Prediction of Postoperative Sepsis Based on Changes in Presepsin Levels of Critically Ill Patients with Acute Kidney Injury after Abdominal Surgery

Presepsin (PSP) is a viable biomarker for the detection of bacterial infection, but it lacks accuracy when acute kidney injury (AKI) develops. Herein, we evaluated the diagnostic and prognostic value of PSP in predicting postoperative sepsis after abdominal surgery respective to the degree of AKI. A total of 311 patients who underwent abdominal surgery and were admitted to a surgical intensive care unit were enrolled and classified into non-AKI, mild-AKI (stage 1, stage 2 and stage 3 without renal replacement therapy (RRT)) and severe-AKI (stage 3 with RRT) group, according to the Kidney Disease Improving Global Outcomes criteria. In each group, PSP and other biomarkers were statistically analyzed between non-sepsis and postoperative sepsis at the admission (T0), 24 h (T1), 48 h (T2) and 72 h (T3) after surgery. In non-AKI and mild-AKI group, PSP levels were significantly higher in postoperative sepsis than non-sepsis group, whereas no difference was detected in the severe-AKI group. Cutoff values of PSP in the mild-AKI group for the prediction of postoperative sepsis were 544 pg/mL (AUC: 0.757, p < 0.001) at T0 and 458.5 pg/mL (AUC: 0.743, p < 0.001) at T1, significantly higher than in non-AKI group. In multivariate analysis, predictors of postoperative sepsis in the mild-AKI group were PSP at T2 (odds ratio (OR): 1.002, p = 0.044) and PSP at T3 (OR: 1.001, p = 0.049). PSP can be useful for predicting newly developed sepsis in patients with transient AKI after abdominal surgery with modified cutoff values.

QSOFA and SOFA scores are valuable tools for predicting postoperative sepsis resulting from ureteroscopic lithotripsy (URSL)

Purpose The SOFA and qSOFA scores are new tools which are used to assess sepsis based on the Third International Consensus Definitions for Sepsis and Septic Shock Task Force. This study aimed to evaluate the feasibility of using the SOFA and qSOFA to predict post-ureteroscopic lithotripsy (URSL) sepsis. Materials and Methods Patients who underwent URSL due to ureteral stone obstruction were retrospectively reviewed using SOFA and qSOFA scores. Patient characteristics including age, gender, comorbidities, American Society of Anesthesiologists Classification (ASA), stone burden, stone location, hydronephrosis status, infectious status, preoperative SOFA and qSOFA score were collected. Preoperative factors were analyzed to determine if they were correlated with postoperative sepsis. Results A total of 830 patients were included in this study, of whom 32 (3.9%) had postoperative sepsis. Multivariate analysis revealed that older age, proximal ureteral stones, severe hydronephrosis, and high preoperative qSOFA or SOFA score were significantly associated with postoperative sepsis. The areas under the curves of a qSOFA score ≥ 1 and SOFA score ≥ 2 for predicting postoperative sepsis were 0.754 and 0.823, respectively. Conclusions Preoperative qSOFA and SOFA scores are convenient and effective for predicting post-URSL sepsis. Further preventive strategies should be performed in these high-risk patients.

Infectious Complications after Etomidate vs. Propofol for Induction of General Anesthesia in Cardiac Surgery—Results of a Retrospective, before–after Study

Background: Etomidate is typically used as an induction agent in cardiac surgery because it has little impact on hemodynamics. It is a known suppressor of adrenocortical function and may increase the risk for post-operative infections, sepsis, and mortality. The aim of this study was to evaluate whether etomidate increases the risk of postoperative sepsis (primary outcome) and infections (secondary outcome) compared to propofol. Methods: This was a retrospective before–after trial (IRB EA1/143/20) performed at a tertiary medical center in Berlin, Germany, between 10/2012 and 01/2015. Patients undergoing cardiac surgery were investigated within two observation intervals, during which etomidate and propofol were the sole induction agents. Results: One-thousand, four-hundred, and sixty-two patients, and 622 matched pairs, after caliper propensity-score matching, were included in the final analysis. Sepsis rates did not differ in the matched cohort (etomidate: 11.5% vs. propofol: 8.2%, p = 0.052). Patients in the etomidate interval were more likely to develop hospital-acquired pneumonia (etomidate: 18.6% vs. propofol: 14.0%, p = 0.031). Conclusion: Our study showed that a single-dose of etomidate is not statistically associated with higher postoperative sepsis rates after cardiac surgery, but is associated with a higher incidence of hospital-acquired pneumonia. However, there is a notable trend towards a higher sepsis rate.

The Association between Pathologic Complete Response after Neoadjuvant Chemoradiotherapy and Postoperative Complications

<b><i>Introduction:</i></b> With growing interest in the watch-and-wait strategy, the benefits of avoiding surgery and its complications must be weighed against possible recurrence and need for salvage surgery. However, the relationship between pathologic complete response (pCR) and postoperative complications has not been well established. <b><i>Methods:</i></b> This is a retrospective study using the National Surgical Quality Improvement Program Proctectomy and Colectomy Procedure-Targeted databases from 2016 to 2018. The association between pCR and major complications, sepsis, anastomotic leak or organ space infection, return to the operating room, or septic shock was analyzed. <b><i>Results:</i></b> A total of 3,878 rectal cancer patients who received chemotherapy or radiation therapy within 90 days of surgery were included in this study. The pCR rate was 12.8%. There was no statistically significant association between pCR and major complications (adjusted odds ratio (OR) = 0.48, <i>p</i> = 0.12) after risk adjustment. Those with pCR had no statistically significant association with anastomotic leak or organ space infection, return to the operating room, or septic shock but had significantly lower odds of sepsis (adjusted OR = 0.42, <i>p</i> = 0.03). <b><i>Conclusions:</i></b> It is reassuring that pCR is not associated with postoperative complications and that those with pCR are less likely to have postoperative sepsis after risk adjustment since postoperative sepsis after rectal surgery has been associated with poorer oncologic outcomes.

Outcomes of a Multicomponent Safe Surgery Intervention in Tanzania’s Lake Zone: A Prospective, Longitudinal Study

Background Evidence-based strategies for improving surgical quality and patient outcomes in low-resource settings are a priority. We evaluated the impact of a multicomponent safe surgery intervention (Safe Surgery 2020) in Tanzania, hypothesizing it would (1) increase adherence to safety practices, teamwork and communication, and documentation in patient files, and (2) reduce the incidence of maternal sepsis, postoperative sepsis, and surgical site infection. Methods We conducted a prospective, longitudinal study in 10 intervention and 10 control facilities in Tanzania’s Lake Zone, across a three-month pre-intervention period in 2018 and three-month post-intervention period in 2019. Safe Surgery 2020 is a multicomponent intervention to support four surgical quality areas: 1) leadership and teamwork, 2) evidence-based surgery, anaesthesia, and equipment sterilization practices, 3) data completeness, and 4) infrastructure. Surgical team members received training and mentorship, and each facility received up to a $10,000 infrastructure grant. Inpatients undergoing major surgery and postpartum women were followed during their stay up to 30 days. We assessed adherence to 14 safety and teamwork and communication measures through direct observation in the operating room. We identified maternal sepsis (vaginal or caesarean delivery), postoperative sepsis, and surgical site infections prospectively through daily surveillance and assessed medical record completeness retrospectively through chart review. We compared changes in surgical quality outcomes between intervention and control facilities using difference-in-differences analyses to determine areas of impact. Results Safety practices improved significantly by an additional 20.5% (95% CI, 7.2%-33.7%; P=.003) and teamwork and communication conversations by 33.3% (95% CI, 5.7%-60.8%; P=.02) in intervention facilities compared to control facilities. Maternal sepsis rates reduced significantly by 1% (95% CI, 0.1%-1.9%; P=.02). Documentation completeness improved by 41.8% (95% CI, 27.4%-56.1%; P&lt;.001) for sepsis and 22.3% (95% CI, 4.7%-39.8%; P=.01) for surgical site infections. Conclusion Our findings demonstrate the benefit of the Safe Surgery 2020 approach. Improvement was observed in adherence to safety practices, teamwork and communication, and data quality, and there was a reduction in maternal sepsis rates. Our results support the emerging evidence that improving surgical quality in a low resource setting requires a focus on the surgical system and culture. Investigation in diverse contexts is necessary to confirm and generalize our results and to understand how to adapt the intervention for different settings. Further work is also necessary to assess the long-term effect and sustainability of such interventions.

Biomarkers to Guide the Timing of Surgery: Neutrophil and Monocyte L-Selectin Predict Postoperative Sepsis in Orthopaedic Trauma Patients

Deciding whether to delay non-lifesaving orthopaedic trauma surgery to prevent multiple organ failure (MOF) or sepsis is frequently disputed and largely based on expert opinion. We hypothesise that neutrophils and monocytes differentially express activation markers prior to patients developing these complications. Peripheral blood from 20 healthy controls and 162 patients requiring major orthopaedic intervention was collected perioperatively. Neutrophil and monocyte L-selectin, CD64, CD11, CD18, and CXCR1 expression were measured using flow cytometry. The predictive ability for MOF and sepsis was assessed using the Receiver Operating Characteristic (ROC) comparing to C-reactive protein (CRP). Neutrophil and monocyte L-selectin were significantly higher in patients who developed sepsis. Neutrophil L-selectin (AUC 0.692 [95%CI 0.574–0.810]) and monocyte L-selectin (AUC 0.761 [95%CI 0.632–0.891]) were significant predictors of sepsis and were not significantly different to CRP (AUC 0.772 [95%CI 0.650–0.853]). Monocyte L-selectin was predictive of MOF preoperatively and postoperatively (preop AUC 0.790 [95%CI 0.622–0.958]). CD64 and CRP were predictive of MOF at one-day postop (AUC 0.808 [95%CI 0.643–0.974] and AUC 0.809 [95%CI 0.662–0.956], respectively). In the perioperative period, elevated neutrophil and monocyte L-selectin are predictors of postoperative sepsis. Larger validation studies should focus on these biomarkers for deciding the timing of long bone/pelvic fracture fixation.

Postoperative abdominal sepsis induces selective and persistent changes in CTCF binding within the MHC-II region of human monocytes

Background Postoperative abdominal infections belong to the most common triggers of sepsis and septic shock in intensive care units worldwide. While monocytes play a central role in mediating the initial host response to infections, sepsis-induced immune dysregulation is characterized by a defective antigen presentation to T-cells via loss of Major Histocompatibility Complex Class II DR (HLA-DR) surface expression. Here, we hypothesized a sepsis-induced differential occupancy of the CCCTC-Binding Factor (CTCF), an architectural protein and superordinate regulator of transcription, inside the Major Histocompatibility Complex Class II (MHC-II) region in patients with postoperative sepsis, contributing to an altered monocytic transcriptional response during critical illness. Results Compared to a matched surgical control cohort, postoperative sepsis was associated with selective and enduring increase in CTCF binding within the MHC-II. In detail, increased CTCF binding was detected at four sites adjacent to classical HLA class II genes coding for proteins expressed on monocyte surface. Gene expression analysis revealed a sepsis-associated decreased transcription of (i) the classical HLA genes HLA-DRA, HLA-DRB1, HLA-DPA1 and HLA-DPB1 and (ii) the gene of the MHC-II master regulator, CIITA (Class II Major Histocompatibility Complex Transactivator). Increased CTCF binding persisted in all sepsis patients, while transcriptional recovery CIITA was exclusively found in long-term survivors. Conclusion Our experiments demonstrate differential and persisting alterations of CTCF occupancy within the MHC-II, accompanied by selective changes in the expression of spatially related HLA class II genes, indicating an important role of CTCF in modulating the transcriptional response of immunocompromised human monocytes during critical illness.

Predicting Individual Survival after Curative Esophagectomy for Squamous Cell Carcinoma of Esophageal

Background. Esophageal cancer is one of the leading causes of cancer-related death worldwide. Despite the significant progress in the overall treatment of esophageal cancer in recent years, the prognosis for patients who require surgery remains poor. Methods. The present study investigated the clinicopathological features of 503 patients who underwent radical esophagectomy at Huashan Hospital of Fudan University between January 2005 and January 2015. Nomograms that predicted the esophageal squamous cell carcinoma (ESCC) survival rates were established using the Cox proportional hazard regression model. Discrimination and calibration, which were calculated after bootstrapping, were used as a measure of accuracy. Results. Multivariate analyses were used to select five independent prognostic variables and build the nomogram. These variables were pathological T stage, pathological N factor, rate of positive LNs, history of chronic obstructive pulmonary disease (COPD) and postoperative sepsis. The nomogram was built to predict the rates for overall survival (OS) and disease-free survival (DFS). The concordance index for the nomogram prediction for OS and DFS was 0.720 and 0.707, respectively. Compared to the conventional TNM staging system, the nomogram had better predictive accuracy for survival (OS 0.720 vs. 0.672, P < 0.001 ; DFS 0.707 vs. 0.667; P < 0.001 ). Conclusions. The present study incorporated pathological T stage, pathological N factor, rate of positive LNs, history of COPD, and postoperative sepsis into a nomogram to predict the OS and DFS of ESCC patients. This practical system may help clinicians in both decision-making and clinical study design. The assessment of lung function for patients with COPD preoperative, and the control of disease progression are needed. Furthermore, the postoperative infection of patients should be controlled. Further studies may help to extend the validation of this method and improve the model through parameter optimization.