Search

Background: The risk of death in severe complicated intra-abdominal sepsis (SCIAS) remains high despite decades of surgical and antimicrobial research. New management strategies are required to improve outcomes. The Closed Or Open after Laparotomy (COOL) trial investigates an open-abdomen (OA) approach with active negative pressure peritoneal therapy. This therapy is hypothesized to better manage peritoneal bacterial contamination, drain inflammatory ascites, and reduce the risk of intra-abdominal hypertension leading to improved survival and decreased complications. The total costs and cost-effectiveness of this therapy (as compared with standard fascial closure) are unknown. Methods: We propose a parallel cost-utility analysis of this intervention to be conducted alongside the 1-year trial, extrapolating beyond that using decision analysis. Using resource use metrics (e.g., length of stay, re-admissions) from patients at all study sites and microcosting data from patients enrolled in Calgary, Alberta, the mean cost difference between treatment arms will be established from a publicly-funded health care payer perspective. Quality of life will be measured at 6 months and 1 year postoperatively with the Euroqol EQ-5D-5 L and SF-36 surveys. A within-trial analysis will establish cost and utility at 1 year, using a bootstrapping approach to provide confidence intervals around an estimated incremental cost-effectiveness ratio. If neither operative strategy is economically dominant, Markov modeling will be used to extrapolate the cost per quality-adjusted life years gained to 2-, 5-, 10-year, and lifetime horizons. Future costs and benefits will be discounted at 1.5% per annum. A cost-effectiveness acceptability curve will be generated using Monte Carlo simulation. If all trial outcomes are similar, the primary analysis will default to a cost-minimization approach. Subgroup analysis will be carried out for patients with and without septic shock at presentation, and for patients whose initial APACHE II scores are > 20 versus ≤ 20. Discussion: In addition to an estimate of the clinical effectiveness of an OA approach for SCIAS, an understanding of its cost effectiveness will be required prior to its adoption in any resource-constrained environment. We will estimate this key parameter for use by clinicians and policymakers. Trial Registration: ClinicalTrials.gov, NCT03163095, registered May 22, 2017. [ABSTRACT FROM AUTHOR]

Background: Computed tomographic scanning and tertiary surveys have resulted in an increase of incidental findings (IFs) unrelated to the trauma. The goals were to (1) characterize the frequency and nature of IFs and (2) explore their management by a trauma nurse practitioner. Methods: A prospective log of IFs and follow-up details was maintained by a trauma nurse practitioner. Supplemental data were obtained through hospital databases. Results: A total of 404 trauma patients were screened for IFs over a 6-month period, and 68% had IFs of varying severity. Conclusion: IFs are frequent in trauma. Appropriate management and follow-up is a major commitment that can be well managed by a trauma nurse practitioner. [ABSTRACT FROM AUTHOR]

Abstract: Background: Acute care surgery (ACS) services are becoming increasingly popular. Methods: Assessment, flow, and disposition of adult ACS patients (acute, nontrauma surgical conditions) through the emergency department (ED) in a large health care system (Calgary) were prospectively analyzed. Results: Among 447 ACS ED consultations over 3 centers (70% admitted to ACS), the median wait time from the consultation request to ACS arrival was 36 minutes, and from ACS arrival to the admission request it was 91 minutes. The total ACS-dependent time was 127 minutes compared with 261 minutes for initial ED activities and 104 minutes for transfer to a hospital ward (P < .05). Forty percent of patients underwent computed tomography (CT) imaging (76% before consultation). The time to ACS consultation was 305 minutes when a CT scan was performed first. Conclusions: An ACS service results in rapid ED assessment of surgical emergencies. Patient waiting is dominated by the time before requesting ACS consultation and/or waiting for transfer to the ward. [Copyright &y& Elsevier]

Bloodstream infection (BSI) is a serious complication of critical illness but it is uncertain whether acquisition of BSI in the intensive care unit (ICU) increases the risk of death. A study was conducted among all Calgary health region (population approximately 1 million) adults admitted to ICUs for 48 h or more during a three-year period to investigate the occurrence, microbiology and risk factors for developing an ICU-acquired BSI and to determine whether these infections independently predict mortality. One hundred and ninety-nine ICU-acquired BSI episodes occurred during 4933 ICU admissions for a cumulative incidence of 4% and an incidence density of 5.4 per 1000 ICU days. The most common isolates were Staphylococcus aureus (18%), coagulase-negative staphylococci (11%), and Enterococcus faecalis (8%); 12% of infections were due to antimicrobial-resistant bacteria. Admission to the regional neurosurgery/trauma ICU [odds ratio (OR) 2.86; 95% confidence interval (CI) 2.10-3.90] and increasing Acute Physiology and Chronic Health Evaluation II (APACHE II) score (OR 1.05 per point, 95% CI 1.03-1.07) were associated with higher risk, whereas a surgical diagnosis (OR 0.69; 95% CI 0.52-0.93) was associated with lower risk of developing ICU-acquired BSI in logistic regression analysis. The crude in-hospital death rate was 45% for patients with ICU-acquired BSI compared with 21% for those without (P < 0.0001) Development of an ICU-acquired BSI was an independent risk factor for death (OR 1.79; 95% CI 1.3-2.5) and increases the risk of dying from critical illness.