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

GB virus C/Hepatitis G virus infection is frequent in American children and young adults.

The novel flavivirus GB virus C/hepatitis G virus (GBV-C/HGV) has been detected in approximately 2% of blood donors in the United States, and neutralizing antibody to the envelope protein (E2), a marker of previous infection with GBV-C/HGV, is present in approximately 9% of donors. The rate of GBV-C/HGV infection among American children is unknown. To determine whether viral infection might occur during childhood, 160 serum specimens (obtained from blood bank samples) from children and young adults with no history of transfusion were tested. Viral RNA and antibody to E2 were detected in 6.3% and 9.4% of subjects, respectively. Evidence of previous or current infection (viremia and/or antibody to E2) was detected in 13.8% of subjects, indicating that GBV-C/HGV infection appears to be common among American children and young adults, even in the absence of blood transfusion

Clinical applications of photoplethysmography in paediatric intensive care

Objective: The photoplethysmographic wave is displayed by most pulse oximeters. It may be used as a non-invasive alternative to invasive arterial blood pressure trace analysis for continuous haemodynamic monitoring in selected situations. Patients and setting: Four cardiac patients treated in a tertiary neonatal-paediatric intensive care unit. Measurements: Simultaneous monitoring of the photoplethysmographic wave, ECG, and invasive blood pressure. Results and conclusions: Photoplethysmography allows for monitoring pulse rate in patients with (possible) heart rate/pulse rate dissociation (pacemaker dependency, pulsatile ventricular assist device); monitoring sudden changes in heart beat volume, which are unrelated to respiration (pulseless electrical activity, pulsus alternans); and monitoring respiratory-dependent fluctuations of the plethysmographic wave (heart failure, hypovolaemia, asthma, upper airway obstruction, pericardial effusion). Deterioration, slowly evolving over time, may be detected by this method