NATURAL HISTORY AND RISK FACTORS OF BEDSIDE PERCUTANEOUS ENDOSCOPIC GASTROSTOMY TUBES IN THE ICU

INTRODUCTION: There is a paucity of literature describing patients receiving bedside placed percutaneous endoscopic gastrostomy (PEG) tubes in an intensive care unit (ICU) setting. This study aims to describe the natural history, and risk factors for complications for ICU patients requiring bedside PEG tube placement in a Level I trauma center. METHODS: Adult patients with bedside placed PEG tubes from 1/1/2017 to 1/1/2022 were identified through retrospective chart review. Patients with at least 6 months of follow up were included in this study. Descriptive statistics were used to illustrate the cohort\u27s natural history. Multivariable logistic regression models adjusting for patient demographics, comorbidities, and index hospitalization factors were fitted to identify risk factors predictive of 6-month all cause complications. Major complications were those requiring invasive intervention. RESULTS: 144 patients were included in this study. Pertinent cohort characteristics include mean age 55.8 years (IQR: 45.6-68.2), 63.9% male sex, 54.9% black race, 28.7% had prior inpatient hospitalization in the past 6 months, 43.4% were transferred from outside hospitals. The most common indications were respiratory failure (31.9%) and blunt trauma (22.9%). The 6-month rate of all-cause and major complication rates were 12.5% and 7.6%, respectively. The most common complications following bedside PEG tube placement were tube dislodgement (44.4%) and surrounding organ injury (27.7%). No deaths associated with PEG tube placement in our study. Bedside PEG tubes were placed on hospital day 15.4 [IQR: 9.7-20.7] and total hospital stay was 34.6 days [IQR: 21.6-43.7]. The most common disposition was to long-term care facility (55.6%). Significant risk factors associated with 6-month all-cause complications include history of diabetes (OR: 5.8, P = 0.038 [95% C.I. 1.1-30.1]). Risk factors for 6-month major complications include prior hospitalization (OR: 5.9, P = 0.05, [95% C.I. 1.01-34]), and increasing serum creatinine (OR: 5.8, P = 0.02, [95% C.I. 1.3-26.6]). CONCLUSIONS: History of diabetes, prior hospitalization, and elevated serum creatinine were associated with increased rates of 6-month complications among ICU patients receiving bedside PEG tubes in our cohort

Does Time of Day Matter for Acute Cholecystectomy in an Acute Care Surgery Model?

INTRODUCTION: Prompt cholecystectomy for acute cholecystitis is well accepted; however, whether this warrants urgent nocturnal surgery remains a matter of debate. Differences in available resources, multitasking, and sleep hygiene may affect performance. This could impact conversion rates to open surgery, operation time, bile duct injury, blood loss, complications, and hospital length of stay. Some evidence supports improved outcomes in patients who can avoid after-hour cholecystectomy. We aimed to determine if outcomes changed based on time of day for laparoscopic cholecystectomy. Our null hypothesis is that nighttime cholecystectomy is associated with worse outcomes. METHODS AND PROCEDURES: Retrospective analysis of 486 patients aged≥18 years who underwent cholecystectomy in a large, urban level 1 tertiary care center with a longstanding acute care surgery model. Demographics, procedural information, time of day of surgery, and postoperative outcomes were collected and stratified over a 4-year period from 2013-2017. Sixty five percent of the patients were female with an average age of 49.6 years and an average BMI of 32.7kg/m2. A total of 230 (47%) patients underwent laparoscopic cholecystectomy for acute cholecystitis. Almost half (45%) underwent nighttime operation defined as procedure start time between the hours of 19:00 to 07:00. RESULTS: Analysis of the 230 patients with acute cholecystitis revealed an overall conversion rate to open of 14% (n=32), bile leak (duct of Luschka or cystic) 3.5% (n=8), 30-day readmission rate of 7.4% (n=17), and length of stay of 3.9 days. Subgroup analysis of patients having nighttime cholecystectomy for cholecystitis (N=103) revealed 6.1% conversion to open, 0.9% (n=2) bile leak, 2.6% (n=6) 30-day readmission rate, and 3.43 days length of stay. Other outcomes including mortality, cardiac events, pneumonia, stroke, PE, blood loss requiring blood transfusion were not statistically significant. One patient had a common bile duct injury in the daytime group that required conversion to open and hepaticojejunostomy. CONCLUSIONS: Despite prior evidence that favors delaying cholecystectomy until daytime to avoid complications, our study did not support this. We found no difference in outcomes between daytime and nighttime cholecystectomy and conclude that cholecystectomy can safely be performed during any time of the day with similar complication rates.This may reflect the volume of experience in after-hours acute care surgery at this regional referral center.https://scholarlycommons.henryford.com/merf2019clinres/1043/thumbnail.jp

Does Time of Day Matter for Acute Cholecystectomy in an Acute Care Surgery Model?

Introduction: Prompt cholecystectomy for acute cholecystitis is well accepted; however, whether this warrants urgent nocturnal surgery remains a matter of debate. Differences in available resources, multitasking, and sleep hygiene may affect performance. This could impact conversion rates to open surgery, length of operation, hospital length of stay, and complications such as bile duct injury, blood loss, and major organ injury. Some evidence supports improved outcomes in patients who can avoid after-hour cholecystectomy. We aimed to determine if outcomes changed based on time of day for laparoscopic cholecystectomy. Our null hypothesis is that night time cholecystectomy is associated with worse outcomes. Methods and Procedures: Retrospective analysis of 486 patients aged ≥ 18 years who underwent cholecystectomy in a large, urban level 1 tertiary care center with a longstanding acute care surgery model. Demographics, procedural information, time of day of surgery, and postoperative outcomes were collected and stratified over a 4-year period from 2013-2017. Sixty five percent of the patients were female with an average age of 49.6 years and an average BMI of 32.7 kg/m2. A total of 230 (47%) patients underwent laparoscopic cholecystectomy for acute cholecystitis. Almost half (45%) underwent nighttime operation defined as procedure start time between the hours of 19:00 to 07:00. Results: Analysis of the 230 patients with acute cholecystitis revealed an overall conversion rate to open of 14% (n = 32), bile leak (duct of Luschka or cystic) 3.5% (n = 8), 30-day readmission rate of 7.4% (n = 17), and length of stay of 3.9 days. Subgroup analysis of patients having nighttime cholecystectomy for cholecystitis (N = 103) revealed 6.1% conversion to open, 0.9% (n = 2) bile leak, 2.6% (n = 6) 30-day readmission rate, and 3.43 days length of stay. Other outcomes including mortality, cardiac events, pneumonia, stroke, PE, blood loss requiring blood transfusion were not statistically significant. One patient had a common bile duct injury in the daytime group that required conversion to open and hepaticojejunostomy. Conclusions: Despite prior evidence that favors delaying cholecystectomy until daytime to avoid complications, our study did not support this. We found no difference in outcomes between daytime and nighttime cholecystectomy and conclude that cholecystectomy can safely be performed during any time of the day with similar complication rates. This may reflect the volume of experience in after-hours acute care surgery at this regional referral center

Clostridium Difficile-Associated Infection in Trauma Patients: Development of the Clostridium Difficile Influencing Factors (CDIF) Score

CONTEXT: Clostridium difficile-associated infection (CDAI) can result in longer hospitalization, increased morbidity, and higher mortality rates for surgical patients. The impact on trauma patients is unknown, however. OBJECTIVE: To assess the effect of CDAI on trauma patients and develop a scoring system to predict CDAI in that population. METHODS: Records of all trauma patients admitted to a Level I Trauma Center from 2001 to 2014 were retrospectively reviewed. Presence of CDAI was defined as evidence of positive toxin or polymerase chain reaction. Patients with CDAI were matched to patients without CDAI using propensity score matching on a ratio of 1:3. MAIN OUTCOME MEASURES: Primary outcome was inhospital mortality. Secondary outcomes included length of stay and need for mechanical ventilation. A decision-tree analysis was performed to develop a predicting model for CDAI in the study population. RESULTS: During the study period, 11,016 patients were identified. Of these, 50 patients with CDAI were matched to 150 patients without CDAI. There were no differences in admission characteristics and demographics. Patients in whom CDAI developed had significantly higher mortality (12% vs 4%, p \u3c 0.01), need for mechanical ventilation (57% vs 23%, p \u3c 0.01), and mean hospital length of stay (15.3 [standard deviation 1.4]) days vs 2.1 [0.6] days, p \u3c 0.0). CONCLUSION: In trauma patients, CDAI results in significant morbidity and mortality. The C difficile influencing factor score is a useful tool in identifying patients at increased risk of CDAI

Does time of day matter for acute cholecystectomy in an acute care surgery model?

INTRODUCTION: Prompt cholecystectomy for acute cholecystitis is well accepted; however, whether this warrants urgent nocturnal surgery remains a matter of debate. Differences in available resources, multitasking, and sleep hygiene may affect performance. This could impact conversion rates to open surgery, operation time, bile duct injury, blood loss, complications, and hospital length of stay. Some evidence supports improved outcomes in patients who can avoid after-hour cholecystectomy. We aimed to determine if outcomes changed based on time of day for laparoscopic cholecystectomy. Our null hypothesis is that nighttime cholecystectomy is associated with worse outcomes. METHODS AND PROCEDURES: Retrospective analysis of 486 patients aged≥18 years who underwent cholecystectomy in a large, urban level 1 tertiary care center with a longstanding acute care surgery model. Demographics, procedural information, time of day of surgery, and postoperative outcomes were collected and stratified over a 4-year period from 2013-2017. Sixty five percent of the patients were female with an average age of 49.6 years and an average BMI of 32.7kg/m2. A total of 230 (47%) patients underwent laparoscopic cholecystectomy for acute cholecystitis. Almost half (45%) underwent nighttime operation defined as procedure start time between the hours of 19:00 to 07:00. RESULTS: Analysis of the 230 patients with acute cholecystitis revealed an overall conversion rate to open of 14% (n=32), bile leak (duct of Luschka or cystic) 3.5% (n=8), 30-day readmission rate of 7.4% (n=17), and length of stay of 3.9 days. Subgroup analysis of patients having nighttime cholecystectomy for cholecystitis (N=103) revealed 6.1% conversion to open, 0.9% (n=2) bile leak, 2.6% (n=6) 30-day readmission rate, and 3.43 days length of stay. Other outcomes including mortality, cardiac events, pneumonia, stroke, PE, blood loss requiring blood transfusion were not statistically significant. One patient had a common bile duct injury in the daytime group that required conversion to open and hepaticojejunostomy. CONCLUSIONS: Despite prior evidence that favors delaying cholecystectomy until daytime to avoid complications, our study did not support this. We found no difference in outcomes between daytime and nighttime cholecystectomy and conclude that cholecystectomy can safely be performed during any time of the day with similar complication rates.This may reflect the volume of experience in after-hours acute care surgery at this regional referral center.https://scholarlycommons.henryford.com/merf2019clinres/1043/thumbnail.jp

Risk factors and natural history of bedside percutaneous endoscopic versus fluoroscopy-guided gastrostomy tubes in intensive care unit patients

INTRODUCTION: There is a paucity of literature comparing patients receiving bedside placed percutaneous endoscopic gastrostomy (PEG) versus fluoroscopic-guided percutaneous gastrostomy tubes (G-tube) in an intensive care unit (ICU) setting. This study aims to investigate and compare the natural history and complications associated with PEG versus fluoroscopic G-tube placement in ICU patients. METHODS: All adult patients admitted in the ICU requiring feeding tube placement at our center from 1/1/2017 to 1/1/2022 with at least 12-month follow up were identified through retrospective chart review. Adjusting for patient comorbidities, hospital factors, and indications for enteral access, a 1-to-2 propensity score matched Cox proportional-hazards model was fitted to evaluate the treatment effect of bedside PEG tube placement versus G-tube placement on patient 1-year complication, readmission, and death rates. Major complications were defined as those requiring operative or procedural intervention. RESULTS: This study included 740 patients, with 178 bedside PEG and 562 fluoroscopic G-tube placements. The overall rate of complication was 22.3% (13% PEG, 25.2% G-tube, P = 0.003). The major complication rate was 11.2% (8.5% PEG, 12.1% G-tube, P = 0.09). Most common complications were tube dysfunction (16.7% PEG; 39.4% G-tube; P = 0.04) and dislodgement (58.3% PEG; 40.8% G-tube). After propensity score matching, G-tube recipients had significantly increased risk for all-cause (HR 2.7, 95% CI 1.56-4.87, P \u3c 0.001) and major complications (HR 2.11, 95% CI 1.05-4.23, P = 0.035). There were no significant differences in 1-year rates of readmission (HR 0.90, 95% CI 0.58-1.38, P = 0.62) or death (HR 1.00, 95% CI 0.70-1.44, P = 0.7). CONCLUSIONS: The overall rate of complications for ICU patients requiring feeding tube in our cohort was 22.3%. ICU patients receiving fluoroscopic-guided percutaneous gastrostomy tube placement had significantly elevated risk of 1-year all-cause and major complications compared to those undergoing bedside PEG