Association Between Preoperative Proteinuria and Postoperative Acute Kidney Injury and Readmission.

Importance: Proteinuria indicates renal dysfunction and is a risk factor for morbidity among medical patients, but less is understood among surgical populations. There is a paucity of studies investigating how preoperative proteinuria is associated with surgical outcomes, including postoperative acute kidney injury (AKI) and readmission. Objective: To assess preoperative urine protein levels as a biomarker for adverse surgical outcomes. Design, Setting, and Participants: A retrospective, population-based study was conducted in a cohort of patients with and without known preoperative renal dysfunction undergoing elective inpatient surgery performed at 119 Veterans Affairs facilities from October 1, 2007, to September 30, 2014. Data analysis was conducted from April 4 to December 1, 2016. Preoperative dialysis, septic, cardiac, ophthalmology, transplantation, and urologic cases were excluded. Exposures: Preoperative proteinuria as assessed by urinalysis using the closest value within 6 months of surgery: negative (0 mg/dL), trace (15-29 mg/dL), 1+ (30-100 mg/dL), 2+ (101-300 mg/dL), 3+ (301-1000 mg/dL), and 4+ (>1000 mg/dL). Main Outcomes and Measures: Primary outcome was postoperative predischarge AKI and 30-day postdischarge unplanned readmission. Secondary outcomes included any 30-day postoperative outcome. Results: Of 346 676 surgeries, 153 767 met inclusion criteria, with the majority including orthopedic (37%), general (29%), and vascular procedures (14%). Evidence of proteinuria was shown in 43.8% of the population (trace: 20.6%, 1+: 16.0%, 2+: 5.5%, 3+: 1.6%) with 20.4%, 14.9%, 4.3%, and 0.9%, respectively, of the patients having a normal preoperative estimated glomerular filtration rate (eGFR). In unadjusted analysis, preoperative proteinuria was significantly associated with postoperative AKI (negative: 8.6%, trace: 12%, 1+: 14.5%, 2+: 21.2%, 3+: 27.6%; P < .001) and readmission (9.3%, 11.3%, 13.3%, 15.8%, 17.5%, respectively, P < .001). After adjustment, preoperative proteinuria was associated with postoperative AKI in a dose-dependent relationship (trace: odds ratio [OR], 1.2; 95% CI, 1.1-1.3, to 3+: OR, 2.0; 95% CI, 1.8-2.2) and 30-day unplanned readmission (trace: OR, 1.0; 95% CI, 1.0-1.1, to 3+: OR, 1.3; 95% CI, 1.1-1.4). Preoperative proteinuria was associated with AKI independent of eGFR. Conclusions and Relevance: Proteinuria was associated with postoperative AKI and 30-day unplanned readmission independent of preoperative eGFR. Simple urine assessment for proteinuria may identify patients at higher risk of AKI and readmission to guide perioperative management.

The Fifth Vital Sign: Postoperative Pain Predicts 30-day Readmissions and Subsequent Emergency Department Visits.

OBJECTIVE: We hypothesized that inpatient postoperative pain trajectories are associated with 30-day inpatient readmission and emergency department (ED) visits. BACKGROUND: Surgical readmissions have few known modifiable predictors. Pain experienced by patients may reflect surgical complications and/or inadequate or difficult symptom management. METHODS: National Veterans Affairs Surgical Quality Improvement data on inpatient general, vascular, and orthopedic surgery from 2008 to 2014 were merged with laboratory, vital sign, health care utilization, and postoperative complications data. Six distinct postoperative inpatient patient-reported pain trajectories were identified: (1) persistently low, (2) mild, (3) moderate or (4) high trajectories, and (5) mild-to-low or (6) moderate-to-low trajectories based on postoperative pain scores. Regression models estimated the association between pain trajectories and postdischarge utilization while controlling for important patient and clinical variables. RESULTS: Our sample included 211,231 surgeries-45.4% orthopedics, 37.0% general, and 17.6% vascular. Overall, the 30-day unplanned readmission rate was 10.8%, and 30-day ED utilization rate was 14.2%. Patients in the high pain trajectories had the highest rates of postdischarge readmissions and ED visits (14.4% and 16.3%, respectively, P < 0.001). In multivariable models, compared with the persistently low pain trajectory, there was a dose-dependent increase in postdischarge ED visits and readmission for pain-related diagnoses, but not postdischarge complications (χ trend P < 0.001). CONCLUSIONS: Postoperative pain trajectories identify populations at risk for 30-day readmissions and ED visits, and do not seem to be mediated by postdischarge complications. Addressing pain control expectations before discharge may help reduce surgical readmissions in high pain categories.

Hospital Readmissions after Surgery: How Important Are Hospital and Specialty Factors?

BACKGROUND: Hospital readmission rates after surgery can represent an overall hospital effect or a combination of specialty and patient effects. We hypothesized that hospital readmission rates for procedures within specialties were more strongly correlated than rates across specialties within the same hospital. STUDY DESIGN: For general, orthopaedic, and vascular specialties at Veterans Affairs hospitals during 2008 to 2014, 30-day risk-adjusted readmission rates were estimated for 6 high-volume procedures and each specialty. Relationships were assessed using the Pearson correlation coefficient. RESULTS: At 84 hospitals, 64,724 orthopaedic, 24,963 general, and 10,399 vascular inpatient procedures were performed; mean readmission rates were 6.3%, 13.6%, and 16.4%, respectively. There was no correlation between specialty-specific adjusted hospital readmission rates: general and orthopaedic (r = 0.21; p = 0.06), general and vascular (r = 0.15; p = 0.19), and vascular and orthopaedic surgery (r = 0.07; p = 0.55). Within specialties, we found modest correlations between knee and hip arthroplasty readmission rates (r = 0.39; p < 0.01) and colectomy and ventral hernia repair (r = 0.24; p = 0.03), but not between lower-extremity bypass and endovascular aortic repair (r = 0.13; p = 0.26). Overall, controlling for patient-level factors, 1.9% of the variation in readmissions was attributable to specialty-level factors; only 0.6% was attributable to hospital-level factors. CONCLUSIONS: Hospital readmission rates for orthopaedic, vascular, and general surgery were not correlated between specialties; within each of the 3 specialties, modest correlations were found between 2 procedures within 2 of these specialties. These findings suggest that hospital surgical readmission rates are primarily explained by patient- and procedure-specific factors and less by broader specialty and/or hospital effects.

Mesenteric venous thrombosis in inflammatory bowel disease.

Mesenteric venous thrombosis (MVT) is a rare but potentially catastrophic clinical complication, which may lead to ischemia or infarction of the intestine and/or the emergence of portal hypertension. An association between inflammatory bowel disease (IBD) and MVT has previously been described, but clinical factors that may contribute to this complication in the setting of IBD are not well characterized. Diagnosis of MVT in IBD is difficult, as patients frequently present with nonspecific abdominal discomfort, which may delay diagnosis and initiation of treatment. We report 6 of 545 IBD patients at our center (1.1%) that developed MVT, and describe presentation, diagnostic approaches, treatment options, underlying contributing factors, and outcome. The diagnosis was determined with abdominal computed tomography (CT) in 5 of 6 cases. Clinical factors, which were thought to contribute to MVT, included underlying hypercoagulability, low-flow state, uncontrolled inflammation, perioperative time period, and prior surgical manipulation of the portal vein following orthotopic liver transplantation. There were no deaths as a result of MVT, although 1 patient developed severe portal hypertension and another experienced intestinal infarction requiring extensive resection. We conclude that MVT is an important clinical consideration in IBD patients, specifically during the perioperative setting, and diagnosis is facilitated with the use of CT scan.

Radiographic underestimation of small bowel stricturing Crohn's disease: a comparison with surgical findings.

BACKGROUND: The purpose of this study was to determine the accuracy of barium radiography compared with intraoperative evaluation with passage of a balloon catheter for assessment of stricturing Crohn's disease (CD). METHODS: After institutional review board approval, we retrospectively reviewed a tertiary inflammatory bowel disease center's consecutive records of surgical patients between 1998 and 2003 with small intestinal CD to compare the number of strictures found at surgery with those identified preoperatively by barium imaging. Age, gender, prior surgical procedures, and steroid usage were recorded. By decision of the surgeons, all patients were treated with an identical approach that utilized intraluminal sizing with passage of a balloon-tipped catheter. RESULTS: In 118 patients, 230 strictures were identified by barium examination; 365 strictures were identified using the balloon catheter technique. Barium examination overestimated or underestimated the number of strictures in 43 of 118 patients (36%). Overall, barium radiography was least accurate in patients with strictures amenable to strictureplasty. Prior surgery and multiple strictures identified preoperatively by barium studies were found to decrease the accuracy of the barium examination, but the decrease did not reach statistical significance. After successful surgery for stricturing small intestinal CD, more than 90% of patients can successfully be weaned from their steroids within 3 months. Failure to be able to wean from steroids may suggest a missed stricture. CONCLUSIONS: Our data suggest that careful exploration and intraoperative, intraluminal testing of intestinal patency identify additional strictures compared with barium radiographs in a significant number of patients with CD undergoing small bowel surgical intervention.

Total antioxidant capacity following extrinsic denervation and small intestinal transplantation in the rat.

Transplantation of small intestine in a rat model has been shown to affect expression of neurochemicals within enteric inhibitory nerves. However, the mechanism for altered expression of inhibitory neurochemicals is uncertain. Based on our previous studies, we hypothesized that small intestinal transplantation would result in altered intestinal levels of antioxidant capacity. Glutathione, total antioxidant capacity, and lipid peroxide levels were measured at 3 months following (1) transection of rat small intestine, (2) transection and extrinsic denervation of rat intestine, and (3) isotransplantation of rat ileum or (4) allotransplantation of rat ileum with cyclosporine therapy to suppress rejection. Glutathione levels were not significantly different among the four groups. There were trends toward increased lipid peroxide levels following isografting and extrinsic denervation. Total antioxidant capacity was increased following extrinsic denervation (P=0.05). Increased intestinal total antioxidant capacity in response to extrinsic denervation may represent a compensatory mechanism for protection against oxidative stress. This result enhances our understanding of the relationship between tissue antioxidant levels and alteration of enteric nerves.

Case report: "Popcorn" dystrophic ileal calcification in a patient with Crohn's disease.

Small bowel calcification is a rare finding, often associated with chronic infection or small intestinal neoplasms. The authors report a patient who developed dystrophic ileal calcification in the setting of medically refractory Crohn's disease. The patient had longstanding, obstructive ileal Crohn's disease, treated with corticosteroids for a 10-year period. Diffuse terminal ileal calcification was evident on radiographic studies, including plain films as well as abdominal CT scan. The patient underwent successful resection of the diseased segment of small bowel and has done well over the ensuing 3-year period. Dystrophic calcification is a rare complication of long-standing chronic inflammation in Crohn's disease that may occur in the absence of adenocarcinoma or chronic infection.

Prevention of blood exposure: body and facial protection

Regardless of the specific clinical setting in the operating room, it is clear that better protection of all personnel is an appropriate objective in the current environment. Better protection through improved PPE and modification of operational practices is essential. A prompt response to blood contact when it does occur is likewise appropriate. With conscientious applications of methods to reduce blood exposure, it is hoped that the operating room can become a safer place with respect to occupational infections from bloodborne pathogens

The migrating myoelectric complex of the small intestine.

Gastric and small intestinal myoelectric and motor activity is divided into two main patterns, fed and fasted. During fasting, the predominant pattern of activity is the migrating myoelectric complex (MMC), a cyclically occurring pattern of electric and mechanical activity that is initiated in the stomach and duodenum almost simultaneously and, from there, propagates the length of the small intestine. Cyclic motor activity also occurs in the lower esophageal sphincter, the gallbladder, and the sphincter of Oddi with a duration that is related to the MMC in the small intestine. Of the possible mechanisms for initiation of the MMC in the small intestine (extrinsic neural control, intrinsic neural control, and hormonal control), intrinsic neural control via a series of coupled is the most likely. The keep this sentence in! hormone motilin also plays a role in the initiation of MMCs. After a meal, in man the MMC is disrupted and replaced by irregular contractions. The physiologic role of the MMC is to clear the stomach and small intestine of residual food, secretions, and desquamated cells and propel them to the colon. Disruption of the MMC cycle is associated with bacterial overgrowth in some patients, an observation that supports the proposed cleansing function of the MMC cycle.