Bloodstream infection rates: PICC vs CVC

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One discussion this week involved the comparison of bloodstream infection rates with PICCs vs CVCs.

Reference: Chopra V, et al. The risk of bloodstream infection associated with peripherally inserted central catheters compared with central venous catheters in adults: a systematic review and meta-analysis. Infection Control and Hospital Epidemiology. 2013 Sep;34(9):908-918. doi:10.1086/671737.

Summary: In 23 studies involving 57,250 patients, pooled meta-analyses revealed that PICCs were associated with a lower risk of central line-associated bloodstream infection (CLABSI) than were CVCs. A subgroup analysis further showed that CLABSI reduction was greatest in outpatients (RR [95% CI], 0.22 [0.18-0.27]) compared with hospitalized patients who received PICCs (RR [95% CI], 0.73 [0.54-0.98]).

The authors conclude that although PICCs are associated with a lower risk of CLABSI than CVCs in outpatients, hospitalized patients may be just as likely to experience CLABSI with PICCs as with CVCs. Consideration of risks and benefits before PICC use in inpatient settings is warranted.

Treatment in uremic bleeding

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One discussion this week involved the treatment for uremic bleeding.

Reference: Hedges SJ, et al. Evidence-based treatment recommendations for uremic bleeding. National Clinical Practice. Nephrology. 2007 Mar;3(3):138-153.

Summary: Hedges et al (2007) provide a review of normal hemostatic and homeostatic mechanisms that operate within the body to prevent unnecessary bleeding, as well as an in-depth discussion of the dysfunctional components that contribute to complications associated with uremic bleeding syndrome. Prevention and treatment options can include one or a combination of the following: dialysis, erythropoietin, cryoprecipitate, desmopressin, and conjugated estrogens.

The article cited is worth a full text read because:

  • Treatment options are compared with regard to their mechanism of action, and onset and duration of efficacy.
  • An extensive review of the clinical trials that have evaluated each treatment is also presented (Tables 3, 4, 5).
  • An evidence-based treatment algorithm to help guide clinicians through most clinical scenarios, and address common questions related to the management of uremic bleeding.

Uremic bleeding in patients with chronic renal failure is extremely complex. One factor contributing to this complexity is the incomplete elucidation of its pathophysiology. Because the mechanisms underlying uremic bleeding are not fully understood, prevention and treatment for many different clinical scenarios are not clearly defined (p.150).

  • EPO works to increase the number of red blood cells, allowing platelets to travel in closer proximity to the endothelium.
  • Cryoprecipitate and desmopressin work to increase the proportion of normal or functional factors that might be dysfunctional in patients with uremic bleeding.
  • Estrogens are thought to work by decreasing NO levels, thereby increasing concentrations of TxA2 and ADP.

Multiple interventions that simultaneously affect different aspects of the pathophysiology of uremic bleeding might most effectively prevent bleeding in high-risk patients and limit active bleeding in those for who cessation of blood loss is more pressing.

By determining which patients are most at risk, clinicians can utilize dialysis and EPO in the early stages of uremic bleeding, and employ desmopressin, cryoprecipitate and/or estrogens prior to a surgical procedure, thereby possibly preventing bleeding secondary to uremic platelet dysfunction.

Early vs late drain removal after pancreatectomy

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One discussion this week included early vs late drain removal in pancreatectomy.

References: Beane JD, et al. Variation of drain management after pancreatoduodenectomy: early versus delayed removal. Annals of Surgery. 2017 Oct. doi: 10.1097/SLA.0000000000002570

Deminski J, et al. Early removal of intraperitoneal drainage after pancreatoduodenectomy in patients without postoperative fistula at POD3: results of a randomized clinical trial. Journal of Visceral Surgery. 2019 Jan 31. pii: S1878-7886(18)30084-5. doi: 10.1016/j.jviscsurg.2018.06.006

Summary:  Early drain removal after pancreatoduodenectomy, when guided by postoperative day (POD) 1 drain fluid amylase (DFA-1), is associated with reduced rates of clinically relevant postoperative pancreatic fistula (CR-POPF).

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Readmission rates following parathyroidectomy for renal disease

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One discussion this week included readmission rates following parathyroidectomy.

References: Ferrandino R, et al. Unplanned 30-day readmissions after parathyroidectomy in patients with chronic kidney disease: a nationwide analysis. Otolaryngology – Head and Neck Surgery. 2017 Dec;157(6):955-965. doi:10.1177/0194599817721154.

Summary: A retrospective cohort study was performed using the 2013 Nationwide Readmissions Database (NRD) of the Healthcare Cost and Utilization Project (HCUP) from the Agency for Healthcare Research and Quality (AHRQ). In a total of 2756 parathyroidectomies performed in patients with chronic kidney disease, 17.2%  had at least one unplanned readmission rate within the first 30-days, and 2.4% had more than one readmission. Overall, readmission rates for chronic kidney disease patients are nearly 5-times that of the general population (Ferrandino et al, 2017).

Hypocalcemia/hungry bone syndrome accounted for 40% of readmissions. While readmissions occurred uniformly throughout the 30 days after discharge, those for hypocalcemia/hungry bone syndrome peaked in the first 10 days and decreased over time.

Weight loss/malnutrition at time of parathyroidectomy and length of stay of 5-6 days conferred increased risk of readmission with adjusted odds ratios of 3.31 and 1.87, respectively. Relative to primary hyperparathyroidism, parathyroidectomies performed for secondary hyperparathyroidism were associated with higher risk of readmission.

The authors conclude: “While there are few patient-specific predictors of readmission, we note that the bulk of these readmissions can be attributed to hypocalcemia. To improve readmission rates after parathyroidectomy in CKD patients, we propose focusing on accurate, appropriate medication reconciliation, and optimizing communication and transitions of care to outside facilities (skilled nursing, dialysis, etc.) to facilitate the comprehensive care of this high-risk patient population” (Ferrandino et al, p.964).

Additional Reading: Sharma J, et al. Improved long-term survival of dialysis patients after near-total parathyroidectomy. Journal of the American College of Surgeons. 2012 Apr;214(4):400-407. doi:10.1016/j.jamcollsurg.2011.12.046.

Westerdahl J, et al. Risk factors for postoperative hypocalcemia after surgery for primary hyperparathyroidism. Archives of Surgery. 2000 Feb;135(2):142-147.

What is the composition of seroma fluid?

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One discussion this week included the composition of post-surgical seroma fluid.

Reference: Valeta-Magara A, et al. Pro-oncogenic cytokines and growth factors are differently expressed in the post-surgical wound fluid from malignant compared to benign breast lesions. SpringerPlus. 2015 Sep 5;4:483. doi:10.1186/s40064-015-1260-8.

Summary: Post-operative accumulation of seroma in the surgical cavity following breast cancer surgery varies in incidence from 2.5 to 51 % of patients. Analysis of seroma has shown that it is an inflammatory exudate, classically seen in the first phase of wound repair. Given that seroma is derived from the wound-healing response of tumor-adjacent stroma, Valeta-Magara et al (2015) explored “whether seroma derived from the excision of benign tumors differs from that of malignant tumors, as malignant and benign tumors may activate or influence the adjacent stroma and infiltrating immune cells differently.”

Post-surgical seroma fluids from 59 patients who had undergone either lumpectomy or mastectomy breast surgery were collected at week 1 or 2 post-surgery by percutaneous aspiration.

It was found that surgical cavity seroma from breast cancer patients has ahigher expression of certain tumorpromoting cytokines, including GRO, ENA-78/CXCL5 and TIMP-2, and lower expression of tumor-inhibiting cytokines IGFBP-1, IL-16, IFN-γ, IL-3 and FGF-9, when compared to seroma from non-cancer patients (p.2). Patients with high body mass index also had higher levels of leptin regardless of malignancy.

In conclusion, breast post-surgical tumor cavity contains factors that are pro-inflammatory regardless of malignant or benign disease, but in malignant disease there is significant enrichment of additional pro-oncogenic chemokines, cytokines and growth factors, and reduction in tumor-inhibiting factors. These results are consistent with tumor conditioning of surrounding normal stromal tissue and creation of a pro-oncogenic environment that persists long after surgical removal of the tumor.

The authors also note that a differential expression of the eight factors between benign and malignant seroma fluid offers research hypotheses to be explored further to determine their role in breast tumor progression, local recurrence and metastasis.

 

Laparoscopic entry techniques

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One discussion this week involved laparoscopic entry techniques.

Reference: Ahmad G, et al. Laparoscopic entry techniques. The Cochrane Database of Systematic Reviews. 2019 Jan 18;1:CD006583. doi: 10.1002/14651858.CD006583.pub5

Summary: In their updated systematic review on the topic, Ahmed et al (2019) included 57 RCTs including four multi-arm trials, with a total of 9865 participants, and evaluated 25 different laparoscopic entry techniques.

Overall, evidence was insufficient to support the use of one laparoscopic entry technique over another. Researchers noted an advantage of direct trocar entry over Veress needle entry for failed entry. Most evidence was of very low quality; the main limitations were imprecision (due to small sample sizes and very low event rates) and risk of bias associated with poor reporting of study methods.

Open-entry vs closed-entry: Evidence was insufficient to show whether there were differences between groups for:

  • vascular injury (Peto OR 0.14, 95% CI 0.00 to 6.82; 4 RCTs; n=915; I²=N/A)
  • visceral injury (Peto OR 0.61, 95% CI 0.06 to 6.08; 4 RCTs; n=915: I²=0%)
  • failed entry (Peto OR 0.45, 95% CI 0.14 to 1.42; 3 RCTs; n=865; I²=63%)

Direct trocar vs Veress needle entry: Trial results show a reduction in failed entry into the abdomen with the use of a direct trocar in comparison with Veress needle entry (Peto OR 0.24, 95% CI 0.17 to 0.34; 8 RCTs; n=3185; I²=45%; moderate-quality evidence).

Direct vision entry vs Veress needle entry: Evidence was insufficient to show whether there were differences between groups in rates of:

  • vascular injury (Peto OR 0.39, 95% CI 0.05 to 2.85; 1 RCT; n=186)
  • visceral injury (Peto OR 0.15, 95% CI 0.01 to 2.34; 2 RCTs; n=380; I²=N/A)

Direct vision entry vs open entry: Evidence was insufficient to show whether there were differences between groups in rates of:

  • visceral injury (Peto OR 0.13, 95% CI 0.00 to 6.50; 2 RCTs; n=392; I²=N/A)
  • solid organ injury (Peto OR 6.16, 95% CI 0.12 to 316.67; 1 RCT; n=60)
  • failed entry (Peto OR 0.40, 95% CI 0.04 to 4.09; 1 RCT; n=60)

Radially expanding (STEP) trocars vs non-expanding trocars: Evidence was insufficient to show whether there were differences between groups in rates of:

  • vascular injury (Peto OR 0.24, 95% Cl 0.05 to 1.21; 2 RCTs; n=331; I²=0%)
  • visceral injury (Peto OR 0.13, 95% CI 0.00 to 6.37; 2 RCTs; n=331)
  • solid organ injury (Peto OR 1.05, 95% CI 0.07 to 16.91; 1 RCT; n=244)

(Ahmed et al, 2019, p.2)

PROSPER trial: A comparison of treatments for rectal prolapse

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One discussion this week involved the PROSPER trial of treatment for rectal prolapse.

References: Senapati A, et al. PROSPER: a randomised comparison of surgical treatments for rectal prolapse. Colorectal Disease. 2013 Jul;15(7):858-868. doi:10.1111/codi.12177

Summary: The PROSPER randomised control trial is a pragmatic, factorial (2 × 2) design trial in which 293 patients were randomised between abdominal and perineal surgery (i) (n=49), suture vs resection rectopexy for those receiving an abdominal procedure (ii) (n=78), or Altemeier’s vs Delorme’s for those receiving a perineal procedure (iii) (n=213). Primary outcome measures were recurrence of the prolapse, incontinence, bowel function and quality of life scores measured up to 3 years.

Recurrence rates were not significant in any comparisons:

  • abdominal vs perineal surgery: 20% vs 26%
  • suture vs resection rectopexy: 13% vs 26%
  • Altemeier’s vs Delorme’s: 24% vs 31%

It was noted that substantial improvements from baseline in quality of life following all procedures. Additionally, Vaizey, bowel thermometer and EQ-5D scores were not significantly different in any of the comparisons (Senapati et al, 2013).

Additional Reading: Bordeianou L, et al. Clinical practice guidelines for the treatment of rectal prolapse. Diseases of the Colon and Rectum. 2017 Nov;60(11):1121-1131. doi:10.1097/DCR.0000000000000889