1 Fredy Ariza, MD., MSc., PhD(a). Servicio de Anestesiología, Reanimación y Medicina Perioperatoria Fundación Valle del Lili

2 2013 2012 2014 2015

3 2016

4 Fundación Valle del Lili, Cali, ColombiaSurgical site infection and sepsis after major surgery: a preliminary report from a prospective registry. Fredy Ariza, M.D., M.S., Andrés Felipe Beltrán, M.D., Dario Alberto Castaño, M.D., Juan Andres Cuervo, M.D., David Ramirez, M.D., Luisa Fernanda Novoa, M.D. Fundación Valle del Lili, Cali, Colombia Introduction Results Surgical site infection (SSI) is a concerning issue for surgical teams. It accounts for 20% of health care associated infections in the United States. The incidence of SSI is 2.9% in developing countries and 2% for the United States (1,2). It leads to increased morbidity and increased hospital length of stay (3). A total of 866 patients were included. Most of them were women (62.2%), with a median age and interquantile range (IQR) of 50 and , respectively. ASA II status was the most prevalent (57.2%). Most frequently performed procedures were abdominal (30.7%) followed by head and neck surgeries (25.9%). The median and IQR of surgical times was 130 and minutes respectively. After adjustment (intraoperative blood loss≥20% of total blood volume) was associated with an increased risk of SSI (OR: 3.81, 95%CI: ). Similarly, we found Association between poor preoperative exercise tolerance (≤4 METs) and sepsis (OR: 3.41, 95%CI: ). Objectives The aim of this study was to determine the incidence of SSI and identify related risk factors in patients undergoing major surgery at a Latin-American referral hospital. Methods This is a partial report from a prospective registry that collected data from patients aged 1 month or older who underwent major Surgery at a tertiary care hospital. Subjects who required at least 24 hours of in-hospital postoperative care between August 2015 and March 2016 were included. Main outcomes were the presence of SSI and sepsis during the first 30 postoperative days. Comparisons were done classifying the population in individuals diagnosed with SSI and those without SSI. Sociodemographic characteristics between groups were compared using Chi-square test or Mann-Whitney U test when appropriate. Statistical associations (OR, 95%CI) between risk factors and outcomes were performed using Fisher´s exact test when unadjusted and Mantel-Haenszel test when adjusted. Bibliografía Conclusions Lewis SS, Moehring RW, Chen LF, et al (2013) Assessing the relative burden of hospital-acquired infections in a network of community hospitals. Infect Control Hosp Epidemiol 34:1229–30. Weigelt JA, Lipsky BA, Tabak YP, et al (2010) Surgical site infections: Causative pathogens and associated outcomes. Am J Infect Control 38:112–120. Kirkland KB, Briggs JP, Trivette SL, et al (1999) The impact of surgical-site infections in the 1990s: attributable mortality, excess length of hospitalization, and extra costs. Infect Control Hosp Epidemiol 20:725–30. Major bleeding and poor preoperative physical condition are independent risk factors for infectious complications in patients undergoing major surgery. Referral centers must focus on protocols for preventing significant bleeding and preoperative cardiopulmonary optimization programs.

5 Fundación Valle del Lili, Cali, ColombiaSurgical site infection occurrence is not influenced by prophylactic use of dexamethasone against postoperative nausea and vomiting in high-risk patients F. Ariza, D. Castaño, S. Galindo , J. Valencia, J.P. Martínez, M. Herrera, L. López Fundación Valle del Lili, Cali, Colombia Introduction Results Dexamethasone is frequently used as unique or combined prophylaxis against postoperative nausea and vomiting (PONV). However, whether this steroid increases the risk of surgical site infection (SSI) in high infectious risk patients such as oncologic or orthopedic patients is still debatable. 1157 patients were included for analysis. Most were women (63.46%) underwent orthopedic procedures (67.56%) and ASA status system classification class II (64%). Dexamethasone alone was used in 14.9% (n=172) and combined with other drugs in 12.6% (n= 146). Dexamethasone was related with a significantly lower risk for PONV during the first 6 postoperative hours. Dexamethasone had not statistically association with SSI [OR 0.94 (95% CI: 0.48­1.88)] (Table 1). Time to SSI was not different between groups . Multivariate analysis showed a significantly higher risk of SSI in patients with COPD (Table 2) Table 1: Outcomes Figure 1 . ORs adjusted by age and ASA physical status. Objectives The aim of this study was to determine the incidence of SSI and identify related risk factors in patients undergoing major surgery at a Latin-American referral hospital. Methods A retrospective cohort study was conducted, including adult patients who underwent major oncologic or orthopedic surgeries between January-2011 and December Patients with active infection, chronic steroid use and intraoperative exposure to other steroids were excluded from analysis. Patients were divided into 2 groups, those receiving dexamethasone alone or combined to other prophylactic drugs against PONV and those who did not received dexamethasone. Main outcome for the study was any kind of SSI during the first 30 postoperative days; secondary outcome was timing of infection. Statistical comparisons were performed using Fisher´s exact test or Chi-square-test for categorical variables and Mann-Whitney U test for continuous variables. Kaplan-Meier analysis was used to evaluate SSI-free survival between groups and a multivariate Cox proportional hazards regression model to assess possible associations between dexamethasone use and other possible risk factors with SSI incidence. Table 2: Risk Model (Odds and Hazard Ratios) Bibliography Conclusions Koh, In Jun, Chong Bum Chang, Jung Ha Lee, Young-Tae Jeon, and Tae Kyun Kim. "Preemptive Low-dose Dexamethasone Reduces Postoperative Emesis and Pain After TKA: A Randomized Controlled Study." Clinical Orthopaedics and Related Research® Clin Orthop Relat Res (2013): Adrian Cheng Kiang Lau, MBBS, FRCSE, Ghim Hoe Neo, MD, Haw Chou Lee. Risk factors of surgical site infections in hip hemiarthroplasty: a single-institution experience over nine years.  Arwert, Esther N., Esther Hoste, and Fiona M. Watt. "Epithelial Stem Cells, Wound Healing and Cancer." Nature Reviews Cancer Nat Rev Cancer 12.3 (2012): Web There is no increased risk of  surgical site infection when using dexamethasone, alone or combined, in the prophylaxis of postoperative nausea and vomiting  in patients who underwent cancer or orthopedic surgery.

6 Surgical site infection is not influenced by prophylactic use of dexamethasone against postoperative nausea and vomiting in high-risk patients

8 Justificación Factores Rx. para ISO Infección de Sitio OperatorioIncapacidad Complicaciones serias Altos costos en salud Factores Rx. para ISO Procedimientos Ortopédicos Procedimientos Oncológicos Prótesis Pancreatectomía BMI >= 30 kg/m2 ASA III-IV Radioterapia

9 Características Demográficas Determinar la Frecuencia de NVPOPObjetivos Determinar una posible asociación entre ISO y el uso profiláctico de dexametasona en pacientes de cirugía oncológica y ortopédica. Características Demográficas Determinar la Frecuencia de NVPOP Valoración del Riesgo

10 Hypothesis Hipótesis NulaNo hay diferencia en el riesgo de ISO cuando se comparaban pacientes que recibían DXM con aquellos que no la recibían

11 Methods Diseño Selection criteria Pacientes Recolectados: 1189C. Inclusión Exclusion criteria Adultos Uso Crónico de Esteroides Cirugía Oncológica (G.O, Cx Gral, Neurocirugía, Urología) Uso Intraoperatorio de otros Esteroides Proc. Ortopédicos Infección Activa Cohortes Retrospectivas Diseño Analítico Observac. Enero 2011-Dic 2012 Pacientes Recolectados: 1189

12 Presencia de ISO en los primeros 30 días postoperatoriosMethods Criterio Inclusión DXM profiláctica No DXM Desenlace Primario Presencia de ISO en los primeros 30 días postoperatorios Desenlace Secundario Tiempo al inicio de ISO

13 Methods Kaplan-Meier analysis Proportional regression modelCategorical variables: Fisher's exact test Chi-square test Kaplan-Meier analysis Continuous variables: Mann-Whitney U test Proportional regression model

14 Resultados Variable Global (n=1156) DXM (n=525) No DXM (n=631) P-valueAge. N° (%) 56 (43-65) 53 (41-65) 60 (46-70) <0.05 Fémale Genre . N° (%) 723 (62.5) 357 (68) 363 (57.5) ASA Status II/III. N° (%) 740/130 (64/11.2) 340/52 (64.8/9.9) 339/78 (63.3/12.3) 0.56 COPD. N° (%) 27 (2.3) 11 (2.1) 0 (0.0) 0.62 Cancer. N° (%) 260 (22.5) 155 (29.5) 105 (16.6) Kidney failure . N° (%) 13 (1.1) 5 (1) 8 (1.3) 0.61 Diabetes mellitus. N° (%) 73 (6.3) 27.8 (5.3) 45 (7.1) 0.21 Congestive heart failure. N° (%) 6 (0,5) 4 (0.8) 2 (0.3) 0.29 Autoinmune diseases. N° (%) 30 (2.6) 20 (3.8) 10 (1.6) 0.06 Prophylactic antibiotic. N° (%) 1079 (93.4) 498 (94.9) 582 (92.2) 0.07 Variable Global (n=1156) DXM (n=525) No DXM (n=631) P-value Type of anesthesia N° (%) <0.05 General 79 (68.5) 462 (88) 329 (52.1) Neuroaxial 187 (16.2) 20 (3.9) 167 (26.5) Regional 89 (7.7) 8 (1.5) 149 (12.9) General/regional 88 (7.6) 35 (6.6) 81 (8.4) Propofol induction. N° (%) 397 (34.3) 242 (46.1) 155 (24.6) <0.05

15 RESULTADOS Variable Global (n=1156) DXM (n=525) No DXM (n=631) P-valueType of surgery. N° (%) <0.05 Orthopedic 781 (67.6) 285 (54.3) 497 (78.7) Oncologic 375 (32.4) 240 (45.7) 134 (21-3) Prosthetic installation. N° (%) 377 (32.6) 113 (21.5) 264 (41.8) 0.01 Nausea at PACU. N° (%) 88 (7.6) 26 (5) 62 (9.9) 0.002 Vomiting at PACU N° (%) 62 (5.4) 17 (3.2) 45 (7,2) 0.003 Nausea at 24 hours. N° (%) 15 (1.3) 6 (1.1) 9 (1.4) 0.67 Vomiting at 24 hours. N° (%) 14 (1.2) 5(1) 0.46

16 Resultados Factor de Riesgo OR (95% CI) P-value HR (95% CI)Dexametasona 0.97 (0.46-2,1) 0.95 0.79 ( ) 0.5 Cáncer 1.65 ( ) 0.27 1.92 ( ) 0.07 Enfermedad Renal 8.45 ( Q 0.13 2.73 ( ) 0.32 Diabetes mellitus 0.79 ( ) 0.82 0.45 ( ) 0.43 Enf. Autoinmune 2.58 ( ) 0.41 2.38 ( ) 0.23 EPOC 11.97 ( ) 0.02 ) 0.18 Prótesis 0.95( ) 0.91 0.86 ( ) 0.68

17 RESULTADOS DESENLACE Global (n=1156) DXM (n=525) No DXM (n=631)P-value ISO. No. (%) 35 (3) 15 (2.9) 19 (3) 0.87 Type of ISO. No. (%) 0.81 No infección 1132 (97.9) 513 (97.7) 611 (96.8) Superficial 12 (1) 4 (0.8) 7 (1.1) Profunda 9 (0.8) 3 (0.6) 6 (1) Organo/cavidad 12 (1.1) 5 (1) Dias para ISO 6 ( ) 6 (4-10) 6 (3-10) 0.94

18 Análisis de Sobrevida

19 No existen diferencias en el momento de aparición de ISOConclusiones No existe un incremento en el riesgo de ISO a 30 días con el uso intraoperatorio de DXM como profilaxis para NVPOP No existen diferencias en el momento de aparición de ISO Factores de Rx. Autoinmunidad EPOC Claro BENEFICIO en la utilización de DXM para evitar riesgo de NVPOP

20