracteristică chirurgiei de urgenţă. Realizări: Asociaţia Americană de Chirurgie a Traumei (AAST) a stabilit curriculum pentru o specialitate nouă – Chirurgia Stărilor Acute (Acute Care Surgery – ACS) care include trei elemente practice de bază: chirurgia de urgenţă, trauma şi terapia stărilor critice. Astfel de compoziţie educaţională asigură o bază vastă de experienţă necesară pentru tratamentul pacienţilor chirurgicali critici. Societatea Europeană de Traumă şi Chirurgie de Urgenţă (ESTES), la fel este în proces de definire a curriculum-ului pentru specialitatea – Chirurgia Generală Urgentă (EGS), deşi fără includerea compartimentului de terapie a stărilor critice, din motivul altor standarde de pregătire a chirurgilor în Europa. Asociaţia Japoneză de Medicină Urgentă (JAAM) a realizat 3 conferinţe anuale comune cu AAST şi a lansat o revistă oficială proprie – Journal of Acute Medicine and Surgery. Evaluarea rezultatelor: O multitudine de literatură demonstrează beneficiile majore în urma creării acestei specialităţi chirurgicale noi. S-a înregistrat ameliorarea rezultatelor tratamentului efectuat de către specialiştii ACS/EGS pentru cea mai răspîndită patologia chirurgicală urgentă – apendicita. La fel, s-au ameliorat rezultatele operaţiilor efectuate de echipe specializate în chirurgia de urgenţă la pacienţii cu afecţiuni biliare şi colorectale acute. Perspective: Specialitatea Chirurgia Generală Urgentă pare să aibă o perspectivă de extindere continuă pe viitor, întrucît chirurgii cu o pregătire specială vor demonstra rezultate superioare. Programele educaţionale în ACS/EGS vor include elementele esenţiale ale ortopediei, neurochirurgiei, reanimatologiei, chirurgiei vasculare, chirurgiei generale de urgenţă, hepatobiliare, toracice şi pediatrice pentru asigurarea capacităților adecvate ale specialiştilor în acordarea asistenţei medicale acestei categorii de bolnavi.Introduction: During the recent decades, both North American and European surgical societies have advocated separation of elective and emergency general surgical specialties. These aspirations have been fueled by poor outcomes in emergency admissions, inadequate leadership, lack of literature and training, scarce allocation of resources, and high complexity of the emergency surgical disease burden. Developments: The American Association for the Surgery of Trauma (AAST) has established a training curriculum for the Acute Care Surgery (ACS) which involves three pillars of practice: emergency surgery, trauma, and surgical critical care. Such a composition of training allows a broad base of expertise to serve the needs of critically ill surgical patients. The European Society of Trauma and Emergency Surgery (ESTES), is likewise in process of defining the training curriculum for the Emergency General Surgery (EGS), however, excluding surgical critical care for reasons adherent to training of surgeons in Europe. The Japanese Association of Acute Medicine (JAAM) has had 3 joint annual meetings with the AAST and JAAM has launched their official publication, the Journal of Acute Medicine and Surgery. Outcome measures: There is a multitude of literature depicting major outcome benefits following establishment of the new surgical specialty. The most common emergent surgical condition such as appendicitis has experienced improved outcomes following care provided by ACS/EGS. Likewise, patients suffering emergency biliary conditions and colorectal emergencies have shown improved outcomes after establishment of dedicated emergency surgical teams. Future perspectives: The EGS specialty will likely expand in the future as outcomes are improving through care under specialists with appropriate training. ACS/EGS fellowship programs will develop their training elements incorporating basic orthopedics, neurosurgery, resuscitation, vascular, emergency general surgery, hepatobiliary, thoracic, pediatric to ensure a adequate capability for this patient category

Transfusion of fresh frozen plasma in non-bleeding ICU patients -TOPIC TRIAL: study protocol for a randomized controlled trial

<p>Abstract</p> <p>Background</p> <p>Fresh frozen plasma (FFP) is an effective therapy to correct for a deficiency of multiple coagulation factors during bleeding. In past years, use of FFP has increased, in particular in patients on the Intensive Care Unit (ICU), and has expanded to include prophylactic use in patients with a coagulopathy prior to undergoing an invasive procedure. Retrospective studies suggest that prophylactic use of FFP does not prevent bleeding, but carries the risk of transfusion-related morbidity. However, up to 50% of FFP is administered to non-bleeding ICU patients. With the aim to investigate whether prophylactic FFP transfusions to critically ill patients can be safely omitted, a multi-center randomized clinical trial is conducted in ICU patients with a coagulopathy undergoing an invasive procedure.</p> <p>Methods</p> <p>A non-inferiority, prospective, multicenter randomized open-label, blinded end point evaluation (PROBE) trial. In the intervention group, a prophylactic transfusion of FFP prior to an invasive procedure is omitted compared to transfusion of a fixed dose of 12 ml/kg in the control group. Primary outcome measure is relevant bleeding. Secondary outcome measures are minor bleeding, correction of International Normalized Ratio, onset of acute lung injury, length of ventilation days and length of Intensive Care Unit stay.</p> <p>Discussion</p> <p>The Transfusion of Fresh Frozen Plasma in non-bleeding ICU patients (TOPIC) trial is the first multi-center randomized controlled trial powered to investigate whether it is safe to withhold FFP transfusion to coagulopathic critically ill patients undergoing an invasive procedure.</p> <p>Trial Registration</p> <p>Trial registration: Dutch Trial Register NTR2262 and ClinicalTrials.gov: <a href="http://www.clinicaltrials.gov/ct2/show/NCT01143909">NCT01143909</a></p

Antimicrobial resistance among migrants in Europe: a systematic review and meta-analysis

BACKGROUND: Rates of antimicrobial resistance (AMR) are rising globally and there is concern that increased migration is contributing to the burden of antibiotic resistance in Europe. However, the effect of migration on the burden of AMR in Europe has not yet been comprehensively examined. Therefore, we did a systematic review and meta-analysis to identify and synthesise data for AMR carriage or infection in migrants to Europe to examine differences in patterns of AMR across migrant groups and in different settings. METHODS: For this systematic review and meta-analysis, we searched MEDLINE, Embase, PubMed, and Scopus with no language restrictions from Jan 1, 2000, to Jan 18, 2017, for primary data from observational studies reporting antibacterial resistance in common bacterial pathogens among migrants to 21 European Union-15 and European Economic Area countries. To be eligible for inclusion, studies had to report data on carriage or infection with laboratory-confirmed antibiotic-resistant organisms in migrant populations. We extracted data from eligible studies and assessed quality using piloted, standardised forms. We did not examine drug resistance in tuberculosis and excluded articles solely reporting on this parameter. We also excluded articles in which migrant status was determined by ethnicity, country of birth of participants' parents, or was not defined, and articles in which data were not disaggregated by migrant status. Outcomes were carriage of or infection with antibiotic-resistant organisms. We used random-effects models to calculate the pooled prevalence of each outcome. The study protocol is registered with PROSPERO, number CRD42016043681. FINDINGS: We identified 2274 articles, of which 23 observational studies reporting on antibiotic resistance in 2319 migrants were included. The pooled prevalence of any AMR carriage or AMR infection in migrants was 25·4% (95% CI 19·1-31·8; I2 =98%), including meticillin-resistant Staphylococcus aureus (7·8%, 4·8-10·7; I2 =92%) and antibiotic-resistant Gram-negative bacteria (27·2%, 17·6-36·8; I2 =94%). The pooled prevalence of any AMR carriage or infection was higher in refugees and asylum seekers (33·0%, 18·3-47·6; I2 =98%) than in other migrant groups (6·6%, 1·8-11·3; I2 =92%). The pooled prevalence of antibiotic-resistant organisms was slightly higher in high-migrant community settings (33·1%, 11·1-55·1; I2 =96%) than in migrants in hospitals (24·3%, 16·1-32·6; I2 =98%). We did not find evidence of high rates of transmission of AMR from migrant to host populations. INTERPRETATION: Migrants are exposed to conditions favouring the emergence of drug resistance during transit and in host countries in Europe. Increased antibiotic resistance among refugees and asylum seekers and in high-migrant community settings (such as refugee camps and detention facilities) highlights the need for improved living conditions, access to health care, and initiatives to facilitate detection of and appropriate high-quality treatment for antibiotic-resistant infections during transit and in host countries. Protocols for the prevention and control of infection and for antibiotic surveillance need to be integrated in all aspects of health care, which should be accessible for all migrant groups, and should target determinants of AMR before, during, and after migration. FUNDING: UK National Institute for Health Research Imperial Biomedical Research Centre, Imperial College Healthcare Charity, the Wellcome Trust, and UK National Institute for Health Research Health Protection Research Unit in Healthcare-associated Infections and Antimictobial Resistance at Imperial College London

The Global Alliance for Infections in Surgery : defining a model for antimicrobial stewardship-results from an international cross-sectional survey

Background: Antimicrobial Stewardship Programs (ASPs) have been promoted to optimize antimicrobial usage and patient outcomes, and to reduce the emergence of antimicrobial-resistant organisms. However, the best strategies for an ASP are not definitively established and are likely to vary based on local culture, policy, and routine clinical practice, and probably limited resources in middle-income countries. The aim of this study is to evaluate structures and resources of antimicrobial stewardship teams (ASTs) in surgical departments from different regions of the world. Methods: A cross-sectional web-based survey was conducted in 2016 on 173 physicians who participated in the AGORA (Antimicrobials: A Global Alliance for Optimizing their Rational Use in Intra-Abdominal Infections) project and on 658 international experts in the fields of ASPs, infection control, and infections in surgery. Results: The response rate was 19.4%. One hundred fifty-six (98.7%) participants stated their hospital had a multidisciplinary AST. The median number of physicians working inside the team was five [interquartile range 4-6]. An infectious disease specialist, a microbiologist and an infection control specialist were, respectively, present in 80.1, 76.3, and 67.9% of the ASTs. A surgeon was a component in 59.0% of cases and was significantly more likely to be present in university hospitals (89.5%, p <0.05) compared to community teaching (83.3%) and community hospitals (66.7%). Protocols for pre-operative prophylaxis and for antimicrobial treatment of surgical infections were respectively implemented in 96.2 and 82.3% of the hospitals. The majority of the surgical departments implemented both persuasive and restrictive interventions (72.8%). The most common types of interventions in surgical departments were dissemination of educational materials (62.5%), expert approval (61.0%), audit and feedback (55.1%), educational outreach (53.7%), and compulsory order forms (51.5%). Conclusion: The survey showed a heterogeneous organization of ASPs worldwide, demonstrating the necessity of a multidisciplinary and collaborative approach in the battle against antimicrobial resistance in surgical infections, and the importance of educational efforts towards this goal.Peer reviewe

Antimicrobials: a global alliance for optimizing their rational use in intra-abdominal infections (AGORA)

Intra-abdominal infections (IAI) are an important cause of morbidity and are frequently associated with poor prognosis, particularly in high-risk patients. The cornerstones in the management of complicated IAIs are timely effective source control with appropriate antimicrobial therapy. Empiric antimicrobial therapy is important in the management of intra-abdominal infections and must be broad enough to cover all likely organisms because inappropriate initial antimicrobial therapy is associated with poor patient outcomes and the development of bacterial resistance. The overuse of antimicrobials is widely accepted as a major driver of some emerging infections (such as C. difficile), the selection of resistant pathogens in individual patients, and for the continued development of antimicrobial resistance globally. The growing emergence of multi-drug resistant organisms and the limited development of new agents available to counteract them have caused an impending crisis with alarming implications, especially with regards to Gram-negative bacteria. An international task force from 79 different countries has joined this project by sharing a document on the rational use of antimicrobials for patients with IAIs. The project has been termed AGORA (Antimicrobials: A Global Alliance for Optimizing their Rational Use in Intra-Abdominal Infections). The authors hope that AGORA, involving many of the world's leading experts, can actively raise awareness in health workers and can improve prescribing behavior in treating IAIs

Global economic burden of unmet surgical need for appendicitis

Background: There is a substantial gap in provision of adequate surgical care in many low-and middle-income countries. This study aimed to identify the economic burden of unmet surgical need for the common condition of appendicitis. Methods: Data on the incidence of appendicitis from 170 countries and two different approaches were used to estimate numbers of patients who do not receive surgery: as a fixed proportion of the total unmet surgical need per country (approach 1); and based on country income status (approach 2). Indirect costs with current levels of access and local quality, and those if quality were at the standards of high-income countries, were estimated. A human capital approach was applied, focusing on the economic burden resulting from premature death and absenteeism. Results: Excess mortality was 4185 per 100 000 cases of appendicitis using approach 1 and 3448 per 100 000 using approach 2. The economic burden of continuing current levels of access and local quality was US $92 492 million using approach 1 and$73 141 million using approach 2. The economic burden of not providing surgical care to the standards of high-income countries was $95 004 million using approach 1 and$75 666 million using approach 2. The largest share of these costs resulted from premature death (97.7 per cent) and lack of access (97.0 per cent) in contrast to lack of quality. Conclusion: For a comparatively non-complex emergency condition such as appendicitis, increasing access to care should be prioritized. Although improving quality of care should not be neglected, increasing provision of care at current standards could reduce societal costs substantially

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

Surgical site infection after gastrointestinal surgery in high-income, middle-income, and low-income countries: a prospective, international, multicentre cohort study

Background: Surgical site infection (SSI) is one of the most common infections associated with health care, but its importance as a global health priority is not fully understood. We quantified the burden of SSI after gastrointestinal surgery in countries in all parts of the world. Methods: This international, prospective, multicentre cohort study included consecutive patients undergoing elective or emergency gastrointestinal resection within 2-week time periods at any health-care facility in any country. Countries with participating centres were stratified into high-income, middle-income, and low-income groups according to the UN's Human Development Index (HDI). Data variables from the GlobalSurg 1 study and other studies that have been found to affect the likelihood of SSI were entered into risk adjustment models. The primary outcome measure was the 30-day SSI incidence (defined by US Centers for Disease Control and Prevention criteria for superficial and deep incisional SSI). Relationships with explanatory variables were examined using Bayesian multilevel logistic regression models. This trial is registered with ClinicalTrials.gov, number NCT02662231. Findings: Between Jan 4, 2016, and July 31, 2016, 13 265 records were submitted for analysis. 12 539 patients from 343 hospitals in 66 countries were included. 7339 (58·5%) patient were from high-HDI countries (193 hospitals in 30 countries), 3918 (31·2%) patients were from middle-HDI countries (82 hospitals in 18 countries), and 1282 (10·2%) patients were from low-HDI countries (68 hospitals in 18 countries). In total, 1538 (12·3%) patients had SSI within 30 days of surgery. The incidence of SSI varied between countries with high (691 [9·4%] of 7339 patients), middle (549 [14·0%] of 3918 patients), and low (298 [23·2%] of 1282) HDI (p < 0·001). The highest SSI incidence in each HDI group was after dirty surgery (102 [17·8%] of 574 patients in high-HDI countries; 74 [31·4%] of 236 patients in middle-HDI countries; 72 [39·8%] of 181 patients in low-HDI countries). Following risk factor adjustment, patients in low-HDI countries were at greatest risk of SSI (adjusted odds ratio 1·60, 95% credible interval 1·05–2·37; p=0·030). 132 (21·6%) of 610 patients with an SSI and a microbiology culture result had an infection that was resistant to the prophylactic antibiotic used. Resistant infections were detected in 49 (16·6%) of 295 patients in high-HDI countries, in 37 (19·8%) of 187 patients in middle-HDI countries, and in 46 (35·9%) of 128 patients in low-HDI countries (p < 0·001). Interpretation: Countries with a low HDI carry a disproportionately greater burden of SSI than countries with a middle or high HDI and might have higher rates of antibiotic resistance. In view of WHO recommendations on SSI prevention that highlight the absence of high-quality interventional research, urgent, pragmatic, randomised trials based in LMICs are needed to assess measures aiming to reduce this preventable complication