Low-risk patients having hernia and vein surgery do not need thromboprophylaxis.

BackgroundThere is currently conflicting evidence surrounding the effects of obesity on postoperative outcomes. Previous studies have found obesity to be associated with adverse events, but others have found no association. The aim of this study was to determine whether increasing body mass index (BMI) is an independent risk factor for development of major postoperative complications.MethodsThis was a multicentre prospective cohort study across the UK and Republic of Ireland. Consecutive patients undergoing elective or emergency gastrointestinal surgery over a 4‐month interval (October–December 2014) were eligible for inclusion. The primary outcome was the 30‐day major complication rate (Clavien–Dindo grade III–V). BMI was grouped according to the World Health Organization classification. Multilevel logistic regression models were used to adjust for patient, operative and hospital‐level effects, creating odds ratios (ORs) and 95 per cent confidence intervals (c.i.).ResultsOf 7965 patients, 2545 (32·0 per cent) were of normal weight, 2673 (33·6 per cent) were overweight and 2747 (34·5 per cent) were obese. Overall, 4925 (61·8 per cent) underwent elective and 3038 (38·1 per cent) emergency operations. The 30‐day major complication rate was 11·4 per cent (908 of 7965). In adjusted models, a significant interaction was found between BMI and diagnosis, with an association seen between BMI and major complications for patients with malignancy (overweight: OR 1·59, 95 per cent c.i. 1·12 to 2·29, P = 0·008; obese: OR 1·91, 1·31 to 2·83, P = 0·002; compared with normal weight) but not benign disease (overweight: OR 0·89, 0·71 to 1·12, P = 0·329; obese: OR 0·84, 0·66 to 1·06, P = 0·147).ConclusionOverweight and obese patients undergoing surgery for gastrointestinal malignancy are at increased risk of major postoperative complications compared with those of normal weight.

Background and aims Indiscriminate coagulation testing in emergency general surgical patients can lead to inappropriate delay in surgery, cause unnecessary concern and is associated with significant cost. The British Committee for Standards in Haematology recommends against coagulation testing to predict peri-operative bleeding risk in unselected patients. Our aim was to assess the appropriateness of coagulation tests performed in emergency general surgical patients and evaluate the effect of a series of educational interventions on clinical practice. Methods and results Appropriate indications for performing coagulation testing included a positive bleeding history, the presence of liver disease/cholestasis, sepsis or use of anticoagulants. Initial data on 142 patients were collected over 2 weeks of receiving. Following analysis, indications for appropriate coagulation testing were highlighted and data were collected on a further 190 patients. Comparing the audit cycles, we observed a decrease in the proportion of patients who underwent routine testing (49.3% vs 32.6%; p = 0.002) and inappropriate testing (67% of tests vs 34% of tests; p < 0.001). Despite being highlighted, there was no evidence of improved documentation of bleeding histories on admission. Conclusions This observational study suggests that simple educational messages can reduce the inappropriate use of coagulation screening tests in general surgical emergencies. This seems to result from clarification of the appropriate surgical indications for coagulation testing in this group.

Background: Patient selection for critical care admission must balance patient safety with optimal resource allocation. This study aimed to determine the relationship between critical care admission, and postoperative mortality after abdominal surgery. Methods: This prespecified secondary analysis of a multicentre, prospective, observational study included consecutive patients enrolled in the DISCOVER study from UK and Republic of Ireland undergoing major gastrointestinal and liver surgery between October and December 2014. The primary outcome was 30-day mortality. Multivariate logistic regression was used to explore associations between critical care admission (planned and unplanned) and mortality, and intercentre variation in critical care admission after emergency laparotomy. Results: Of 4529 patients included, 37.8% (n¼1713) underwent planned critical care admissions from theatre. Some 3.1% (n¼86/2816) admitted to ward-level care subsequently underwent unplanned critical care admission. Overall 30-day mortality was 2.9% (n¼133/4519), and the risk-adjusted association between 30-day mortality and critical care admission was higher in unplanned [odds ratio (OR): 8.65, 95% confidence interval (CI): 3.51e19.97) than planned admissions (OR: 2.32, 95% CI: 1.43e3.85). Some 26.7% of patients (n¼1210/4529) underwent emergency laparotomies. After adjustment, 49.3% (95% CI: 46.8e51.9%, P<0.001) were predicted to have planned critical care admissions, with 7% (n¼10/145) of centres outside the 95% CI. Conclusions: After risk adjustment, no 30-day survival benefit was identified for either planned or unplanned postoperative admissions to critical care within this cohort. This likely represents appropriate admission of the highest-risk patients. Planned admissions in selected, intermediate-risk patients may present a strategy to mitigate the risk of unplanned admission. Substantial inter-centre variation exists in planned critical care admissions after emergency laparotomies.

AimsHenoch-Schönlein purpura (HSP) is an IgA mediated commonest systemic vasculitis with risk of long-term renal involvement. The regional pathway (Alder Hey) recommends a six- month nurse led follow-up with stratification of children into either Standard Pathway(SP) or Proteinuria Pathway(PP) at one week after presentation with PP cohort at increased risk of renal involvement. Our objectives were to compare our local practice management with regional pathway and study its cost implications.MethodsA retrospective audit involving 50 consecutive children (33 males;17 females) diagnosed with HSP from 2011–14 formed the study cohort. The mean age at presentation was four years and one child was followed-up at a different organisation. At presentation, blood pressure(BP) and urine analysis(UA) were undertaken in all 50 patients. 29 patients had normal UA and BP, 16 had abnormal UA and 4 had hypertension. All 49 patients were evaluated at one week and sub-classified into SP (47) and PP (2), but an additional 5 children in SP became proteinuric during the study course.ResultsSP cohort had far more than the recommended number of health professional(HP) reviews, UA and BP monitoring but at a random/variable frequency. PP cohort had more than the recommended number of HP reviews in the initial few weeks of presentation but the majority missed the later key intensive scheduled reviews. UA and BP was done at the majority of the reviews but none had the Primary investigations (Urea and electrolytes, Urine microscopy and Urine protein creatinine ratio), potentially missing out on early identification of renal involvement. None of the seven patients in the Proteinuriapathway developed any long-term renal sequelae. Altogether there were atleast 171 HP reviews and 15 inpatient admissions which were unwarranted and far more frequent UA monitoring. This created more anxiety/inconvenience among patient families and stretched HP resources.ConclusionWe introduced a modified local nurse-led community pathway(mLNCP) to standardise care, improve clinical care and cost-efficiency without compromising safety. Adherence to the new mLNCP would have resulted in an estimated cost-savings of £48,000. The second part of the audit evaluating the efficacy of mLNCP is on-going (2016 onwards) and closure of the audit loop is anticipated in near future.