In the Literature: February 2010

The Hospitalist. 2010 February;2010(02):

February 1, 2010|The Hospitalist

Jill Goldenberg, MD;Alan Briones, MD;Dennis Chang, MD;Brian Markoff, MD, FHM;Erin Rule, MD;Andrew Dunn, MD, FACP, FHM;Division Of General

In This Edition

Literature at a Glance

A guide to this month’s studies

Perioperative oxygen use and infection rate.
Effects of adverse events and healthcare costs
Impact of DVT on PE rates in trauma
VTE prevention and treatment in cancer patients
Effect of perioperative beta-blocker discontinuation
Endovascular vs. open AAA repair
OTC analgesics in patients with hepatic dysfunction
Cardiovascular disease and risk of hip fracture

High Perioperative Oxygen Fraction Does Not Improve Surgical-Site Infection Frequency after Abdominal Surgery

Clinical question: Does the use of 80% oxygen perioperatively in abdominal surgery decrease the frequency of surgical-site infection within 14 days without increasing the rate of pulmonary complications?

Background: Low oxygen tension in wounds can negatively impact immune response and healing. Increasing inspiratory oxygen fraction during the perioperative period translates into higher wound oxygen tension. However, the benefit of increased oxygen fraction therapy in abdominal surgery healing and complications is not clear, nor is the frequency of pulmonary complications.

Study design: Patient- and observer-blinded clinical trial.

Setting: Fourteen Danish hospitals from October 2006 to October 2008.

Synopsis: Patients were randomized to receive a fraction of inspired oxygen (FIO₂) of 0.80 or 0.30. The primary outcome—surgical-site infection in the superficial or deep wound or intra-abdominal cavity within 14 days of surgery—was defined using Centers for Disease Control and Prevention (CDC) criteria. Secondary outcomes included pulmonary complications within 14 days (pneumonia, atelectasis, or respiratory failure), 30-day mortality, duration of post-op course, ICU stay within 14 days post-op, and any abdominal operation within 14 days. The 1,386 patients were enrolled in the intention-to-treat analysis.

Infection occurred in 19.1% of patients given 0.80 FIO2 and in 20.1% of patients given 0.30 FIO2; odds ratio of 0.94 (95% CI 0.72 to 1.22; P=0.64). Numbers of pulmonary complications were not significantly different between the groups.

This trial included acute and nonacute laparotomies with followup for adverse outcomes. Study limitations included the inability to ensure that both groups received timely antibiotics and prevention for hypothermia. Of patients in the 30% FIO2 group, 7.3% required higher oxygen administration. Additionally, infection might have been underestimated in 11.3% of patients who were not followed up on between days 13 and 30.

Bottom line: High oxygen concentration administered during and after laparotomy did not lead to fewer surgical site infections, nor did it significantly increase the frequency of pulmonary complications or death.

Citation: Meyhoff CS, Wetterslev J, Jorgensen LN, et al. Effect of high perioperative oxygen fraction on surgical site infection and pulmonary complications after abdominal surgery: the PROXI randomized clinical trial. JAMA. 2009;302(14):1543-1550.

Clinical Shorts

Therapy with corticosteroids in severe alcoholic hepatitis is not associated with higher infection risK

Prospective study demonstrating that patients with severe alcoholic hepatitis are at high risk for infection; patients with a limited response to steroids are more likely to develop infection than responders.

Citation: Louvet A, Wartel F, Castel H, et al. Infection in patients with severe alcoholic hepatitis treated with steroids: early response to therapy is the key factor. Gastroenterology. 2009;137(2):541-548.

Postoperative pain and analgesic consumption are predicted by multiple factors

A systematic review showed that preoperative pain, anxiety, age, and type of surgery predict postoperative pain, and psychological distress, age, and type of surgery predict postoperative analgesic consumption.

Citation: Ip HY, Abrishami A, Peng PW, Wong J, Chung F. Predictors of postoperative pain and analgesic consumption: a qualitative and systematic review. Anesthesiology. 2009;111(3):657-677.

Delirium in postoperative patients did not limit PCA use

This nested cohort study of 335 postoperative patients showed patients with delirium required higher doses of narcotics compared with nondelirious patients without reducing their pain scores.

Citation: Leung JM, Sands LP, Paul S, Joseph T, Kinjo S, Tsai T. Does postoperative delirium limit the use of patient-controlled analgesia in older surgical patients? Anesthesiology. 2009;111(3):625-631.

Patients starting dialysis are at approximately EIGHTfold higher risk FOR cardiac and noncardiac death

Administrative database of European patients starting dialysis found all-cause mortality increased from 12 per 1,000 person-years in the general population to 192 per 1,000 person-years in patients starting dialysis.

Citation: De Jager DJ, Grootendorst DC, Jager KJ, et al. Cardiovascular and noncardiovascular mortality among patients starting dialysis. JAMA. 2009;302(16):1782-1799.

Bronchoalveolar lavage (BAL) enzyme-linked immunospot (ELISpot) is effective for diagnosis of smear-negative pulmonary tuberculosis

Prospective multicenter trial found that BAL mononuclear cell ELISpot effectively differentiated active pulmonary tuberculosis (TB) from latent TB with a sensitivity of 91% and specificity of 80%.

Citation: Jafari C, Thijsen S, Sotgiu G, et al. Bronchoalveolar lavage enzyme-linked immunospot for a rapid diagnosis of tuberculosis: a Tuberculosis Network European Trialsgroup study. Am J Respir Crit Care Med. 2009;180(7):666-673.

Moxifloxacin is equivalent to Isoniazid in a Four-drug regimen for treatment of pulmonary tuberculosis

Randomized, blinded, placebo-controlled trial with smear positive TB treated with isoniazid or moxifloxacin in addition to rifampin, pyrazinamide, and ethambutol showed no difference in culture negativity or side effects at eight weeks.

Citation: Dorman SE, Johnson JL, Goldberg S, et al. Substitution of moxifloxacin for isoniazid during intensive phase treatment of pulmonary tuberculosis. Am J Respir Crit Care Med. 2009;180(3):273-280.

Intensity of rate control in persistent atrial fibrillation does not affect outcomes

In persistent atrial fibrillation, heart rate <80 versus heart rate ≥80 showed no difference in cardiovascular morbidity, mortality, or quality of life.

Citation: Groenveld HF, Crijns HJ, Rienstra M, Van den Berg MP, Van Veldhuisen DJ, Van Gelder IC. Does intensity of rate control influence outcome in persistent atrial fibrillation? Data of the RACE study. Am Heart J. 2009; 158(5):785-791.

N-acetylcysteine can improve nonacetaminophen acute liver failure

Patients with early-stage, non-acetaminophen-related acute liver failure have better transplant-free survival at three weeks and one year with N-acetylcysteine. There was no benefit in late-stage patients.

Citation: Lee WM, Hynan LS, Rossaro L, et al. Intravenous N-acetylcysteine improves transplant-free survival in early stage non-acetaminophen acute liver failure. Gastroenterology. 2009;137(3):856-864.