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He P, Hai Y. The efficacy of nursing interventions in preventing surgical site infections in patients undergoing surgery for congenital heart disease. Int Wound J 2024; 21:e14850. [PMID: 38522429 PMCID: PMC10961171 DOI: 10.1111/iwj.14850] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2024] [Revised: 03/06/2024] [Accepted: 03/08/2024] [Indexed: 03/26/2024] Open
Abstract
Surgical site infections (SSIs) pose significant risks to patients undergoing surgery for congenital heart disease (CHD), impacting recovery and increasing healthcare burdens. This study assesses the efficacy of targeted nursing interventions in reducing SSIs and enhancing wound healing in this vulnerable patient group. A prospective cohort study was conducted from January 2022 to August 2023 at a single institution, involving 120 paediatric patients divided into control (standard postoperative care) and observation (specialized nursing interventions) groups. Nursing interventions included preoperative disinfection, strategic use of antibiotics, rigorous aseptic techniques and comprehensive postoperative care. Inclusion criteria encompassed a broad spectrum of CHD patients, while exclusion criteria aimed to minimize confounders. The Institutional Ethics Committee approved the study protocols. Baseline characteristics were comparable across groups, ensuring homogeneity. The observation group exhibited significantly lower SSI rates (1.7%) compared to the control group (11.6%), with a notable increase in optimal wound healing (Grade A) outcomes (73.3% vs. 30%). The differences in healing efficacy and infection rates between the two groups were statistically significant, emphasizing the effectiveness of the targeted nursing interventions in enhancing postoperative recovery for paediatric patients undergoing CHD surgery. The study demonstrates that targeted nursing interventions can significantly reduce SSI rates and improve wound healing in paediatric CHD surgery patients. These results underscore the importance of specialized nursing care in postoperative management. Future research, including larger-scale clinical trials, is necessary to validate these findings and develop comprehensive nursing care guidelines for this population.
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Affiliation(s)
- Ping He
- Department of Cardiovascular MedicineThe First Affiliated Hospital of China Medical UniversityShenyang CityChina
| | - Yue Hai
- Department of Cardiovascular MedicineThe First Affiliated Hospital of China Medical UniversityShenyang CityChina
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Furnaz S, Shaikh AS, Qureshi R, Fatima S, Bangash SK, Karim M, Amanullah M. Factors associated with poor outcomes after congenital heart surgery in low-resource setting in Pakistan: insight from the IQIC Registry - a descriptive analysis. BMJ Open 2023; 13:e078884. [PMID: 38070894 PMCID: PMC10729235 DOI: 10.1136/bmjopen-2023-078884] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/16/2023] [Accepted: 11/23/2023] [Indexed: 12/18/2023] Open
Abstract
OBJECTIVE This study aimed to assess the International Quality Improvement Collaborative single-site data from a developing country to identify trends in outcomes and factors associated with poor outcomes. DESIGN Retrospective descriptive study. SETTING The National Institute of Cardiovascular Diseases, Karachi, Pakistan. PARTICIPANTS Patients undergoing surgery for congenital heart disease (CHD). OUTCOME MEASURE Key factors were examined, including preoperative, procedural and demographic data, as well as surgical complications and outcomes. We identified risk factors for mortality, bacterial sepsis and 30-day mortality using multivariable logistic regression. RESULTS A total of 3367 CHD surgical cases were evaluated; of these, 59.4% (2001) were male and 82.8% (2787) were between the ages of 1 and 17 years. Only 0.2% (n=6) were infants (≤30 days) and 2.3% (n=77) were adults (≥18 years). The in-hospital mortality rate was 6.7% (n=224), and 4.4% (n=147) and 0.8% (n=27) had bacterial sepsis and surgical site infections, respectively. The 30-day status was known for 90.8% (n=3058) of the patients, of whom 91.6% (n=2800) were alive. On multivariable analysis, the adjusted OR for in-hospital mortality was 0.40 (0.29-0.56) for teenagers compared with infancy/childhood and 1.95 (1.45-2.61) for patients with oxygen saturation <85%. Compared with Risk Adjustment for Congenital Heart Surgery (RACHS-1) risk category 1, the adjusted OR for in-hospital mortality was 1.78 (1.1-2.87) for RACHS-1 risk category 3 and 2.92 (1.03-8.31) for categories 4-6. The adjusted OR for 30-day mortality was 0.40 (0.30-0.55) for teenagers and 1.52 (1.16-1.98) for patients with oxygen saturation <85%. The 30-day mortality rate was significantly higher in RACHS-1 risk category 3 compared with category 1, with an adjusted OR of 1.64 (1.06-2.55). CONCLUSIONS We observed a high prevalence of postoperative infections and mortality, especially for high-risk procedures, according to RACHS-1 risk category, in infancy/childhood, in children with genetic syndrome or those with low oxygen saturation (<85%).
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Affiliation(s)
- Shumaila Furnaz
- National Institute of Cardiovascular Diseases, Karachi, Pakistan
| | | | - Rayyan Qureshi
- National Institute of Cardiovascular Diseases, Karachi, Pakistan
| | - Subhani Fatima
- National Institute of Cardiovascular Diseases, Karachi, Pakistan
| | | | - Musa Karim
- National Institute of Cardiovascular Diseases, Karachi, Pakistan
| | - Muneer Amanullah
- National Institute of Cardiovascular Diseases, Karachi, Pakistan
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Alpat S, Asam M. The use of protocolised care bundle to prevent paediatric cardiac surgical site infection in resource-limited setting. Cardiol Young 2023; 33:1307-1311. [PMID: 37518864 DOI: 10.1017/s1047951123001798] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/01/2023]
Abstract
OBJECTIVE Surgical site infection is an important concern due to its association with morbidity and mortality after paediatric cardiac surgery. The aim of this study was to present our approach and experience in the utilisation of a modified care bundle in a recently established paediatric cardiac surgical unit in the low-income region of Turkey. METHODS Between 2019 and 2021, we identified children who underwent cardiac surgical procedures and retrospectively collected relevant demographic data, disease characteristics, operational data, Risk Adjustment For Congenital Heart Surgery (RACHS-1) scores, and post-operative factors such as morbidities, mortality, critical care, and in-hospital stay lengths. Surgical site infections and late infections were scanned. RESULTS Ninety-six patients (49 males, 47 females) underwent a total of 127 surgical procedures during the study period. Overall adherence to the protocol was 94%, 100%, and 96% in the pre-operative, intra-operative, and post-operative periods, respectively. There was no reported surgical site infection, and no late infection was encountered throughout the follow-up period. CONCLUSIONS We conclude that a low rate of surgical site infection, or even a rate of nil, is attainable through the utilisation of locally standardised guidelines for its prevention.
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Affiliation(s)
- Safak Alpat
- Paediatric Cardiac Surgery, University of Health Sciences, Van Training and Research Hospital, Van, Turkey
| | - Mehmet Asam
- Paediatric Cardiac Surgery, University of Health Sciences, Van Training and Research Hospital, Van, Turkey
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Peri-Operative Prophylaxis in Patients of Neonatal and Pediatric Age Subjected to Cardiac and Thoracic Surgery: A RAND/UCLA Appropriateness Method Consensus Study. Antibiotics (Basel) 2022; 11:antibiotics11050554. [PMID: 35625198 PMCID: PMC9137830 DOI: 10.3390/antibiotics11050554] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2022] [Revised: 04/12/2022] [Accepted: 04/14/2022] [Indexed: 02/04/2023] Open
Abstract
Surgical site infections (SSIs) represent a potential complication of surgical procedures, with a significant impact on mortality, morbidity, and healthcare costs. Patients undergoing cardiac surgery and thoracic surgery are often considered patients at high risk of developing SSIs. This consensus document aims to provide information on the management of peri-operative antibiotic prophylaxis for the pediatric and neonatal population undergoing cardiac and non-cardiac thoracic surgery. The following scenarios were considered: (1) cardiac surgery for the correction of congenital heart disease and/or valve surgery; (2) cardiac catheterization without the placement of prosthetic material; (3) cardiac catheterization with the placement of prosthetic material; (4) implantable cardiac defibrillator or epicardial pacemaker placement; (5) patients undergoing ExtraCorporal Membrane Oxygenation; (6) cardiac tumors and heart transplantation; (7) non-cardiac thoracic surgery with thoracotomy; (8) non-cardiac thoracic surgery using video-assisted thoracoscopy; (9) elective chest drain placement in the pediatric patient; (10) elective chest drain placement in the newborn; (11) thoracic drain placement in the trauma setting. This consensus provides clear and shared indications, representing the most complete and up-to-date collection of practice recommendations in pediatric cardiac and thoracic surgery, in order to guide physicians in the management of the patient, standardizing approaches and avoiding the abuse and misuse of antibiotics.
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Savary L, De Luca A, El Arid JM, Ma I, Soule N, Garnier E, Neville P, Chantepie A, Maakaroun Z, Lefort B. Systematic skin and nasal decolonization lowers Staphylococcus infection in pediatric cardiac surgery. Arch Pediatr 2022; 29:177-182. [PMID: 35094904 DOI: 10.1016/j.arcped.2022.01.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2021] [Revised: 11/29/2021] [Accepted: 01/13/2022] [Indexed: 10/19/2022]
Abstract
BACKGROUND Postoperative infections occur in approximately 10% of pediatric cardiac surgeries, involving Staphylococcus species in most cases. Nasal decontamination of Staphylococcus with mupirocin has been reported to reduce postoperative Staphylococcus infections after cardiac surgery in adults, but the effect of preoperative decontamination in children undergoing cardiac surgery has not been sufficiently studied to reach consensus. METHODS We conducted a single-center retrospective study to evaluate the impact of systematic preoperative decolonization with intranasal mupirocin application and skin-washing with chlorhexidine soap on postoperative Staphylococcus infection in children undergoing cardiac surgery. Our population was divided into three groups according to decolonization protocol (group N: no decolonization; group T: targeted decolonization in Staphylococcus aureus [SA] carriers only; and group S: systematic decolonization). RESULTS A total of 393 children were included between October 2011 and August 2015 (122 in group N, 148 in group T, and 123 in group S). The Staphylococcus infection rate significantly decreased in group S compared to group N (0.8% vs. 7.7%; p < 0.05) and tended to decrease in group S compared to group T (0.8% vs. 4.7%; p = 0.06). Systematic decontamination also significantly reduced the rate of infections starting from the skin (including surgical site infections and bloodstream infections) compared to targeted decolonization or lack of decolonization, but had no effect on the rate of pulmonary infections. CONCLUSION The results of our study suggest that systematic preoperative skin and nasal decontamination, regardless of SA carriage status, could reduce the rate of postoperative Staphylococcus infections after cardiac surgery in children.
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Affiliation(s)
- L Savary
- Institut des Cardiopathies Congénitales de Tours, CHRU Tours, France; Université François Rabelais, Tours, France
| | - A De Luca
- Université François Rabelais, Tours, France; Nutrition Pédiatrique - Unité Mobile de Nutrition, CHRU Tours, France; INSERM UMR 1069 "Nutrition, Croissance et Cancer", Tours, France
| | - J-M El Arid
- Institut des Cardiopathies Congénitales de Tours, CHRU Tours, France
| | - I Ma
- Institut des Cardiopathies Congénitales de Tours, CHRU Tours, France; Université François Rabelais, Tours, France
| | - N Soule
- Institut des Cardiopathies Congénitales de Tours, CHRU Tours, France
| | - E Garnier
- Institut des Cardiopathies Congénitales de Tours, CHRU Tours, France
| | - P Neville
- Institut des Cardiopathies Congénitales de Tours, CHRU Tours, France
| | - A Chantepie
- Institut des Cardiopathies Congénitales de Tours, CHRU Tours, France; Université François Rabelais, Tours, France
| | - Z Maakaroun
- Médecine interne et Maladies Infectieuses, CHRU Tours, France
| | - B Lefort
- Institut des Cardiopathies Congénitales de Tours, CHRU Tours, France; Université François Rabelais, Tours, France; INSERM UMR 1069 "Nutrition, Croissance et Cancer", Tours, France.
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Microbiology of Post-Cardiac Surgery Infections in Children with Congenital Heart Diseases, A Single-Center Experience, Mashhad, Iran. ARCHIVES OF PEDIATRIC INFECTIOUS DISEASES 2021. [DOI: 10.5812/pedinfect.115992] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background: Children who have undergone cardiac surgeries due to congenital heart disease are prone to various kinds of infections. Objectives: This study was done to investigate the prevalence of nosocomial infections and microbiology of post-cardiac surgery infections in pediatric patients with congenital heart disease (CHD). Methods: In this cross-sectional study, the epidemiology and microbiology of post-cardiac surgery for pediatric patients with CHD at Imam Reza Hospital of Mashhad University of Medical Sciences between 2014 and 2017 were investigated. Demographic and clinical information was recorded, and the findings were analyzed using SPSS 16. Results: Out of 1128 patients with open heart surgery during the four years of the study, 135 patients, including 80 males (60.1%) and 55 females (39.9%) with a mean age of 8.06 ± 3.86 months, were enrolled in the study. The prevalence of infection was 11.96%. The most common isolated bacteria were Acinetobacter (19/135, 14.1%), Pseudomonas spp. (13/135, 9.6%), and Enterobacter (13/135, 9.6%) as Gram-negative ones and Corynebacterium diphtheria (10/135, 7.4%) and Staphylococcus epidermidis (10/135, 7.4%) as Gram-positive types. Candida albicans (14/135, 10.4%) were also the most frequent fungi. The frequency of infection-causing masses did not differ significantly between different cardiac abnormalities (P = 0.831), sex (P = 0.621), age (P = 0.571), and weight (P = 0.786) groups. Also, the duration of hospitalization, intubation, bypass time, and urinary catheterization in positive culture cases were significantly longer than in negative cases. Conclusions: In our study, the most common infections in children who underwent heart surgery were Acinetobacter, C. albicans, Pseudomonas, and Enterobacter. It is suggested to reduce the hospitalization, intubation, bypass, and urinary catheterization time to reduce nosocomial infections in these patients and decrease treatment costs.
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Heinisch PP, Nucera M, Bartkevics M, Erdoes G, Hutter D, Gloeckler M, Kadner A. Early-experience with a novel suture device for sternal closure in pediatric cardiac surgery. Ann Thorac Surg 2021; 114:1804-1809. [PMID: 34610333 DOI: 10.1016/j.athoracsur.2021.08.066] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/02/2021] [Revised: 08/24/2021] [Accepted: 08/30/2021] [Indexed: 11/18/2022]
Abstract
BACKGROUND Sternal closure by absorbable suture material is an established method for chest closure in pediatric cardiac surgery. However, the formation of granuloma around knotted suture material is frequently observed and has potential for prolonged wound healing and infection, particularly in newborns and infants. This retrospective study analyses the suitability and reliability of a novel absorbable, self-locking, multi-anchor knotless suture with antibacterial technology for sternal closure in pediatric cardiac surgery. METHODS The applied material (STRATAFIXTMSymmetric PDS Plus, Ethicon) presents a poly-dioxanon PDS suture with a self-locking, multi anchor design, which enables a sternal closure in a continuous knotless suture technique. All children undergoing knotless closure after standard median sternotomy were examined for the occurrence of sternal wound infection or sternal instability by applying the screening criteria of the Centers for Disease Control and Prevention at hospital discharge, at 30 and 60 days. RESULTS In 130 cases, the new knotless sternal closure was used. Patients` mean age was 19.0±31.9 months (range: 0 to 142 months), mean bodyweight 7.8±6.6 kg (range: 2.4 to 35 kg). Delayed sternal closure occurred in 23 cases with a mean closure time after 2.9±2.6 days. One superficial incisional sternal site infection but no cases of deep sternal site infection or sternal instability were observed. CONCLUSIONS The application of the absorbable, knotless suture technique provides excellent results regarding the rate of sternal wound infection and improved healing after median sternotomy in pediatric patients.
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Affiliation(s)
- Paul Philipp Heinisch
- Centre for Congenital Heart Disease, Department of Cardiovascular Surgery, Inselspital, University Hospital, University of Bern, Bern, Switzerland; Department of Congenital and Pediatric Heart Surgery, German Heart Centre Munich, Technical University of Munich, Munich, Germany
| | - Maria Nucera
- Centre for Congenital Heart Disease, Department of Cardiovascular Surgery, Inselspital, University Hospital, University of Bern, Bern, Switzerland
| | - Maris Bartkevics
- Centre for Congenital Heart Disease, Department of Cardiovascular Surgery, Inselspital, University Hospital, University of Bern, Bern, Switzerland
| | - Gabor Erdoes
- Department of Anaesthesiology and Pain Medicine, Inselspital, University Hospital, University Bern, Bern, Switzerland
| | - Damian Hutter
- Centre for Congenital Heart Disease, Department of Cardiology, Inselspital, University Hospital, University Bern, Bern, Switzerland
| | - Martin Gloeckler
- Centre for Congenital Heart Disease, Department of Cardiology, Inselspital, University Hospital, University Bern, Bern, Switzerland
| | - Alexander Kadner
- Centre for Congenital Heart Disease, Department of Cardiovascular Surgery, Inselspital, University Hospital, University of Bern, Bern, Switzerland.
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Alshaya MA, Almutairi NS, Shaath GA, Aldosari RA, Alnami SK, Althubaiti A, Abu-Sulaiman RM. Original Article--Surgical site infections following pediatric cardiac surgery in a tertiary care hospital: Rate and risk factors. J Saudi Heart Assoc 2021; 33:1-8. [PMID: 33880325 PMCID: PMC8051332 DOI: 10.37616/2212-5043.1234] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2020] [Revised: 01/17/2021] [Accepted: 01/19/2021] [Indexed: 11/20/2022] Open
Abstract
BACKGROUND Surgical site infections [SSIs] are the second most common type of healthcare-associated infections and leading cause of postoperative morbidity and mortality in pediatric cardiac surgery. This study aims to determine the rate of, risk factors for, and most common pathogen associated with the development of SSIs after pediatric cardiac surgery. METHODS Patients aged ≤14 years who underwent cardiac surgery at our tertiary care hospital between January 2010 and December 2015 were retrospectively reviewed. RESULTS The SSI rate was 7.8% among the 1510 pediatric patients reviewed. Catheter-associated urinary tract infection [CAUTI] [odds ratio [OR] 5.7; 95% confidence interval [CI] 2.3-13.8; P < 0.001], ventilator-associated pneumonia [VAP] [OR 3.2; 95% CI 1.4-7.2; P = 0.005], longer postoperative stay [≥25 days] [OR 4.1; 95% CI 2.1-8.1; P < 0.001], and a risk adjustment in congenital heart surgery [RACHS-1] score of ≥2 [OR 2.4; 95% CI 1.2-5.6; P = 0.034] were identified as risk factors for SSIs. Staphylococcus aureus was the most common pathogen [32.2%]. CONCLUSIONS SSI risk factors were longer postoperative stay, CAUTI, VAP, and RACHS-1 score of ≥2. Identification and confirmation of risk factors in this study is important in order to reduce the rate of SSIs following cardiac surgery.
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Affiliation(s)
- Milad A. Alshaya
- College of Medicine, King Saud Bin Abdulaziz University for Health Sciences, Riyadh,
Saudi Arabia
| | - Nouf S. Almutairi
- College of Medicine, King Saud Bin Abdulaziz University for Health Sciences, Riyadh,
Saudi Arabia
| | - Ghassan A. Shaath
- Department of Cardiac Sciences, King Abdulaziz Cardiac Center, King Abdulaziz Medical City, Ministry of National Guard-Health Affairs, Riyadh,
Saudi Arabia
| | - Rahmah A. Aldosari
- College of Medicine, King Saud Bin Abdulaziz University for Health Sciences, Riyadh,
Saudi Arabia
| | - Sadeem K. Alnami
- College of Medicine, King Saud Bin Abdulaziz University for Health Sciences, Riyadh,
Saudi Arabia
| | - Alaa Althubaiti
- Department of Basic Medical Sciences, College of Medicine, King Saud Bin Abdulaziz University for Health Sciences, Jeddah,
Saudi Arabia
- King Abdullah International Medical Research Centre, Jeddah,
Saudi Arabia
| | - Riyadh M. Abu-Sulaiman
- College of Medicine, King Saud Bin Abdulaziz University for Health Sciences, Riyadh,
Saudi Arabia
- Department of Cardiac Sciences, King Abdulaziz Cardiac Center, King Abdulaziz Medical City, Ministry of National Guard-Health Affairs, Riyadh,
Saudi Arabia
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Meng L, Li J, He Y, Xiong Y, Li J, Wang J, Shi Y, Liu Y. The risk factors analysis and establishment of an early warning model for healthcare-associated infections after pediatric cardiac surgery: A STROBE-compliant observational study. Medicine (Baltimore) 2020; 99:e23324. [PMID: 33285709 PMCID: PMC7717841 DOI: 10.1097/md.0000000000023324] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/21/2019] [Revised: 08/10/2020] [Accepted: 10/21/2020] [Indexed: 11/25/2022] Open
Abstract
The aim of this study was to identify the main risk factors for health-care-associated infections (HAIs) following cardiac surgery and to establish an effective early warning model for HAIs to enable intervention in an earlier stage.In total, 2227 patients, including 222 patients with postoperative diagnosis of HAIs and 2005 patients with no-HAIs, were continuously enrolled in Beijing Anzhen Hospital, Beijing, China. Propensity score matching was used and 222 matched pairs were created. The risk factors were analyzed with the methods of univariate and multivariate logistic regression. The receiver operating characteristic (ROC) curve was used to test the accuracy of the HAIs early warning model.After propensity score matching, operation time, clamping time, intubation time, urinary catheter time, central venous catheter time, ≥3 blood transfusions, re-endotracheal intubation, length of hospital stay, and length of intensive care unit stay, still showed significant differences between the 2 groups. After logistic model analysis, the independent risk factors for HAIs were medium to high complexity, intubation time, urinary catheter time, and central venous catheter time. The ROC showed the area under curve was 0.985 (confidence interval: 0.975-0.996). When the probability was 0.529, the model had the highest prediction rate, the corresponding sensitivity was 0.946, and the specificity was 0.968.According to the results, the early warning model containing medium to high complexity, intubation time, urinary catheter time, and central venous catheter time enables more accurate predictions and can be used to guide early intervention after pediatric cardiac surgery.
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Affiliation(s)
- Lihui Meng
- Pediatric Cardiac Center, Department of Cardiac Surgery
- Health-care Associated Infection Management Office, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Jiachen Li
- Pediatric Cardiac Center, Department of Cardiac Surgery
| | - Yan He
- Pediatric Cardiac Center, Department of Cardiac Surgery
| | - Ying Xiong
- Health-care Associated Infection Management Office, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Jingming Li
- Health-care Associated Infection Management Office, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Jing Wang
- Health-care Associated Infection Management Office, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Ying Shi
- Health-care Associated Infection Management Office, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Yinglong Liu
- Pediatric Cardiac Center, Department of Cardiac Surgery
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Brown KL, Pagel C, Ridout D, Wray J, Tsang VT, Anderson D, Banks V, Barron DJ, Cassidy J, Chigaru L, Davis P, Franklin R, Grieco L, Hoskote A, Hudson E, Jones A, Kakat S, Lakhani R, Lakhanpaul M, McLean A, Morris S, Rajagopal V, Rodrigues W, Sheehan K, Stoica S, Tibby S, Utley M, Witter T. Early morbidities following paediatric cardiac surgery: a mixed-methods study. HEALTH SERVICES AND DELIVERY RESEARCH 2020. [DOI: 10.3310/hsdr08300] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023] Open
Abstract
Background
Over 5000 paediatric cardiac surgeries are performed in the UK each year and early survival has improved to > 98%.
Objectives
We aimed to identify the surgical morbidities that present the greatest burden for patients and health services and to develop and pilot routine monitoring and feedback.
Design and setting
Our multidisciplinary mixed-methods study took place over 52 months across five UK paediatric cardiac surgery centres.
Participants
The participants were children aged < 17 years.
Methods
We reviewed existing literature, ran three focus groups and undertook a family online discussion forum moderated by the Children’s Heart Federation. A multidisciplinary group, with patient and carer involvement, then ranked and selected nine key morbidities informed by clinical views on definitions and feasibility of routine monitoring. We validated a new, nurse-administered early warning tool for assessing preoperative and postoperative child development, called the brief developmental assessment, by testing this among 1200 children. We measured morbidity incidence in 3090 consecutive surgical admissions over 21 months and explored risk factors for morbidity. We measured the impact of morbidities on quality of life, clinical burden and costs to the NHS and families over 6 months in 666 children, 340 (51%) of whom had at least one morbidity. We developed and piloted methods suitable for routine monitoring of morbidity by centres and co-developed new patient information about morbidities with parents and user groups.
Results
Families and clinicians prioritised overlapping but also different morbidities, leading to a final list of acute neurological event, unplanned reoperation, feeding problems, renal replacement therapy, major adverse events, extracorporeal life support, necrotising enterocolitis, surgical infection and prolonged pleural effusion. The brief developmental assessment was valid in children aged between 4 months and 5 years, but not in the youngest babies or 5- to 17-year-olds. A total of 2415 (78.2%) procedures had no measured morbidity. There was a higher risk of morbidity in neonates, complex congenital heart disease, increased preoperative severity of illness and with prolonged bypass. Patients with any morbidity had a 6-month survival of 81.5% compared with 99.1% with no morbidity. Patients with any morbidity scored 5.2 points lower on their total quality of life score at 6 weeks, but this difference had narrowed by 6 months. Morbidity led to fewer days at home by 6 months and higher costs. Extracorporeal life support patients had the lowest days at home (median: 43 days out of 183 days) and highest costs (£71,051 higher than no morbidity).
Limitations
Monitoring of morbidity is more complex than mortality, and hence this requires resources and clinician buy-in.
Conclusions
Evaluation of postoperative morbidity provides important information over and above 30-day survival and should become the focus of audit and quality improvement.
Future work
National audit of morbidities has been initiated. Further research is needed to understand the implications of feeding problems and renal failure and to evaluate the brief developmental assessment.
Funding
This project was funded by the NIHR Health Services and Delivery Research programme and will be published in full in Health Services and Delivery Research; Vol. 8, No. 30. See the NIHR Journals Library website for further project information.
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Affiliation(s)
- Katherine L Brown
- Heart and Lung Division, Great Ormond Street Hospital NHS Foundation Trust, London, UK
| | - Christina Pagel
- Clinical Operational Research Unit, University College London, London, UK
| | - Deborah Ridout
- Population, Policy and Practice Programme, UCL Great Ormond Street Institute of Child Health, London, UK
| | - Jo Wray
- Heart and Lung Division, Great Ormond Street Hospital NHS Foundation Trust, London, UK
| | - Victor T Tsang
- Heart and Lung Division, Great Ormond Street Hospital NHS Foundation Trust, London, UK
| | - David Anderson
- Departments of Paediatric Intensive Care, Cardiology and Cardiac Surgery, Evelina London Children’s Hospital, London, UK
| | - Victoria Banks
- Heart and Lung Division, Great Ormond Street Hospital NHS Foundation Trust, London, UK
| | - David J Barron
- Departments of Intensive Care and Paediatric Cardiac Surgery, Birmingham Children’s Hospital, Birmingham, UK
| | - Jane Cassidy
- Departments of Intensive Care and Paediatric Cardiac Surgery, Birmingham Children’s Hospital, Birmingham, UK
| | - Linda Chigaru
- Heart and Lung Division, Great Ormond Street Hospital NHS Foundation Trust, London, UK
| | - Peter Davis
- Departments of Intensive Care and Paediatric Cardiac Surgery, Bristol Royal Hospital for Children, Bristol, UK
| | - Rodney Franklin
- Paediatric Cardiology Department, Royal Brompton and Harefield NHS Foundation Trust, London, UK
| | - Luca Grieco
- Clinical Operational Research Unit, University College London, London, UK
| | - Aparna Hoskote
- Heart and Lung Division, Great Ormond Street Hospital NHS Foundation Trust, London, UK
| | - Emma Hudson
- Department of Applied Health Research, University College London, London, UK
| | - Alison Jones
- Departments of Intensive Care and Paediatric Cardiac Surgery, Birmingham Children’s Hospital, Birmingham, UK
| | - Suzan Kakat
- Heart and Lung Division, Great Ormond Street Hospital NHS Foundation Trust, London, UK
| | - Rhian Lakhani
- Departments of Paediatric Intensive Care, Cardiology and Cardiac Surgery, Evelina London Children’s Hospital, London, UK
| | - Monica Lakhanpaul
- Population, Policy and Practice Programme, UCL Great Ormond Street Institute of Child Health, London, UK
- Community Child Health, UCL Great Ormond Street Institute of Child Health, London, UK
| | - Andrew McLean
- Department of Intensive care, Royal Hospital for Children, Glasgow, UK
| | - Steve Morris
- Department of Applied Health Research, University College London, London, UK
| | - Veena Rajagopal
- Heart and Lung Division, Great Ormond Street Hospital NHS Foundation Trust, London, UK
| | - Warren Rodrigues
- Department of Intensive care, Royal Hospital for Children, Glasgow, UK
| | - Karen Sheehan
- Departments of Intensive Care and Paediatric Cardiac Surgery, Bristol Royal Hospital for Children, Bristol, UK
| | - Serban Stoica
- Departments of Intensive Care and Paediatric Cardiac Surgery, Bristol Royal Hospital for Children, Bristol, UK
| | - Shane Tibby
- Departments of Paediatric Intensive Care, Cardiology and Cardiac Surgery, Evelina London Children’s Hospital, London, UK
| | - Martin Utley
- Clinical Operational Research Unit, University College London, London, UK
| | - Thomas Witter
- Departments of Paediatric Intensive Care, Cardiology and Cardiac Surgery, Evelina London Children’s Hospital, London, UK
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Yu X, Chen M, Liu X, Chen Y, Hao Z, Zhang H, Wang W. Risk factors of nosocomial infection after cardiac surgery in children with congenital heart disease. BMC Infect Dis 2020; 20:64. [PMID: 31964345 PMCID: PMC6975050 DOI: 10.1186/s12879-020-4769-6] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2019] [Accepted: 01/07/2020] [Indexed: 01/22/2023] Open
Abstract
Background The aim of our study was to analyze the risk factors of nosocomial infection after cardiac surgery in children with congenital heart disease (CHD). Methods We performed a retrospective cohort study, and children with CHD who underwent open-heart surgeries at Shanghai Children’s Medical Center from January 1, 2012 to December 31, 2018 were included. The baseline characteristics of these patients of different ages, including neonates (0–1 months old), infants (1–12 months old) and children (1–10 years old), were analyzed, and the association of risk factors with postoperative nosocomial infection were assessed. Results A total of 11,651 subjects were included in the study. The overall nosocomial infection rate was 10.8%. Nosocomial infection rates in neonates, infants, and children with congenital heart disease were 32.9, 15.4, and 5.2%, respectively. Multivariate logistic regression analysis found age (OR 0798, 95%CI: 0.769–0.829; P < 0.001), STS risk grade (OR 1.267, 95%CI: 1.159–1.385; P < 0.001), body mass index (BMI) <5th percentile (OR 1.295, 95%CI: 1.023–1.639; P = 0.032), BMI >95th percentile (OR 0.792, 95%CI: 0.647–0.969; P = 0.023), cardiopulmonary bypass (CPB) time (OR 1.008, 95%CI: 1.003–1.012; P < 0.001) and aortic clamping time (OR 1.009, 1.002–1.015; P = 0.008) were significantly associated with nosocomial infection in CHD infants. After adjusted for confounding factors, we found STS risk grade (OR 1.38, 95%CI: 1.167–1.633; P < 0.001), BMI < 5th percentile (OR 1.934, 95%CI: 1.377–2.715; P < 0.001), CPB time (OR 1.018, 95%CI: 1.015–1.022; P < 0.001), lymphocyte/WBC ratio<cut off value (OR 3.818, 95%CI: 1.529–9.533; P = 0.004) and AST>cut off value (OR 1.546, 95%CI: 1.119–2.136; P = 0.008) were significantly associated with nosocomial infection in CHD children. Conclusion Our study suggested STS risk grade, BMI, CPB duration, low lymphocyte/WBC or high neutrophil/WBC ratio were independently associated with nosocomial infection in CHD infant and children after cardiac surgery.
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Affiliation(s)
- Xindi Yu
- Department of Cardiothoracic Surgery, Shanghai Children's Medical Center, School of Medicine, Shanghai Jiao Tong University, 1678 Dongfang Road, Pudong district, Shanghai, China
| | - Maolin Chen
- Department of Cardiothoracic Surgery, Shanghai Children's Medical Center, School of Medicine, Shanghai Jiao Tong University, 1678 Dongfang Road, Pudong district, Shanghai, China
| | - Xu Liu
- Department of Cardiothoracic Surgery, Shanghai Children's Medical Center, School of Medicine, Shanghai Jiao Tong University, 1678 Dongfang Road, Pudong district, Shanghai, China
| | - Yiwei Chen
- Shanghai Synyi Medical Technology Co., Ltd, Shanghai, China
| | - Zedong Hao
- Shanghai Synyi Medical Technology Co., Ltd, Shanghai, China
| | - Haibo Zhang
- Department of Cardiothoracic Surgery, Shanghai Children's Medical Center, School of Medicine, Shanghai Jiao Tong University, 1678 Dongfang Road, Pudong district, Shanghai, China.
| | - Wei Wang
- Department of Cardiothoracic Surgery, Shanghai Children's Medical Center, School of Medicine, Shanghai Jiao Tong University, 1678 Dongfang Road, Pudong district, Shanghai, China.
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Brown KL, Ridout D, Pagel C, Wray J, Anderson D, Barron DJ, Cassidy J, Davis PJ, Rodrigues W, Stoica S, Tibby S, Utley M, Tsang VT. Incidence and risk factors for important early morbidities associated with pediatric cardiac surgery in a UK population. J Thorac Cardiovasc Surg 2019; 158:1185-1196.e7. [DOI: 10.1016/j.jtcvs.2019.03.139] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/15/2018] [Revised: 03/20/2019] [Accepted: 03/22/2019] [Indexed: 11/29/2022]
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Tweddell S, Loomba RS, Cooper DS, Benscoter AL. Health care‐associated infections are associated with increased length of stay and cost but not mortality in children undergoing cardiac surgery. CONGENIT HEART DIS 2019; 14:785-790. [DOI: 10.1111/chd.12779] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2019] [Revised: 03/16/2019] [Accepted: 04/10/2019] [Indexed: 11/27/2022]
Affiliation(s)
- Sarah Tweddell
- Division of Cardiology, Department of Pediatrics Cincinnati Children’s Hospital Medical Center Cincinnati Ohio
| | - Rohit S. Loomba
- Division of Cardiology, Department of Pediatrics Cincinnati Children’s Hospital Medical Center Cincinnati Ohio
| | - David S. Cooper
- Division of Cardiology, Department of Pediatrics Cincinnati Children’s Hospital Medical Center Cincinnati Ohio
| | - Alexis L. Benscoter
- Division of Cardiology, Department of Pediatrics Cincinnati Children’s Hospital Medical Center Cincinnati Ohio
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A Postoperative Care Bundle Reduces Surgical Site Infections in Pediatric Patients Undergoing Cardiac Surgeries. Jt Comm J Qual Patient Saf 2019; 45:156-163. [DOI: 10.1016/j.jcjq.2018.05.009] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2018] [Revised: 05/24/2018] [Accepted: 05/25/2018] [Indexed: 11/18/2022]
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Abstract
BACKGROUND Healthcare-associated infections (HAIs) represent serious complications for patients within pediatric cardiac intensive care units (CICU). HAIs are associated with increased morbidity, mortality and resource utilization. There are few studies describing the epidemiology of HAIs across the entire spectrum of patients (surgical and nonsurgical) receiving care in dedicated pediatric CICUs. METHODS Retrospective analyses of 22,839 CICU encounters from October 2013 to September 2016 across 22 North American CICUs contributing data to the Pediatric Cardiac Critical Care Consortium clinical registry. RESULTS HAIs occurred in 2.4% of CICU encounters at a rate of 3.3 HAIs/1000 CICU days, with 73% of HAIs occurring in children <1 year. Eighty encounters (14%) had ≥2 HAIs. Aggregate rates for the 4 primary HAIs are as follows: central line-associated blood stream infection, 1.1/1000 line days; catheter-associated urinary tract infections, 1.5/1000 catheter days; ventilator-associated pneumonia, 1.9/1000 ventilator days; surgical site infections, 0.81/100 operations. Surgical and nonsurgical patients had similar HAIs rates/1000 CICU days. Incidence was twice as high in surgical encounters and increased with surgical complexity; postoperative infection occurred in 2.8% of encounters. Prematurity, younger age, presence of congenital anomaly, Society of Thoracic Surgeons-European Association for Cardio-Thoracic Surgery Congenital Heart Surgery Mortality Categories (STAT) 4-5 surgery, admission with an active medical condition, open sternum and extracorporeal membrane oxygenation were independently associated with HAIs. In univariable analysis, HAI was associated with longer hospital length of stay and durations of urinary catheter, central venous catheter and ventilation. Mortality was 24.4% in patients with HAIs versus 3.4% in those without, P < 0.0001. CONCLUSIONS We provide comprehensive multicenter benchmark data regarding rates of HAIs within dedicated pediatric CICUs. We confirm that although rare, HAIs of all types are associated with significant resource utilization and mortality.
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Abstract
BACKGROUND Perioperative infections have significant consequences for children with congenital heart disease (CHD), which can manifest as acute or chronic infection followed by poor growth and progressive cardiac failure. The consequences include delayed or higher-risk surgery, and increased postoperative morbidity and mortality. METHODS A systematic search for studies evaluating the burden and interventions to reduce perioperative infections in children with CHD was undertaken using PubMed. RESULTS Limited studies conducted in low- to middle-income countries demonstrated the large burden of perioperative infections among children with CHD. Most studies focussed on infections after surgery. Few studies evaluated strategies to prevent preoperative infection or the impact of infection on decision-making around the timing of surgery. Children with CHD have multiple risk factors for infections including delayed presentation, inadequate treatment of cardiac failure, and poor nutrition. CONCLUSIONS The burden of perioperative infections is high among children with CHD, and studies evaluating the effectiveness of interventions to reduce these infections are lacking. As good nutrition, early corrective surgery, and measures to reduce nosocomial infection are likely to play a role, practical steps can be taken to make surgery safer.
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Sen AC, Morrow DF, Balachandran R, Du X, Gauvreau K, Jagannath BR, Kumar RK, Kupiec JK, Melgar ML, Chau NT, Potter-Bynoe G, Tamariz-Cruz O, Jenkins KJ. Postoperative Infection in Developing World Congenital Heart Surgery Programs: Data From the International Quality Improvement Collaborative. Circ Cardiovasc Qual Outcomes 2017; 10:CIRCOUTCOMES.116.002935. [PMID: 28408715 DOI: 10.1161/circoutcomes.116.002935] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/27/2016] [Accepted: 03/03/2017] [Indexed: 11/16/2022]
Abstract
BACKGROUND Postoperative infections contribute substantially to morbidity and mortality after congenital heart disease surgery and are often preventable. We sought to identify risk factors for postoperative infection and the impact on outcomes after congenital heart surgery, using data from the International Quality Improvement Collaborative for Congenital Heart Surgery in Developing World Countries. METHODS AND RESULTS Pediatric cardiac surgical cases performed between 2010 and 2012 at 27 participating sites in 16 developing countries were included. Key variables were audited during site visits. Demographics, preoperative, procedural, surgical complexity, and outcome data were analyzed. Univariate and multivariable logistic regression were used to identify risk factors for infection, including bacterial sepsis and surgical site infection, and other clinical outcomes. Standardized infection ratios were computed to track progress over time. Of 14 545 cases, 793 (5.5%) had bacterial sepsis and 306 (2.1%) had surgical site infection. In-hospital mortality was significantly higher among cases with infection than among those without infection (16.7% versus 5.3%; P<0.001), as were postoperative ventilation duration (80 versus 14 hours; P<0.001) and intensive care unit stay (216 versus 68 hours; P<0.001). Younger age at surgery, higher surgical complexity, lower oxygen saturation, and major medical illness were independent risk factors for infection. The overall standardized infection ratio was 0.65 (95% confidence interval, 0.58-0.73) in 2011 and 0.59 (95% confidence interval, 0.54-0.64) in 2012, compared with that in 2010. CONCLUSIONS Postoperative infections contribute to mortality and morbidity after congenital heart surgery. Younger, more complex patients are at particular risk. Quality improvement targeted at infection risk may reduce morbidity and mortality in the developing world.
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Affiliation(s)
- Amitabh Chanchal Sen
- From the Department of Cardiac Anesthesiology (A.C.S., R.B.) and Department of Pediatric Cardiology (R.K.K.), Amrita Institute of Medical Sciences, Amrita Vishwa Vidyapeetham, Kochi, India; Department of Cardiology (D.F.M., K.G., J.K.K., K.J.J.) and Infection Prevention and Control (G.P.-B.), Boston Children's Hospital, MA; Department of Cardiovascular Surgery, Shanghai Children's Medical Center, Shanghai Jiaotong University School of Medicine, China (X.D.); Department of Cardiovascular Surgery, Star Hospital, Hyderabad, India (B.R.J.); Department of Family Medicine, Scripps Mercy Hospital Chula Vista, CA (M.L.M.); Department of Intensive Care, Nhi Dong No 1 (Children's Hospital No 1), Ho Chi Minh City, Viet Nam (N.T.C.); and Department of Cardiac Anesthesiology and Critical Care, Instituto Nacional de Pediatria and Kardias/American British Chowdry Hospital Project, Mexico City (O.T.-C.).
| | - Debra Forbes Morrow
- From the Department of Cardiac Anesthesiology (A.C.S., R.B.) and Department of Pediatric Cardiology (R.K.K.), Amrita Institute of Medical Sciences, Amrita Vishwa Vidyapeetham, Kochi, India; Department of Cardiology (D.F.M., K.G., J.K.K., K.J.J.) and Infection Prevention and Control (G.P.-B.), Boston Children's Hospital, MA; Department of Cardiovascular Surgery, Shanghai Children's Medical Center, Shanghai Jiaotong University School of Medicine, China (X.D.); Department of Cardiovascular Surgery, Star Hospital, Hyderabad, India (B.R.J.); Department of Family Medicine, Scripps Mercy Hospital Chula Vista, CA (M.L.M.); Department of Intensive Care, Nhi Dong No 1 (Children's Hospital No 1), Ho Chi Minh City, Viet Nam (N.T.C.); and Department of Cardiac Anesthesiology and Critical Care, Instituto Nacional de Pediatria and Kardias/American British Chowdry Hospital Project, Mexico City (O.T.-C.)
| | - Rakhi Balachandran
- From the Department of Cardiac Anesthesiology (A.C.S., R.B.) and Department of Pediatric Cardiology (R.K.K.), Amrita Institute of Medical Sciences, Amrita Vishwa Vidyapeetham, Kochi, India; Department of Cardiology (D.F.M., K.G., J.K.K., K.J.J.) and Infection Prevention and Control (G.P.-B.), Boston Children's Hospital, MA; Department of Cardiovascular Surgery, Shanghai Children's Medical Center, Shanghai Jiaotong University School of Medicine, China (X.D.); Department of Cardiovascular Surgery, Star Hospital, Hyderabad, India (B.R.J.); Department of Family Medicine, Scripps Mercy Hospital Chula Vista, CA (M.L.M.); Department of Intensive Care, Nhi Dong No 1 (Children's Hospital No 1), Ho Chi Minh City, Viet Nam (N.T.C.); and Department of Cardiac Anesthesiology and Critical Care, Instituto Nacional de Pediatria and Kardias/American British Chowdry Hospital Project, Mexico City (O.T.-C.)
| | - Xinwei Du
- From the Department of Cardiac Anesthesiology (A.C.S., R.B.) and Department of Pediatric Cardiology (R.K.K.), Amrita Institute of Medical Sciences, Amrita Vishwa Vidyapeetham, Kochi, India; Department of Cardiology (D.F.M., K.G., J.K.K., K.J.J.) and Infection Prevention and Control (G.P.-B.), Boston Children's Hospital, MA; Department of Cardiovascular Surgery, Shanghai Children's Medical Center, Shanghai Jiaotong University School of Medicine, China (X.D.); Department of Cardiovascular Surgery, Star Hospital, Hyderabad, India (B.R.J.); Department of Family Medicine, Scripps Mercy Hospital Chula Vista, CA (M.L.M.); Department of Intensive Care, Nhi Dong No 1 (Children's Hospital No 1), Ho Chi Minh City, Viet Nam (N.T.C.); and Department of Cardiac Anesthesiology and Critical Care, Instituto Nacional de Pediatria and Kardias/American British Chowdry Hospital Project, Mexico City (O.T.-C.)
| | - Kimberlee Gauvreau
- From the Department of Cardiac Anesthesiology (A.C.S., R.B.) and Department of Pediatric Cardiology (R.K.K.), Amrita Institute of Medical Sciences, Amrita Vishwa Vidyapeetham, Kochi, India; Department of Cardiology (D.F.M., K.G., J.K.K., K.J.J.) and Infection Prevention and Control (G.P.-B.), Boston Children's Hospital, MA; Department of Cardiovascular Surgery, Shanghai Children's Medical Center, Shanghai Jiaotong University School of Medicine, China (X.D.); Department of Cardiovascular Surgery, Star Hospital, Hyderabad, India (B.R.J.); Department of Family Medicine, Scripps Mercy Hospital Chula Vista, CA (M.L.M.); Department of Intensive Care, Nhi Dong No 1 (Children's Hospital No 1), Ho Chi Minh City, Viet Nam (N.T.C.); and Department of Cardiac Anesthesiology and Critical Care, Instituto Nacional de Pediatria and Kardias/American British Chowdry Hospital Project, Mexico City (O.T.-C.)
| | - Byalal R Jagannath
- From the Department of Cardiac Anesthesiology (A.C.S., R.B.) and Department of Pediatric Cardiology (R.K.K.), Amrita Institute of Medical Sciences, Amrita Vishwa Vidyapeetham, Kochi, India; Department of Cardiology (D.F.M., K.G., J.K.K., K.J.J.) and Infection Prevention and Control (G.P.-B.), Boston Children's Hospital, MA; Department of Cardiovascular Surgery, Shanghai Children's Medical Center, Shanghai Jiaotong University School of Medicine, China (X.D.); Department of Cardiovascular Surgery, Star Hospital, Hyderabad, India (B.R.J.); Department of Family Medicine, Scripps Mercy Hospital Chula Vista, CA (M.L.M.); Department of Intensive Care, Nhi Dong No 1 (Children's Hospital No 1), Ho Chi Minh City, Viet Nam (N.T.C.); and Department of Cardiac Anesthesiology and Critical Care, Instituto Nacional de Pediatria and Kardias/American British Chowdry Hospital Project, Mexico City (O.T.-C.)
| | - Raman Krishna Kumar
- From the Department of Cardiac Anesthesiology (A.C.S., R.B.) and Department of Pediatric Cardiology (R.K.K.), Amrita Institute of Medical Sciences, Amrita Vishwa Vidyapeetham, Kochi, India; Department of Cardiology (D.F.M., K.G., J.K.K., K.J.J.) and Infection Prevention and Control (G.P.-B.), Boston Children's Hospital, MA; Department of Cardiovascular Surgery, Shanghai Children's Medical Center, Shanghai Jiaotong University School of Medicine, China (X.D.); Department of Cardiovascular Surgery, Star Hospital, Hyderabad, India (B.R.J.); Department of Family Medicine, Scripps Mercy Hospital Chula Vista, CA (M.L.M.); Department of Intensive Care, Nhi Dong No 1 (Children's Hospital No 1), Ho Chi Minh City, Viet Nam (N.T.C.); and Department of Cardiac Anesthesiology and Critical Care, Instituto Nacional de Pediatria and Kardias/American British Chowdry Hospital Project, Mexico City (O.T.-C.)
| | - Jennifer Koch Kupiec
- From the Department of Cardiac Anesthesiology (A.C.S., R.B.) and Department of Pediatric Cardiology (R.K.K.), Amrita Institute of Medical Sciences, Amrita Vishwa Vidyapeetham, Kochi, India; Department of Cardiology (D.F.M., K.G., J.K.K., K.J.J.) and Infection Prevention and Control (G.P.-B.), Boston Children's Hospital, MA; Department of Cardiovascular Surgery, Shanghai Children's Medical Center, Shanghai Jiaotong University School of Medicine, China (X.D.); Department of Cardiovascular Surgery, Star Hospital, Hyderabad, India (B.R.J.); Department of Family Medicine, Scripps Mercy Hospital Chula Vista, CA (M.L.M.); Department of Intensive Care, Nhi Dong No 1 (Children's Hospital No 1), Ho Chi Minh City, Viet Nam (N.T.C.); and Department of Cardiac Anesthesiology and Critical Care, Instituto Nacional de Pediatria and Kardias/American British Chowdry Hospital Project, Mexico City (O.T.-C.)
| | - Monica L Melgar
- From the Department of Cardiac Anesthesiology (A.C.S., R.B.) and Department of Pediatric Cardiology (R.K.K.), Amrita Institute of Medical Sciences, Amrita Vishwa Vidyapeetham, Kochi, India; Department of Cardiology (D.F.M., K.G., J.K.K., K.J.J.) and Infection Prevention and Control (G.P.-B.), Boston Children's Hospital, MA; Department of Cardiovascular Surgery, Shanghai Children's Medical Center, Shanghai Jiaotong University School of Medicine, China (X.D.); Department of Cardiovascular Surgery, Star Hospital, Hyderabad, India (B.R.J.); Department of Family Medicine, Scripps Mercy Hospital Chula Vista, CA (M.L.M.); Department of Intensive Care, Nhi Dong No 1 (Children's Hospital No 1), Ho Chi Minh City, Viet Nam (N.T.C.); and Department of Cardiac Anesthesiology and Critical Care, Instituto Nacional de Pediatria and Kardias/American British Chowdry Hospital Project, Mexico City (O.T.-C.)
| | - Nguyen Tran Chau
- From the Department of Cardiac Anesthesiology (A.C.S., R.B.) and Department of Pediatric Cardiology (R.K.K.), Amrita Institute of Medical Sciences, Amrita Vishwa Vidyapeetham, Kochi, India; Department of Cardiology (D.F.M., K.G., J.K.K., K.J.J.) and Infection Prevention and Control (G.P.-B.), Boston Children's Hospital, MA; Department of Cardiovascular Surgery, Shanghai Children's Medical Center, Shanghai Jiaotong University School of Medicine, China (X.D.); Department of Cardiovascular Surgery, Star Hospital, Hyderabad, India (B.R.J.); Department of Family Medicine, Scripps Mercy Hospital Chula Vista, CA (M.L.M.); Department of Intensive Care, Nhi Dong No 1 (Children's Hospital No 1), Ho Chi Minh City, Viet Nam (N.T.C.); and Department of Cardiac Anesthesiology and Critical Care, Instituto Nacional de Pediatria and Kardias/American British Chowdry Hospital Project, Mexico City (O.T.-C.)
| | - Gail Potter-Bynoe
- From the Department of Cardiac Anesthesiology (A.C.S., R.B.) and Department of Pediatric Cardiology (R.K.K.), Amrita Institute of Medical Sciences, Amrita Vishwa Vidyapeetham, Kochi, India; Department of Cardiology (D.F.M., K.G., J.K.K., K.J.J.) and Infection Prevention and Control (G.P.-B.), Boston Children's Hospital, MA; Department of Cardiovascular Surgery, Shanghai Children's Medical Center, Shanghai Jiaotong University School of Medicine, China (X.D.); Department of Cardiovascular Surgery, Star Hospital, Hyderabad, India (B.R.J.); Department of Family Medicine, Scripps Mercy Hospital Chula Vista, CA (M.L.M.); Department of Intensive Care, Nhi Dong No 1 (Children's Hospital No 1), Ho Chi Minh City, Viet Nam (N.T.C.); and Department of Cardiac Anesthesiology and Critical Care, Instituto Nacional de Pediatria and Kardias/American British Chowdry Hospital Project, Mexico City (O.T.-C.)
| | - Orlando Tamariz-Cruz
- From the Department of Cardiac Anesthesiology (A.C.S., R.B.) and Department of Pediatric Cardiology (R.K.K.), Amrita Institute of Medical Sciences, Amrita Vishwa Vidyapeetham, Kochi, India; Department of Cardiology (D.F.M., K.G., J.K.K., K.J.J.) and Infection Prevention and Control (G.P.-B.), Boston Children's Hospital, MA; Department of Cardiovascular Surgery, Shanghai Children's Medical Center, Shanghai Jiaotong University School of Medicine, China (X.D.); Department of Cardiovascular Surgery, Star Hospital, Hyderabad, India (B.R.J.); Department of Family Medicine, Scripps Mercy Hospital Chula Vista, CA (M.L.M.); Department of Intensive Care, Nhi Dong No 1 (Children's Hospital No 1), Ho Chi Minh City, Viet Nam (N.T.C.); and Department of Cardiac Anesthesiology and Critical Care, Instituto Nacional de Pediatria and Kardias/American British Chowdry Hospital Project, Mexico City (O.T.-C.)
| | - Kathy J Jenkins
- From the Department of Cardiac Anesthesiology (A.C.S., R.B.) and Department of Pediatric Cardiology (R.K.K.), Amrita Institute of Medical Sciences, Amrita Vishwa Vidyapeetham, Kochi, India; Department of Cardiology (D.F.M., K.G., J.K.K., K.J.J.) and Infection Prevention and Control (G.P.-B.), Boston Children's Hospital, MA; Department of Cardiovascular Surgery, Shanghai Children's Medical Center, Shanghai Jiaotong University School of Medicine, China (X.D.); Department of Cardiovascular Surgery, Star Hospital, Hyderabad, India (B.R.J.); Department of Family Medicine, Scripps Mercy Hospital Chula Vista, CA (M.L.M.); Department of Intensive Care, Nhi Dong No 1 (Children's Hospital No 1), Ho Chi Minh City, Viet Nam (N.T.C.); and Department of Cardiac Anesthesiology and Critical Care, Instituto Nacional de Pediatria and Kardias/American British Chowdry Hospital Project, Mexico City (O.T.-C.)
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Fluid Overload and Cumulative Thoracostomy Output Are Associated With Surgical Site Infection After Pediatric Cardiothoracic Surgery. Pediatr Crit Care Med 2017; 18:770-778. [PMID: 28486386 DOI: 10.1097/pcc.0000000000001193] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES To determine the impact of cumulative, postoperative thoracostomy output, amount of bolus IV fluids and peak fluid overload on the incidence and odds of developing a deep surgical site infection following pediatric cardiothoracic surgery. DESIGN A single-center, nested, retrospective, matched case-control study. SETTING A 26-bed cardiac ICU in a 303-bed tertiary care pediatric hospital. PATIENTS Cases with deep surgical site infection following cardiothoracic surgery were identified retrospectively from January 2010 through December 2013 and individually matched to controls at a ratio of 1:2 by age, gender, Risk Adjustment for Congenital Heart Surgery score, Society of Thoracic Surgeons-European Association for Cardiothoracic Surgery category, primary cardiac diagnosis, and procedure. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Twelve cases with deep surgical site infection were identified and matched to 24 controls without detectable differences in perioperative clinical characteristics. Deep surgical site infection cases had larger thoracostomy output and bolus IV fluid volumes at 6, 24, and 48 hours postoperatively compared with controls. For every 1 mL/kg of thoracostomy output, the odds of developing a deep surgical site infection increase by 13%. By receiver operative characteristic curve analysis, a cutoff of 49 mL/kg of thoracostomy output at 48 hours best discriminates the development of deep surgical site infection (sensitivity 83%, specificity 83%). Peak fluid overload was greater in cases than matched controls (12.5% vs 6%; p < 0.01). On receiver operative characteristic curve analysis, a threshold value of 10% peak fluid overload was observed to identify deep surgical site infection (sensitivity 67%, specificity 79%). Conditional logistic regression of peak fluid overload greater than 10% on the development of deep surgical site infection yielded an odds ratio of 9.4 (95% CI, 2-46.2). CONCLUSIONS Increased postoperative peak fluid overload and cumulative thoracostomy output were associated with deep surgical site infection after pediatric cardiothoracic surgery. We suspect the observed increased thoracostomy output, fluid overload, and IV fluid boluses may have altered antimicrobial prophylaxis. Although analysis of additional pharmacokinetic data is warranted, providers may consider modification of antimicrobial prophylaxis dosing or alterations in fluid management and diuresis in response to assessment of peak fluid overload and fluid volume shifts in the immediate postoperative period.
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Abstract
BACKGROUND Morbidity is defined as a state of being unhealthy or of experiencing an aspect of health that is "generally bad for you", and postoperative morbidity linked to paediatric cardiac surgery encompasses a range of conditions that may impact the patient and are potential targets for quality assurance. METHODS As part of a wider study, a multi-disciplinary group of professionals aimed to define a list of morbidities linked to paediatric cardiac surgery that was prioritised by a panel reflecting the views of both professionals from a range of disciplines and settings as well as parents and patients. RESULTS We present a set of definitions of morbidity for use in routine audit after paediatric cardiac surgery. These morbidities are ranked in priority order as acute neurological event, unplanned re-operation, feeding problems, the need for renal support, major adverse cardiac events or never events, extracorporeal life support, necrotising enterocolitis, surgical site of blood stream infection, and prolonged pleural effusion or chylothorax. It is recognised that more than one such morbidity may arise in the same patient and these are referred to as multiple morbidities, except in the case of extracorporeal life support, which is a stand-alone constellation of morbidity. CONCLUSIONS It is feasible to define a range of paediatric cardiac surgical morbidities for use in routine audit that reflects the priorities of both professionals and parents. The impact of these morbidities on the patient and family will be explored prospectively as part of a wider ongoing, multi-centre study.
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Gonzalez DO, Ambeba E, Minneci PC, Deans KJ, Nwomeh BC. Surgical site infection after stoma closure in children: outcomes and predictors. J Surg Res 2017; 209:234-241. [DOI: 10.1016/j.jss.2016.10.029] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2016] [Revised: 09/29/2016] [Accepted: 10/27/2016] [Indexed: 10/20/2022]
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De Cock PAJG, Mulla H, Desmet S, De Somer F, McWhinney BC, Ungerer JPJ, Moerman A, Commeyne S, Vande Walle J, Francois K, Van Hasselt JGC, De Paepe P. Population pharmacokinetics of cefazolin before, during and after cardiopulmonary bypass to optimize dosing regimens for children undergoing cardiac surgery. J Antimicrob Chemother 2016; 72:791-800. [DOI: 10.1093/jac/dkw496] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2016] [Accepted: 10/17/2016] [Indexed: 02/03/2023] Open
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Abstract
OBJECTIVES The objectives of this review are to discuss the prevalence and risk factors associated with the development of hospital-acquired infections in pediatric patients undergoing cardiac surgery and the published antimicrobial prophylaxis regimens and rational approaches to the diagnosis, prevention, and treatment of nosocomial infections in these patients. DATA SOURCE MEDLINE and PubMed. CONCLUSION Hospital-acquired infections remain a significant source of potentially preventable morbidity and mortality in pediatric cardiac surgical patients. Through improved understanding of these conditions and implementation of avoidance strategies, centers caring for these patients may improve outcomes in this vulnerable population.
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Axelrod DM, Alten JA, Berger JT, Hall MW, Thiagarajan R, Bronicki RA. Immunologic and Infectious Diseases in Pediatric Cardiac Critical Care: Proceedings of the 10th International Pediatric Cardiac Intensive Care Society Conference. World J Pediatr Congenit Heart Surg 2016; 6:575-87. [PMID: 26467872 DOI: 10.1177/2150135115598211] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
Since the inception of the Pediatric Cardiac Intensive Care Society (PCICS) in 2003, remarkable advances in the care of children with critical cardiac disease have been developed. Specialized surgical approaches, anesthesiology practices, and intensive care management have all contributed to improved outcomes. However, significant morbidity often results from immunologic or infectious disease in the perioperative period or during a medical intensive care unit admission. The immunologic or infectious illness may lead to fever, which requires the attention and resources of the cardiac intensivist. Frequently, cardiopulmonary bypass leads to an inflammatory state that may present hemodynamic challenges or complicate postoperative care. However, inflammation unchecked by a compensatory anti-inflammatory response may also contribute to the development of capillary leak and lead to a complicated intensive care unit course. Any patient admitted to the intensive care unit is at risk for a hospital acquired infection, and no patients are at greater risk than the child treated with mechanical circulatory support. In summary, the prevention, diagnosis, and management of immunologic and infectious diseases in the pediatric cardiac intensive care unit is of paramount importance for the clinician. This review from the tenth PCICS International Conference will summarize the current knowledge in this important aspect of our field.
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Affiliation(s)
- David M Axelrod
- Department of Pediatrics (Cardiology), Stanford University School of Medicine, Palo Alto, CA, USA
| | - Jeffrey A Alten
- Section of Pediatric Cardiac Critical Care Medicine, University of Alabama at Birmingham, Children's of Alabama, Birmingham, AL, USA
| | - John T Berger
- Division of Critical Care Medicine, George Washington University School of Medicine, Children's National Health System, Washington, DC, USA Division of Cardiology, George Washington University School of Medicine, Children's National Health System, Washington, DC, USA
| | - Mark W Hall
- The Ohio State University College of Medicine, Critical Care Medicine, Nationwide Children's Hospital, Columbus, OH, USA
| | - Ravi Thiagarajan
- Intensive Care Unit, Harvard Medical School, Boston Children's Hospital, Boston, MA, USA
| | - Ronald A Bronicki
- Section of Critical Care Medicine and Cardiology, Baylor College of Medicine, Texas Children's Hospital, Houston, TX, USA
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Cannon M, Hersey D, Harrison S, Joy B, Naguib A, Galantowicz M, Simsic J. Improving Surveillance and Prevention of Surgical Site Infection in Pediatric Cardiac Surgery. Am J Crit Care 2016; 25:e30-7. [PMID: 26932925 DOI: 10.4037/ajcc2016531] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Abstract
BACKGROUND Postoperative cardiovascular surgical site infections are preventable events that may lead to increased morbidity, mortality, and health care costs. OBJECTIVE To improve surgical wound surveillance and reduce the incidence of surgical site infections. METHODS An institutional review of surgical site infections led to implementation of 8 surveillance and process measures: appropriate preparation the night before surgery and the day of surgery, use of appropriate preparation solution in the operating room, appropriate timing of preoperative antibiotic administration, placement of a photograph of the surgical site in the patient's chart at discharge, sending a photograph of the surgical site to the patient's primary care physician, 30-day follow-up of the surgical site by an advanced nurse practitioner, and placing a photograph of the surgical site obtained on postoperative day 30 in the patient's chart. RESULTS Mean overall compliance with the 8 measures from March 2013 through February 2014 was 88%. Infections occurred in 10 of 417 total operative cases (2%) in 2012, in 8 of 437 total operative cases (2%) in 2013, and in 7 of 452 total operative cases (1.5%) in 2014. CONCLUSIONS Institution of the surveillance process has resulted in improved identification of suspected surgical site infections via direct rather than indirect measures, accurate identification of all surgical site infections based on definitions of the National Healthcare Safety Network, collaboration with all persons involved, and enhanced communication with patients' family members and referring physicians.
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Affiliation(s)
- Melissa Cannon
- Melissa Cannon is an advanced nurse practitioner, Diane Hersey is a nurse clinician, Sheilah Harrison is a quality coordinator, Brian Joy is a cardiologist, Aymen Naguib is a cardiac anesthesiologist, Mark Galantowicz is a cardiac surgeon, and Janet Simsic is a cardiologist, The Heart Center, Nationwide Children’s Hospital, Columbus, Ohio
| | - Diane Hersey
- Melissa Cannon is an advanced nurse practitioner, Diane Hersey is a nurse clinician, Sheilah Harrison is a quality coordinator, Brian Joy is a cardiologist, Aymen Naguib is a cardiac anesthesiologist, Mark Galantowicz is a cardiac surgeon, and Janet Simsic is a cardiologist, The Heart Center, Nationwide Children’s Hospital, Columbus, Ohio
| | - Sheilah Harrison
- Melissa Cannon is an advanced nurse practitioner, Diane Hersey is a nurse clinician, Sheilah Harrison is a quality coordinator, Brian Joy is a cardiologist, Aymen Naguib is a cardiac anesthesiologist, Mark Galantowicz is a cardiac surgeon, and Janet Simsic is a cardiologist, The Heart Center, Nationwide Children’s Hospital, Columbus, Ohio
| | - Brian Joy
- Melissa Cannon is an advanced nurse practitioner, Diane Hersey is a nurse clinician, Sheilah Harrison is a quality coordinator, Brian Joy is a cardiologist, Aymen Naguib is a cardiac anesthesiologist, Mark Galantowicz is a cardiac surgeon, and Janet Simsic is a cardiologist, The Heart Center, Nationwide Children’s Hospital, Columbus, Ohio
| | - Aymen Naguib
- Melissa Cannon is an advanced nurse practitioner, Diane Hersey is a nurse clinician, Sheilah Harrison is a quality coordinator, Brian Joy is a cardiologist, Aymen Naguib is a cardiac anesthesiologist, Mark Galantowicz is a cardiac surgeon, and Janet Simsic is a cardiologist, The Heart Center, Nationwide Children’s Hospital, Columbus, Ohio
| | - Mark Galantowicz
- Melissa Cannon is an advanced nurse practitioner, Diane Hersey is a nurse clinician, Sheilah Harrison is a quality coordinator, Brian Joy is a cardiologist, Aymen Naguib is a cardiac anesthesiologist, Mark Galantowicz is a cardiac surgeon, and Janet Simsic is a cardiologist, The Heart Center, Nationwide Children’s Hospital, Columbus, Ohio
| | - Janet Simsic
- Melissa Cannon is an advanced nurse practitioner, Diane Hersey is a nurse clinician, Sheilah Harrison is a quality coordinator, Brian Joy is a cardiologist, Aymen Naguib is a cardiac anesthesiologist, Mark Galantowicz is a cardiac surgeon, and Janet Simsic is a cardiologist, The Heart Center, Nationwide Children’s Hospital, Columbus, Ohio
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Izquierdo-Blasco J, Campins-Martí M, Soler-Palacín P, Balcells J, Abella R, Gran F, Castillo F, Nuño R, Sanchez-de-Toledo J. Impact of the implementation of an interdisciplinary infection control program to prevent surgical wound infection in pediatric heart surgery. Eur J Pediatr 2015; 174:957-63. [PMID: 25652766 DOI: 10.1007/s00431-015-2493-9] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/24/2014] [Revised: 01/11/2015] [Accepted: 01/16/2015] [Indexed: 10/24/2022]
Abstract
UNLABELLED Surgical site infection (SSI) remains a major source of morbidity, mortality, and increased health care costs in children undergoing heart surgery. The aim of this study was to assess the effectiveness of an intervention program designed to reduce the high incidence of SSI observed at our center in pediatric patients. An interdisciplinary infection control program including pre-, intra-, and postoperative measures was introduced for children undergoing heart surgery with cardiopulmonary bypass. We conducted a quasi-experimental interventional study comparing a pre-intervention cohort (June 2009 to March 2010) and a post-intervention cohort (July 2011 to July 2012). A significant drop in SSI incidence from 10.9 % (95 % CI 4.7-18.8) to 1.92 % (95 % CI 0.4-5.52) was observed. Variables significantly associated with infection risk were median age (14 days in infected vs 2.3 years in non-infected patients; p<0.01), hospitalization unit (10.3 % SSI cumulative incidence in the neonatal intensive care unit vs 0 cases in the pediatric intensive care unit; p<0.01), and median preoperative hospital stay (14 days in infected vs 1 day in non-infected patients; p=0.03). CONCLUSIONS The implementation of a new intervention program was associated with an 82 % (95 % CI 34-94) reduction in SSI incidence in children undergoing heart surgery at our center. WHAT IS KNOWN • Surgical site infection (SSI) is associated with significant morbidity and mortality following pediatric cardiac surgery. • Younger patients and longer cardiopulmonary bypass times are associated with higher SSI rates. What is New: • Comprehensive infection control program including preoperative, intraoperative and postoperative nonpharmacologic measures is a key factor for the prevention of SSI. • A significant reduction in SSI rates can be achieve despite a narrower-spectrum antibiotic usage.
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Affiliation(s)
- Jaume Izquierdo-Blasco
- Department of Pediatric Intensive Care Medicine, Hospital Universitari Vall d'Hebron, Universitat Autònoma de Barcelona, Barcelona, Spain
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Turcotte RF, Brozovich A, Corda R, Demmer RT, Biagas KV, Mangino D, Covington L, Ferris A, Thumm B, Bacha E, Smerling A, Saiman L. Health care-associated infections in children after cardiac surgery. Pediatr Cardiol 2014; 35:1448-55. [PMID: 24996642 DOI: 10.1007/s00246-014-0953-z] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/16/2013] [Accepted: 06/12/2014] [Indexed: 11/25/2022]
Abstract
Few recent studies have assessed the epidemiology of health care-associated infections (HAIs) in the pediatric population after cardiac surgery. A retrospective cohort study was performed to assess the epidemiology of several types of HAIs in children 18 years of age or younger undergoing cardiac surgery from July 2010 to June 2012. Potential pre-, intra-, and postoperative risk factors, including adherence to the perioperative antibiotic prophylaxis regimen at the authors' hospital, were assessed by multivariable analysis using Poisson regression models. Microorganisms associated with HAIs and their susceptibility patterns were described. Overall, 634 surgeries were performed, 38 (6 %) of which were complicated by an HAI occurring within 90 days after surgery. The HAIs included 7 central line-associated bloodstream infections (CLABSIs), 12 non-CLABSI bacteremias, 6 episodes of early postoperative infective endocarditis (IE), 9 surgical-site infections (SSIs), and 4 ventilator-associated pneumonias (VAPs). Mechanical ventilation (rate ratio [RR] 1.07 per day; 95 % confidence interval [CI] 1.03-1.11; p = 0.0002), postoperative transfusion of blood products (RR 3.12; 95 %, CI 1.38-7.06; p = 0.0062), postoperative steroid use (RR 3.32; 95 % CI 1.56-7.02; p = 0.0018), and continuation of antibiotic prophylaxis longer than 48 h after surgery (RR 2.56; 95 % CI 1.31-5.03; p = 0.0062) were associated with HAIs. Overall, 66.7 % of the pathogens associated with SSIs were susceptible to cefazolin, the perioperative antibiotic prophylaxis used by the authors' hospital. In conclusion, HAIs occurred after 6 % of cardiac surgeries. Bacteremia and CLABSI were the most common. This study identified several potentially modifiable risk factors that suggest interventions. Further studies should assess the role of improving adherence to perioperative antibiotic prophylaxis, the age of transfused red blood cells, and evidence-based guidelines for postoperative steroids.
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Affiliation(s)
- Rebecca F Turcotte
- Department of Pediatrics, Columbia University Medical Center, 3959 Broadway, CHN 10-24, New York, NY, 10032, USA,
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Toltzis P, O'Riordan M, Cunningham DJ, Ryckman FC, Bracke TM, Olivea J, Lyren A. A statewide collaborative to reduce pediatric surgical site infections. Pediatrics 2014; 134:e1174-80. [PMID: 25201794 DOI: 10.1542/peds.2014-0097] [Citation(s) in RCA: 41] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND Surgical site infections (SSIs) are preventable events associated with significant morbidity and cost. Few interventions have been tested to reduce SSIs in children. METHODS A quality improvement collaboration was established in Ohio composed of all referral children's hospitals. Collaborative leaders developed an SSI reduction bundle for selected cardiac, orthopedic, and neurologic operations. The bundle was composed of 3 elements: prohibition of razors for skin preparation, chlorhexidine-alcohol use for incisional site preparation, and correct timing of prophylactic antibiotic administration. The incidence of SSIs across the collaborative was compared before and after institution of the bundle. The association between 1 of the bundle elements, namely correct timing of antibiotic prophylaxis, and the proportion of centers achieving 0 SSIs per month was measured. RESULTS Eight pediatric hospitals participated. The proportion of months in which 0 SSIs per center was recorded was 56.9% before introduction of the bundle, versus 81.8% during the intervention (P < .001). Correct timing of preoperative prophylactic antibiotics also significantly improved; 39.4% of centers recorded correct timing in every eligible surgical procedure per month ("perfect timing") before the intervention versus 78.7% after (P < .001). The achievement of 0 SSIs per center in a given month was associated with the achievement of perfect antibiotic timing for that month (P < .003). CONCLUSIONS A statewide collaborative of children's hospitals was successful in reducing the occurrence of SSIs across Ohio.
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Affiliation(s)
- Philip Toltzis
- Rainbow Babies and Children's Hospital, Cleveland, Ohio;
| | | | | | | | - Tracey M Bracke
- Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Jason Olivea
- Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Anne Lyren
- Rainbow Babies and Children's Hospital, Cleveland, Ohio
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Skeletal muscle and plasma concentrations of cefazolin during cardiac surgery in infants. J Thorac Cardiovasc Surg 2014; 148:2634-41. [PMID: 25131168 DOI: 10.1016/j.jtcvs.2014.06.064] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/20/2014] [Revised: 05/30/2014] [Accepted: 06/05/2014] [Indexed: 12/20/2022]
Abstract
OBJECTIVE To describe the pharmacokinetics and tissue disposition of prophylactic cefazolin into skeletal muscle in a pediatric population undergoing cardiac surgery. METHODS The subjects included 12 children, with a median age of 146 days (interquartile range, 136-174) and median weight of 5.5 kg (interquartile range, 5.2-7.3) undergoing cardiac surgery and requiring cardiopulmonary bypass with or without deep hypothermic circulatory arrest. Institutional cefazolin at standard doses of 25 mg/kg before incision and 25 mg/kg in the bypass prime solution were administered. Serial plasma and skeletal muscle microdialysis samples were obtained intraoperatively and the unbound cefazolin concentrations measured. Noncompartmental pharmacokinetic analyses were performed and the tissue disposition evaluated. RESULTS After the first dose of cefazolin, the skeletal muscle concentrations peaked at a median microdialysis collection interval of 30 to 38.5 minutes. After the second dose, the peak concentrations were delayed a median of 94 minutes in subjects undergoing deep hypothermic circulatory arrest. Skeletal muscle exposure to cefazolin measured by the area under concentration time curve 0-last measurement was less in the subjects who underwent deep hypothermic circulatory arrest than in those who received cardiopulmonary bypass alone (P = .04). The skeletal muscle concentrations of cefazolin exceeded the goal concentrations for methicillin-sensitive Staphylococcus aureus prophylaxis; however, the goal concentrations for gram-negative pathogens associated with surgical site infections were achieved only 42.1% to 84.2% and 0% to 11.2% of the intraoperative time in subjects undergoing cardiopulmonary bypass alone or deep hypothermic circulatory arrest, respectively. CONCLUSIONS This cefazolin dosing strategy resulted in skeletal muscle concentrations that are likely not effective for surgical prophylaxis against gram-negative pathogens but are effective against methicillin-sensitive S aureus in infants undergoing cardiac surgery.
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Murray MT, Corda R, Turcotte R, Bacha E, Saiman L, Krishnamurthy G. Implementing a standardized perioperative antibiotic prophylaxis protocol for neonates undergoing cardiac surgery. Ann Thorac Surg 2014; 98:927-33. [PMID: 25038006 DOI: 10.1016/j.athoracsur.2014.04.090] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/04/2014] [Revised: 04/11/2014] [Accepted: 04/21/2014] [Indexed: 12/01/2022]
Abstract
BACKGROUND A lack of perioperative antibiotic prophylaxis guidelines for neonates undergoing cardiac surgery has resulted in a wide variation in practice. We sought to do the following: (1) Determine the safety of a perioperative antibiotic prophylaxis protocol for neonatal cardiac surgery as measured by surgical site infections (SSIs) rates before and after implementation of the protocol; and (2) evaluate compliance with selected process measures for perioperative antibiotic prophylaxis. METHODS This quasi-experimental study included all cardiac procedures performed on neonates from July 2009 to June 2012 at a single center. An interdisciplinary task force developed a standardized perioperative antibiotic prophylaxis protocol in the fourth quarter of 2010. The SSI rates were compared in the preintervention (July 2009 to December 2010) versus the postintervention periods (January 2011 to June 2012). Compliance with process measures (appropriate drug, dose, timing, and discontinuation of perioperative antibiotic prophylaxis) was compared in the 2 periods. RESULTS During the study period, 283 cardiac procedures were performed. The SSI rates were similar in the preintervention and postintervention periods (6.21 vs 5.80 per 100 procedures, respectively). Compliance with the 4 process measures significantly improved postintervention. CONCLUSIONS Restricting the duration of perioperative antibiotic prophylaxis after neonatal cardiac surgery to 48 hours in neonates with a closed sternum and to 24 hours after sternal closure was safe and did not increase the rate of SSIs. Compliance with selected process measures improved in the postintervention period. Additional multicenter studies are needed to develop national guidelines for perioperative prophylaxis for this population.
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Affiliation(s)
- Meghan T Murray
- School of Nursing, Columbia University Medical Center, New York, New York
| | - Rozelle Corda
- School of Nursing, Columbia University Medical Center, New York, New York; Department of Surgery, Columbia University Medical Center, New York, New York
| | - Rebecca Turcotte
- Department of Pediatrics, Columbia University Medical Center, New York, New York
| | - Emile Bacha
- Department of Surgery, Columbia University Medical Center, New York, New York
| | - Lisa Saiman
- Department of Pediatrics, Columbia University Medical Center, New York, New York; Department of Infection Prevention and Control, New York-Presbyterian Hospital, New York, New York
| | - Ganga Krishnamurthy
- Department of Pediatrics, Columbia University Medical Center, New York, New York.
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Atchley KD, Pappas JM, Kennedy AT, Coffin SE, Gerber JS, Fuller SM, Spray TL, McCardle K, Gaynor JW. Use of administrative data for surgical site infection surveillance after congenital cardiac surgery results in inaccurate reporting of surgical site infection rates. Ann Thorac Surg 2013; 97:651-7; discussion 657-8. [PMID: 24365216 DOI: 10.1016/j.athoracsur.2013.08.076] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/04/2013] [Revised: 08/23/2013] [Accepted: 08/27/2013] [Indexed: 10/25/2022]
Abstract
BACKGROUND The National Healthcare Safety Network (NHSN) is a safety surveillance system managed by the Centers for Disease Control and Prevention that monitors procedure specific rates of surgical site infections (SSIs). At our institution, SSI data is collected and reported by three different methods: (1) the NHSN database with reporting to the Centers for Disease Control and Prevention; (2) the hospital billing database with reporting to payers; and (3) The Society of Thoracic Surgeons Congenital Heart Surgery Database. A quality improvement initiative was undertaken to better understand issues with SSI reporting and to evaluate the effect of different data sources on annual SSI rates. METHODS Annual cardiac surgery procedure volumes for all three data sources were compared. All episodes of SSI identified in any data source were reviewed and adjudicated using NHSN SSI criteria, and the effect on SSI rates was evaluated. RESULTS From January 1, 2008, to December 31, 2011, 2,474 cardiac procedures were performed and reported to The Society of Thoracic Surgeons Congenital Heart Surgery Database. Billing data identified 1,865 cardiac surgery procedures using the 63 CARD International Classification of Diseases-Ninth Revision codes from the NHSN inclusion criteria. Only 1,425 procedures were targeted for NHSN surveillance using the NHSN's CARD operative procedure group in the same period. Procedures identified for NHSN surveillance annually underestimated the number of cardiac operations performed by 17% to 71%. As a result, annual SSI rates potentially differed by 12% to 270%. CONCLUSIONS The NHSN CARD surveillance guidelines for SSI fail to identify all pediatric cardiac surgical procedures. Failure to target all at-risk procedures leads to inaccurate reporting of SSI rates largely based on identifying the denominator. Inaccurate recording of SSI data has implications for public reporting, benchmarking of outcomes, and denial of payment. Use of The Society of Thoracic Surgeons Congenital Heart Surgery Database as the gold standard to identify procedures for surveillance will lead to more accurate reporting of SSI rates.
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Affiliation(s)
- Krista D Atchley
- The Cardiac Center, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania.
| | - Janine M Pappas
- The Cardiac Center, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Andrea T Kennedy
- The Cardiac Center, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Susan E Coffin
- Division of Infectious Diseases, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Jeffrey S Gerber
- Division of Infectious Diseases, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Stephanie M Fuller
- Division of Cardiothoracic Surgery, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Thomas L Spray
- Division of Cardiothoracic Surgery, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Kenneth McCardle
- The Cardiac Center, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - J William Gaynor
- Division of Cardiothoracic Surgery, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
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Murray MT, Krishnamurthy G, Corda R, Turcotte RF, Jia H, Bacha E, Saiman L. Surgical site infections and bloodstream infections in infants after cardiac surgery. J Thorac Cardiovasc Surg 2013; 148:259-65. [PMID: 24113023 DOI: 10.1016/j.jtcvs.2013.08.048] [Citation(s) in RCA: 40] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/28/2013] [Revised: 08/05/2013] [Accepted: 08/16/2013] [Indexed: 11/16/2022]
Abstract
OBJECTIVE Few recent studies have assessed the epidemiology of and risk factors for surgical site infections (SSIs) and bloodstream infections (BSIs) in infants after cardiac surgery. We hypothesized that infants younger than 30 days old and those with higher Risk Adjustment in Congenital Heart Surgery-1 scores would have an increased risk of SSIs, but not an increased risk of BSIs after surgery. METHODS We performed a retrospective cohort study of infants younger than 1 year of age undergoing cardiac surgery from January 2010 to December 2011 to determine the rates of SSIs and BSIs occurring within 3 months of surgery, risk factors associated with these infections, and causative pathogens. Multivariable associations using Cox proportional hazard modeling assessed potential risk factors for BSIs or SSIs. RESULTS Overall, 8.7% (48 of 552) of surgical procedures were complicated by SSIs (n = 19) or BSIs (n = 29). Thus, SSIs and BSIs occurred after 3.4% and 5.3% of procedures, respectively. Multivariate models found age younger than 30 days, incorrect timing of preoperative antibiotics, and excessive bleeding within 24 hours of surgery to be significant predictors for SSIs, and duration of use of arterial lines to be a significant predictor for BSIs. Gram-positive bacteria caused 75% of SSIs and BSIs and methicillin-susceptible Staphylococcus aureus caused 63% of SSIs. DISCUSSION We identified some potential strategies to reduce risk, including closer monitoring of timing of preoperative antimicrobial prophylaxis and enhanced efforts to achieve intraoperative hemostasis and earlier removal of arterial lines. CONCLUSIONS SSIs and BSIs remain important complications after cardiac surgery in infants.
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Affiliation(s)
- Meghan T Murray
- Department of Pediatrics, Columbia University Medical Center, New York, NY
| | | | - Rozelle Corda
- Department of Surgery, Columbia University Medical Center, New York, NY; School of Nursing, Columbia University Medical Center, New York, NY
| | - Rebecca F Turcotte
- Department of Pediatrics, Columbia University Medical Center, New York, NY
| | - Haomiao Jia
- School of Nursing, Columbia University Medical Center, New York, NY
| | - Emile Bacha
- Department of Surgery, Columbia University Medical Center, New York, NY
| | - Lisa Saiman
- Department of Pediatrics, Columbia University Medical Center, New York, NY; Department of Infection Prevention and Control, NewYork-Presbyterian Hospital, New York, NY.
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[Antibiotic prophylaxis for surgical wound infection in cardiac surgery: results of a Spanish survey]. An Pediatr (Barc) 2013; 79:26-31. [PMID: 23291524 DOI: 10.1016/j.anpedi.2012.11.018] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2012] [Revised: 11/19/2012] [Accepted: 11/20/2012] [Indexed: 11/23/2022] Open
Abstract
INTRODUCTION No Spanish guidelines for the prevention of surgical wound infection in paediatric cardiac surgery are currently available. The aim of this study was to analyse the nationwide variability in antibiotic prophylaxis use. MATERIAL AND METHODS An online questionnaire was distributed to all members of the Cardiology Group of the Spanish Society of Paediatric Intensive Care. Fifteen centres participated in the study. RESULTS In heart surgery with no delayed sternal closure, all 15 centres used a 1st or 2nd generation cephalosporin in paediatric patients, while 3 hospitals used a broader-spectrum antibiotic therapy in neonates. Prophylaxis was maintained for 12-72h in 11 centres and until drainage removal in four. Thirteen centres used delayed sternal closure, eight of which followed the same protocol for these patients as for standard procedures. Prophylaxis was maintained for 12-72h in 6 centres, and until sternal closure at the rest. Five out of 10 centres performing extracorporeal membrane oxygenation (ECMO) maintained the same antibiotic protocol as in standard surgery. CONCLUSIONS A wide variability was observed in antibiotic prophylaxis use in high-risk patients. Thus, national protocols need to be standardised.
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Harder EE, Gaies MG, Yu S, Donohue JE, Hanauer DA, Goldberg CS, Hirsch JC. Risk factors for surgical site infection in pediatric cardiac surgery patients undergoing delayed sternal closure. J Thorac Cardiovasc Surg 2012; 146:326-33. [PMID: 23102685 DOI: 10.1016/j.jtcvs.2012.09.062] [Citation(s) in RCA: 46] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/15/2012] [Revised: 08/10/2012] [Accepted: 09/21/2012] [Indexed: 01/06/2023]
Abstract
OBJECTIVES To determine the incidence of surgical site infections (SSIs) in congenital heart surgery (CHS) patients undergoing delayed sternal closure (DSC) and to evaluate risk factors for SSI. METHODS A nested case-control study was performed within a cohort of CHS patients undergoing DSC at our institution between 2005 and 2009. Cases met 2008 Centers for Disease Control and Prevention criteria for SSI; control subjects were matched based on year of surgery. Uni- and multivariate logistic regressions were performed to identify SSI risk factors. RESULTS Of 375 patients who underwent DSC, 43 (11%) developed an SSI. The analysis included 172 patients (43 cases, 129 controls); 118 (69%) were neonates, 80 (47%) had undergone Norwood procedure, and 150 (87%) had DSC initiated in the operating room. Case and control subjects were similar based on pre- and intraoperative characteristics. Duration of mechanical ventilation, intensive care unit and hospital length of stay, and mortality were significantly greater in patients with an SSI. Multiple periods of DSC, longer duration of DSC, greater dependence on parenteral nutrition, and extracorporeal membrane oxygenation were significantly associated with SSI in univariate analyses. Multivariate analysis demonstrated that multiple periods of DSC (adjusted odds ratio, 5.9; 95% confidence interval, 1.7-20.1) and extracorporeal membrane oxygenation (adjusted odds ratio, 2.9; 95% confidence interval, 1.1-7.6) remained independent risk factors for SSI. CONCLUSIONS For CHS patients undergoing DSC, extracorporeal membrane oxygenation and multiple periods of DSC are independent risk factors for SSI. New strategies for prevention and prophylaxis of SSI may be indicated for these high-risk patients who have worse outcomes and greater health care resource utilization.
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Affiliation(s)
- Erika E Harder
- Division of Pediatric Cardiology, Department of Pediatrics, University of Michigan, Ann Arbor, Mich 48109-4204, USA
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Should intravenous immunoglobulin be given to patients with postoperative chylothorax? Pediatr Crit Care Med 2012; 13:599-600. [PMID: 22955461 DOI: 10.1097/pcc.0b013e31824ea2e6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Adler AL, Martin ET, Cohen G, Jeffries H, Gilbert M, Smith J, Zerr DM. A Comprehensive Intervention Associated With Reduced Surgical Site Infections Among Pediatric Cardiovascular Surgery Patients, Including Those With Delayed Closure. J Pediatric Infect Dis Soc 2012; 1:35-43. [PMID: 26618691 DOI: 10.1093/jpids/pis008] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/15/2011] [Accepted: 01/12/2012] [Indexed: 11/12/2022]
Abstract
BACKGROUND Surgical site infections (SSIs) cause significant morbidity and mortality in patients undergoing cardiovascular (CV) surgery. Following an increase in SSIs in this population, driven by a high rate in those with delayed closure, we implemented an intervention to reduce these infections and assessed the intervention using both population- and patient-level analyses. METHODS An intervention drawing from existing guidelines and targeting preoperative preparation of the patient, prophylactic antibiotics, and postoperative incision care was implemented. Special attention was paid to standardizing the care of the incision of patients with delayed closure. National Healthcare Safety Network criteria were used to prospectively identify SSIs. Population-level intervention effect was assessed using interrupted time series. To assess intervention adherence and effect in our patient population, retrospective chart review was performed on a cohort of patients undergoing cardiac procedures pre- and postintervention. Multivariate analysis was used to assess risk of SSI at the patient level. RESULTS Timely preoperative prophylactic antibiotic dosing increased from 60% preintervention to 92% postintervention, and redosing during prolonged surgeries increased from 5% to 79% (both, P < .001). At the population-level, a decrease of 6.7 infections per 100 surgeries per 6 months was observed directly following the intervention (P = .002). The SSI rate decreased from 40% to 0.8% (P < .001) in patients with delayed closure and from 4.3% to 1.8% (P = .02) in patients with immediate closure. In multivariate analyses, surgery prior to the intervention was the strongest predictor for SSI (incidence rate ratio, 3.98; 95% confidence interval, 1.59 to 9.97). CONCLUSIONS Our intervention decreased SSIs in pediatric CV surgery patients, particularly those with delayed closures.
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Affiliation(s)
| | | | - Gordon Cohen
- Seattle Children's Hospital, and Surgery, University of Washington, Seattle
| | - Howard Jeffries
- Seattle Children's Hospital, and Departments of Pediatrics, and
| | - Michael Gilbert
- Seattle Children's Hospital, and Departments of Pediatrics, and
| | | | - Danielle M Zerr
- Seattle Children's Hospital, and Departments of Pediatrics, and
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Cornell TT, Sun L, Hall MW, Gurney JG, Ashbrook MJ, Ohye RG, Shanley TP. Clinical implications and molecular mechanisms of immunoparalysis after cardiopulmonary bypass. J Thorac Cardiovasc Surg 2011; 143:1160-1166.e1. [PMID: 21996297 DOI: 10.1016/j.jtcvs.2011.09.011] [Citation(s) in RCA: 52] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/24/2011] [Revised: 07/14/2011] [Accepted: 09/15/2011] [Indexed: 12/20/2022]
Abstract
OBJECTIVE We used a whole blood assay to characterize the immune system's response after cardiopulmonary bypass (CPB) in children to identify the risk for postoperative infections. We assessed the impact of CPB on histone methylation as a potential mechanism for altering gene expression necessary for the immune system's capacity to defend against infections. METHODS We prospectively enrolled patients less than 18 years old undergoing heart surgery requiring CPB at C.S. Mott Children's Hospital. Blood was obtained from patients before CPB, on CPB, and on postoperative days 1, 3, and 5. Ex vivo lipopolysaccharide-induced tumor necrosis factor-alpha production measured the capacity of the immune system. Serum cytokines were measured using a multiplex assay. Chromatin immunoprecipitation to detect histone modifications at the interleukin (IL) 10 promoter was performed on circulating mononuclear cells from a subgroup of patients. RESULTS We enrolled 92 patients, and postoperative day 1 samples identified a subpopulation of immunocompetent patients at low risk for infections with a specificity of 93% (confidence interval [CI], 83%-98%) and a negative predictive value of 88% (CI, 77%-95%; P = .006). Patients classified as immunoparalyzed had serum IL-10 levels 2.4-fold higher than the immunocompetent group (mean, 14.3 ± 18.3 pg/mL vs 6.0 ± 5.0 pg/mL; P = .01). In a subgroup of patients, we identified a greater percent of the "gene on" epigenetic signature, H3K4me3, associated with the IL-10 promoter after CPB. CONCLUSIONS Our data demonstrate that immunophenotyping patients after CPB can predict their risk for the development of postoperative infections. Novel mechanistic data suggest that CPB affects epigenetic alterations in IL-10 gene regulation.
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Affiliation(s)
- Timothy T Cornell
- Division of Critical Care Medicine, C.S. Mott Children’s Hospital, F-6882, 1500 East Medical Center Dr, Ann Arbor, MI 48109-0243, USA.
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