Successful recovery after major surgery: moving beyond length of stay.

There is strong evidence that Enhanced Recovery Pathways improve length of hospital stay, readmission rates, and complications after major surgery. However, recovery is a complex process that only finishes when the patient returns to normal function. Future studies should also address the patient experience, as well as functional recovery and quality of life after major surgery.

A prospective comparison of a noninvasive cardiac output monitor versus esophageal doppler monitor for goal-directed fluid therapy in colorectal surgery patients

Copyright © 2014 International Anesthesia Research Society.BACKGROUND: Goal-directed fluid therapy (GDFT) is associated with improved outcomes after surgery. The esophageal Doppler monitor (EDM) is widely used, but has several limitations. The NICOM, a completely noninvasive cardiac output monitor (Cheetah Medical), may be appropriate for guiding GDFT. No prospective studies have compared the NICOM and the EDM. We hypothesized that the NICOM is not significantly different from the EDM for monitoring during GDFT. METHODS: One hundred adult patients undergoing elective colorectal surgery participated in this study. Patients in phase I (n = 50) had intraoperative GDFT guided by the EDM while the NICOM was connected, and patients in phase II (n = 50) had intraoperative GDFT guided by the NICOM while the EDM was connected. Each patient's stroke volume was optimized using 250- mL colloid boluses. Agreement between the monitors was assessed, and patient outcomes (postoperative pain, nausea, and return of bowel function), complications (renal, pulmonary, infectious, and wound complications), and length of hospital stay (LOS) were compared. RESULTS: Using a 10% increase in stroke volume after fluid challenge, agreement between monitors was 60% at 5 minutes, 61% at 10 minutes, and 66% at 15 minutes, with no significant systematic disagreement (McNemar P > 0.05) at any time point. The EDM had significantly more missing data than the NICOM. No clinically significant differences were found in total LOS or other outcomes. The mean LOS was 6.56 ± 4.32 days in phase I and 6.07 ± 2.85 days in phase II, and 95% confidence limits for the difference were -0.96 to +1.95 days (P = 0.5016). CONCLUSIONS: The NICOM performs similarly to the EDM in guiding GDFT, with no clinically significant differences in outcomes, and offers increased ease of use as well as fewer missing data points. The NICOM may be a viable alternative monitor to guide GDFT.

Outcomes and Predictors of Mortality in Neurosurgical Patients at Mbarara Regional Referral Hospital

Background:

Knowing the scope of neurosurgical disease at Mbarara Hospital is critical for infrastructure planning, education and training. In this study, we aim to evaluate the neurosurgical outcomes and identify predictors of mortality in order to potentiate platforms for more effective interventions and inform future research efforts at Mbarara Hospital.

Methods:

This is retrospective chart review including patients of all ages with a neurosurgical disease or injury presenting to Mbarara Regional Referral Hospital (MRRH) between January 2012 to September 2015. Descriptive statistics were presented. A univariate analysis was used to obtain the odds ratios of mortality and 95% confidence intervals. Predictors of mortality were determined using multivariate logistic regression model.

Results:

A total of 1876 charts were reviewed. Of these, 1854 (had complete data and were?) were included in the analysis. The overall mortality rate was 12.75%; the mortality rates among all persons who underwent a neurosurgical procedure was 9.72%, and was 13.68% among those who did not undergo a neurosurgical procedure. Over 50% of patients were between 19 and 40 years old and the majority of were males (76.10%). The overall median length of stay was 5 days. Of all neurosurgical admissions, 87% were trauma patients. In comparison to mild head injury, closed head injury and intracranial hematoma patients were 5 (95% CI: 3.77, 8.26) and 2.5 times (95% CI: 1.64,3.98) more likely to die respectively. Procedure and diagnostic imaging were independent negative predictors of mortality (P <0.05). While age, ICU admission, admission GCS were positive predictors of mortality (P <0.05).

Conclusions:

The majority of hospital admissions were TBI patients, with RTIs being the most common mechanism of injury. Age, ICU admission, admission GCS, diagnostic imaging and undergoing surgery were independent predictors of mortality. Going forward, further exploration of patient characteristics is necessary to fully describe mortality outcomes and implement resource appropriate interventions that ultimately improve morbidity and mortality.

Potential Cost-effectiveness of Early Identification of Hospital-acquired Infection in Critically Ill Patients.

RATIONALE: Limitations in methods for the rapid diagnosis of hospital-acquired infections often delay initiation of effective antimicrobial therapy. New diagnostic approaches offer potential clinical and cost-related improvements in the management of these infections. OBJECTIVES: We developed a decision modeling framework to assess the potential cost-effectiveness of a rapid biomarker assay to identify hospital-acquired infection in high-risk patients earlier than standard diagnostic testing. METHODS: The framework includes parameters representing rates of infection, rates of delayed appropriate therapy, and impact of delayed therapy on mortality, along with assumptions about diagnostic test characteristics and their impact on delayed therapy and length of stay. Parameter estimates were based on contemporary, published studies and supplemented with data from a four-site, observational, clinical study. Extensive sensitivity analyses were performed. The base-case analysis assumed 17.6% of ventilated patients and 11.2% of nonventilated patients develop hospital-acquired infection and that 28.7% of patients with hospital-acquired infection experience delays in appropriate antibiotic therapy with standard care. We assumed this percentage decreased by 50% (to 14.4%) among patients with true-positive results and increased by 50% (to 43.1%) among patients with false-negative results using a hypothetical biomarker assay. Cost of testing was set at $110/d. MEASUREMENTS AND MAIN RESULTS: In the base-case analysis, among ventilated patients, daily diagnostic testing starting on admission reduced inpatient mortality from 12.3 to 11.9% and increased mean costs by $1,640 per patient, resulting in an incremental cost-effectiveness ratio of $21,389 per life-year saved. Among nonventilated patients, inpatient mortality decreased from 7.3 to 7.1% and costs increased by $1,381 with diagnostic testing. The resulting incremental cost-effectiveness ratio was $42,325 per life-year saved. Threshold analyses revealed the probabilities of developing hospital-acquired infection in ventilated and nonventilated patients could be as low as 8.4 and 9.8%, respectively, to maintain incremental cost-effectiveness ratios less than $50,000 per life-year saved. CONCLUSIONS: Development and use of serial diagnostic testing that reduces the proportion of patients with delays in appropriate antibiotic therapy for hospital-acquired infections could reduce inpatient mortality. The model presented here offers a cost-effectiveness framework for future test development.