Surgical site infections are there, and every now and then, we see that nicely closed incision bubbling pus. Lancet Infectious Diseases published a week ago the new WHO recommendations for surgical site infection prevention . And what would be a recommendation without low and moderate quality of evidence? But on the other hand, in most of the recommended interventions the benefits outweighed the risks. Do not discontinue immunosuppressive medications, feed the underweight, bathe the patients, nasal carriage of S. aureus = mupirocin if cardiothoracic or orthopaedic surgery, elective colorectal surgery = mechanical bowel preparation + oral antibiotics, do not shave your patients, surgical antibiotic prophylaxis (if indicated) within 120min before incision, wash your hands with a antimicrobial soap and water or alcohol-based hand rub before gloving, alcohol-based chlorhexidine for surgical site skin preparation, antimicrobial skin sealants are useless. Again, the recommendations are based on low/moderate quality of evidence.
I gotta tell you something: regarding prevention of ventilator-associated pneumonia (VAP) even the head of the bed elevated might generate discussion. Now, imagine subglottic secretion suction (Triple-S). Our friends from China published a meta-analysis  evaluating the role of Triple-S on VAP prevention. Twenty trials were included. It might be more interesting to look at the results of VAP incidence in the analysis of the 4 high-quality trials (901 patients), with a RR of 0.54 (95 % CI 0.40–0.74; p<0.00001) for Triple-S. No differences in ICU LOS, ICU mortality, and hospital mortality. If you have this resource available, it’s fair to use it. Ok, now, should I use intermittent or continuous aspiration? I have no idea! I don’t even know if the method we use to diagnose VAP is good enough.
Raise your hand if you ever admitted a patient with a diagnostic of septic shock, and after examining him you thought: Wait a minute, where is the source of infection?! And you wait, not only a minute, but 24h. Sometimes you’ll find the source, sometimes you won’t. Maybe because there wasn’t any, or maybe because you didn’t look thoroughly. Damien Contou and colleagues published a prospective cohort evaluating septic shock with no diagnosis at 24 hours . In their cohort, they found that “one of four patients admitted in the ICU with a suspicion of septic shock had no infection identified at 24h of shock onset”. Of these patients without early-confirmed septic shock, 28% had a infection (identified with a median of 2 days), 44% had non-infectious etiology identified within 2 days (drug reaction, malignancies, mesenteric ischemia…), and 28% remained without diagnosis by the end of the ICU stay (shock of unknown origin). Think about it next time you hear that a patient with COPD exacerbation /pneumonia /pulmonary edema receiving steroids, Lasix, antibiotics and inhaled beta agonists will be admitted on your shift.
How many times, dear readers, in the path of life you had the opportunity to report the first case of something? Unfortunately, some of us will never have this glory. And sometimes I think it’s better this way. In 2001 a guy published “The first case of homosexual necrophilia in the mallard Anas platyrhynchos”. But wait, it gets better. I’ll have to quote the abstract, because I don’t have the intellectual capacity to summarize what happened in the summer of 2001: “On 5 June 1995 an adult male mallard (Anas platyrhynchos) collided with the glass façade of the Natuurmuseum Rotterdam and died. An other drake mallard raped the corpse almost continuously for 75 minutes. Then the author disturbed the scene and secured the dead duck. Dissection showed that the rape-victim indeed was of the male sex. It is concluded that the mallards were engaged in an ‘Attempted Rape Flight’ that resulted in the first described case of homosexual necrophilia in the mallard”. That’s it, I can’t even make a joke out of it.
1. Allegranzi B, Bischoff P, de Jonge S, et al. New WHO recommendations on preoperative measures for surgical site infection prevention: an evidence-based global perspective. Lancet Infect Dis. 2016.
2. Mao Z, Gao L, Wang G, et al. Subglottic secretion suction for preventing ventilator-associated pneumonia: an updated meta-analysis and trial sequential analysis. Crit Care. 2016;20(1):353.
3. Contou D, Roux D, Jochmans S, et al. Septic shock with no diagnosis at 24 hours: a pragmatic multicenter prospective cohort study. Crit Care. 2016;20(1):360.
4. Moeliker CW. The first case of homosexual necrophilia in the mallard Anas platyrhynchos (Aves: Anatidae). Deinsea. 2001;8:243-247