The Effect of Chronic Preoperative Opioid Use on Surgical Site Infections, Length of Stay, and Readmissions.

BACKGROUND: Chronic opioid use in the United States is a well-recognized public health concern with many negative downstream consequences. Few data exist regarding the use of preoperative opioids in relation to outcomes after elective colorectal surgery. OBJECTIVE: The purpose of this study was to determine if chronic opioid use before colorectal surgery is associated with a detriment in postoperative outcomes. DESIGN: This is a retrospective review of administrative data supplemented by individual chart review. SETTING: This study was conducted in a single-institution, multisurgeon, community colorectal training practice. PATIENTS: All patients undergoing elective colorectal surgery over a 3-year time frame (2011-2014) were selected. MAIN OUTCOME MEASURES: Opioid use was stratified based on total dose of morphine milligram equivalents (naive, sporadic use (>0-15 mg/day), regular use (>15-45 mg/day), and frequent use (>45 mg/day)). Primary outcomes were surgical site infections, length of hospital stay, and readmissions. RESULTS: Of the 923 patients, 23% (n = 213) were using opioids preoperatively. The preoperative opioid group contained more women (p = 0.047), underwent more open surgery (p = 0.003), had more nonmalignant indications (p = 0.013), and had a higher ASA classification (p = 0.003). Although median hospital stay was longer (4.7 days vs 4.0, p < 0.001), there was no difference in any surgical site infections (10.3% vs 7.1%, p = 0.123) or readmissions (14.2% vs 14.1%, p=0.954). Multivariable analysis identified preoperative opioid use (17.0% longer length of stay; 95% CI, 6.8%-28.2%) and ASA 3 or 4 (27.2% longer length of stay; 95% CI, 17.1-38.3) to be associated with an increase in length of stay. LIMITATIONS: Retrospectively abstracted opioid use and small numbers limit the conclusions regarding any dose-related responses on outcomes. CONCLUSIONS: Although preoperative opioid use was not associated with an increased rate of surgical site infections or readmissions, it was independently associated with an increased hospital length of stay. Innovative perioperative strategies will be necessary to eliminate these differences for patients on chronic opioids. See Video Abstract at http://links.lww.com/DCR/B280. EFECTOS DEL CONSUMO CRÓNICO DE OPIOIDES EN EL PREOPERATORIO CON RELACIÓN A LAS INFECCIONES DE LA HERIDA QUIRÚRGICA, LA DURACIÓN DE LA ESTADÍA Y LA READMISIÓN: El consumo crónico de opioides en los Estados Unidos es un problema de salud pública bien reconocido a causa de sus multiples consecuencias negativas ulteriores. Existen pocos datos sobre el consumo de opioides en el preoperatorio relacionado con los resultados consecuentes a una cirugía colorrectal electiva.El propósito es determinar si el consumo crónico de opioides antes de la cirugía colorrectal se asocia con un detrimento en los resultados postoperatorios.Revisión retrospectiva de datos administrativos complementada por la revisión de un gráfico individual.Ejercicio durante la formación de multiples residentes en cirugía colorrectal enTodos los pacientes de cirugía colorrectal electiva durante un período de 3 años (2011-2014).El uso de opioides se estratificó en función de la dosis total de equivalentes de miligramos de morfínicos (uso previo, uso esporádico [> 0-15 mg / día], uso regular (> 15-45 mg / día) y uso frecuente (> 45 mg / día)). Los resultados primarios fueron las infecciones de la herida quirúrgica, la duración de la estadía hospitalaria y la readmisión.De los 923 pacientes, el 23% (n = 213) consumían opioides antes de la operación. El grupo con opioides preoperatorios tenía más mujeres (p = 0.047), se sometió a una cirugía abierta (p = 0.003), tenía mas indicaciones no malignas (p = 0.013) y tenía una clasificación ASA más alta (p = 0.003). Aunque la mediana de la estadía hospitalaria fue más larga (4,7 días frente a 4,0; p <0,001), no hubo diferencia en ninguna infección de la herida quirúrgica (10,3% frente a 7,1%, p = 0,123) o las readmisiones (14,2% frente a 14,1%, p = 0,954). El análisis multivariable identificó que el uso de opioides preoperatorios (17.0% más larga LOS; IC 95%: 6.8%, 28.2%) y ASA 3 o 4 (27.2% más larga LOS; IC 95%: 17.1, 38.3) se asocia con un aumento en LOS.La evaluación retrospectiva poco precisa del consumo de opioides y el pequeño número de casos limitan las conclusiones sobre cualquier respuesta relacionada con la dosis - resultado.Si bien el consumo de opioides preoperatorios no se asoció con un aumento en la tasa de infecciones de la herida quirúrgica o las readmisiones, ella se asoció de forma independiente con un aumento de la LOS hospitalaria. Serán necesarias estrategias perioperatorias innovadoras para eliminar estas diferencias en los pacientes consumidores cronicos de opioides. Consulte Video Resumen en http://links.lww.com/DCR/B280.

Resident impact on operative duration for elective general surgical procedures.

BACKGROUND: Resident involvement in operations increases operative duration. This study investigated resident impact on operative time for a single general surgeon in an outpatient surgical setting. METHODS: A retrospective review was performed of index general surgical operations meeting inclusion criteria. Operative duration, patient demographics, 30-day complication/readmission rates, and degree of resident involvement were collected. RESULTS: 625 cases were analyzed. Patient demographics were similar for all procedural comparison groups. Operative time increased with resident involvement for each operation-umbilical hernia repairs were associated with a 19% increase (22.3 ± 6.7 versus 26.5 ± 7.5 min, p = 0.002), laparoscopic cholecystectomies demonstrated a 15% increase (25.8 ± 8.7 versus 29.7 ± 10.2 min, p = 0.001), and laparoscopic inguinal hernia repairs demonstrated a 25% increase (32.1 ± 11.3 versus 40.2 ± 8.9 min, p < 0.001). CONCLUSIONS: Each surgeon must decide if the increase in operative duration caused by resident involvement is justified by the intangible benefits residents provide.

Old dogs and new tricks: length of stay for appendicitis improves with an acute care surgery program and transition from private surgical practice to multispecialty group practice.

Acute care surgery (ACS) programs have emerged mainly at academic medical centers to provide timely care for emergency general surgery and trauma patients. We hypothesized that the development of an ACS program in a multispecialty group practice would improve outcomes for patients with acute appendicitis. A retrospective analysis of patients with acute appendicitis was performed in two time periods: 18 months of private practice and the following 12 months with ACS coverage. Length of stay was the primary outcome measure. A total of 871 patients were studied (526 private practice, 345 ACS). The ACS group had a greater proportion of laparoscopic appendectomies (P < 0.001) and more transitions in care between surgeons (P < 0.001). Length of stay was shorter in the ACS group (1.6 ± 1.5 [mean ± standard deviation] vs 1.9 ± 2.4 days, P = 0.01) and a greater proportion of surgeries were performed during the daytime (44.9 vs 36.6%, P = 0.02). Multivariate analysis demonstrated length of stay was related to appendicitis grade (P < 0.001), American Society of Anesthesiologists class (P < 0.001), symptom duration (P = 0.001), and laparoscopic approach (P < 0.001). The initial transition from private practice to ACS resulted in decreased length of stay with no increase in morbidity related to transitions of surgical care in patients with appendicitis.

The impact of location and number of cores on the diagnostic accuracy of renal mass biopsy: an ex vivo study.

OBJECTIVE: To evaluate whether renal mass biopsy (RMB) biopsy location or number affected diagnostic accuracy in a prospective ex vivo study. METHODS: Three cores (1 central and 2 peripheral) were obtained for histologic processing from each of 48 renal masses after nephrectomy. Individual biopsy cores were evaluated independently for tumor subtype and grade by a single, blinded GU pathologist. RESULTS: Although individual biopsy cores were informative and confirmed accurate in only 59 % of samples, accuracy increased to 85 % with three-core biopsy (p < 0.01). Cancer identification with a single peripheral core increased to 77 % by adding a central core (p = 0.005), to 80 % with a second peripheral core (p = 0.008), and to 85 % with three cores (p = 0.001). Similarly, diagnostic yield for histologic subtyping increased from 44 % for 1-core biopsy to 59-63 % with 2-core biopsy (p = 0.03) and to 67 % with 3-core biopsy (p = 0.02). The correct subtype was confirmed at nephrectomy for 63 % of clear cell RCC, 60 % of papillary RCC, 100 % of chromophobe RCC and 75 % of oncocytomas. When recorded, nuclear grade corresponded to final grade assignment in 56 % and was within 1 grade in an additional 37 %. CONCLUSIONS: RMB has not been used routinely in the evaluation of renal cortical neoplasms because of reportedly high rates of indeterminate or inaccurate diagnoses. In this prospective, ex vivo study, single-core RMB results in a low diagnostic yield. Obtaining multiple cores significantly improved diagnostic yield, with similar results with two-core and three-core RMB. We therefore recommend that RMB for suspicion of cancer include at least two peripheral cores.

Schwannoma of the diaphragm--a pediatric case report and review of the literature.

Diaphragmatic tumors are uncommon and difficult to diagnose in the pediatric population. Schwannoma is a benign, slow-growing peripheral nerve sheath tumor that is most commonly associated with the extremities in childhood. We herein report a schwannoma of the diaphragm in a pediatric patient and review the pediatric literature.

Megestrol acetate improves weight gain in pediatric patients with chronic kidney disease.

OBJECTIVE: Megestrol acetate (MA) has been used to treat weight loss in pediatric patients with malignancies, cystic fibrosis and HIV/AIDS. We herein report our experience with MA in pediatric patients with chronic kidney disease (CKD). DESIGN: We conducted a retrospective cohort study. Charts were evaluated for clinical, treatment, and laboratory data at six time points: approximately 6 months prior to initiation of MA, at initiation and cessation of MA, and at 2-, 4-, and 8-month follow-up. Anthropometric measurements were corrected for age and sex by conversion to z scores. SETTING: Division of Pediatric Nephrology, Helen DeVos Children's Hospital, Grand Rapids, MI. PATIENTS: Pediatric patients (n = 25) with CKD and poor weight gain. INTERVENTION: Patients were administered MA at initial and tapered doses of 14.4 ± 8.1 mg/kg/d and 10.1 ± 6.5 mg/kg/d, respectively, for 5.4 ± 6.3 months. RESULTS: The study population (n = 25) was 60% male, 16% African American, 72% white, and 12% Hispanic with a mean ± SD age of 8.9 ± 5.4 years. Prior to MA therapy, patients demonstrated a decrease in BMI and poor weight gain. The treatment phase was associated with significant increases in BMI (P < .0001) and weight (P < .0001), which were well sustained at 8-month follow-up (P < 0.01 and P < 0.001, respectively). Patients demonstrated continued increases in height. A single patient exhibited physical adverse side effects (cushingoid features) associated with MA; otherwise, MA was well tolerated. CONCLUSIONS: MA appears to effectively improve weight gain in pediatric CKD patients with minimal adverse side effects and may therefore serve as a safe, short-term, nutritional strategy.

Rasburicase improves hyperuricemia in infants with acute kidney injury.

Recent data suggest that elevated levels of uric acid (UA) might contribute to the progression of renal disease. Rasburicase, recombinant urate oxidase, is a highly safe and efficacious hypo-uricosuric agent for treatment of elevated UA levels from tumor lysis. We adopted the use of rasburicase for management of hyperuricemia in infants with acute kidney injury (AKI) and, herein, report our experience. We conducted a retrospective chart review of infants with hyperuricemia (UA > 8 mg/dl) secondary to AKI (serum creatinine > 1.5 mg/dl) treated with rasburicase. Seven infants (mean age 34 +/- 55 days, six male), with a mean weight of 3.2 +/- 1.2 kg, were identified. Rasburicase was administered intravenously as a single, onetime, bolus of 0.17 +/- 0.04 mg/kg body weight. Within 24 h, serum UA had decreased from 13.6 +/- 4.5 mg/dl to 0.9 +/- 0.6 mg/dl (P < 0.05), creatinine had decreased from 3.2 +/- 2.0 mg/dl to 2.0 +/- 1.2 mg/dl (P < 0.05), and urinary output had increased from 2.4 +/- 1.2 ml/kg per hour to 5.9 +/- 1.8 ml/kg per hour (P < 0.05). Continued improvements in UA, creatinine, and urinary output were observed in the week following administration of rasburicase, without rebound of the UA. We observed no treatment-related side effects. All patients demonstrated a normalization of uric acid level without need of renal replacement therapy. In conclusion, a single intravenously administered bolus of rasburicase appears to be a novel treatment for hyperuricemia in infants with AKI.

Severe paediatric systemic lupus erythematosus nephritis--a single-centre experience.

BACKGROUND: Paediatric patients with systemic lupus erythematosus (SLE) often have severe presentations including lupus nephritis (LN). Few paediatric studies have evaluated the anticardiolipin antibody (aCL) and renal histology. The purpose of this study was to evaluate clinicopathologic features, including aCL, short-term clinical and renal histologic outcomes of paediatric patients with new-onset SLE nephritis. METHODS: We conducted a single centre, retrospective inception cohort study. Charts were reviewed at presentation (initial renal biopsy), 6-month (follow-up biopsy) and 12-month follow-up. RESULTS: The population consisted of 21 patients (median age, 14.5 years): 19/21 were female, 6/21 African American, 3/21 Asian, 9/21 Caucasian and 3/21 Hispanic. At presentation, 19/21 had elevated aCL, 15/21 hypertensive, 12/21 nephrotic and 7/21 required haemodialysis (HD)-2/7 HD patients had thrombotic microangiopathy, 1/7 crescentic glomerulonephritis. Two patients had thromboembolism: both had aCL, were taking oral contraceptives and required HD, one was nephrotic and the other had elevated lupus anticoagulant. Initial biopsies revealed 6/21 ISN/RPS class II nephritis, 3/21 class III, 7/21 class IV and 5/21 class V. Treatment consisted of methylprednisolone, corticosteroids, cyclophosphamide or mycophenolate mofetil. Follow-up biopsies revealed 12/13 to have improved histology. Indication for a follow-up biopsy was severe illness at presentation. At 12-month follow-up, no patients were nephrotic (P < 0.001) or required HD (P < 0.001), and 3/14 had elevated aCL (P < 0.001). CONCLUSION: Elevated aCL, hypertension, nephrotic syndrome and need for HD were common presentations among our paediatric SLE nephritis population. Renal histology and aCL were helpful in the therapeutic management.

Nutritional management of hyperkalemic infants with chronic kidney disease, using adult renal formulas.

OBJECTIVE: This study sought to evaluate the use of adult renal formulas in hyperkalemic infants with chronic kidney disease (CKD). DESIGN: This was a retrospective, single-center cohort study. SETTING: This study took place at the Department of Pediatric Nephrology, Dialysis, and Transplantation at Helen DeVos Children's Hospital (Grand Rapids, MI). PATIENTS: Seven hyperkalemic infants (mean age, 6.9 months) comprised the study population: 29% with stage 3 CKD, 29% with stage 4 CKD, and 42% with stage 5 CKD. INTERVENTION: Infants were empirically treated with adult renal formulas for an average duration of 9.6 months. Six of seven infants were started on breast milk or infant formula (Similac PM 60/40, Abbott Laboratories, Columbus, OH), but because of inadequate growth and hyperkalemia, were transitioned to adult renal formulas (Suplena, Abbott Laboratories, Columbus, OH; Nepro, Abbott Laboratories, Columbus, OH; and/or Renalcal, Nestle Nutrition, Minnetonka, MN). One infant received adult renal formula at birth. MAIN OUTCOME MEASURES: The outcome measures included amount of potassium delivered by infant and adult renal formulas, level of serum potassium, and anthropometric measurements adjusted for age and gender (z-scores). RESULTS: The transition from infant to adult renal formula resulted in a decrease in mean amount of potassium delivered by formula (from 2.6 to 1.0 mEq/kg/day, P < .001) and a decrease in mean serum potassium (from 5.1 to 4.0 mmol/L, P < .01). During treatment with adult renal formula, the infants demonstrated a significant increase in mean weight z-score (from -1.0 to 0.5, P < .01), height z-score (from -1.9 to -0.5, P < .01), and head-circumference z-score (from -1.5 to -1.0, P=.03). Adult renal formulas were well-tolerated. CONCLUSIONS: Hyperkalemic infants with CKD can be nutritionally managed on adult renal formula.

Volatility of elevated serum ferritin in anemic hemodialysis patients.

BACKGROUND: Value of serum ferritin (SF) as an iron store index in hemodialysis (HD) patients has been questioned, especially at ranges >or=200. The objective of this study was to determine the variability of SF in patients with high SF (500-1,200.) and low TSAT (or=18 years, HD >or=90 days, SF 500-1,200., TSAT or=22,500 IU/week or >or=225 IU/kg/week and or=100., >or=200. and >or=300. were 61.0%, 29.3% and 12.2%, respectively, and 27% exhibited positive changes in SF. CONCLUSIONS: SF is a volatile and imprecise indicator of tissue iron stores in anemic HD patients with high SF and low TSAT. This volatility limits clinical utility of SF in this population.

Renovascular hypertension and intrarenal artery aneurysms in a preschool child.

Renovascular hypertension from renal artery aneurysmal formation is a rare complication of fibromuscular dysplasia. Few data exist to direct the management of intrarenal artery aneurysms in pediatric patients. We report the presentation, diagnosis and management of renovascular hypertension and intrarenal aneurysmal disease in a preschool child.