Failure to Rescue in Major Abdominal Surgery: A Regional Australian Experience.

BACKGROUND: Failure to rescue (FTR) is increasingly recognised as a measure of the quality care provided by a health service in recognising and responding to patient deterioration. We report the association between a patient's pre-operative status and FTR following major abdominal surgery. METHODS: A retrospective chart review was conducted on patients who underwent major abdominal surgery and who suffered Clavien-Dindo (CDC) III-V complications at the University Hospital Geelong between 2012 and 2019. For each patient suffering a major complication, pre-operative risk factors including demographics, comorbidities (Charlson Comorbidity Index (CCI)), American Society of Anaesthesiology (ASA) Score and biochemistry were compared for patients who survived and patients who died. Statistical analysis utilised logistic regression with results reported as odds ratios (ORs) and 95% confidence intervals (CIs). RESULTS: There were 2579 patients who underwent major abdominal surgery, of whom 374 (14.5%) suffered CDC III-V complications. Eighty-eight patients subsequently died from their complication representing a 23.5% FTR and an overall operative mortality of 3.4%. Pre-operative risk factors for FTR included ASA score ≥ 3, CCI ≥ 3 and pre-operative serum albumin of < 35 g/L. Operative risk factors included emergency surgery, cancer surgery, greater than 500 ml intraoperative blood loss and need for ICU admission. Patients who suffered end-organ failure were more likely to die from their complication. CONCLUSION: Identification of patients at high risk of FTR should they develop a complication would inform shared decision-making, highlight the need for optimisation prior to surgery, or in some cases, result in surgery not being undertaken.

Risk Factors for Surgical Site Infection in Minor Dermatological Surgery: A Systematic Review.

OBJECTIVE: To identify patient- and procedure-related risk factors for surgical site infection following minor dermatological surgery. DATA SOURCES: The MEDLINE, Cumulative Index of Nursing and Allied Health Literature, Informit, and Scopus databases were searched for relevant literature on patient populations receiving minor surgery, where risk factors for surgical site infection were explicitly stated. STUDY SELECTION: Studies involving major dermatological surgery were excluded. The preliminary search yielded 820 studies after removing duplicates; 210 abstracts were screened, and 42 full texts were assessed for eligibility. A total of 13 articles were included. Studies were appraised using the Newcastle-Ottawa Quality Assessment Scale. DATA EXTRACTION: An electronic data collection tool was constructed to extract information from the eligible studies, and this information was distributed to participating authors. DATA SYNTHESIS: Risk factors identified included age, sex, diabetes mellitus, chronic obstructive pulmonary disease, use of antihypertensive or corticosteroid medications, smoking, surgery on the lower or upper extremities, excision of nonmelanocytic skin cancers, large skin excisions, and complex surgical techniques. No more than two studies agreed on any given risk factor, and there were insufficient studies for meta-analysis. CONCLUSIONS: Re-excision of skin cancer, below-knee excisions, and intraoperative hemorrhagic complications were predictive for infection in more than one study. More high-quality studies are required to accurately identify risk factors so they can be reliably used in clinical guidelines.

Building a bridge from the swamp to the ivory tower: Conducting randomised controlled trials in general practice

BACKGROUND: Primary care research is underfunded. Few randomised controlled trials (RCTs) are conducted in a primary care setting. However, it is important that clinical practice be informed by adequate primary care evidence so general practitioners (GPs) have tools and guidelines applicable to the patients they see. OBJECTIVE: The aim of this article is to describe and reflect on the experience of conducting five RCTs between 2003 and 2017 in a general practice setting with minimal funding, in North Queensland. DISCUSSION: Enabling factors include using grassroots research questions and engaging practice nurses. Barriers include ethics applications and insufficient funding. Recommendations to reduce study costs include compensating practice nurses rather than GP time. The findings are designed to encourage grassroots GPs to consider participating in pragmatic, feasible projects. The success of the projects was underpinned by the fact that they were established by a group of GPs who had interesting questions that were relevant to their clinical practice and not answered by current evidence.

Comparative trial assessing suture techniques and types of urinary catheters in vesicourethral anastomotic tensile strength in a porcine model.

PURPOSE: Vesicourethal anastomosis (VUA) during radical prostatectomy can be achieved using various suture plication techniques. Traditionally, an indwelling urinary catheter remains in-situ to facilitate the healing process of the reconstructed VUA. Compromise or rupture of this anastomosis may lead to acute urinary leak and subsequent urinoma or stricture formation. This ex-vivo porcine model aims to evaluate VUA tensile strength using different suture techniques and catheter types. METHODS: Male porcine bladders were obtained and prostatectomy was performed. The specimens were randomized and VUA were created using 3-point interrupted, 6-point interrupted or 6 point continuous 3-0 monocryl suture. 20Fr catheters were utilized, specifically varying manufacturers (A and B) and catheter balloon shapes (round versus oval). The VUA model was placed within a reproducible pulley system and graduated weights were applied until failure of the catheter balloon or the model VUA. Model failure was defined as either 'VUA rupture', 'Catheter passage through VUA' or 'catheter failure'. RESULTS: Twenty consecutive porcine bladders were prepared, tested and utilized for analysis. VUA reconstructed with 3-point fixation was more likely to suffer VUA rupture (p=0.025) compared to 6-point interrupted or 6-point continuous VUA. Higher tensile pressure causing catheter balloon rupture (p=0.009) was observed for Manufacturer A. Catheters with oval-balloon shape were more likely to dislodge past the VUA without disruption of the anastomosis (p=0.002). CONCLUSIONS: During prostatectomy, anastomotic technique and catheter selection can significantly alter the tensile properties of the VUA. Further research is required to validate our findings in clinical models.

Congenital contralateral venous drainage of a right ectopic kidney to left common iliac vein: a rare case report

Arterial renovascular variation is common. However, specific reports of variations in renal venous drainage are limited. We report a case of a rare renovascular anatomical variant incidentally identified via abdominal computed tomography (CT). The right kidney was anteriorly rotated and low lying (iliac). The arterial supply entered the hilum of the kidney from two branches, specifically, from the abdominal aorta at L3/L4 and at the bifurcation of the aorta. Venous drainage was similarly variant with the superior pole draining into the inferior vena cava (IVC) at L3/L4. The inferior pole drained to the contralateral (left) common iliac vein coursing anteriorly to the right common iliac vein. To our knowledge, this particular venous variation has not been previously documented. This case is discussed in relation to renovascular embryology and clinical relevance for specialists operating within the retroperitoneum

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