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E Patchen Dellinger
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ABSTRACT: Much effort has been put into the Surgical Care Improvement Project (SCIP) in an effort to reduce surgical complications with a significant emphasis on reducing the rate of surgical site infections. The causes and the prevention of surgical site infections are complex and multifactorial. By the nature of its size and scope, SCIP is naturally somewhat oversimplified and incomplete. Nevertheless, all the measures are supported by strong prospective evidence. Stulberg et al. examine the association between adherence to SCIP infection measures and the occurrence of surgical site infections in a large administrative database and conclude that while the individual measures for the most part do not appear to be associated with a lower surgical site infection risk, the performance of all relevant measures does.
Future Microbiology 12/2010; 5(12):1781-5. · 3.82 Impact Factor
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Joseph S Solomkin,
John E Mazuski,
John S Bradley,
Keith A Rodvold,
Ellie J C Goldstein,
Ellen J Baron,
Patrick J O'Neill,
Anthony W Chow, E Patchen Dellinger,
Soumitra R Eachempati,
Sherwood Gorbach,
Mary Hilfiker,
Addison K May,
Avery B Nathens,
Robert G Sawyer,
John G Bartlett
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ABSTRACT: Evidence-based guidelines for managing patients with intra-abdominal infection were prepared by an Expert Panel of the Surgical Infection Society and the Infectious Diseases Society of America. These updated guidelines replace those previously published in 2002 and 2003. The guidelines are intended for treating patients who either have these infections or may be at risk for them. New information, based on publications from the period 2003-2008, is incorporated into this guideline document. The panel has also added recommendations for managing intra-abdominal infection in children, particularly where such management differs from that of adults; for appendicitis in patients of all ages; and for necrotizing enterocolitis in neonates.
Surgical Infections 02/2010; 11(1):79-109. · 1.80 Impact Factor
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Joseph S Solomkin,
John E Mazuski,
John S Bradley,
Keith A Rodvold,
Ellie J C Goldstein,
Ellen J Baron,
Patrick J O'Neill,
Anthony W Chow, E Patchen Dellinger,
Soumitra R Eachempati,
Sherwood Gorbach,
Mary Hilfiker,
Addison K May,
Avery B Nathens,
Robert G Sawyer,
John G Bartlett
[show abstract]
[hide abstract]
ABSTRACT: Evidence-based guidelines for managing patients with intra-abdominal infection were prepared by an Expert Panel of the Surgical Infection Society and the Infectious Diseases Society of America. These updated guidelines replace those previously published in 2002 and 2003. The guidelines are intended for treating patients who either have these infections or may be at risk for them. New information, based on publications from the period 2003-2008, is incorporated into this guideline document. The panel has also added recommendations for managing intra-abdominal infection in children, particularly where such management differs from that of adults; for appendicitis in patients of all ages; and for necrotizing enterocolitis in neonates.
Clinical Infectious Diseases 01/2010; 50(2):133-64. · 9.15 Impact Factor
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ABSTRACT: Recent reports have increasingly recognized methicillin-resistant Staphylococcus aureus (MRSA) as an important etiology of pyomyositis, an uncommon disease entity. Specific virulence factors such as the Panton-Valentine leukocidin protein have been identified that may play a role in the pathophysiology of pyomyositis, especially when community-acquired MRSA is implicated.
We review a case of disseminated pyomyositis and septic pulmonary emboli in an immunocompetent adult in whom a pvl+ USA300 clone was isolated.
The degree of dissemination in this patient suggests an emerging level of virulence for community-acquired MRSA that has not been reported previously.
The clinical history and management of severe disseminated pyomyositis, including diagnostic modalities, antimicrobial therapy, and surgical drainage, require an aggressive approach.
Surgical Infections 11/2009; 11(1):59-63. · 1.80 Impact Factor
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JAMA The Journal of the American Medical Association 10/2009; 302(14):1584-5. · 30.03 Impact Factor
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Darrell A Campbell,
William G Henderson,
Michael J Englesbe,
Bruce L Hall,
Michael O'Reilly,
Dale Bratzler, E Patchen Dellinger,
Leigh Neumayer,
Barbara L Bass,
Matthew M Hutter,
James Schwartz,
Clifford Ko,
Kamal Itani,
Steven M Steinberg,
Allan Siperstein,
Robert G Sawyer,
Douglas J Turner,
Shukri F Khuri
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ABSTRACT: Surgical site infections (SSI) continue to be a significant problem in surgery. The American College of Surgeons-National Surgical Quality Improvement Program (ACS-NSQIP) Best Practices Initiative compared process and structural characteristics among 117 private sector hospitals in an effort to define best practices aimed at preventing SSI.
Using standard NSQIP methodologies, we identified 20 low outlier and 13 high outlier hospitals for SSI using data from the ACS-NSQIP in 2006. Each hospital was administered a process of care survey, and site visits were conducted to five hospitals. Comparisons between the low and high outlier hospitals were made with regard to patient characteristics, operative variables, structural variables, and processes of care.
Hospitals that were high outliers for SSI had higher trainee-to-bed ratios (0.61 versus 0.25, p < 0.0001), and the operations took significantly longer (128.3+/-104.3 minutes versus 102.7+/-83.9 minutes, p < 0.001). Patients operated on at low outlier hospitals were less likely to present to the operating room anemic (4.9% versus 9.7%, p=0.007) or to receive a transfusion (5.1% versus 8.0%, p=0.03). In general, perioperative policies and practices were very similar between the low and high outlier hospitals, although low outlier hospitals were readily identified by site visitors. Overall, low outlier hospitals were smaller, efficient in the delivery of care, and experienced little operative staff turnover.
Our findings suggest that evidence-based SSI prevention practices do not easily distinguish well from poorly performing hospitals. But structural and process of care characteristics of hospitals were found to have a significant association with good results.
Journal of the American College of Surgeons 12/2008; 207(6):810-20. · 4.55 Impact Factor
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ABSTRACT: Only limited data exist on the relationship of lung function to patients with extreme obesity. To assess the relationship between lung function tests and clinical characteristics in a cohort of morbidly obese patients undergoing evaluation for bariatric procedures in a university hospital in the United States.
Consecutive patients undergoing clinical evaluation were reviewed. The variables included demographic, anthropometric, clinical, and pulmonary function data.
A total of 229 patients underwent a standardized preoperative evaluation. Of these 229 patients, 136 (59%) had evaluable data and 102 (75%) were women. The mean +/- standard deviation age was 45 +/- 10 years, the mean weight was 164 +/- 42 kg, and the mean body mass index was 57 +/- 13 kg/m2. Smoking or asthma was reported in 38% and 24% of patients, respectively. The mean forced vital capacity and forced expiratory volume in 1 s was 80% +/- 17% of predicted and 76% +/- 19% of predicted, respectively. Of the 136 patients, 29% had a measured forced expiratory volume in 1 s/forced vital capacity of >or=.08 below the predicted ratio. The mean total lung capacity was 86% +/- 14% of predicted; 26% of subjects had a total lung capacity <80% of predicted. Multivariate logistic regression analysis demonstrated an association of obstructive ventilatory defects with male gender (odds ratio [OR] 2.35, 95% confidence interval [CI] 1.00-5.50) and current or previous smoking (OR 2.41, 95% CI 1.10-5.30), but not body mass index. Restrictive defects were associated with body mass index (OR 1.06, 95% CI 1.01-1.10), in particular, obesity hypoventilation syndrome (OR 3.7, 95% CI 1.2-11.1).
The mean preoperative spirometry, lung volumes, and gas exchange values were within the established reference ranges. Restrictive ventilatory defects were less common than obstructive ventilatory patterns and were most prominently associated with obesity hypoventilation syndrome.
Surgery for Obesity and Related Diseases 08/2008; 4(5):632-9; discussion 639. · 3.93 Impact Factor
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ABSTRACT: A subset of obese people develop a pannus hanging to the floor. This panniculus morbidus prevents weight loss, as the patient cannot exercise. It prevents hygiene, leading to a profound odor and ultimately results in intertrigo, cellulitis, and/or abdominal ulceration. The only two options are to live/die with it or resect it. Some of these people are otherwise ready for a weight loss program. For this group, resection of the panniculus morbidus may be indicated. The authors reviewed the literature and found the condition has not been addressed in this Journal since 1994 and was not considered in the recent supplement on body contouring. In 1998, the authors began resecting panniculus morbidus for this small group. The authors found the learning curve to be profoundly steep, with many wound complications, a finding that is quite in conflict with the literature on the subject, and decided to present their experience.
The authors conducted a retrospective chart review of 23 patients and collected data on demographics, ambulation, hygiene, technique, complications, and outcome.
The technique of closure evolved as the authors struggled with complications. The current method of closure is three suture layers over four suction drains with a small wound vacuum-assisted closure device at each end of the incision. All patients ultimately healed and found it easier to ambulate and perform hygiene.
Resection of panniculus morbidus is a beneficial salvage procedure for some morbidly obese people, but the learning curve is steep and the current literature is misleading.
Plastic and reconstructive surgery 02/2008; 121(1):108-14. · 2.74 Impact Factor
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E Patchen Dellinger,
Jose M. Tellado,
Norberto E. Soto,
Stanley W. Ashley,
Philip S. Barie,
Thierry Dugernier,
Clement W. Imrie,
Colin D. Johnson,
Hanns-Peter Knaebel,
Pierre-Francois Laterre,
Enrique Maravi-Poma,
Jorge J. Olsina Kissler,
Miguel Sanchez Garcia,
Stefan Utzolino,
for the Pancreatitis Study Group
Annals of Surgery 01/2008; 247(2):394-395. · 7.49 Impact Factor
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JAMA The Journal of the American Medical Association 10/2007; 298(12):1442-4. · 30.03 Impact Factor
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E Patchen Dellinger,
Jose M Tellado,
Norberto E Soto,
Stanley W Ashley,
Philip S Barie,
Thierry Dugernier,
Clement W Imrie,
Colin D Johnson,
Hanns-Peter Knaebel,
Pierre-Francois Laterre,
Enrique Maravi-Poma,
Jorge J Olsina Kissler,
Miguel Sanchez-Garcia,
Stefan Utzolino
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ABSTRACT: In patients with severe, necrotizing pancreatitis, it is common to administer early, broad-spectrum antibiotics, often a carbapenem, in the hope of reducing the incidence of pancreatic and peripancreatic infections, although the benefits of doing so have not been proved.
A multicenter, prospective, double-blind, placebo-controlled randomized study set in 32 centers within North America and Europe. Participants: One hundred patients with clinically severe, confirmed necrotizing pancreatitis: 50 received meropenem and 50 received placebo. Interventions: Meropenem (1 g intravenously every 8 hours) or placebo within 5 days of the onset of symptoms for 7 to 21 days. Main Outcome Measures: Primary endpoint: development of pancreatic or peripancreatic infection within 42 days following randomization. Other endpoints: time between onset of pancreatitis and the development of pancreatic or peripancreatic infection; all-cause mortality; requirement for surgical intervention; development of nonpancreatic infections within 42 days following randomization.
Pancreatic or peripancreatic infections developed in 18% (9 of 50) of patients in the meropenem group compared with 12% (6 of 50) in the placebo group (P = 0.401). Overall mortality rate was 20% (10 of 50) in the meropenem group and 18% (9 of 50) in the placebo group (P = 0.799). Surgical intervention was required in 26% (13 of 50) and 20% (10 of 50) of the meropenem and placebo groups, respectively (P = 0.476).
This study demonstrated no statistically significant difference between the treatment groups for pancreatic or peripancreatic infection, mortality, or requirement for surgical intervention, and did not support early prophylactic antimicrobial use in patients with severe acute necrotizing pancreatitis.
Annals of Surgery 05/2007; 245(5):674-83. · 7.49 Impact Factor
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ABSTRACT: Necrotizing soft-tissue infections (NSTIs) are highly lethal. They are frequent enough that general and specialty physicians will likely have to be involved with the management of at least 1 patient with NSTI during their practice, but they are infrequent enough that familiarity with the disease will seldom be achieved. Establishing the diagnosis of NSTI can be the main challenge in treating patients with NSTI, and knowledge of all available tools is key for early and accurate diagnosis. The laboratory risk indicator for necrotizing fasciitis score can be helpful for distinguishing between cases of cellulitis, which should respond to medical management alone, and NSTI, which requires operative debridement in addition to antimicrobial therapy. Imaging studies are less helpful. The mainstay of treatment is early and complete surgical debridement, combined with antimicrobial therapy, close monitoring, and physiologic support. Novel therapeutic strategies, including hyperbaric oxygen and intravenous immunoglobulin, have been described, but their effect is controversial. Identification of patients at high risk of mortality is essential for selection of patients that may benefit from future novel treatments and for development and comparison of future trials.
Clinical Infectious Diseases 04/2007; 44(5):705-10. · 9.15 Impact Factor
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ABSTRACT: Obesity is common in the Western world, and obese persons constitute a growing population of surgical patients for both bariatric and non-bariatric operations. It is the traditional perception that obese patients have a higher risk of perioperative morbidity and mortality, although different studies show contradictory results.
To better delineate the perioperative morbidity and mortality in obese patients.
Review of the pertinent English-language literature
Obesity is a risk factor for nosocomial infection, particularly surgical site infection (SSI). The mechanisms by which obese patients may be at higher risk for SSI are reviewed, and specific recommendations are outlined that should be implemented when treating obese patients to minimize potentially preventable SSIs.
The growing prevalence of obesity and the increasing number of operations performed on obese patients, whether to achieve weight loss or for other purposes, will have a substantial impact on health care resources. Vigilant identification of high-risk patients and provision of all proved preventive measures must suffice until new methods of prevention are identified and validated.
Surgical Infections 11/2006; 7(5):473-80. · 1.80 Impact Factor
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ABSTRACT: Case series demonstrate that bariatric surgery can be performed with a low rate of perioperative mortality (0.5%), but the rate among high-risk patients and the community at large is unknown.
To evaluate the risk of early mortality among Medicare beneficiaries and to determine the relative risk of death among older patients.
Retrospective cohort study.
All fee-for-service Medicare beneficiaries, 1997-2002.
Thirty-day, 90-day, and 1-year postsurgical all-cause mortality among patients undergoing bariatric procedures.
A total of 16 155 patients underwent bariatric procedures (mean age, 47.7 years [SD, 11.3 years]; 75.8% women). The rates of 30-day, 90-day, and 1-year mortality were 2.0%, 2.8%, and 4.6%, respectively. Men had higher rates of early death than women (3.7% vs 1.5%, 4.8% vs 2.1%, and 7.5% vs 3.7% at 30 days, 90 days, and 1 year, respectively; P<.001). Mortality rates were greater for those aged 65 years or older compared with younger patients (4.8% vs 1.7% at 30 days, 6.9% vs 2.3% at 90 days, and 11.1% vs 3.9% at 1 year; P<.001). After adjustment for sex and comorbidity index, the odds of death within 90 days were 5-fold greater for older Medicare beneficiaries (aged > or =75 years; n = 136) than for those aged 65 to 74 years (n = 1381; odds ratio, 5.0; 95% confidence interval, 3.1-8.0). The odds of death at 90 days were 1.6 times higher (95% confidence interval, 1.3-2.0) for patients of surgeons with less than the median surgical volume of bariatric procedures (among Medicare beneficiaries during the study period) after adjusting for age, sex, and comorbidity index.
Among Medicare beneficiaries, the risk of early death after bariatric surgery is considerably higher than previously suggested and associated with advancing age, male sex, and lower surgeon volume of bariatric procedures. Patients aged 65 years or older had a substantially higher risk of death within the early postoperative period than younger patients.
JAMA The Journal of the American Medical Association 10/2005; 294(15):1903-8. · 30.03 Impact Factor
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ABSTRACT: Despite a large body of evidence describing care processes known to reduce the incidence of surgical site infections, many are underutilized in practice.
Fifty-six hospitals volunteered to redesign their systems as part of the National Surgical Infection Prevention Collaborative, a 1-year demonstration project sponsored by the Centers for Medicare & Medicaid Services. Each facility selected quality improvement objectives for a select group of surgical procedures and reported monthly clinical process measure data.
Forty-four hospitals reported data on 35,543 surgical cases. Hospitals improved in measures related to appropriate antimicrobial agent selection, timing, and duration; normothermia; oxygenation; euglycemia; and appropriate hair removal. The infection rate decreased 27%, from 2.3% to 1.7% in the first versus last 3 months.
The Collaborative demonstrated improvement in processes known to be associated with reduced risk of surgical site infections. Quality improvement organizations can be effective resources for quality improvement in the surgical arena.
The American Journal of Surgery 08/2005; 190(1):9-15. · 2.78 Impact Factor
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ABSTRACT: Surgical site infections (SSIs) are a major contributor to patient injury, mortality, and health care costs. Despite evidence of effectiveness of antimicrobials to prevent SSIs, previous studies have demonstrated inappropriate timing, selection, and excess duration of administration of antimicrobial prophylaxis. We herein describe the use of antimicrobial prophylaxis for Medicare patients undergoing major surgery.
National retrospective cohort study with medical record review.
Two thousand nine hundred sixty-five acute-care US hospitals.
A systematic random sample of 34,133 Medicare inpatients undergoing coronary artery bypass grafting; other open-chest cardiac surgery (excluding transplantation); vascular surgery, including aneurysm repair, thromboendarterectomy, and vein bypass operations; general abdominal colorectal surgery; hip and knee total joint arthroplasty (excluding revision surgery); and abdominal and vaginal hysterectomy from January 1 through November 30, 2001.
The proportion of patients who had parenteral antimicrobial prophylaxis initiated within 1 hour before the surgical incision; the proportion of patients who were given a prophylactic antimicrobial agent that was consistent with currently published guidelines; and the proportion of patients whose antimicrobial prophylaxis was discontinued within 24 hours after surgery.
An antimicrobial dose was administered to 55.7% (95% confidence interval [CI], 54.8%-56.6%) of patients within 1 hour before incision. Antimicrobial agents consistent with published guidelines were administered to 92.6% (95% CI, 92.3%-92.8%) of the patients. Antimicrobial prophylaxis was discontinued within 24 hours of surgery end time for only 40.7% (95% CI, 40.2%-41.2%) of patients.
Substantial opportunities exist to improve the use of prophylactic antimicrobials for patients undergoing major surgery.
Archives of Surgery 03/2005; 140(2):174-82. · 4.24 Impact Factor
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ABSTRACT: Although peritonitis has been recognized as a common and complex disease entity since ancient times, the true understanding and pathophysiology, as well as treatment of peritonitis, continue to plague surgeons and physicians. The clinical course and outcome of peritonitis is dependent upon the struggle between the quantity and virulence of the pathogen and host's physiologic reserve, including the ensuing inflammatory response. The current multimodality treatment of intraabdominal infections is based upon the fundamental principles established by Polk in 1979: surgical source control, fluid resuscitation, adequate nutrition, support of failing organ systems, and antibiotics. Although dramatic advances have been made in the pharmacological treatment of intraabdominal infections, mortality for complicated cases remains high. Consequently, future directions in management of peritonitis may require agents that target specific endotoxin receptors, inflammatory signaling molecules, or immunomodulatory moieties.
Surgical technology international 02/2005; 14:29-33.
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ABSTRACT: Bariatric procedures are increasingly performed but their impact on survival is unknown.
We evaluated short- and longterm mortality rates of patients undergoing gastric bypass on a population level compared with a nonoperated cohort of patients with morbid obesity in a retrospective study, using the Washington State Comprehensive Hospital Abstract Reporting System database and the Vital Statistics database. The study included all patients (age 18 to 65 years) from 1987 to 2001 who underwent gastric bypass with ICD-9 diagnostic codes for obesity. The comparator group included patients of similar age with a diagnosis of obesity or morbid obesity who did not have a bariatric procedure. Survival analysis was used to determine the association of surgeon experience on 30-day mortality and of the procedure on survival while controlling for age, gender, and comorbidity index.
Of the 66,109 obese patients we evaluated, 3,328 had a bariatric procedure. Incidence of the procedure increased from 0.7 to 10.6 per 100,000 from 1987 to 2001, with a 2.5-fold increase in incidence rate of the procedure in the years after 1996 (incidence rate ratio, 2.5; 95% CI, 2.4 to 2.7). Thirty-day mortality was 1.9% and was associated with surgical inexperience. Within the surgeon's first 19 procedures the odds of death within 30 days were 4.7 times higher (95% CI, 1.2 to 18.2) than at later points in a surgeon's case order. At 15 years followup, 16.3% of nonoperated patients had died as compared with 11.8% of patients who had the bariatric procedure. When survival was compared beginning 1 year after the procedure, the adjusted hazard for death was 33% lower than that of nonoperated patients (hazard ratio 0.67; 95% CI, 0.54 to 0.85).
Thirty-day mortality after gastric bypass is higher than previously reported and closely linked to surgeon inexperience. A modest overall survival benefit was associated with the procedure but a marked survival advantage was noted for patients who survive to the first postoperative year.
Journal of the American College of Surgeons 11/2004; 199(4):543-51. · 4.55 Impact Factor
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ABSTRACT: Blood transfusions remain common practice in the critical care and surgical settings. Transfusions carry significant risks, including risks for transmission of infectious agents and immune suppression. Transmission of bacterial infections, although rare, is the most common adverse event with transfusion. The risk for transmission of viral infections has decreased over time, clearly because tests are becoming more sensitive in detecting certain viral infections such as hepatitis B, hepatitis C, and HIV. Several immunomodulatory effects are thought to be related to transfusions, and these can result in cancer recurrence, mortality, and postoperative infections. Numerous studies have been performed to examine the role of leukoreduction in decreasing these transfusion-related complications but results remain contradictory. We review the infectious risks associated with blood transfusion and the most recent data on its immunologic effects, specifically on cancer recurrence, mortality, and postoperative infections in surgical patients. We also review the use of leukoreduction in blood transfusion and its role in preventing transfusion-transmitted infections and immunomodulatory complications.
Critical care (London, England) 02/2004; 8 Suppl 2:S18-23. · 4.61 Impact Factor
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ABSTRACT: Our objective was to compare the economic benefits of cefepime plus metronidazole with those of imipenem/cilastatin in the treatment of complicated intra-abdominal infections.
We used a retrospective analysis of clinical outcomes and health resource utilization data collected during a randomized, double-blind, multi-center clinical trial. Seventeen university-affiliated hospitals in the United States and Canada participated, as did 323 patients with complicated intra-abdominal infections. Decision analysis was conducted using a decision node of cefepime vs. imipenem, and chance nodes that included an Acute Physiology and Chronic Health Evaluation (APACHE) II score of #15 versus .15; a need for posttreatment surgical procedures; and clinical outcomes. Effectiveness of treatment was measured by differences in the length and cost of hospital stays, the number and cost of surgical procedures after treatment, cure rates, and the cost of antibiotics. Also evalulated were the incremental costs of cure (i.e., the costs of additional cures).
Comparing cefepime plus metronidazole with imipenem/cilastatin, the expected cost of patient care was $8,218 versus $10,414, respectively, and the cost-effectiveness ratio per cure was $10,058 versus $13,685. For severely ill patients (APACHE II score .15), the expected cost was $12,962 versus $23,153, and the cost-effectiveness ratio per cure was $15,321 versus $64,313.
Cefepime plus metronidazole was more cost-effective than imipenem/cilastatin in the treatment of complicated intra-abdominal infections, primarily because of fewer post-treatment surgical procedures and shorter hospital stays. The primary advantage accrued to severely ill patients who had an APACHE II score .15.
Surgical Infections 02/2004; 5(3):269-80. · 1.80 Impact Factor
