Medicine (Austin & Northern Health) - Research Publications

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    Health economic implications of postoperative complications following liver resection surgery: a systematic review.
    Cosic, L ; Ma, R ; Churilov, L ; Nikfarjam, M ; Christophi, C ; Weinberg, L (Wiley, 2019-12)
    BACKGROUND: Limited data exists concerning the health economics of liver resection, with even less information on the costs emerging from complications, despite this remaining an important target from a health economic perspective. Our objective was to describe the financial burden of complications following liver resection. METHODS: We conducted a systematic search and included studies reporting resource use of in-hospital complications during the index liver resection admission. All indications for liver resection were considered. All techniques were considered. Data was collected using a data extraction table and a narrative synthesis was performed. RESULTS: We identified 12 eligible articles. There was considerable heterogeneity in study designs, patient populations and outcome definitions. We found weak evidence of increased costs associated with major liver resection compared to minor resections. We found robust evidence supporting the increasing economic burden arising from complications after liver resection. Acceptable evidence for increased cost due to the presence and grade of complication was found. Strong evidence concerning the association of length of stay with costs was demonstrated. CONCLUSIONS: The presence and grade of complications increase hospital cost across diverse settings. The costing methodology should be transparent and complication grading systems should be consistent in future studies.
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    The effects of 0.9% saline versus Plasma-Lyte 148 on renal function as assessed by creatinine concentration in patients undergoing major surgery: A single-centre double-blinded cluster crossover trial
    Weinberg, L ; Li, MH-G ; Churilov, L ; Macgregor, C ; Garrett, K ; Eyles, J ; Bellomo, R ; Dal Pizzol, F (PUBLIC LIBRARY SCIENCE, 2021-05-19)
    OBJECTIVES: Saline and Plasma-Lyte have different physiochemical contents; consequently, they may differently affect patients' renal function. We compared the effects of fluid therapy with 0.9% saline and with Plasma-Lyte 148 on renal function as assessed by creatinine concentration among patients undergoing major surgery. METHODS: We conducted a prospective, double-blinded cluster crossover trial comparing the effects of the two fluids on major surgery patients. The primary aim was to establish the pilot feasibility, safety and preliminary efficacy evidence base for a large interventional trial to establish whether saline or Plasma-Lyte is the preferred crystalloid fluid for managing major surgery patients. The primary efficacy outcome was the proportion of patients with changes in renal function as assessed by creatinine concentration during their index hospital admission. We used changes in creatinine to define acute kidney injury (AKI) according to the RIFLE criteria. RESULTS: The study was feasible with 100% patient and clinician acceptance. There were no deviations from the trial protocol. After screening, we allocated 602 patients to saline and 458 to Plasma-Lyte. The median (IQR) volume of intraoperative fluid received was 2000 mL (1000:2000) in both groups. Forty-nine saline patients (8.1%) and 49 Plasma-Lyte patients (10.7%) developed a postoperative AKI (adjusted incidence rate ratio [aIRR]: 1.34; 95% CI: 0.93-1.95; p = 0.120). No differences were observed in the development of postoperative complications (aIRR: 0.98; 95% CI: 0.89-1.08) or the severity of the worst complication (aIRR: 1.00; 95% CI: 0.78-1.30). The median (IQR) length of hospital stay was six days (3:11) for the saline group and five days (3:10) for the Plasma-Lyte group (aIRR: 0.85; 95% CI: 0.73-0.98). There were no serious adverse events relating to the trial fluids, nor were there fluid crossover or contamination events. CONCLUSIONS: The study design was feasible to support a future follow-up larger clinical trial. Patients treated with saline did not demonstrate an increased incidence of postoperative AKI (defined as changes in creatinine) compared to those treated with Plasma-Lyte. Our findings imply that clinicians can reasonably use either solution intraoperatively for adult patients undergoing major surgery. TRIAL REGISTRATION: Registry: Australian New Zealand Clinical Trials Registry; ACTRN12613001042730; URL: https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=364988.
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    Health costs of post-operative complications following rectal resection: a systematic review
    Johnston, S ; Louis, M ; Churilov, L ; Ma, R ; Christophi, C ; Weinberg, L (WILEY, 2020-02-13)
    BACKGROUND: Post-operative complications following rectal resection pose significant health and cost implications for patients and health providers. The objective of this study is to review the associated cost of complications following rectal resection. This included reporting on the proportion and severity of these complications, associated length of stay and surgical technique used. Studies were sourced from Embase OVID, MEDLINE OVID (ALL) and Cochrane Library databases by utilizing a search strategy. METHODS: This search contained studies from 1 January 2010 until 13 February 2019. Studies were included from the year 2010 to account for the implementation of enhanced recovery after surgery protocols. Studies that reported the financial cost associated with complications were included. Any indication for rectal resection was considered. Data was extracted into a formatted table and a narrative synthesis was performed. RESULTS: We identified 13 eligible studies for inclusion. There was strong evidence to suggest that complications are associated with increased costs. There was considerable variation as to the costs attributable to complications ($1443 (P < 0.001) to $17 831 (P < 0.0012), n = 12). The presence of complications was associated with an increased length of stay (5.54 (P-value not given) to 21.04 (P < 0.0001) days, n = 7). There was significant variation in the proportion of complications (6.41 to 64.71%, n = 8). Weak evidence existed around surgical technique used and the associated cost of complications. There was considerable heterogeneity among included studies. CONCLUSIONS: Complications following rectal resection increased health costs. Costs should be standardized and provide a clear methodology for their calculation. Complications should be standardized and include a grading of severity.
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    The hemodynamic effects of intravenous paracetamol (acetaminophen) vs normal saline in cardiac surgery patients: A single center placebo controlled randomized study
    Chiam, E ; Bellomo, R ; Churilov, L ; Weinberg, L ; Nanayakkara, PWB (PUBLIC LIBRARY SCIENCE, 2018-04-16)
    The hemodynamic effects of intravenous (IV) paracetamol in patients undergoing cardiac surgery are unknown. We performed a prospective single center placebo controlled randomized study with parallel group design in adult patients undergoing elective cardiac surgery. Participants received paracetamol (1 gram) IV or placebo (an equal volume of 0.9% saline) preoperatively followed by two postoperative doses 6 hours apart. The primary endpoint was the absolute change in systolic (SBP) 30 minutes after the preoperative infusion, analysed using an ANCOVA model. Secondary endpoints included absolute changes in mean arterial pressure (MAP) and diastolic blood pressure (DPB), and other key hemodynamic variables after each infusion. All other endpoints were analysed using random-effect generalized least squares regression modelling with individual patients treated as random effects. Fifty participants were randomly assigned to receive paracetamol (n = 25) or placebo (n = 25). Post preoperative infusion, paracetamol decreased SBP by a mean (SD) of 13 (18) mmHg, p = 0.02, compared to a mean (SD) of 1 (11) mmHg with saline. Paracetamol decreased MAP and DBP by a mean (SD) of 9 (12) mmHg and 8 (9) mmHg (p = 0.01 and 0.02), respectively, compared to a mean (SD) of 1 (8) mmHg and 0 (6) mmHg with placebo. Postoperatively, there were no significant differences in pressure or flow based hemodynamic parameters in both groups. This study provides high quality evidence that the administration of IV paracetamol in patients undergoing cardiac surgery causes a transient decrease in preoperative blood pressure when administered before surgery but no adverse hemodynamic effects when administered in the postoperative setting.
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    Anaesthetists' attitudes towards attending the funerals of their patients: A cross-sectional study among Australian and New Zealand anaesthetists
    Kim, K ; Churilov, L ; Tan, CO ; Phan, T ; Geertsema, J ; Krieser, R ; Mehra, R ; Stewart, PA ; Rachbuch, C ; Huang, A ; Weinberg, L ; Hurst, DJ (PUBLIC LIBRARY SCIENCE, 2020-11-05)
    A patient's death can pose significant stress on the family and the treating anaesthetist. Anaesthetists' attitudes about the benefits of and barriers to attending a patient's funeral are unknown. Therefore, we performed a prospective, cross-sectional study to ascertain the frequency of anaesthetists' attendance at a patient's funeral and their perceptions about the benefits and barriers. The primary aim was to investigate the attitudes of anaesthetists towards attending the funeral of a patient. The secondary aims were to examine the perceived benefits of and barriers to attending the funeral and to explore the rate of bonds being formed between anaesthetists, patients and families. Of the 424 anaesthetists who completed the survey (response rate 21.2%), 25 (5.9%) had attended a patient's funeral. Of the participants, 364 (85.9%) rarely formed special bonds with patients or their families; 233 (55%) believed that forming a special bond would increase the likelihood of their attendance. Showing respect to patients or their families was the most commonly perceived benefit of attending a funeral. Participants found expression of personal grief and caring for the patient at the end-of-life and beyond beneficial to themselves and the family. Fear of their attendance being misinterpreted or perceived as not warranted by the family as well as time restraints were barriers for their attendance. Most anaesthetists had never attended a patient's funeral. Few anaesthetists form close relationships with patients or their families. Respect, expression of grief and caring beyond life were perceived benefits of attendance. Families misinterpreting the purpose of attendance or not expecting their attendance and time restraints were commonly perceived barriers. Trial registration: ACTRN 12618000503224.
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    Assessment of agreement and interchangeability between the TEG5000 and TEG6S thromboelastography haemostasis analysers: a prospective validation study
    Lloyd-Donald, P ; Churilov, L ; Zia, F ; Bellomo, R ; Hart, G ; McCall, P ; Martensson, J ; Glassford, N ; Weinberg, L (BMC, 2019-03-30)
    BACKGROUND: TEG6S® and TEG5000® (Haemonetics Corp, USA) are haemostasis analysers that measure viscoelasticity properties of whole blood. Both use different mechanisms to assess similar components of the coagulation process. The aim of this study was to assess agreement and interchangeability between the TEG6S and TEG5000 analysers. METHODS: 3.5 mL whole blood was collected from 25 adult patients in a tertiary intensive care unit (ICU). Analysis was performed using TEG6S and TEG5000 haemostatic platforms. Agreement between platforms was measured using Lin's concordance coefficient (Lin's CC), further validated using intraclass correlation coefficients and reduced major axis regression (RMAR). RESULTS: Sixteen (64%) patients were male; mean (range) age: 59yo (23-86). TEG6S and TEG5000 systems were broadly interchangeable. The majority of TEG variables demonstrated almost perfect or substantial agreement and minimal proportional bias (maximum amplitude demonstrated a fixed bias). LY30%, however, demonstrated poor agreement and a proportional bias. Lin's CC coefficients (95% CI, RMAR slope, intercept) between TEG6S and TEG5000 variables were: R time: 0.78 (0.64-0.92, 0.76, 0.92); K time: 0.82 (0.69-0.94, 1.30, - 0.93); alpha angle: 0.79 (0.64-0.95, 1.04, - 1.43); maximum amplitude (MA): 0.90 (0.83-0.96, 0.99, - 5.0); LY30%: 0.34 (0.1-0.58, 0.43, 0.04). CONCLUSIONS: Adult patients with critical illness demonstrate almost perfect agreement in the R time and MA, substantial agreement in K time and alpha angle, but poor agreement in LY30%, as measured by the TEG6S and TEG5000 analysers. With the exception of LY30%, the TEG6S and TEG5000 platforms appear interchangeable. This has important implications for use in clinical practice and multi-site research programs. TRIAL REGISTRATION: ANZCRT number: 12617000062325 , registered 12/Jan17. Retrospectively registered.
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    The financial impact of postoperative complications following liver resection
    Cosic, L ; Ma, R ; Churilov, L ; Debono, D ; Nikfarjam, M ; Christophi, C ; Weinberg, L (LIPPINCOTT WILLIAMS & WILKINS, 2019-07-01)
    The aim of the study was to determine the financial burden of complications and examine the cost differentials between complicated and uncomplicated hospital stays, including the differences in cost due to extent of resection and operative technique.Liver resection carries a high financial cost. Despite improvements in perioperative care, postoperative morbidity remains high. The contribution of postoperative complications to the cost of liver resection is poorly quantified, and there is little data to help guide cost containment strategies.Complications for 317 consecutive adult patients undergoing liver resection were recorded using the Clavien-Dindo classification. Patients were stratified based on the grade of their worst complication to assess the contribution of morbidity to resource use of specific cost centers. Costs were calculated using an activity-based costing methodology.Complications dramatically increased median hospital cost ($22,954 vs $15,593, P < .001). Major resection cost over $10,000 more than minor resection and carried greater morbidity (82% vs 59%, P < .001). Similarly, open resection cost more than laparoscopic resection ($21,548 vs $15,235, P < .001) and carried higher rates of complications (72% vs 41.5%, P < .001). Hospital cost increased with increasing incidence and severity of complications. Complications increased costs across all cost centers. Minor complications (Clavien-Dindo Grade I and II) were shown to significantly increase costs compared with uncomplicated patients.Liver resection continues to carry a high incidence of complications, and these result in a substantial financial burden. Hospital cost and length of stay increase with greater severity and number of complications. Our findings provide an in-depth analysis by stratifying total costs by cost centers, therefore guiding future economic studies and strategies aimed at cost containment for liver resection.
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    The financial burden of complications following rectal resection A cohort study
    Johnston, SA ; Louis, M ; Churilov, L ; Ma, R ; Marhoon, N ; Bui, A ; Christophi, C ; Weinberg, L (Lippincott, Williams & Wilkins, 2020-05-01)
    To investigate the costs associated with postoperative complications following rectal resection. Rectal resection is a major surgical procedure that carries a significant risk of complications. The occurrence of complications following surgery has both health and financial consequences. There are very few studies that examine the incidence and severity of complications and their financial implications following rectal resection. We identified 381 consecutive patients who underwent a rectal resection within a major university hospital. Patients were included using the International Classification of Diseases (ICD) codes. Complications in the postoperative period were reported using the validated Clavien-Dindo classification system. Both the number and severity of complications were recorded. Activity-based costing methodology was used to report financial outcomes. Preoperative results were also recorded and assessed. A 76.9% [95% CI: 68.3:86.2] of patients experienced one or more complications. Patients who had a complication had a median total cost of $22,567 [IQR 16,607:33,641]. Patients who did not have a complication had a median total cost of $15,882 [IQR 12,971:19,861]. The adjusted additional median cost for patients who had a complication was $5308 [95% CI: 2938:7678] (P < .001). Patients who experienced a complication tended to undergo an open procedure (P = .001), were emergent patients (P = .003), preoperatively had lower albumin levels (36 vs 38, P = .0003) and were anemic (P = .001). Complications following rectal resection are common and are associated with increased costs. Our study highlights the importance of evaluating and preventing complications in the postoperative period.
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    Goal directed fluid therapy for major liver resection: A multicentre randomized controlled trial
    Weinberg, L ; Ianno, D ; Churilov, L ; Mcguigan, S ; Mackley, L ; Banting, J ; Shen, SH ; Riedel, B ; Nikfarjam, M ; Christophi, C (ELSEVIER SCI LTD, 2019-09-01)
    BACKGROUND: The effect a restrictive goal directed therapy (GDT) fluid protocol combined with an enhanced recovery after surgery (ERAS) programme on hospital stay for patients undergoing major liver resection is unknown. METHODS: We conducted a multicentre randomized controlled pilot trial evaluating whether a patient-specific, surgery-specific intraoperative restrictive fluid optimization algorithm would improve duration of hospital stay and reduce perioperative fluid related complications. RESULTS: Forty-eight participants were enrolled. The median (IQR) length of hospital stay was 7.0 days (7.0:8.0) days in the restrictive fluid optimization algorithm group (Restrict group) vs. 8.0 days (6.0:10.0) in the conventional care group (Conventional group) (Incidence rate ratio 0.85; 95% Confidence Interval 0.71:1.1; p = 0.17). No statistically significant difference in expected number of complications per patient between groups was identified (IRR 0.85; 95%CI: 0.45-1.60; p = 0.60). Patients in the Restrict group had lower intraoperative fluid balances: 808 mL (571:1565) vs. 1345 mL (900:1983) (p = 0.04) and received a lower volume of fluid per kg/hour intraoperatively: 4.3 mL/kg/hr (2.6:5.8) vs. 6.0 mL/kg/hr (4.2:7.6); p = 0.03. No significant differences in the proportion of patients who received vasoactive drugs intraoperatively (p = 0.56) was observed. CONCLUSION: In high-volume hepatobiliary surgical units, the addition of a fluid restrictive intraoperative cardiac output-guided algorithm, combined with a standard ERAS protocol did not significantly reduce length of hospital stay or fluid related complications. Our findings are hypothesis-generating and a larger confirmatory study may be justified.
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    Assessing TEG6S reliability between devices and across multiple time points: A prospective thromboelastography validation study
    Lloyd-Donald, P ; Churilov, L ; Cheong, B ; Bellomo, R ; McCall, PR ; Martensson, J ; Glassford, N ; Weinberg, L (NATURE PUBLISHING GROUP, 2020-04-27)
    The TEG6S is a novel haemostasis analyser utilising resonance technology. It offers potentially greater coagulation information and ease of use, however has not been independently validated in a clinical setting. We aimed to determine if the TEG6S is reliable between devices and across time points. We performed a prospective observational study with ethical approval. For interdevice reliability, we performed simultaneous analysis on two TEG6S devices on 25 adult ICU patients. For time point reliability, we performed repeated sampling across five different time points on 15 adult participants. Blood was collected with informed consent, or as standard care, before four-channel citrated kaolin analysis. We observed almost perfect interdevice reliability across all TEG parameters. The Lin's concordance correlation coefficients (95% CI, major axis regression slope, intercept) were R-time: 0.96 (0.92-0.99, 0.88, 0.57); K-time: 0.93 (0.87-0.98, 1.07, 0.00); Alpha Angle: 0.87 (0.78-0.96, 1.20, -14.10); Maximum Amplitude: 0.99 (0.98-0.99, 1.02, -1.38); Clot Lysis: 0.89 (0.82-0.97, 1.20, 0.07). Additionally, we observed moderate-to-high reliability across time points. Demonstrating almost perfect agreement across different devices and moderate-to-high reliability across multiple time points, suggests the TEG6S platform can be used with haemostatic accuracy and generalisability. This has potentially significant implications for clinical practice and multi-site research programs.