The Fragility Index (FI) is the minimum number of participants in a randomized clinical trial (RCT) whose status would have to change from a nonevent (not experiencing the primary end point) to an ...event (experiencing the primary end point) required to turn a statistically significant result to a nonsignificant result. The FI measures the robustness (or fragility) of the results of an RCT and is an important aid to the clinician's interpretation of RCT results. It has now been recognized that RCTs, which provide the foundation for treatment guideline recommendations, may not be robust.
Most RCTs in surgery and general medicine are fragile (with a low FI score), in contrast to those in cardiac disease and heart failure, where most RCTs are robust (with high FI scores). For clinical trials of trauma, we identified that the median (interquartile range) FI score was 3 (1-8), which means that adding 3 events to the opposite treatment arm in a given RCT eliminated statistical significance. The median Fragility Quotient (the FI score divided by the total study sample size) was 0.016 (0.0043-0.0408).
The provision of high-quality, evidence-based clinical care in surgery for optimal patient outcomes requires a foundation of robust clinical research evidence, and knowledge of the FI will assist in future surgical RCT design. We strongly recommend the routine reporting of FI scores for all future trauma and surgical RCTs to assist in appropriate and optimal decision making in the care of patients who have experienced trauma and/or need surgery. We also recommend the routine inclusion of the FI score in the development of clinical guidelines to assist the clinician in ascertaining whether guideline recommendations are robust. Surgeons should be aware to particularly exercise caution when considering a potential change in clinical practice based on RCTs with a low FI score.
Tracheostomy is a common procedure performed in critically ill patients requiring prolonged mechanical ventilation for acute respiratory failure and for airway issues. The ideal timing (early vs ...late) and techniques (percutaneous dilatational, other new percutaneous techniques, open surgical) for tracheostomy have been topics of considerable debate. In this review, we address general issues regarding tracheostomy (epidemiology, indications, and outcomes) and specifically review the literature regarding appropriate timing of tracheostomy tube placement. Based on evidence from 2 recent large randomized trials, it is reasonable to wait at least 10 d to be certain that a patient has an ongoing need for mechanical ventilation before consideration of tracheostomy. Percutaneous tracheostomy with flexible bronchoscopy guidance is recommended, and optimal percutaneous techniques, indications, and contraindications and results in high-risk patients (coagulopathy, thrombocytopenia, obesity) are reviewed. Additional issues related to tracheostomy diagnosis-related groups, charges, and procedural costs are reviewed. New advances regarding tracheostomy include the use of real-time ultrasound guidance for percutaneous tracheostomy in high-risk patients. New tracheostomy tubes (tapered with low-profile cuffs that fit better on the tapered dilators, longer percutaneous tracheostomy tubes) are discussed for optimal use with percutaneous dilatational tracheostomy. Two new percutaneous techniques, a balloon inflation technique (Dolphin) and the PercuTwist procedure, are reviewed. The efficacy of tracheostomy teams and tracheostomy hospital services with standardized protocols for tracheostomy insertion and care has been associated with improved outcomes. Finally, the UK National Tracheostomy Safety Project developed standardized resources for education of both health care providers and patients, including emergency algorithms for tracheostomy incidents, and serves as an excellent educational resource in this important area.
Massive transfusion (MT) is a lifesaving treatment of hemorrhagic shock, but can be associated with significant complications.
The lethal triad of acidosis, hypothermia, and coagulopathy associated ...with MT is associated with a high mortality rate. Other
complications include hypothermia, acid/base derangements, electrolyte abnormalities (hypocalcemia, hypomagnesemia, hypokalemia,
hyperkalemia), citrate toxicity, and transfusion-associated acute lung injury. Blood transfusion in trauma, surgery, and critical
care has been identified as an independent predictor of multiple organ failure, systemic inflammatory response syndrome, increased
infection, and increased mortality in multiple studies. Once definitive control of hemorrhage has been established, a restrictive
approach to blood transfusion should be implemented to minimize further complications.
Exsanguinating torso hemorrhage is a leading killer of trauma patients. The most appropriate means of hemorrhage control must be used. Trauma surgeons should have expertise with all approaches for ...prompt hemorrhage control laparotomy, thoracotomy, resuscitative endovascular balloon occlusion of the aorta (REBOA), and resuscitative thoracotomy. REBOA is an exciting adjunct for hemorrhage control as it can be deployed quickly and placed percutaneously. Balloon inflation can vary dependent on patient physiology. REBOA is effective in hemorrhagic shock as a bridge to definitive hemostasis. Endovascular training is important for trauma surgeons caring for patients at high risk of death from traumatic hemorrhage.
Clostridium difficile infections are the leading cause of health care–associated infectious diarrhea, posing a significant risk for both medical and surgical patients. Because of the significant ...morbidity and mortality associated with C difficile infections, knowledge of the epidemiology of C difficile in combination with a high index of suspicion and susceptible patient populations (including surgical, postcolectomy, and inflammatory bowel disease patients) is warranted. C difficile infections present with a wide spectrum of disease, ranging from mild diarrhea to fulminant colitis or small bowel enteritis and recurrent C difficile infections. Early implementation of medical and operative treatment strategies for C difficile infections is imperative for optimal patient outcomes. National and international guidelines recommend early operative consultation and total abdominal colectomy with end ileostomy and preservation of rectum. Diverting loop ileostomy and colonic lavage followed by intravenous metronidazole and intracolonic vancomycin administered via the efferent limb of the ileostomy should be considered as an alternative to total colectomy in selected patients. New and emerging strategies for C difficile infection treatment include monoclonal antibodies, vaccines, probiotics, biotherapeutics, and new antibiotics. A successful C difficile prevention and eradication program requires a multidisciplinary approach that includes early disease recognition, implementation of guidelines for monitoring adherence to environmental control, judicious hand hygiene, evidence-based treatment and management strategies, and a focused antibiotic stewardship program. Surgeons are an important part of the clinical team in the management of C difficile infection prevention and treatment.
Intra-abdominal Infections Napolitano, Lena M
Seminars in respiratory and critical care medicine,
02/2022, Volume:
43, Issue:
1
Journal Article
Peer reviewed
Intra-abdominal infections (IAIs) are a common cause of sepsis, and frequently occur in intensive care unit (ICU) patients. IAIs include many diagnoses, including peritonitis, cholangitis, ...diverticulitis, pancreatitis, abdominal abscess, intestinal perforation, abdominal trauma, and pelvic inflammatory disease. IAIs are the second most common cause of infectious morbidity and mortality in the ICU after pneumonia. IAIs are also the second most common cause of sepsis in critically ill patients, and affect approximately 5% of ICU patients. Mortality with IAI in ICU patients ranges from 5 to 50%, with the wide variability related to the specific IAI present, associated patient comorbidities, severity of illness, and organ dysfunction and failures. It is important to have a comprehensive understanding of IAIs as potential causes of life-threatening infections in ICU patients to provide the best diagnostic and therapeutic care for optimal patient outcomes in the ICU.
•Beta-lactamases are not antibiotics. They are enzymes produced by gram-negative bacteria and result in resistance to β-lactam antibiotics.•The classification of antibiotics in the meta-analysis is ...confusing; there is concern for misclassification of antibiotics in some studies.•The authors recommend Carbapenems if surgery is contraindicated, but Carbapenems had twice the recurrence vs. Cephalosporin/Metronidazole.
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