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Nallani R, Miller BJ, Noel-MacDonnell JR, Tracy M, Brown JR, O'Brien JE, Jensen DR. Impact of Tracheostomy Status on Sternal Wound Infections in Children Following Median Sternotomy. Otolaryngol Head Neck Surg 2024. [PMID: 39126285 DOI: 10.1002/ohn.939] [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: 03/09/2024] [Revised: 06/13/2024] [Accepted: 07/27/2024] [Indexed: 08/12/2024]
Abstract
OBJECTIVE Sternal wound infection (SWI) is a rare but potentially life-threatening complication in children following sternotomy. Risk factors include young age, extended preoperative hospitalization, and prolonged ventilatory support. Few studies have explored the impact of pre-existing tracheostomy on SWI in pediatric patients. The purpose of this study is to measure the effect of tracheostomy and other factors on SWI in children undergoing sternotomy. STUDY DESIGN Retrospective cohort study of a 12 year period. SETTING Tertiary children's hospital. METHODS Children with a tracheostomy prior to sternotomy (TPS) were identified and matched by age, height, and weight to children who underwent sternotomy alone. Demographics, medical comorbidities, surgical details, SWI diagnosis and management information, and surgical outcomes were collected. RESULTS We identified 60 unique individuals representing 80 sternotomies. The incidence of SWI was 22.5% (n = 9) in children with a tracheostomy and 2.5% (n = 1) in those without. The incidence of SWI was greater in children with a tracheostomy (90% vs 10% in those without, P = .007) and underlying pulmonary disease (90% vs 10% in those without, P = .020). Infections in the TPS group also demonstrated greater frequency of Pseudomonas aeruginosa (n = 3) and polymicrobial growth (n = 2). CONCLUSION The risk of developing a SWI in children undergoing sternotomy is significantly greater in those with a tracheostomy and underlying pulmonary disease. Further study is needed to understand other contributing factors and ways to mitigate this risk.
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Affiliation(s)
- Rohit Nallani
- Department of Otolaryngology-Head and Neck Surgery, University of Kansas Medical Center, Kansas City, Kansas, USA
| | - Brevin J Miller
- University of Missouri-Kansas City School of Medicine, Kansas City, Missouri, USA
| | - Janelle R Noel-MacDonnell
- University of Missouri-Kansas City School of Medicine, Kansas City, Missouri, USA
- Division of Pediatric Otolaryngology, Children's Mercy Hospital, Kansas City, Missouri, USA
| | - Meghan Tracy
- Division of Pediatric Otolaryngology, Children's Mercy Hospital, Kansas City, Missouri, USA
| | - Jason R Brown
- University of Missouri-Kansas City School of Medicine, Kansas City, Missouri, USA
- Division of Pediatric Otolaryngology, Children's Mercy Hospital, Kansas City, Missouri, USA
| | - James E O'Brien
- University of Missouri-Kansas City School of Medicine, Kansas City, Missouri, USA
- Division of Pediatric Cardiothoracic Surgery, Children's Mercy Hospital, Kansas City, Missouri, USA
| | - Daniel R Jensen
- University of Missouri-Kansas City School of Medicine, Kansas City, Missouri, USA
- Division of Pediatric Otolaryngology, Children's Mercy Hospital, Kansas City, Missouri, USA
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2
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Schneider K, de Loizaga S, Beck AF, Morales DLS, Seo J, Divanovic A. Socioeconomic Influences on Outcomes Following Congenital Heart Disease Surgery. Pediatr Cardiol 2024; 45:1072-1078. [PMID: 38472658 PMCID: PMC11056327 DOI: 10.1007/s00246-024-03451-7] [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: 11/09/2023] [Accepted: 02/12/2024] [Indexed: 03/14/2024]
Abstract
Associations between social determinants of health (SDOH) and adverse outcomes for children with congenital heart disease (CHD) are starting to be recognized; however, such links remain understudied. We examined the relationship between community-level material deprivation on mortality, readmission, and length of stay (LOS) for children undergoing surgery for CHD. We performed a retrospective cohort study of patients who underwent cardiac surgery at our institution from 2015 to 2018. A community-level deprivation index (DI), a marker of community material deprivation, was generated to contextualize the lived experience of children with CHD. Generalized mixed-effects models were used to assess links between the DI and outcomes of mortality, readmission, and LOS following cardiac surgery. The DI and components were scaled to provide mean differences for a one standard deviation (SD) increase in deprivation. We identified 1,187 unique patients with surgical admissions. The median LOS was 11 days, with an overall mortality rate of 4.6% and readmission rate of 7.6%. The DI ranged from 0.08 to 0.85 with a mean of 0.37 (SD 0.12). The DI was associated with increased LOS for patients with more complex heart disease (STAT 3, 4, and 5), which persisted after adjusting for factors that could prolong LOS (all p < 0.05). The DI approached but did not meet a significant association with mortality (p = 0.0528); it was not associated with readmission (p = 0.36). Community-level deprivation is associated with increased LOS for patients undergoing cardiac surgery. Future work to identify the specific health-related social needs contributing to LOS and identify targets for intervention is needed.
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Affiliation(s)
- Kristin Schneider
- The Heart Institute, Cincinnati Children's Hospital Medical Center, 3333 Burnet Avenue, MLC 2003, Cincinnati, OH, 45229, USA.
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, USA.
| | - Sarah de Loizaga
- The Heart Institute, Cincinnati Children's Hospital Medical Center, 3333 Burnet Avenue, MLC 2003, Cincinnati, OH, 45229, USA
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Andrew F Beck
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, USA
- Divisions of General & Community Pediatrics and Hospital Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - David L S Morales
- The Heart Institute, Cincinnati Children's Hospital Medical Center, 3333 Burnet Avenue, MLC 2003, Cincinnati, OH, 45229, USA
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - JangDong Seo
- The Heart Institute, Cincinnati Children's Hospital Medical Center, 3333 Burnet Avenue, MLC 2003, Cincinnati, OH, 45229, USA
| | - Allison Divanovic
- The Heart Institute, Cincinnati Children's Hospital Medical Center, 3333 Burnet Avenue, MLC 2003, Cincinnati, OH, 45229, USA
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, USA
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3
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Gal DB, Cleveland JD, Kipps AK. Early Wound and Sternal Management Following Pediatric Cardiac Surgery. World J Pediatr Congenit Heart Surg 2024; 15:313-318. [PMID: 38263797 DOI: 10.1177/21501351231216448] [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] [Indexed: 01/25/2024]
Abstract
Early postoperative wound management following congenital heart surgery remains an area without equipoise. Precautionary restrictions can impact quality of life, development, and delay access to other needed care. The influence of different practices on wound healing and complications is unknown. We surveyed Pediatric Acute Care Cardiology Collaborative member centers regarding postoperative wound closure, wound vacuum-assisted closure (VAC) use, sternal precautions, and restrictions in the early postoperative period. We analyzed responses using descriptive statistics. Responses were submitted by 35/46 (76%) centers. Most centers perform primary skin closure with subcutaneous sutures. Wound covers are removed after 48 h at 43% (15/35) of centers and after ≥72 h at 34% (12/35) of centers. For delayed sternal closure, 16 centers close skin with interrupted, externalized sutures, 5 utilize wound VAC-assisted closure, and 12 use variable practices. Generally, 33 centers use wound VACs for wound care. Patient selection for VAC use and length of therapy varies. We found great variability in duration of sternal precautions and in activity, bathing, and submersion restrictions. Finally, 29 centers require a waiting period between cardiothoracic surgery and other surgeries such as tracheostomy or gastrostomy tube placement. Postoperative wound and sternal management lack consistency across North American pediatric heart institutes. Some restrictive practices may prolong length of stay and/or negatively impact quality of life and neurodevelopment. Practices may also impact wound infection rates. Research linking practices with clinical outcomes is needed to better define standards of care and reduce potential negative consequences of overly conservative or aggressive practices.
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Affiliation(s)
- Dana B Gal
- Department of Pediatrics, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
- Division of Pediatric Cardiology, Children's Hospital of Los Angeles, Los Angeles, CA, USA
| | - John D Cleveland
- Division of Pediatric Cardiology, Children's Hospital of Los Angeles, Los Angeles, CA, USA
- Department of Cardiothoracic Surgery, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - Alaina K Kipps
- Division of Pediatric Cardiology, Department of Pediatrics, Stanford University School of Medicine, Palo Alto, CA, USA
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4
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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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5
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Kahan Y, Tope SG, Ovadia A, Shpring A, Shatzman-Steuerman R, Sherman G, Barkai G, Mandelberg A, Armoni-Domany K, Tasher D. Risk Factors and Characteristics of Candidemia After Cardiac Surgery in Pediatric Patients in Central Israel. Pediatr Infect Dis J 2023; 42:368-373. [PMID: 36854105 DOI: 10.1097/inf.0000000000003847] [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] [Indexed: 03/02/2023]
Abstract
BACKGROUND Candidemia is a serious complication in pediatric patients with congenital heart defects (CHD) after cardiac surgery. Information about the epidemiology, clinical characteristics and risk factors for candidemia in this vulnerable population remains limited. METHODS This retrospective case-control study was conducted in 2 pediatric intensive care units between 2004 and 2019. All patients <18 years old who developed candidemia following cardiac surgery were included. Each case was matched with 2 control patients based on age and date of surgery. Multivariable logistic regression analysis was conducted to determine the risk factors for postoperative candidemia. RESULTS Thirty-five candidemia cases were identified and matched to 70 control cases. The incidence of candidemia was 6.3 episodes per 1000 admissions. The median age for candidemia cases was 4 months. The attributable mortality was 28.5%. The predominant (54%) pathogens isolated were non- albicans Candida species, of which C. parapsilosis isolates demonstrated high resistance to fluconazole (70%). Independent risk factors associated with candidemia included cumulative antibiotic exposure for ≥4 days [OR: -4.3; 95% confidence interval (CI): 1.3-14.6; P = 0.02], the need for total parenteral nutrition or peritoneal dialysis (OR: -6.1; 95% CI: 2-18.8; P = 0.001), male sex (OR: 6.2; 95% CI: 1.9-20.3; P = 0.002) and delayed sternal closure≥2 days (OR: -3.2; 95% CI: 1-11.2; P = 0.05). CONCLUSIONS Postoperative candidemia in children with CHD is an uncommon but severe complication. Our study revealed an unexpectedly high frequency of fluconazole-resistant C. parapsilosis as the main cause of non- albicans candidemia. In addition to confirming previously recognized risk factors, our results reveal new potential risk factors such as delayed sternal closure and male sex.
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Affiliation(s)
- Yaara Kahan
- Pediatric Infectious Diseases Unit, Edith Wolfson Medical Center, Holon, Israel
- Pediatric Infectious Disease Unit, Edmond and Lily Safra Children's Hospital, Sheba Medical Center, Tel-Hashomer, Israel
| | - Samantha G Tope
- Pediatric Infectious Disease Unit, Edmond and Lily Safra Children's Hospital, Sheba Medical Center, Tel-Hashomer, Israel
| | - Adi Ovadia
- Pediatric Infectious Disease Unit, Edmond and Lily Safra Children's Hospital, Sheba Medical Center, Tel-Hashomer, Israel
- Department of Pediatrics, Edith Wolfson Medical Center, Holon, Israel
| | - Adi Shpring
- Pediatric Infectious Disease Unit, Edmond and Lily Safra Children's Hospital, Sheba Medical Center, Tel-Hashomer, Israel
- Department of Pediatrics, Edith Wolfson Medical Center, Holon, Israel
| | - Rachel Shatzman-Steuerman
- Pediatric Infectious Disease Unit, Edmond and Lily Safra Children's Hospital, Sheba Medical Center, Tel-Hashomer, Israel
| | - Gilad Sherman
- Pediatric Infectious Disease Unit, Edmond and Lily Safra Children's Hospital, Sheba Medical Center, Tel-Hashomer, Israel
| | - Galia Barkai
- Pediatric Infectious Disease Unit, Edmond and Lily Safra Children's Hospital, Sheba Medical Center, Tel-Hashomer, Israel
| | - Avigdor Mandelberg
- Pediatric Infectious Disease Unit, Edmond and Lily Safra Children's Hospital, Sheba Medical Center, Tel-Hashomer, Israel
- Department of Pediatrics, Edith Wolfson Medical Center, Holon, Israel
| | - Keren Armoni-Domany
- Pediatric Infectious Disease Unit, Edmond and Lily Safra Children's Hospital, Sheba Medical Center, Tel-Hashomer, Israel
- Department of Pediatrics, Edith Wolfson Medical Center, Holon, Israel
| | - Diana Tasher
- Pediatric Infectious Diseases Unit, Edith Wolfson Medical Center, Holon, Israel
- Pediatric Infectious Disease Unit, Edmond and Lily Safra Children's Hospital, Sheba Medical Center, Tel-Hashomer, Israel
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6
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Cooch PB, Kim MO, Swami N, Tamma PD, Tabbutt S, Steurer MA, Wattier RL. Broad- Versus Narrow-Spectrum Perioperative Antibiotics and Outcomes in Pediatric Congenital Heart Disease Surgery: Analysis of the Vizient Clinical Data Base. J Pediatric Infect Dis Soc 2023; 12:205-213. [PMID: 37018466 PMCID: PMC10146935 DOI: 10.1093/jpids/piad022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/22/2022] [Accepted: 04/04/2023] [Indexed: 04/07/2023]
Abstract
BACKGROUND Despite guidelines recommending narrow-spectrum perioperative antibiotics (NSPA) as prophylaxis for most children undergoing congenital heart disease (CHD) surgery, broad-spectrum perioperative antibiotics (BSPA) are variably used, and their impact on postoperative outcomes is poorly understood. METHODS We used administrative data from U.S. hospitals participating in the Vizient Clinical Data Base. Admissions from 2011 to 2018 containing a qualifying CHD surgery in children 0-17 years old were evaluated for exposure to BSPA versus NSPA. Propensity score-adjusted models were used to compare postoperative length of hospital stay (PLOS) by exposure group, while adjusting for confounders. Secondary outcomes included subsequent antimicrobial treatment and in-hospital mortality. RESULTS Among 18 088 eligible encounters from 24 U.S. hospitals, BSPA were given in 21.4% of CHD surgeries, with mean BSPA use varying from 1.7% to 96.1% between centers. PLOS was longer for BSPA-exposed cases (adjusted hazard ratio 0.79; 95% confidence interval [CI]: 0.71-0.89, P < .0001). BSPA was associated with higher adjusted odds of subsequent antimicrobial treatment (odds ratio [OR] 1.24; 95% CI: 1.06-1.48), and there was no significant difference in adjusted mortality between exposure groups (OR 2.06; 95% CI: 1.0-4.31; P = .05). Analyses of subgroups with the most BSPA exposure, including high-complexity procedures and delayed sternal closure, also did not find (but could not exclude) a measurable benefit from BSPA on PLOS. CONCLUSIONS BSPA use was common in high-risk populations, and varied substantially between centers. Standardizing perioperative antibiotic practices between centers may reduce unnecessary broad-spectrum antibiotic exposure and improve clinical outcomes.
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Affiliation(s)
- Peter B Cooch
- Department of Pediatrics, Division of Infectious Diseases and Global Health, University of California San Francisco, San Francisco, California, USA
- Department of Pediatrics, Kaiser Permanente Northern California, Oakland, California, USA
| | - Mi-Ok Kim
- Department of Epidemiology and Biostatistics, University of California San Francisco, San Francisco, California, USA
| | - Naveen Swami
- Department of Surgery, Division of Pediatric Cardiothoracic Surgery, University of California San Francisco, San Francisco, CaliforniaUSA
| | - Pranita D Tamma
- Department of Pediatrics, Division of Infectious Diseases, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Sarah Tabbutt
- Department of Pediatrics, Division of Critical Care, University of California San Francisco, San Francisco, California, USA
| | - Martina A Steurer
- Department of Pediatrics, Division of Critical Care, University of California San Francisco, San Francisco, California, USA
| | - Rachel L Wattier
- Department of Pediatrics, Division of Infectious Diseases and Global Health, University of California San Francisco, San Francisco, California, USA
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7
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Ghosh S, Balachandran R, Neema PK, Kottayil BP, Bhaskaran R, Sudhakar A, Krishna Kumar R. Impact of Type of Enteral Feeds on Early Postoperative Outcomes After Congenital Heart Surgery in Neonates and Young Infants: A Single Center Experience in a Limited Resource Environment. World J Pediatr Congenit Heart Surg 2023; 14:300-306. [PMID: 36823964 DOI: 10.1177/21501351231154207] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/25/2023]
Abstract
Background: Breast milk is known to prevent infections and is recommended for enteral feeding of infants after congenital heart surgery (CHS). During the Covid-19 pandemic, expressed breast milk (EBM) was not always available; hence, feeding after CHS was maintained with EBM or infant formula (IF) or both; we evaluated the impact of enteral feed type on early postoperative outcomes after CHS. Methods: In a prospective observational study, consecutive neonates and infants <4 months undergoing CHS were divided into EBM, IF, or EBM+IF groups; incidences of postoperative infections, ventilation duration, intensive care unit (ICU) stay, and mortality were studied. Results: Among 270 patients; 90 (33.3%) received EBM, 89 (32.9%) received IF, and 91 (33.7%) received EBM+IF. IF group had more neonates (78.7%[IF] vs 42.2%[EBM] and 52.7%[EBM+IF], P < 0.001) and greater surgical complexity. Postoperative infections were 9 (10.0%) in EBM; 23 (25.8%) in IF; and 14 (15.4%) in EBM+IF (P = .016). IF group (OR 2.58 [1.05-6.38], P = .040), absence of preoperative feeding (OR 6.97 [1.06-45.97], P = .040), and increase in cardiopulmonary bypass time (OR 1.005 [1.001-1.010], P = .027) were associated with postoperative infection. Ventilation duration in hours was 26 (18-47.5) in EBM; 47 (28-54.5) in IF; and 40 (17.5-67) in EBM+IF (P = .004). ICU stay in days was 4 (3-7) in EBM; 6 (5-9) in IF; and 5 (3-9) in EBM+IF (P = .001). Mortality did not differ (P = .556). Conclusion: IF group had a greater proportion of neonates with higher surgical complexity. Patients who received EBM after CHS had fewer postoperative infections and better postoperative outcomes compared to those receiving IF or EBM+IF.
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Affiliation(s)
- Sreepurna Ghosh
- Department of Cardiac Anesthesia, 29286Amrita Institute of Medical Sciences and Research Centre, Kochi, Kerala, India
| | - Rakhi Balachandran
- Department of Cardiac Anesthesia, 29286Amrita Institute of Medical Sciences and Research Centre, Kochi, Kerala, India
| | - Praveen Kumar Neema
- Department of Cardiac Anesthesia, 29286Amrita Institute of Medical Sciences and Research Centre, Kochi, Kerala, India
| | - Brijesh P Kottayil
- Department of Cardiovascular and Thoracic Surgery, 29286Amrita Institute of Medical Sciences and Research Centre, Kochi, Kerala, India
| | - Renjitha Bhaskaran
- Department of Biostatistics, 29286Amrita Institute of Medical Sciences and Research Centre, Kochi, Kerala, India
| | - Abish Sudhakar
- Department of Pediatric Cardiology, 29286Amrita Institute of Medical Sciences and Research Centre, Kochi, Kerala, India
| | - R Krishna Kumar
- Department of Pediatric Cardiology, 29286Amrita Institute of Medical Sciences and Research Centre, Kochi, Kerala, India
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8
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Long-Term Quality of Life in Congenital Heart Disease Surgical Survivors: Multicenter Retrospective Study of Surgical and ICU Explanatory Factors. Pediatr Crit Care Med 2023; 24:391-398. [PMID: 37140331 DOI: 10.1097/pcc.0000000000003190] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/24/2023]
Abstract
OBJECTIVES Greater congenital heart disease (CHD) complexity is associated with lower health-related quality of life (HRQOL). There are no data on the association between surgical and ICU factors and HRQOL in CHD survivors. This study assess the association between surgical and ICU factors and HRQOL in child and adolescent CHD survivors. DESIGN This was a corollary study of the Pediatric Cardiac Quality of Life Inventory (PCQLI) Testing Study. SETTING Eight pediatric hospitals participating in the PCQLI Study. PATIENTS Patients in the study had the Fontan procedure, surgery for tetralogy of Fallot (TOF), and transposition of the great arteries (TGAs). MEASUREMENTS AND MAIN RESULTS Surgical/ICU explanatory variables were collected by reviewing the medical records. Primary outcome variables (PCQLI Total patient and parent scores) and covariates were obtained from the Data Registry. General linear modeling was used to create the multivariable models. There were 572 patients included: mean ± sd of age 11.7 ± 2.9 years; CHD Fontan 45%, TOF/TGA 55%; number of cardiac surgeries 2 (1-9); and number of ICU admissions 3 (1-9). In multivariable models, lowest body temperature on cardiopulmonary bypass (CPB) was negatively associated with patient total score (p < 0.05). The total number of CPB runs was negatively associated with parent-reported PCQLI Total score (p < 0.02). Cumulative days on an inotropic/vasoactive drug in the ICU was negatively associated with all patient-/parent-reported PCQLI scores (p < 0.04). Neurological deficit at discharge was negatively associated with parent-reported PCQLI total score (p < 0.02). The variance explained by these factors ranged from 24% to 29%. CONCLUSIONS Surgical/ICU factors, demographic, and medical care utilization variables explain a low-to-moderate amount of variation in HRQOL. Research is needed to determine whether modification of these surgical and ICU factors improves HRQOL, and to identify other factors that contribute to unexplained variability.
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9
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Shostak E, Schiller O, Amir G, Georgy F, Shochat T, Livni G, Ben-Zvi H, Manor O, Dagan O. Preceding Clinical Events in High-risk, Postoperative, Pediatric Cardiac Patients- A Novel Association With Bacteremia. J Intensive Care Med 2022; 38:457-463. [PMID: 36562148 DOI: 10.1177/08850666221147824] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Objective: Blood stream infections (BSIs) are well described in pediatric cardiac intensive care units (PCICU). We noted that postoperative high-risk patients may develop BSI after a preceding clinical event (PCE). The study aim was to investigate whether high-risk patients who developed bacteremia experienced more PCEs than a similar group of high-risk patients. Design: Retrospective case-control study. Setting: Referral pediatric center. Patients: We enrolled patients who developed bacteremia from March 2010 to November 2019, after undergoing open-heart surgery at a pediatric center. The control group was comprised of case-matched patients with immediate consecutive same surgery. Interventions: None. Measurements: We recorded operative data, common risk factors, postoperative indicators of organ dysfunction, mortality, and PCEs 72 to 24 h before bacteremia emerged. Main results: A total of 200 patients were included (100 with bacteremia and 100 controls). Key demographic and operative parameters were matched. Bacteremia emerged on average on postoperative day 12.8. Skin-associated Gram-positive bacteria were cultured in 10% and Gram-negative bacteria in 84% of the patients. Average central-venous lines (CVL) duration was 9.5 ± 8.4 days. Postoperatively (72 h), indicators of organ dysfunction were significantly worse in patients with bacteremia, with a higher rate of postoperative complications during PCICU length-of-stay (LOS). In the bacteremia group, 72 to 24 h prior to the development of bacteremia, 92 (92%) PCEs were recorded, as compared to 21 (21%) in controls during their entire LOS (odds ratio [OR] 43.3, confidence interval [CI] 18.2-103.1, P < .0001). Conclusions: We propose a 3-hit model demonstrating that high-risk patients undergoing open-heart surgery have significantly higher risk for bacteremia after a PCE.
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Affiliation(s)
- Eran Shostak
- Pediatric Cardiac Intensive Care Unit, Schneider Children's Medical Center, Petach Tikva, Israel.,Sackler Faculty of Medicine, 58408Tel Aviv University, Tel Aviv, Israel
| | - Ofer Schiller
- Pediatric Cardiac Intensive Care Unit, Schneider Children's Medical Center, Petach Tikva, Israel.,Sackler Faculty of Medicine, 58408Tel Aviv University, Tel Aviv, Israel
| | - Gabriel Amir
- Sackler Faculty of Medicine, 58408Tel Aviv University, Tel Aviv, Israel.,Pediatric Cardiothoracic Surgery Unit, 36739Schneider Children's Medical Center, Petach Tikva, Israel
| | - Frenkel Georgy
- Sackler Faculty of Medicine, 58408Tel Aviv University, Tel Aviv, Israel.,Pediatric Cardiothoracic Surgery Unit, 36739Schneider Children's Medical Center, Petach Tikva, Israel
| | - Tzippy Shochat
- Statistical Consultant, 36632Rabin Medical Center, Petach Tikva, Israel
| | - Gilat Livni
- Sackler Faculty of Medicine, 58408Tel Aviv University, Tel Aviv, Israel.,Pediatric Infectious Diseases Unit, Schneider Children's Medical Center, Petach Tikva, Israel
| | - Haim Ben-Zvi
- Sackler Faculty of Medicine, 58408Tel Aviv University, Tel Aviv, Israel.,Clinical Microbiology Laboratories, 36632Rabin Medical Center, Beilinson Hospital, Petah-Tikva, Israel
| | - Orit Manor
- Pediatric Cardiac Intensive Care Unit, Schneider Children's Medical Center, Petach Tikva, Israel.,Sackler Faculty of Medicine, 58408Tel Aviv University, Tel Aviv, Israel
| | - Ovadia Dagan
- Pediatric Cardiac Intensive Care Unit, Schneider Children's Medical Center, Petach Tikva, Israel.,Sackler Faculty of Medicine, 58408Tel Aviv University, Tel Aviv, Israel
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10
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Kwiatkowski DM, Ball MK, Savorgnan FJ, Allan CK, Dearani JA, Roth MD, Roth RZ, Sexson KS, Tweddell JS, Williams PK, Zender JE, Levy VY. Neonatal Congenital Heart Disease Surgical Readiness and Timing. Pediatrics 2022; 150:189888. [PMID: 36317977 DOI: 10.1542/peds.2022-056415d] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/29/2022] [Indexed: 11/06/2022] Open
Affiliation(s)
- David M Kwiatkowski
- Department of Pediatrics, Texas Tech University Health Sciences Center, Lubbock, Texas
| | - Molly K Ball
- Department of Pediatrics, Nationwide Children's Hospital, Columbus, Ohio
| | - Fabio J Savorgnan
- Department of Pediatrics, UT Southwestern, Children's Health, Dallas, Texas
| | - Catherine K Allan
- Department of Cardiology, Harvard Medical School, Boston Children's Hospital, Boston, Massachusetts
| | - Joseph A Dearani
- Department of Cardiovascular Surgery, Mayo College of Medicine, Mayo Clinic, Rochester, Minnesota
| | | | | | - Kristen S Sexson
- Department of Pediatrics, UT Southwestern, Children's Health, Dallas, Texas
| | - James S Tweddell
- Department of Surgery, University of Cincinnati, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Patricia K Williams
- Department of Pediatrics, University of Oklahoma College of Medicine, Oklahoma City, Oklahoma
| | - Jill E Zender
- Department of Pediatrics, UT Southwestern, Children's Health, Dallas, Texas
| | - Victor Y Levy
- Department of Pediatrics, Texas Tech University Health Sciences Center, Lubbock, Texas
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11
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Ortinau CM, Smyser CD, Arthur L, Gordon EE, Heydarian HC, Wolovits J, Nedrelow J, Marino BS, Levy VY. Optimizing Neurodevelopmental Outcomes in Neonates With Congenital Heart Disease. Pediatrics 2022; 150:e2022056415L. [PMID: 36317967 PMCID: PMC10435013 DOI: 10.1542/peds.2022-056415l] [Citation(s) in RCA: 16] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/29/2022] [Indexed: 11/05/2022] Open
Abstract
Neurodevelopmental impairment is a common and important long-term morbidity among infants with congenital heart disease (CHD). More than half of those with complex CHD will demonstrate some form of neurodevelopmental, neurocognitive, and/or psychosocial dysfunction requiring specialized care and impacting long-term quality of life. Preventing brain injury and treating long-term neurologic sequelae in this high-risk clinical population is imperative for improving neurodevelopmental and psychosocial outcomes. Thus, cardiac neurodevelopmental care is now at the forefront of clinical and research efforts. Initial research primarily focused on neurocritical care and operative strategies to mitigate brain injury. As the field has evolved, investigations have shifted to understanding the prenatal, genetic, and environmental contributions to impaired neurodevelopment. This article summarizes the recent literature detailing the brain abnormalities affecting neurodevelopment in children with CHD, the impact of genetics on neurodevelopmental outcomes, and the best practices for neonatal neurocritical care, focusing on developmental care and parental support as new areas of importance. A framework is also provided for the infrastructure and resources needed to support CHD families across the continuum of care settings.
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Affiliation(s)
- Cynthia M. Ortinau
- Department of Pediatrics, Washington University in St. Louis, St. Louis, Missouri
| | - Christopher D. Smyser
- Department of Pediatrics, Washington University in St. Louis, St. Louis, Missouri
- Department of Neurology, Washington University in St. Louis, St. Louis, Missouri
- Mallinckrodt Institute of Radiology, Washington University in St. Louis, St. Louis, Missouri
| | - Lindsay Arthur
- Department of Pediatrics, University of Arkansas for Medical Sciences, Little Rock, Arkansas
| | - Erin E. Gordon
- Department of Pediatrics, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Haleh C. Heydarian
- Department of Pediatrics, University of Cincinnati College of Medicine, Division of Cardiology, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio
| | - Joshua Wolovits
- Department of Pediatrics, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Jonathan Nedrelow
- Department of Neonatology, Cook Children’s Medical Center, Fort Worth, Texas
| | - Bradley S. Marino
- Department of Pediatrics, Northwestern University Feinberg School of Medicine, Divisions of Cardiology and Critical Care Medicine, Ann & Robert H. Lurie Children’s Hospital of Chicago
| | - Victor Y. Levy
- Department of Pediatrics, Stanford University School of Medicine, Lucile Packard Children’s Hospital, Palo Alto, California
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12
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Vachirapuranon S, Vijarnsorn C, Kanjanauthai S, Tocharoenchok T, Durongpisitkul K, Chanthong P, Chungsomprasong P, Pacharapakornpong T, Soongswang J, Rungmaitree S, Peerananrangsee C, Nitiyarom E, Tantiwongkosri K, Subtaweesin T, Phachiyanukul A. Major infections following pediatric cardiac surgery pre- and post-CLABSI bundle implementation. PeerJ 2022; 10:e14279. [PMID: 36325177 PMCID: PMC9620976 DOI: 10.7717/peerj.14279] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2022] [Accepted: 09/29/2022] [Indexed: 01/24/2023] Open
Abstract
Background Postoperative infection contributes to the worsening of congenital cardiac surgery (CCS) outcomes. Surgical site infection (SSI), bloodstream infection (BSI) and ventilator associated pneumonia (VAP) are common. An additional bundle of preventive measures against central-line associated bloodstream infection (CLABSI) bundle was implemented in April 2019. Objectives To compare the incidence of major infections after pediatric CCS before and after the implementation of the CLABSI bundle and to identify risk factors for major infections. Methods We conducted a single-center, retrospective study to assess the incidence of major infections including bloodstream infection (BSI), surgical site infection (SSI), and ventilator-associated pneumonia (VAP) after pediatric CCS one year before and after implementation of the CLABSI bundle during April 2018-March 2020. The demographics and outcomes of the patients were explored, and risk factors for major infections were identified using multivariate analysis. Results A total of 548 children (53% male) underwent CCS with a median age of 1.9 years (range 0.01-17.5 years). The median Aristotle Basic Complexity score was 7.1 (range 3-14.5). The CLABSI bundle was applied in 262 patients. Overall mortality was 5.5%. 126 patients (23%) experienced major postoperative infections. During the year after the implementation of the CLABSI bundle, BSI was reduced from 8.4% to 3.1% (p = 0.01), with a smaller reduction in VAP (21% to 17.6%; p = 0.33). The incidence of SSI was unchanged (1.7% to 1.9%; p = 0.77). The independent risk factors for major infections were age at surgery <6 months (p = 0.04), postoperative ventilator usage >2 days (p < 0.01), central line usage >4 days (p = 0.04), and surgery during the pre-CLABSI bundle period (p = 0.01). Conclusion Following the implementation of the CLABSI prevention package in our pediatric CCS unit, the incidence of BSI was significantly reduced. The incidence of VAP tended to decrease, while the SSI was unchanged. Sustainability of the prevention package through nurse empowerment and compliance audits is an ongoing challenge.
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Affiliation(s)
- Somthida Vachirapuranon
- Department of Pediatrics, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Chodchanok Vijarnsorn
- Department of Pediatrics, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Supaluck Kanjanauthai
- Department of Pediatrics, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Teerapong Tocharoenchok
- Department of Surgery, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Krivikrom Durongpisitkul
- Department of Pediatrics, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Prakul Chanthong
- Department of Pediatrics, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Paweena Chungsomprasong
- Department of Pediatrics, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Thita Pacharapakornpong
- Department of Pediatrics, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Jarupim Soongswang
- Department of Pediatrics, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Supattra Rungmaitree
- Department of Pediatrics, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Charn Peerananrangsee
- Department of Pharmacology, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Ekarat Nitiyarom
- Department of Surgery, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | | | - Thaworn Subtaweesin
- Department of Surgery, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Amornrat Phachiyanukul
- Pediatric Nursing Division, Department of Nursing, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
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13
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Bonello K, Emani S, Sorensen A, Shaw L, Godsay M, Delgado M, Sperotto F, Santillana M, Kheir JN. Prediction of Impending Central Line Associated Bloodstream Infections in Hospitalized Cardiac Patients: Development and Testing of a Machine-Learning Model. J Hosp Infect 2022; 127:44-50. [PMID: 35738317 DOI: 10.1016/j.jhin.2022.06.003] [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: 03/12/2022] [Revised: 06/06/2022] [Accepted: 06/06/2022] [Indexed: 10/18/2022]
Abstract
BACKGROUND While modeling of central line-associated blood stream infection (CLABSI) risk factors is common, models that predict an impending CLABSI in real time are lacking. AIM To build a prediction model which identifies patients who will develop a CLABSI in the ensuing 24 hours. METHODS We collected variables potentially related to infection identification in all patients admitted to the cardiac ICU or cardiac ward at Boston Children's Hospital in whom a central venous catheter (CVC) was in place between January 2010 and August 2020, excluding those with a diagnosis of bacterial endocarditis. We created models predicting whether a patient would develop CLABSI in the ensuing 24 hours. We assessed model performance based on area under the curve (AUC), sensitivity, and false positive rate (FPR) of models run on an independent testing set (40%). FINDINGS 104,035 patient-days and 139,662 line-days corresponding to 7,468 unique patients were included in the analysis. There were 399 positive blood cultures (0.38%), most commonly with Staphylococcus aureus (23% of infections). Major predictors included a prior history of infection, elevated maximum heart rate, elevated maximum temperature, elevated C-reactive protein, exposure to parenteral nutrition, and use of alteplase for CVC clearance. The model identified 25% of positive cultures with an FPR of 0.11% (AUC = 0.82). CONCLUSIONS A machine learning model can be used to predict 25% of patients with impending CLABSI with only 1.1/1,000 of these predictions being incorrect. Once prospectively validated, this tool may allow for early treatment or prevention.
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Affiliation(s)
- Kristin Bonello
- Department of Cardiology, Boston Children's Hospital; Department of Paediatrics, Harvard Medical School, Boston, Massachusetts
| | - Sivaram Emani
- Department of Cardiology, Boston Children's Hospital; Department of Paediatrics, Harvard Medical School, Boston, Massachusetts
| | | | - Lauren Shaw
- Department of Cardiology, Boston Children's Hospital
| | | | | | - Francesca Sperotto
- Department of Cardiology, Boston Children's Hospital; Department of Paediatrics, Harvard Medical School, Boston, Massachusetts; Paediatric Cardiac Intensive Care Unit, Department of Women's and Children's Health, University of Padova, Padova, Italy
| | - Mauricio Santillana
- Harvard Institute for Applied Computational Science, Harvard University, Cambridge, Massachusetts; Computational Health Informatics Program, Boston Children's Hospital
| | - John N Kheir
- Department of Cardiology, Boston Children's Hospital; Department of Paediatrics, Harvard Medical School, Boston, Massachusetts.
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14
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Bianchini S, Nicoletti L, Monaco S, Rigotti E, Corbelli A, Colombari A, Auriti C, Caminiti C, Conti G, De Luca M, Donà D, Galli L, Garazzino S, Inserra A, La Grutta S, Lancella L, Lima M, Lo Vecchio A, Pelizzo G, Petrosillo N, Piacentini G, Pietrasanta C, Principi N, Puntoni M, Simonini A, Tesoro S, Venturini E, Staiano A, Caramelli F, Gargiulo GD, Esposito S. 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; 11:554. [PMID: 35625198 PMCID: PMC9137830 DOI: 10.3390/antibiotics11050554] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [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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Affiliation(s)
- Sonia Bianchini
- Pediatric Clinic, University Hospital, Department of Medicine and Surgery, University of Parma, 43126 Parma, Italy; (S.B.); (L.N.); (S.M.)
| | - Laura Nicoletti
- Pediatric Clinic, University Hospital, Department of Medicine and Surgery, University of Parma, 43126 Parma, Italy; (S.B.); (L.N.); (S.M.)
| | - Sara Monaco
- Pediatric Clinic, University Hospital, Department of Medicine and Surgery, University of Parma, 43126 Parma, Italy; (S.B.); (L.N.); (S.M.)
| | - Erika Rigotti
- Pediatric Clinic, Azienda Ospedaliera Universitaria Integrata, 37134 Verona, Italy; (E.R.); (A.C.); (A.C.); (G.P.)
| | - Agnese Corbelli
- Pediatric Clinic, Azienda Ospedaliera Universitaria Integrata, 37134 Verona, Italy; (E.R.); (A.C.); (A.C.); (G.P.)
| | - Annamaria Colombari
- Pediatric Clinic, Azienda Ospedaliera Universitaria Integrata, 37134 Verona, Italy; (E.R.); (A.C.); (A.C.); (G.P.)
| | - Cinzia Auriti
- Neonatology and Neonatal Intensive Care Unit, IRCCS Bambino Gesù Children’s Hospital, 00165 Rome, Italy;
| | - Caterina Caminiti
- Clinical and Epidemiological Research Unit, University Hospital of Parma, 43126 Parma, Italy; (C.C.); (M.P.)
| | - Giorgio Conti
- Pediatric ICU and Trauma Center, Fondazione Policlinico Universitario A. Gemelli IRCCS, 00165 Rome, Italy;
| | - Maia De Luca
- Paediatric and Infectious Disease Unit, Academic Department of Pediatrics, IRCCS Bambino Gesù Children’s Hospital, 00165 Rome, Italy; (M.D.L.); (L.L.)
| | - Daniele Donà
- Division of Paediatric Infectious Diseases, Department for Woman and Child Health, University of Padua, 35100 Padua, Italy;
| | - Luisa Galli
- Pediatric Infectious Diseases Unit, Meyer’s Children Hospital, 50139 Florence, Italy; (L.G.); (E.V.)
| | - Silvia Garazzino
- Pediatric Infectious Diseases Unit, Regina Margherita Children’s Hospital, University of Turin, 10122 Turin, Italy;
| | - Alessandro Inserra
- General Surgery Department, IRCCS Bambino Gesù Children’s Hospital, 00165 Rome, Italy;
| | - Stefania La Grutta
- Institute of Translational Pharmacology IFT, National Research Council, 90146 Palermo, Italy;
| | - Laura Lancella
- Paediatric and Infectious Disease Unit, Academic Department of Pediatrics, IRCCS Bambino Gesù Children’s Hospital, 00165 Rome, Italy; (M.D.L.); (L.L.)
| | - Mario Lima
- Pediatric Surgery, IRCCS Azienda Ospedaliera-Universitaria di Bologna, 40138 Bologna, Italy;
| | - Andrea Lo Vecchio
- Department of Translational Medical Science, Section of Pediatrics, University of Naples “Federico II”, 80138 Naples, Italy;
| | - Gloria Pelizzo
- Pediatric Surgery Department, “Vittore Buzzi” Children’s Hospital, 20154 Milan, Italy; (G.P.); (A.S.)
| | - Nicola Petrosillo
- Infectious Disease and Infection Control Unit, Campus Bio-Medico, Medicine University Hospital, 00128 Rome, Italy;
| | - Giorgio Piacentini
- Pediatric Clinic, Azienda Ospedaliera Universitaria Integrata, 37134 Verona, Italy; (E.R.); (A.C.); (A.C.); (G.P.)
| | - Carlo Pietrasanta
- NICU, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Department of Mother, Child and Infant, 20122 Milan, Italy;
| | | | - Matteo Puntoni
- Clinical and Epidemiological Research Unit, University Hospital of Parma, 43126 Parma, Italy; (C.C.); (M.P.)
| | - Alessandro Simonini
- Pediatric Anesthesia and Intensive Care Unit, Salesi Children’s Hospital, 60123 Ancona, Italy;
| | - Simonetta Tesoro
- Division of Anesthesia, Analgesia, and Intensive Care, Department of Surgical and Biomedical Sciences, University of Perugia, 06129 Perugia, Italy;
| | - Elisabetta Venturini
- Pediatric Infectious Diseases Unit, Meyer’s Children Hospital, 50139 Florence, Italy; (L.G.); (E.V.)
| | - Annamaria Staiano
- Pediatric Surgery Department, “Vittore Buzzi” Children’s Hospital, 20154 Milan, Italy; (G.P.); (A.S.)
| | - Fabio Caramelli
- General and Pediatric Anesthesia and Intensive Care Department, IRCCS Azienda Ospedaliero-Universitaria di Bologna, 40138 Bologna, Italy;
| | - Gaetano Domenico Gargiulo
- Department of Cardio-Thoracic and Vascular Medicine, Adult Cardiac Surgery, IRCCS Azienda Ospedaliero-Universitaria di Bologna, 40138 Bologna, Italy;
| | - Susanna Esposito
- Pediatric Clinic, University Hospital, Department of Medicine and Surgery, University of Parma, 43126 Parma, Italy; (S.B.); (L.N.); (S.M.)
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15
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Zhang HT, Han XK, Wang CS, Zhang H, Li ZS, Chen Z, Pan K, Zhong K, Pan T, Wang DJ. Diagnosis of infection after cardiovascular surgery (DICS): a study protocol for developing and validating a prediction model in prospective observational study. BMJ Open 2021; 11:e048310. [PMID: 34548352 PMCID: PMC8458369 DOI: 10.1136/bmjopen-2020-048310] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/21/2023] Open
Abstract
INTRODUCTION Postoperative infection (PI) is one of the main severe complications after cardiovascular surgery. Therefore, antibiotics are routinely used during the first 48 hours after cardiovascular surgery. However, there is no effective method for early diagnosis of infection after cardiovascular surgery, particularly, to determine whether postoperative patients need to prolong the use of antibiotics after the first 48 hours. In this study, we aim to develop and validate a diagnostic model to help identify whether a patient has been infected after surgery and guide the appropriate use of antibiotics. METHODS AND ANALYSIS In this prospective study, we will develop and validate a diagnostic model to determine whether the patient has a bacterial infection within 48 hours after cardiovascular surgery. Baseline data will be collected through the electronic medical record system. A total of 2700 participants will be recruited (n=2000 for development, n=700 for validation). The primary outcome of the study is the newly PI during the first 48 hours after cardiovascular surgery. Logistic regression penalised with elastic net regularisation will be used for model development and bootstrap and k-fold cross-validation aggregation will be performed for internal validation. The derived model will be also externally validated in patients who are continuously included in another time period (N=700). We will evaluate the calibration and differentiation performance of the model by Hosmer-Lemeshow good of fit test and the area under the curve, respectively. We will report sensitivity, specificity, positive predictive value and negative predictive value in the validation data-set, with a target of 80% sensitivity. ETHICS AND DISSEMINATION Ethical approval was obtained from Medical Ethics Committee of Affiliated Nanjing Drum Tower Hospital, Nanjing University Medical College (2020-249-01). TRIAL REGISTRATION NUMBER Chinese Clinical Trial Register (www.chictr.org.cn, ChiCTR2000038762); Pre-results.
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Affiliation(s)
- Hai-Tao Zhang
- Department of Cardio-Thoracic Surgery, Nanjing Drum Tower Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Peking Union Medical College Graduate School, Nanjing, China
| | - Xi-Kun Han
- Statistical Genetics, QIMR Berghofer Medical Research Institute, Herston, Queensland, Australia
- School of Medicine, The University of Queensland, St Lucia, Queensland, Australia
| | - Chuang-Shi Wang
- Medical Research & Biometrics Center, National Center for Cardiovascular Diseases, Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Xicheng District, Beijing, China
| | - He Zhang
- Department of Cardio-Thoracic Surgery, Nanjing Drum Tower Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Peking Union Medical College Graduate School, Nanjing, China
| | - Ze-Shi Li
- Department of Cardio-Thoracic Surgery, Nanjing Drum Tower Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Peking Union Medical College Graduate School, Nanjing, China
| | - Zhong Chen
- Department of Cardio-Thoracic Surgery, Nanjing Drum Tower Hospital, Nanjing Medical University, Nanjing, Jiangsu, China
| | - Ke Pan
- Nanjing Drum Tower Hospital, Xuzhou Medical University, Xuzhou, Jiangsu, China
| | - Kai Zhong
- Department of Cardio-Thoracic Surgery, Nanjing Drum Tower Hospital, Nanjing Medical University, Nanjing, Jiangsu, China
| | - Tuo Pan
- Department of Cardio-Thoracic Surgery, Nanjing Drum Tower Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Peking Union Medical College Graduate School, Nanjing, China
| | - Dong-Jin Wang
- Department of Cardio-Thoracic Surgery, Nanjing Drum Tower Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Peking Union Medical College Graduate School, Nanjing, China
- Department of Cardio-Thoracic Surgery, Nanjing Drum Tower Hospital, Nanjing Medical University, Nanjing, Jiangsu, China
- Nanjing Drum Tower Hospital, Xuzhou Medical University, Xuzhou, Jiangsu, China
- Department of Cardio-Thoracic Surgery, Nanjing Drum Tower Hospital, the Affiliated Hospital of Nanjing University Medical School, Nanjing, China
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16
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Yang Y, Wang J, Cai L, Peng W, Mo X. Surgical site infection after delayed sternal closure in neonates with congenital heart disease: retrospective case-control study. Ital J Pediatr 2021; 47:182. [PMID: 34496939 PMCID: PMC8424398 DOI: 10.1186/s13052-021-01138-w] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/13/2021] [Accepted: 08/27/2021] [Indexed: 12/02/2022] Open
Abstract
Objectives To determine the prevalence of surgical site infections (SSIs) in neonatal congenital heart disease patients undergoing delayed sternal closure (DSC) and evaluate risk factors for SSI. Methods Hospital records of 483 consecutive neonates who underwent surgical intervention between January 2013 and December 2017 were reviewed, and perioperative variables were recorded. Results We found that the prevalence of SSI was 87.5% when the body weight was less than 1500 g. When the operative age was between seven and 14 days, the probability of no SSI is about 93.9%. When the duration of the aortic cross-clamp was more than 60 min, the prevalence of SSI was 91.2%. The prevalence without SSI was 96.6% when the duration of DSC was less than 24 h. However, when the duration of DSC was more than 120 h, the prevalence of SSI was 88.9% (p = 0.000). Conclusions With the prolongation of aortic clamping duration, the probability of occurrence of SSI increased in neonatal CHD with DSC. The age at operation and body weight are closely related to the occurrence of SSI in neonatal CHD patients with DSC.
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Affiliation(s)
- Yuzhong Yang
- Department of Cardiothoracic Surgery, Children's Hospital of Nanjing Medical University, No.72 Guangzhou Road, Nanjing, Jiangsu Province, People's Republic of China, 210008
| | - Jie Wang
- Department of General Surgery and Ear-Nose-Throat, Children's Hospital of Nanjing Medical University, Nanjing, China
| | - Lina Cai
- Department of Cardiothoracic Surgery, Children's Hospital of Nanjing Medical University, No.72 Guangzhou Road, Nanjing, Jiangsu Province, People's Republic of China, 210008
| | - Wei Peng
- Department of Cardiothoracic Surgery, Children's Hospital of Nanjing Medical University, No.72 Guangzhou Road, Nanjing, Jiangsu Province, People's Republic of China, 210008
| | - Xuming Mo
- Department of Cardiothoracic Surgery, Children's Hospital of Nanjing Medical University, No.72 Guangzhou Road, Nanjing, Jiangsu Province, People's Republic of China, 210008.
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Payton KSE, Brunetti MA. Antibiotic Stewardship in Pediatrics. Adv Pediatr 2021; 68:37-53. [PMID: 34243858 DOI: 10.1016/j.yapd.2021.05.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Affiliation(s)
- Kurlen S E Payton
- Department of Pediatrics, Division of Neonatology, Cedars-Sinai Medical Center, 8700 Beverly Boulevard, NT Suite 4221, Los Angeles, CA 90048, USA.
| | - Marissa A Brunetti
- University of Pennsylvania Perelman School of Medicine, Children's Hospital of Philadelphia, 3401 Civic Center Boulevard Suite 8NE51, Philadelphia, PA 19104, USA
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18
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Prendin A, Tabacco B, Fazio PC, Strini V, Brugnaro L, De Barbieri I. Survey on Sternal Wound Management in the Italian Pediatric Cardiac Intensive Care Units. Healthcare (Basel) 2021; 9:healthcare9070869. [PMID: 34356247 PMCID: PMC8308053 DOI: 10.3390/healthcare9070869] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2021] [Revised: 07/06/2021] [Accepted: 07/07/2021] [Indexed: 11/16/2022] Open
Abstract
(1) Background: a review of the literature found a lack of standardized pediatric guidelines regarding wound management after cardiac surgery. (2) Objective: the aim of the study is to investigate the cardiac surgical wound management in Italian pediatric cardiac intensive care units. (3) Methods: we sent an online questionnaire to the 13 Italian pediatric cardiac intensive care units. (4) Results: ten pediatric cardiac intensive care units (77%) have a protocol for the management of the cardiac surgical wound. The staff members that mainly have the responsibility for the wound management after cardiac surgery are registered nurses and physicians together both in the pediatric cardiac intensive care units (69%), and when a patient is transferred to another ward (62%). Thirty-eight percent of the pediatric cardiac intensive care units have a protocol used to monitor wound infection, and the staff mostly uses a written shift report (54%) to monitor the infection. (5) Discussion: this is the first survey to investigate the management of the wound after cardiac surgery in Italian pediatric cardiac intensive care units. The small sample size and the fact that the centers involved are only Italian cardiac intensive care units are the limits of this study. (6) Conclusions: in the Italian pediatric cardiac intensive care units it emerged that there is a diversity in the treatments adopted and a lack of specific protocols in the management of the pediatric cardiac surgical wound.
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Affiliation(s)
- Angela Prendin
- Independent Researcher, 35100 Padua, Italy
- Correspondence:
| | | | - Paola Claudia Fazio
- Pediatric Intensive Care Unit, University-Hospital of Padua, 35100 Padua, Italy;
| | - Veronica Strini
- Clinical Research Unit, University-Hospital of Padua, 35100 Padua, Italy;
| | - Luca Brugnaro
- Training and Development Unit of the Health Professions, University-Hospital of Padua, 35100 Padua, Italy;
| | - Ilaria De Barbieri
- Nurse Coordinator Woman’s & Child’s Health Department, University-Hospital of Padua, 35100 Padua, Italy;
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Is arterial switch operation possible with neonatology-focused intensive care unit modality. TURK GOGUS KALP DAMAR CERRAHISI DERGISI-TURKISH JOURNAL OF THORACIC AND CARDIOVASCULAR SURGERY 2021; 29:136-142. [PMID: 34104506 PMCID: PMC8167476 DOI: 10.5606/tgkdc.dergisi.2021.20309] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/15/2020] [Accepted: 01/06/2021] [Indexed: 11/29/2022]
Abstract
Background
In this study, we aimed to examine the feasibility of arterial switch operation and its perioperative management with neonatology-focused intensive care modality in a region of Turkey where the birth rate and the number of asylum seekers who had to leave their country due to regional conflicts are high.
Methods
Between December 2017 and June 2020, a total of 57 patients (48 males, 9 females; median age: 12.2 days; range, 2 to 50 days) who were diagnosed with transposition of the great arteries in our clinic and underwent arterial switch operation were retrospectively analyzed. All patients were followed by the neonatologist in the neonatal intensive care unit during the preoperative and postoperative period.
Results
Thirty-eight (66.7%) patients had intact ventricular septum, 16 (28.1%) had ventricular septal defect, two (3.5%) had coarctation of the aorta, and one (1.7%) had Taussig-Bing anomaly. Coronary artery anomaly was present in 14 (24.5%) patients. The most common complications in the intensive care unit were renal failure requiring peritoneal dialysis in seven (12.3%) patients, supraventricular tachyarrhythmia in six (10.5%) patients, and eight (14%) patients left their chests open. The median length of stay in intensive care unit was 13.8 (range, 9 to 25) days and the median length of hospital stay was 24.5 (range, 16 to 47) days. The overall mortality rate for all patients was 12.3% (n=7). The median follow-up was 8.2 months. A pulmonary valve peak Doppler gradient of ≥36 mmHg was detected in five patients (8.7%) who were followed, and these patients were monitored by providing medical treatment. None of the patients needed reoperation or reintervention.
Conclusion
We believe that arterial switch operation, one of the complex neonatal cardiac surgery, can be performed with an acceptable mortality and morbidity rate with the use of neonatology-focused intensive care modality, which is supported by pediatric cardiology and pediatric cardiac surgery.
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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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Ren C, Wu C, Pan Z, Wang Q, Li Y. Pulmonary infection after cardiopulmonary bypass surgery in children: a risk estimation model in China. J Cardiothorac Surg 2021; 16:71. [PMID: 33827623 PMCID: PMC8025064 DOI: 10.1186/s13019-021-01450-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2020] [Accepted: 03/23/2021] [Indexed: 01/21/2023] Open
Abstract
OBJECTIVES The occurrence of pulmonary infection after congenital heart disease (CHD) surgery can lead to significant increases in intensive care in cardiac intensive care unit (CICU) retention time, medical expenses, and risk of death risk. We hypothesized that patients with a high risk of pulmonary infection could be screened out as early after surgery. Hence, we developed and validated the first risk prediction model to verify our hypothesis. METHODS Patients who underwent CHD surgery from October 2012 to December 2017 in the Children's Hospital of Chongqing Medical University were included in the development group, while patients who underwent CHD surgery from December 2017 to October 2018 were included in the validation group. The independent risk factors associated with pulmonary infection following CHD surgery were screened using univariable and multivariable logistic regression analyses. The corresponding nomogram prediction model was constructed according to the regression coefficients. Model discrimination was evaluated by the area under the receiver operating characteristic curve (ROC) (AUC), and model calibration was conducted with the Hosmer-Lemeshow test. RESULTS The univariate and multivariate logistic regression analyses identified the following six independent risk factors of pulmonary infection after cardiac surgery: age, weight, preoperative hospital stay, risk-adjusted classification for congenital heart surgery (RACHS)-1 score, cardiopulmonary bypass time and intraoperative blood transfusion. We established an individualized prediction model of pulmonary infection following cardiopulmonary bypass surgery for CHD in children. The model displayed accuracy and reliability and was evaluated by discrimination and calibration analyses. The AUCs for the development and validation groups were 0.900 and 0.908, respectively, and the P-values of the calibration tests were 0.999 and 0.452 respectively. Therefore, the predicted probability of the model was consistent with the actual probability. CONCLUSIONS Identified the independent risk factors of pulmonary infection after cardiopulmonary bypass surgery. An individualized prediction model was developed to evaluate the pulmonary infection of patients after surgery. For high-risk patients, after surgery, targeted interventions can reduce the risk of pulmonary infection.
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Affiliation(s)
- Chunnian Ren
- Department of Cardiothoracic Surgery, Children's Hospital of Chongqing Medical University, No.136, Zhongshan 2nd Road, Yuzhong Dis, Chongqing, 400014, P.R. China.,Ministry of Education Key Laboratory of Child Development and Disorders; National Clinical Research Center for Child Health and Disorders (Chongqing); China International Science and Technology Cooperation base of Child Development and Critical Disorders, Chongqing, P.R. China.,Chongqing Key Laboratory of Pediatrics, Chongqing Medical University, Chongqing, P. R. China
| | - Chun Wu
- Department of Cardiothoracic Surgery, Children's Hospital of Chongqing Medical University, No.136, Zhongshan 2nd Road, Yuzhong Dis, Chongqing, 400014, P.R. China.,Ministry of Education Key Laboratory of Child Development and Disorders; National Clinical Research Center for Child Health and Disorders (Chongqing); China International Science and Technology Cooperation base of Child Development and Critical Disorders, Chongqing, P.R. China.,Chongqing Key Laboratory of Pediatrics, Chongqing Medical University, Chongqing, P. R. China
| | - Zhengxia Pan
- Department of Cardiothoracic Surgery, Children's Hospital of Chongqing Medical University, No.136, Zhongshan 2nd Road, Yuzhong Dis, Chongqing, 400014, P.R. China.,Ministry of Education Key Laboratory of Child Development and Disorders; National Clinical Research Center for Child Health and Disorders (Chongqing); China International Science and Technology Cooperation base of Child Development and Critical Disorders, Chongqing, P.R. China.,Chongqing Key Laboratory of Pediatrics, Chongqing Medical University, Chongqing, P. R. China
| | - Quan Wang
- Department of Cardiothoracic Surgery, Children's Hospital of Chongqing Medical University, No.136, Zhongshan 2nd Road, Yuzhong Dis, Chongqing, 400014, P.R. China.,Ministry of Education Key Laboratory of Child Development and Disorders; National Clinical Research Center for Child Health and Disorders (Chongqing); China International Science and Technology Cooperation base of Child Development and Critical Disorders, Chongqing, P.R. China.,Chongqing Key Laboratory of Pediatrics, Chongqing Medical University, Chongqing, P. R. China
| | - Yonggang Li
- Department of Cardiothoracic Surgery, Children's Hospital of Chongqing Medical University, No.136, Zhongshan 2nd Road, Yuzhong Dis, Chongqing, 400014, P.R. China. .,Ministry of Education Key Laboratory of Child Development and Disorders; National Clinical Research Center for Child Health and Disorders (Chongqing); China International Science and Technology Cooperation base of Child Development and Critical Disorders, Chongqing, P.R. China. .,Chongqing Key Laboratory of Pediatrics, Chongqing Medical University, Chongqing, P. R. China.
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Invasive Bacterial and Fungal Infections After Pediatric Cardiac Surgery: A Single-center Experience. Pediatr Infect Dis J 2021; 40:310-316. [PMID: 33230058 DOI: 10.1097/inf.0000000000003005] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Discrimination of infectious and noninfectious complications in children with inflammatory signs after cardiac surgery is challenging. Given the low prevalence of infectious complications after heart surgery, there might be a risk of excessive antibiotic usage. We performed this study to determine the rate of invasive bacterial or fungal infections in children after cardiac surgery at our institution and to evaluate our postoperative management. METHODS This single-center retrospective observational cohort study included children 16 years of age or younger who underwent cardiac surgery at our institution between January 2012 and December 2015. RESULTS We analyzed 395 surgical procedures. Thirty-five postoperative invasive bacterial or fungal infections were detected in 29 episodes (7%, 0.42 per 100 admission days). Among bacterial infections, the most common infection sites were bacteremia and pneumonia, accounting for 37% (13/35) and 23% (8/35) of infections respectively. The rate of postoperative infections was associated with surgical complexity score and length of postoperative pediatric intensive care unit (PICU) stay. In 154 (43%) of 357 episodes without microbiologically documented infection, uninterrupted postoperative antibiotic administration was continued for more than 3 days and in 80 (22%) for more than 5 days. CONCLUSIONS The rate of postoperative bacterial or fungal infection at our institution is comparable to current literature. High surgical complexity score and prolonged length of PICU stay were risk factors for bacterial or fungal infections in this patient population.
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Expanding antimicrobial stewardship strategies for the NICU: Management of surgical site infections, perioperative prophylaxis, and culture negative sepsis. Semin Perinatol 2020; 44:151327. [PMID: 33160696 DOI: 10.1016/j.semperi.2020.151327] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
OBJECTIVE To review antibiotic stewardship strategies for neonatal intensive care units (NICU) in the areas of management of surgical site infections, perioperative prophylaxis and culture negative late onset sepsis. FINDING Review of local microbiology, stratification of surgical procedures by risk of contamination of the surgical site, and adherence to evidence-based principles of perioperative antibiotic administration (targeted therapy, effective dosing, appropriate timing and limiting duration post-operatively) can help to minimize unnecessary antibiotic use for neonatal surgery. Creating a late onset sepsis case definition, appropriate collection and interpretation of blood cultures, and instituting antibiotic time-outs can minimize the overuse of antibiotics for culture negative sepsis. CONCLUSION Effective implementation of these antimicrobial stewardship strategies in the NICU can reduce unnecessary antimicrobial use and limit the emergence of resistant pathogens.
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Yaroustovsky M, Abramyan M, Rogalskaya E, Komardina E. Selective Polymyxin Hemoperfusion in Complex Therapy of Sepsis in Children after Cardiac Surgery. Blood Purif 2020; 50:222-229. [PMID: 33242859 DOI: 10.1159/000510126] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2020] [Accepted: 07/09/2020] [Indexed: 11/19/2022]
Abstract
BACKGROUND To date, sepsis remains one of the main challenges of intensive care in pediatrics. Newborns with low birth weight and infants with chronic diseases and congenital disorders are particularly at risk. The incidence of infectious complications in pediatric cardiac surgery is known to be approximately 15-30%. The main etiological factor of sepsis is endotoxin. AIM To evaluate the efficiency and safety of polymyxin (PMX) B-immobilized column-direct hemoperfusion in complex intensive therapy of sepsis in children after cardiac surgery with cardiopulmonary bypass. DESIGN Prospective cohort study. METHODS This study enrolled 15 children, aged 9-96 months, with congenital heart diseases and with body weights of 6.2-22.5 kg. The criteria for admission were body weight >6 kg and clinical and laboratory signs of sepsis (microbiological analysis, procalcitonin [PCT] >2 ng/mL, and endotoxin activity assay [ЕАА] >0.6). Intensive care included inotropic and vasopressor support, mechanical ventilation, broad-spectrum antibiotic therapy, and PMX hemoperfusion procedures. Extracorporeal therapy was initiated within 24 h following the sepsis diagnosis. Every patient underwent 2 hemoperfusion sessions with the use of a PMX B-immobilized column; the session duration was 180 min. RESULTS We noted improvements in hemodynamic parameters, oxygenation index, and laboratory signs of sepsis, with decreases in the endotoxin concentration according to the EAA, PCT, and presepsin levels. The 28-day survival of the patients in this severely affected group was 80%. Main Conclusion: The inclusion of extracorporeal methods of blood purification, aimed at the selective elimination of circulating endotoxin, in the treatment of sepsis increases the survival rates of children after open heart surgery. Second Conclusion: The obtained results of sepsis therapy with PMX hemoperfusion in children after cardiac surgery enable us to suggest the sufficient safety and efficiency of the procedures in this category of severely affected patients.
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Affiliation(s)
- Michail Yaroustovsky
- Federal State Budget Institution "A.N. Bakulev National Medical Research Centre for Cardiovascular Surgery" of the Ministry of Healthcare of the Russian Federation (Bakulev NMRCCS), Moscow, Russian Federation,
| | - Marina Abramyan
- Federal State Budget Institution "A.N. Bakulev National Medical Research Centre for Cardiovascular Surgery" of the Ministry of Healthcare of the Russian Federation (Bakulev NMRCCS), Moscow, Russian Federation
| | - Ekaterina Rogalskaya
- Federal State Budget Institution "A.N. Bakulev National Medical Research Centre for Cardiovascular Surgery" of the Ministry of Healthcare of the Russian Federation (Bakulev NMRCCS), Moscow, Russian Federation
| | - Ekaterina Komardina
- Federal State Budget Institution "A.N. Bakulev National Medical Research Centre for Cardiovascular Surgery" of the Ministry of Healthcare of the Russian Federation (Bakulev NMRCCS), Moscow, Russian Federation
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Sternal Precautions and Prone Positioning of Infants Following Median Sternotomy: A Nationwide Survey. Pediatr Phys Ther 2020; 32:339-345. [PMID: 32925814 DOI: 10.1097/pep.0000000000000734] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE To describe current practice of pediatric sternal precautions (PSPs) and prone positioning restrictions (PPRs) in infants after median sternotomy. METHODS A Web-based survey with 21 questions was developed on the basis of a review of current literature and expert consultation. Snowball sampling resulted in 68 participants well represented by profession throughout the United States. RESULTS Approximately 80% of participants reported having institutional protocols for PSPs. Most common reported PSPs were no lifting at the axillae and no pulling of arms to achieve sitting. PSPs also included PPRs. The opinions of participants supported no PPRs or modified PPRs compared with strict PPRs. CONCLUSIONS Types of PPRs varied across participants, with the majority of participants in favor of modified PPRs while PSPs were less varied. Research is needed to examine the effects of PSPs and PPRs in infants post-median sternotomy.
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Global Leadership in Paediatric and Congenital Cardiac Care: "Using data to improve outcomes - an interview with Jennifer S. Li, MD, MHS". Cardiol Young 2020; 30:1226-1230. [PMID: 32921334 DOI: 10.1017/s1047951120002875] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Dr. Jennifer Li is the focus of our second in a planned series of interviews in Cardiology in the Young entitled, "Global Leadership in Paediatric and Congenital Cardiac Care". Dr. Li was born in Boston, Massachusetts, United States of America, and moved to Indianapolis, Indiana where she completed her secondary education. She then attended Stanford University, majoring in Chemistry and English and graduating with distinction in 1983. Dr. Li then attended Duke University School of Medicine, graduating in 1987. She then completed her internship at Children's Hospital of Philadelphia in 1987-1989, returning to Duke University Medical Center to complete both her residency in general paediatrics in 1989-1990 followed by her fellowship in paediatric cardiology in 1990-1993. She would later complete her Master's Degree in Health Sciences at Duke University in 2005.Dr. Li has spent her entire career as a paediatric cardiologist at Duke University Medical Center, where she was appointed a Professor of Pediatrics and Professor of Medicine in 2008 and has held the position as Beverly C. Morgan Endowed Professor of Pediatrics since 2012. She has served as the Chief of Paediatric Cardiology at Duke University Medical Center since 2006. She also was the Director of Paediatric Research at Duke Clinical Research Institute from 2001-2015. Dr. Li has played an instrumental role in evaluating the safety and efficacy of drugs in children, as well as in analysing and linking large multicentric databases to evaluate the outcomes, quality, and cost of paediatric and congenital cardiac care. Dr. Li has received funding from the National Institute of Health of the United States of America, as well as from industry and foundation grants. This article presents our interview with Dr. Li, an interview that covers her experience collaborating with governmental organizations and industry in the pursuit of common interests to design clinical drug trials, link and analyse large, multicentric databases, and improve paediatric health care.
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Dohogne BJ, Srinivasan S, Arif-Tiwari H, Potharaju A. Nontyphoidal Salmonella as a Cause of Mediastinal Abscess in a Patient With Extensive Cardiac Surgery. Cureus 2020; 12:e9924. [PMID: 32968585 PMCID: PMC7505638 DOI: 10.7759/cureus.9924] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
Focal infections caused by nontyphoidal Salmonella (NTS) are relatively rare and usually self-limited. Those with cardiac surgical history are predisposed to intrathoracic seeding, including mediastinal infections and abscesses. We report a case of a 39-year-old Hispanic male with a complex past medical history of Tetralogy of Fallot with an initial presentation of Salmonella gastroenteritis and concern for sepsis. The patient did not clinically improve on ceftriaxone despite appropriate cultures and susceptibilities, and another source of infection was speculated. A chest CT scan showed development of a mediastinal abscess with compression of the right ventricular outflow tract. The patient was not deemed an appropriate surgical candidate and was managed conservatively on ceftriaxone and ciprofloxacin. He was discharged in stable condition. This case of NTS infection associated with a mediastinal abscess is a rare occurrence, and management is complicated. To improve morbidity and mortality, early imaging is essential to diagnose distal seeding of the infection in patients with enteral infections who do not show clinical improvement despite appropriate antibiotic treatment. Surgery is the standard of care, but conservative management might be required in certain high-risk cases.
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Affiliation(s)
| | | | - Hina Arif-Tiwari
- Radiology, University of Arizona College of Medicine, Tucson, USA
| | - Anil Potharaju
- Internal Medicine, University of Arizona College of Medicine, Tucson, USA
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Congenital Heart Disease and Risk of Central Nervous System Infections: A Nationwide Cohort Study. Pediatr Cardiol 2020; 41:869-876. [PMID: 32162026 DOI: 10.1007/s00246-020-02324-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/01/2019] [Accepted: 02/17/2020] [Indexed: 12/30/2022]
Abstract
Congenital heart disease (CHD) is associated with risk factors of central nervous system (CNS) infections including infective endocarditis, cardiac shunt physiology, and immune deficiencies. We aimed to investigate the risk of CNS infections in the CHD population compared to the general population. In this cohort study, we used Danish nationwide medical registries to identify individuals diagnosed with CHD at any age, born between 1977 and 2012. For each CHD individual, we matched 10 individuals on sex and birth year from the general population. Subjects were followed until first-time hospital diagnosis of CNS infection, death, emigration, or end of study. We computed cumulative incidences of CNS infections with death as a competing risk, as well as hazard ratios (HRs) with corresponding 95% confidence intervals (CIs) adjusted for birth year and sex. We identified 17,550 individuals with CHD (50% male). Among subjects with CHD, the cumulative incidence of CNS infection at age 30 years was 1.0% compared to 0.6% in the general population. The overall HR of CNS infections in CHD subjects relative to the general population was 2.1 (95% CI 1.6-2.7). The HR was 1.9 (95% CI 1.4-2.7) for mild to moderate CHD, 2.1 (95% CI 1.3-3.3) for severe CHD and 3.0 (95% CI 1.1-8.2) for univentricular physiology. The HR for CHD subjects without record of infective endocarditis was 2.0 (95% CI 1.5-2.5). The risk of CNS infections was increased among individuals with CHD compared to the general population, and the risk was not limited to individuals with infective endocarditis.
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Agarwal R, Varghese R, Jesudian V, Moses J. The heterotaxy syndrome: associated congenital heart defects and management. Indian J Thorac Cardiovasc Surg 2020; 37:67-81. [PMID: 33603285 DOI: 10.1007/s12055-020-00935-y] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2019] [Revised: 01/22/2020] [Accepted: 01/31/2020] [Indexed: 12/23/2022] Open
Abstract
Heterotaxy syndrome (HS) constitutes a spectrum of anomalies arising from embryological errors that result in abnormalities of lateralization involving thoraco-abdominal viscera and culminate in loss of normal asymmetric arrangement of these organs. Besides the unique challenges involved in planning and execution of surgical procedures aimed at correction or palliation of these anomalies, they have the potential to cause profound physiological and immunological consequences in the individual patient due to their cardiac and extra-cardiac manifestations. This article aims to review the literature on this rare and extraordinary subset of developmental anomalies with the intention of familiarizing the reader on the modes of presentation, manifestations, and the variations thereof while dealing with this anomaly. In our institutional experience with HS, 75 consecutive patients were seen between January 2011 and September 2018. Of these, 48 (64%) were confirmed to have isomerism of right atrial appendages (IRAA) and the rest had isomerism of left atrial appendages (ILAA). The cardiac and extra-cardiac manifestations of these patients were listed out. Fifty-four patients (34 with IRAA and 20 with ILAA) underwent 83 surgical procedures. While 49 patients were palliated on the univentricular pathway, 5 underwent biventricular repair. The in-hospital mortality was 7 (13%) in both groups combined (5 for patients with IRAA and 2 for ILAA). In conclusion, the surgical management of HS is associated with satisfactory outcomes in current era.
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Affiliation(s)
- Ravi Agarwal
- Division of Pediatric Cardiac Surgery, The Madras Medical Mission, 4-A, Dr. J.J. Nagar, Mogappair, Chennai, Tamil Nadu India
| | - Roy Varghese
- Division of Pediatric Cardiac Surgery, The Madras Medical Mission, 4-A, Dr. J.J. Nagar, Mogappair, Chennai, Tamil Nadu India
| | - Vimala Jesudian
- Department of Pediatric Cardiology, The Madras Medical Mission, 4-A, Dr. J.J. Nagar, Mogappair, Chennai, Tamil Nadu India
| | - Jeswin Moses
- Division of Pediatric Cardiac Surgery, The Madras Medical Mission, 4-A, Dr. J.J. Nagar, Mogappair, Chennai, Tamil Nadu India
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The authors reply. Pediatr Crit Care Med 2020; 21:302. [PMID: 32142036 DOI: 10.1097/pcc.0000000000002222] [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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Donnelly P, Fine-Goulden MR. How to use near-infrared spectroscopy. Arch Dis Child Educ Pract Ed 2020; 105:58-63. [PMID: 31186270 DOI: 10.1136/archdischild-2018-315532] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/10/2019] [Indexed: 11/04/2022]
Affiliation(s)
- Peter Donnelly
- Paediatric Intensive Care Unit, Belfast Children's Hospital, Belfast, UK
| | - Miriam R Fine-Goulden
- Paediatric Intensive Care, Evelina Children's Hospital, Guy's and St. Thomas' NHS Foundation Trust, 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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De Jesus-Brugman N, Hobson MJ, Herrmann JL, Friedman ML, Cordes T, Mastropietro CW. Improved outcomes in neonates who require venoarterial extracorporeal membrane oxygenation after the Norwood procedure. Int J Artif Organs 2019; 43:180-188. [PMID: 31623516 DOI: 10.1177/0391398819882020] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
BACKGROUND Extracorporeal membrane oxygenation after the Norwood procedure has historically been associated with poor outcomes, with reported hospital survival rates of 13%-48%. We hypothesized that contemporary outcomes in this population have improved. We aimed to compare clinical outcomes of contemporary cohorts of patients with functional single ventricle physiology who did and did not receive extracorporeal membrane oxygenation after the Norwood procedure. METHODS Single-center retrospective cohort study of patients with single ventricle anatomy who underwent the Norwood procedure between 2009 and 2017 was performed. Kaplan-Meier survival curves were constructed, and Cox proportional hazard regression analyses were performed to compare transplant-free survival in patients who did and did not receive venoarterial extracorporeal membrane oxygenation. RESULTS In total, 85 patients met inclusion criteria. Venoarterial extracorporeal membrane oxygenation was utilized in 25 patients (29%). A total of 18 patients (72%) who received venoarterial extracorporeal membrane oxygenation survived to hospital discharge, compared to 54 patients (92%) who did not receive venoarterial extracorporeal membrane oxygenation (p = 0.013). Post-discharge transplant-free survival was not significantly different between patients who did and did not receive venoarterial extracorporeal membrane oxygenation (log-rank p value = 0.28). Cox proportional hazard regression analysis revealed that the occurrence of cardiac arrest requiring cardiopulmonary resuscitation (hazard ratio = 4.5; 95% confidence interval = 2.0-10.1) during the perioperative period was independently associated with death or transplantation, whereas venoarterial extracorporeal membrane oxygenation was not an independent risk factor for death or transplantation (hazard ratio = 2.0; 95% confidence interval = 0.8-4.9). CONCLUSION In our cohort of children who received venoarterial extracorporeal membrane oxygenation after the Norwood procedure, hospital survival was improved compared to historical data. In addition, venoarterial extracorporeal membrane oxygenation utilization was not independently associated with worse outcomes.
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Affiliation(s)
- Nicole De Jesus-Brugman
- Department of Pediatrics, Division of Critical Care, Indiana University School of Medicine, Riley Hospital for Children at Indiana University Health, Indianapolis, IN, USA
| | - Michael Joe Hobson
- Department of Pediatrics, Division of Critical Care, Indiana University School of Medicine, Riley Hospital for Children at Indiana University Health, Indianapolis, IN, USA
| | - Jeremy L Herrmann
- Department of Surgery, Division of Vascular and Cardiothoracic Surgery, Indiana University School of Medicine, Riley Hospital for Children at Indiana University Health, Indianapolis, IN, USA
| | - Matthew L Friedman
- Department of Pediatrics, Division of Critical Care, Indiana University School of Medicine, Riley Hospital for Children at Indiana University Health, Indianapolis, IN, USA
| | - Timothy Cordes
- Department of Pediatrics, Division of Cardiology, Indiana University School of Medicine, Riley Hospital for Children at Indiana University Health, Indianapolis, IN, USA
| | - Christopher W Mastropietro
- Department of Pediatrics, Division of Critical Care, Indiana University School of Medicine, Riley Hospital for Children at Indiana University Health, Indianapolis, IN, USA
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Wang L, Huang G, Peng Q, Duan C, Dai Y, Shao S, Zhong WW, Yu D, Chen J, Xue L, He P, Tan N, Liu Y. Risk predictive ability of ACEF score for infection in patients with ST-segment elevation myocardial infarction undergoing percutaneous coronary intervention. Eur J Prev Cardiol 2019; 27:220-222. [PMID: 31619086 DOI: 10.1177/2047487319873142] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Affiliation(s)
- Litao Wang
- Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, School of Medicine, South China University of Technology, Guangzhou, China
| | - Guangjun Huang
- Department of Cardiology, The Second People's Hospital of Shantou, Shantou, China
| | - Qunkai Peng
- Department of Cardiology, Guangdong Cardiovascular Institute, Guangdong Provincial, Key Laboratory of Coronary Heart Disease Prevention, Guangdong Provincial People's, Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China
| | - Chongyang Duan
- Department of Biostatistics, Southern Medical University, Guangzhou, China
| | - Yining Dai
- Department of Cardiology, Guangdong Cardiovascular Institute, Guangdong Provincial, Key Laboratory of Coronary Heart Disease Prevention, Guangdong Provincial People's, Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China
| | - Shuai Shao
- Department of Cardiology, Guangdong Cardiovascular Institute, Guangdong Provincial, Key Laboratory of Coronary Heart Disease Prevention, Guangdong Provincial People's, Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China
| | - Wei-Wen Zhong
- Department of Cardiology, The Second People's Hospital of Shantou, Shantou, China
| | - Danqing Yu
- Department of Cardiology, Guangdong Cardiovascular Institute, Guangdong Provincial, Key Laboratory of Coronary Heart Disease Prevention, Guangdong Provincial People's, Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China
| | - Jiyan Chen
- Department of Cardiology, Guangdong Cardiovascular Institute, Guangdong Provincial, Key Laboratory of Coronary Heart Disease Prevention, Guangdong Provincial People's, Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China
| | - Ling Xue
- Department of Cardiology, Guangdong Cardiovascular Institute, Guangdong Provincial, Key Laboratory of Coronary Heart Disease Prevention, Guangdong Provincial People's, Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China
| | - Pengcheng He
- Department of Cardiology, Guangdong Cardiovascular Institute, Guangdong Provincial, Key Laboratory of Coronary Heart Disease Prevention, Guangdong Provincial People's, Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China
| | - Ning Tan
- Department of Cardiology, Guangdong Cardiovascular Institute, Guangdong Provincial, Key Laboratory of Coronary Heart Disease Prevention, Guangdong Provincial People's, Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China
| | - Yuanhui Liu
- Department of Cardiology, Guangdong Cardiovascular Institute, Guangdong Provincial, Key Laboratory of Coronary Heart Disease Prevention, Guangdong Provincial People's, Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China
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Yabrodi M, Hermann JL, Brown JW, Rodefeld MD, Turrentine MW, Mastropietro CW. Minimization of Surgical Site Infections in Patients With Delayed Sternal Closure After Pediatric Cardiac Surgery. World J Pediatr Congenit Heart Surg 2019; 10:400-406. [PMID: 31307311 DOI: 10.1177/2150135119846040] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Delayed sternal closure (DSC) following pediatric cardiac surgery is commonly implemented at many centers. Infectious complications occur in 18.7% of these patients based on recent multicenter data. We aimed to describe our experience with DSC, hypothesizing that our practices surrounding the implementation and maintenance of the open sternum during DSC minimize the risk of infectious complications. METHODS We reviewed patients less than 365 days who underwent DSC between 2012 and 2016 at our institution. Infectious complications as defined by the Society of Thoracic Surgeons Congenital Heart Surgery Database were recorded. Patients with and without infectious complications were compared using Wilcoxon rank sum tests or Fisher exact tests as appropriate. RESULTS We identified 165 patients less than 365 days old who underwent DSC, 135 (82%) of whom had their skin closed over their open sternum. Median duration of open sternum was 3 days (range: 1-32 days). Infectious complications occurred in 15 (9.1%) patients-13 developed clinical sepsis with positive blood cultures, one patient developed ventilator-associated pneumonia, and one patient developed wound infection (0.6%). No cases of mediastinitis occurred. No statistical differences in characteristics between patients with and without infectious complications could be identified. CONCLUSION Infectious complications after DSC at our institution were notably less than reported in recent literature, primarily due to minimization of surgical site infections. Practices described in the article, including closing skin over the open sternum whenever possible, could potentially aid other institutions aiming to reduce infectious complications associated with DSC.
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Affiliation(s)
- Mouhammad Yabrodi
- 1 Division of Critical Care, Department of Pediatrics, Riley Hospital for Children at Indiana University Health, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Jeremy L Hermann
- 2 Division of Cardiothoracic Surgery, Department of Surgery, Riley Hospital for Children at Indiana University Health, Indiana University School of Medicine, Indianapolis, IN, USA
| | - John W Brown
- 2 Division of Cardiothoracic Surgery, Department of Surgery, Riley Hospital for Children at Indiana University Health, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Mark D Rodefeld
- 2 Division of Cardiothoracic Surgery, Department of Surgery, Riley Hospital for Children at Indiana University Health, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Mark W Turrentine
- 2 Division of Cardiothoracic Surgery, Department of Surgery, Riley Hospital for Children at Indiana University Health, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Christopher W Mastropietro
- 1 Division of Critical Care, Department of Pediatrics, Riley Hospital for Children at Indiana University Health, Indiana University School of Medicine, Indianapolis, IN, USA
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Abstract
OBJECTIVES Although open chest management optimizes hemodynamics after cardiac surgery, it increases postoperative infections and leads to increased mortality. Despite the importance of antibiotic prophylaxis during open chest management, no specific recommendations exist. We aimed to compare the occurrence rates of bloodstream infection and surgical site infection between the different prophylactic antibiotic regimens for open chest management after pediatric cardiac surgery. DESIGN Retrospective, single-center, observational study. SETTING PICU at a tertiary children's hospital. PATIENTS Consecutive patients younger than or equal to 18 years old with open chest management after cardiac surgery followed by delayed sternal closure, between January 2012 and June 2018. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS We compared the composite occurrence rate of postoperative bloodstream infection and surgical site infection within 30 days after cardiac surgery between three prophylactic antibiotic regimens: 1) cefazolin, 2) cefazolin + vancomycin, and 3) vancomycin + meropenem. In 63 pediatric cardiac surgeries with open chest management, 17 bloodstream infections, and 12 surgical site infections were identified postoperatively. The composite occurrence rates of bloodstream infection and surgical site infection were 10 of 15 (67%), 10 of 19 (53%), and nine of 29 (31%) in the cefazolin, cefazolin + vancomycin, and vancomycin + meropenem regimens, respectively (p = 0.07). After adjusting for age, open chest management duration, extracorporeal membrane oxygenation use, and nasal methicillin-resistant Staphylococcus aureus colonization in multivariable analysis, there was no significant difference between the cefazolin and the cefazolin + vancomycin regimens (p = 0.19), while the vancomycin + meropenem regimen had a lower occurrence rate of bloodstream infection and surgical site infection than the cefazolin regimen (odds ratio, 0.0885; 95% CI, 0.0176-0.446; p = 0.003). CONCLUSIONS In this study, a lower occurrence rate of postoperative bloodstream infection and surgical site infection was observed among patients with broad-spectrum antibiotic regimen after pediatric cardiac surgery with open chest management. Further studies, ideally randomized controlled studies investigating the efficacy of broad-spectrum antibiotics and their complications, are warranted before routine implementation of broad-spectrum prophylactic antibiotic regimen.
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Ueno K, Seki S, Shiokawa N, Matsuba T, Miyazono A, Hazeki D, Imoto Y, Kawano Y. Validation of acute kidney injury according to the modified KDIGO criteria in infants after cardiac surgery for congenital heart disease. Nephrology (Carlton) 2019; 24:294-300. [PMID: 29451341 DOI: 10.1111/nep.13240] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/10/2018] [Indexed: 11/29/2022]
Abstract
AIM We aimed to validate the incidence of, risk factors for, and postoperative outcomes of acute kidney injury (AKI) according to the modified Kidney Disease Improving Global Outcomes (m-KDIGO) criteria and compare this criteria with both the paediatric Risk, Injury, Failure, Loss, End-stage disease (pRIFLE) and Acute Kidney Injury Network (AKIN) criteria in infants after cardiac surgery. METHODS We retrospectively enrolled 145 consecutive infants who underwent open-heart surgery at Kagoshima University Hospital. RESULTS Acute kidney injury was present in 55 (37.9%), 111 (75.9%), and 95 (65.5%) patients according to the m-KDIGO, pRIFLE, and AKIN criteria, respectively. Among these, 71.9% of patients pRIFLE Risk patients and 60.5% of AKIN 1 patients were categorized in the 'no-AKI' group according to the m-KDIGO criteria. Low body weight (m-KDIGO odds ratio [OR], 0.73; P = 0.015; pRIFLE OR, 0.66; P = 0.001; AKIN OR 0.69, P = 0.002) and prolonged cross-clamp time (m-KDIGO OR, 1.02; <P = 0.001; pRIFLE OR, 1.02; P = 0.003; AKIN OR, 1.02; P = 0.001) were independent risk factors for the development of AKI. Further, m-KDIGO-based AKI grade was more strongly associated with higher incidence of requiring renal replacement therapy and mortality than both the pRIFLE- and AKIN- based AKI grade. CONCLUSION Application of the three criteria resulted in different AKI incidences, but each criterion could be useful for detecting risk factors for AKI. Notably, using m-KDIGO criteria provides more important subsequent postoperative outcomes. The m-KDIGO AKI criteria describe clinically relevant AKI in infants after cardiac surgery.
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Affiliation(s)
- Kentaro Ueno
- Department of Pediatrics, Kagoshima University Graduate School of Medical and Dental Sciences, Kagoshima, Japan
| | - Shunji Seki
- Department of Pediatrics, Kagoshima University Graduate School of Medical and Dental Sciences, Kagoshima, Japan
| | - Naohiro Shiokawa
- Department of Pediatrics, Kagoshima University Graduate School of Medical and Dental Sciences, Kagoshima, Japan
| | - Tomoyuki Matsuba
- Department of Cardiovascular and Gastroenterological Surgery, Kagoshima University Graduate School of Medical and Dental Sciences, Kagoshima, Japan
| | - Akinori Miyazono
- Department of Pediatrics, Kagoshima University Graduate School of Medical and Dental Sciences, Kagoshima, Japan
| | - Daisuke Hazeki
- Department of Pediatrics, Kagoshima University Graduate School of Medical and Dental Sciences, Kagoshima, Japan
| | - Yutaka Imoto
- Department of Cardiovascular and Gastroenterological Surgery, Kagoshima University Graduate School of Medical and Dental Sciences, Kagoshima, Japan
| | - Yoshifumi Kawano
- Department of Pediatrics, Kagoshima University Graduate School of Medical and Dental Sciences, Kagoshima, Japan
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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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Cefoxitin Prophylaxis During Pediatric Cardiac Surgery: Retrospective Exploration of Postoperative Trough Levels. Pediatr Infect Dis J 2019; 38:484-489. [PMID: 30169486 DOI: 10.1097/inf.0000000000002179] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
BACKGROUND This study aimed to explore inter-individual variability of cefoxitin trough levels, predictors of serum cefoxitin concentration and the probability of target attainment of drug levels above 4 mg/L after pediatric cardiac surgery. METHODS Retrospective study on children scheduled for elective cardiac surgery and having cefoxitin trough levels available up to 24 hours postsurgery. RESULTS Overall, 68 children (9 neonates, 34 infants, 15 children below or equal to 10 years old and 10 patients above this age) were included. Of these, 16 surgeries were performed off cardiopulmonary bypass and 52 were performed on cardiopulmonary bypass. The free cefoxitin concentrations showed a median (interquartile range) concentration of 1.7 (0.6-4.2) mg/L. The range of cefoxitin concentrations showed a 150-fold and 340-fold variability at cardiac intensive care unit admission and after 24 hours, respectively. The pharmacodynamics (PD) targets of free cefoxitin at 100% of the dosing interval, considering Eucast breakpoints for Methicillin Sensitive Staphylococcus Aureus (4 mg/L) and E.Coli (8 mg/L), were obtained in 28% and 16% of patients, respectively. Patient weight (odds ratio, 0.7; 95% confidence interval, 0.62-0.92; P = 0.006) and serum creatinine concentrations (odds ratio, 25; 95% confidence interval, 18-36; P = 0.004) showed a significant relationship with the PD targets. CONCLUSIONS Cefoxitin trough concentrations vary significantly in the first 24 hours after pediatric cardiac surgery. Both serum creatinine and body weight showed independent associations with cefoxitin concentration. The PD target was not obtained in the vast majority of the explored population, regardless of the target bacteria.
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Santos FCGB, Croti UA, Marchi CHD, Murakami AN, Brachine JDP, Borim BC, Finoti RG, Godoy MFD. Surgical Treatment for Congenital Heart Defects in Down Syndrome Patients. Braz J Cardiovasc Surg 2019; 34:1-7. [PMID: 30810666 PMCID: PMC6385838 DOI: 10.21470/1678-9741-2018-0358] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2018] [Accepted: 12/23/2018] [Indexed: 01/23/2023] Open
Abstract
OBJECTIVE To analyze data related to surgical treatment in patients with congenital heart defects (CHD) and Down syndrome (DS) based on information from International Quality Improvement Collaborative Database for Congenital Heart Disease (IQIC). METHODS Between July 1, 2010 and December 31, 2017, 139 patients with CHD and DS underwent surgery at Hospital de Base and Hospital da Criança e Maternidade de São José do Rio Preto (FUNFARME)/Faculdade de Medicina de São José do Rio Preto - SP (FAMERP). A quantitative, observational and cross-sectional study was performed in which the pre, intra and postoperative data were analyzed in an IQIC database. The data included gender, age, prematurity, weight, preoperative procedures, diagnosis, associated cardiac and non-cardiac anomalies, Risk Adjustment for Congenital Heart Surgery (RACHS-1), type of surgery, cardiopulmonary bypass (CPB), perfusion time, aortic clamping time and CPB temperature, bacterial sepsis, surgical site infection and other infections, length of stay in intensive care unit (ICU), length of hospital stay and in-hospital mortality. RESULTS The most prevalent procedures were complete atrioventricular septal defect repair (58 - 39.45%), followed by closure of ventricular septal defect (36 - 24.49%). The RACHS-1 categories 1, 2, 3 and 4 were distributed as 22 (15%); 49 (33.3%); 72 (49%) and 4 (2.7%), respectively. There were no procedures classified as categories 5 or 6. Bacterial sepsis occurred in 10.2% of cases, surgical site infection in 6.1%, other infections in 14.3%. The median length of ICU stay was 5 days and the median length of hospital stay was 11 days. In-hospital mortality was 6.8%. CONCLUSION Surgical treatment in patients with CHD and DS usually does not require highly complex surgical procedures, but are affected by infectious complications, resulting in a longer ICU and hospital length of stay with considerable mortality.
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Affiliation(s)
- Fernando Cesar Gimenes Barbosa Santos
- Serviço de Cardiologia e Cirurgia Cardiovascular Pediátrica de São José do Rio Preto - Hospital da Criança e Maternidade de São José do Rio Preto (FUNFARME) - Faculdade de Medicina de São José do Rio Preto (FAMERP), São José do Rio Preto, SP, Brazil
| | - Ulisses Alexandre Croti
- Serviço de Cardiologia e Cirurgia Cardiovascular Pediátrica de São José do Rio Preto - Hospital da Criança e Maternidade de São José do Rio Preto (FUNFARME) - Faculdade de Medicina de São José do Rio Preto (FAMERP), São José do Rio Preto, SP, Brazil
| | - Carlos Henrique De Marchi
- Serviço de Cardiologia e Cirurgia Cardiovascular Pediátrica de São José do Rio Preto - Hospital da Criança e Maternidade de São José do Rio Preto (FUNFARME) - Faculdade de Medicina de São José do Rio Preto (FAMERP), São José do Rio Preto, SP, Brazil
| | - Alexandre Noboru Murakami
- Serviço de Cirurgia Cardíaca do Norte do Paraná, Universidade Estadual de Londrina (UEL), Londrina, PR, Brazil
| | - Juliana Dane Pereira Brachine
- Serviço de Cardiologia e Cirurgia Cardiovascular Pediátrica de São José do Rio Preto - Hospital da Criança e Maternidade de São José do Rio Preto (FUNFARME) - Faculdade de Medicina de São José do Rio Preto (FAMERP), São José do Rio Preto, SP, Brazil
| | - Bruna Cury Borim
- Serviço de Cardiologia e Cirurgia Cardiovascular Pediátrica de São José do Rio Preto - Hospital da Criança e Maternidade de São José do Rio Preto (FUNFARME) - Faculdade de Medicina de São José do Rio Preto (FAMERP), São José do Rio Preto, SP, Brazil
| | - Renata Geron Finoti
- Serviço de Cardiologia e Cirurgia Cardiovascular Pediátrica de São José do Rio Preto - Hospital da Criança e Maternidade de São José do Rio Preto (FUNFARME) - Faculdade de Medicina de São José do Rio Preto (FAMERP), São José do Rio Preto, SP, Brazil
| | - Moacir Fernandes de Godoy
- Serviço de Cardiologia e Cirurgia Cardiovascular Pediátrica de São José do Rio Preto - Hospital da Criança e Maternidade de São José do Rio Preto (FUNFARME) - Faculdade de Medicina de São José do Rio Preto (FAMERP), São José do Rio Preto, SP, Brazil
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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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SooHoo M, Griffin B, Jovanovich A, Soranno DE, Mack E, Patel SS, Faubel S, Gist KM. Acute kidney injury is associated with subsequent infection in neonates after the Norwood procedure: a retrospective chart review. Pediatr Nephrol 2018; 33:1235-1242. [PMID: 29508077 PMCID: PMC6326095 DOI: 10.1007/s00467-018-3907-5] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/07/2017] [Revised: 01/18/2018] [Accepted: 01/26/2018] [Indexed: 01/06/2023]
Abstract
BACKGROUND Acute kidney injury (AKI) and infection are common complications after pediatric cardiac surgery. No pediatric study has evaluated for an association between postoperative AKI and infection. The objective of this study was to determine if AKI in neonates after cardiopulmonary bypass was associated with the development of a postoperative infection. METHODS We performed a single center retrospective chart review from January 2009 to December 2015 of neonates (age ≤ 30 days) undergoing the Norwood procedure. AKI was defined by the modified neonatal Kidney Disease Improving Global outcomes serum creatinine criteria using (1) measured serum creatinine and (2) creatinine corrected for fluid balance on postoperative days 1-4. Infection, (culture positive or presumed), must have occurred after a diagnosis of AKI and within 60 days of surgery. RESULTS Ninety-five patients were included, of which postoperative infection occurred in 42 (44%). AKI occurred in 38 (40%) and 42 (44%) patients by measured serum creatinine and fluid overload corrected creatinine, respectively, and was most commonly diagnosed on postoperative day 2. The median time to infection from the time of surgery and AKI was 7 days (IQR 5-14 days) and 6 days (IQR 3-13 days), respectively. After adjusting for confounders, the odds of a postoperative infection were 3.64 times greater in patients with fluid corrected AKI (95% CI, 1.36-9.75; p = 0.01). CONCLUSIONS Fluid corrected AKI was independently associated with the development of a postoperative infection. These findings support the notion that AKI is an immunosuppressed state that increases the risk of infection.
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Affiliation(s)
- Megan SooHoo
- Department of Pediatrics, Children’s Hospital Colorado, The Heart Institute, University of Colorado, 13123 E 16th Ave, B100, Aurora, CO 80045, USA
| | - Benjamin Griffin
- Renal Division, Department Medicine, University of Colorado, Aurora, CO, USA
| | - Anna Jovanovich
- Renal Division, Department Medicine, University of Colorado, Aurora, CO, USA,Denver VA Medical Center, Denver, CO, USA
| | - Danielle E. Soranno
- Department of Pediatrics, Children’s Hospital Colorado, The Kidney Center, University of Colorado, Aurora, CO, USA
| | - Emily Mack
- Department of Pediatrics, Children’s Hospital Colorado, The Heart Institute, University of Colorado, 13123 E 16th Ave, B100, Aurora, CO 80045, USA
| | - Sonali S. Patel
- Department of Pediatrics, Children’s Hospital Colorado, The Heart Institute, University of Colorado, 13123 E 16th Ave, B100, Aurora, CO 80045, USA
| | - Sarah Faubel
- Renal Division, Department Medicine, University of Colorado, Aurora, CO, USA,Department of Pediatrics, Children’s Hospital Colorado, The Kidney Center, University of Colorado, Aurora, CO, USA
| | - Katja M. Gist
- Department of Pediatrics, Children’s Hospital Colorado, The Heart Institute, University of Colorado, 13123 E 16th Ave, B100, Aurora, CO 80045, USA
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Dopamine and the Risk for Hospital-Acquired Infections. Pediatr Crit Care Med 2018; 19:269-270. [PMID: 29499024 DOI: 10.1097/pcc.0000000000001446] [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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Abstract
OBJECTIVES Healthcare-associated infections after pediatric cardiac surgery are significant causes of morbidity and mortality. We aimed to identify the risk factors for the occurrence of healthcare-associated infections after pediatric cardiac surgery. DESIGN Retrospective, single-center observational study. SETTING PICU at a tertiary children's hospital. PATIENTS Consecutive pediatric patients less than or equal to 18 years old admitted to the PICU after cardiac surgery, between January 2013 and December 2015. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS All the data were retrospectively collected from the medical records of patients. We assessed the first surgery during a single PICU stay and identified four common healthcare-associated infections, including bloodstream infection, surgical site infection, pneumonia, and urinary tract infection, according to the definitions of the Centers for Disease Control and Prevention and National Healthcare Safety Network. We assessed the pre-, intra-, and early postoperative potential risk factors for these healthcare-associated infections via multivariable analysis. In total, 526 cardiac surgeries (394 patients) were included. We identified 81 cases of healthcare-associated infections, including, bloodstream infections (n = 30), surgical site infections (n = 30), urinary tract infections (n = 13), and pneumonia (n = 8). In the case of 71 of the surgeries (13.5%), at least one healthcare-associated infection was reported. Multivariable analysis indicated the following risk factors for postoperative healthcare-associated infections: mechanical ventilation greater than or equal to 3 days (odds ratio, 4.81; 95% CI, 1.89-12.8), dopamine use (odds ratio, 3.87; 95% CI, 1.53-10.3), genetic abnormality (odds ratio, 2.53; 95% CI, 1.17-5.45), and delayed sternal closure (odds ratio, 3.78; 95% CI, 1.16-12.8). CONCLUSIONS Mechanical ventilation greater than or equal to 3 days, dopamine use, genetic abnormality, and delayed sternal closure were associated with healthcare-associated infections after pediatric cardiac surgery. Since the use of dopamine is an easily modifiable risk factor, and may serve as a potential target to reduce healthcare-associated infections, further studies are needed to establish whether dopamine negatively impacts the development of healthcare-associated infections.
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Furlong-Dillard J, Bailly D, Amula V, Wilkes J, Bratton S. Resource Use and Morbidities in Pediatric Cardiac Surgery Patients with Genetic Conditions. J Pediatr 2018; 193:139-146.e1. [PMID: 29246465 DOI: 10.1016/j.jpeds.2017.09.085] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/14/2017] [Revised: 08/24/2017] [Accepted: 09/29/2017] [Indexed: 01/21/2023]
Abstract
OBJECTIVE To evaluate and describe resource use and perioperative morbidities among those patients with genetic conditions undergoing cardiac surgery. STUDY DESIGN Using the Pediatric Health Information System database, we identified patients ≤18 years old with cardiac surgery classified by Risk Adjustment for Congenital Heart Surgery (RACHS) during 2003-2014. A total of 95 253 patients met study criteria and included no genetic conditions (84.6%), trisomy 21 (9.9%), trisomy 13 or 18 (0.2%), 22q11 deletion (0.8%), Turner syndrome (0.4%), and "other" genetic conditions (4.2%). We compared perioperative complications and procedures in each genetic condition with patients without genetic conditions using regression analysis. RESULTS All groups with genetic conditions, excluding trisomy 21 RACHS 3-5, experienced increased length of stay and cost among survivors. Complications varied by genetic condition, with patients with trisomy 21 having increased odds of pulmonary hypertension and nosocomial infections. Patients with 22q11 only had increased odds of infection. Patients with Turner syndrome had increased odds of acute renal failure (OR 2.35). Patients with trisomy 13 or 18 had increased odds of pulmonary hypertension (OR 3.13), acute renal failure (OR 2.93), cardiac arrest (OR 2.84), and nosocomial infections (OR 3.53), and those with "other" genetic conditions had increased odds of all complications. CONCLUSIONS Children with congenital heart disease and genetic conditions, except trisomy 21 RACHS 3-5, had increased costs and length of stay. Perioperative morbidities were more common and differed across genetic condition subgroups. Patient-specific risk factors are important for risk stratification, benchmarking, and counseling with families.
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Affiliation(s)
- Jamie Furlong-Dillard
- Department of Pediatrics, Division Critical Care, University of Utah School of Medicine, Salt Lake City, UT
| | - David Bailly
- Department of Pediatrics, Division Critical Care, University of Utah School of Medicine, Salt Lake City, UT
| | - Venugopal Amula
- Department of Pediatrics, Division Critical Care, University of Utah School of Medicine, Salt Lake City, UT
| | - Jacob Wilkes
- Quality and Informatics, Intermountain Healthcare, Salt Lake City, UT
| | - Susan Bratton
- Department of Pediatrics, Division Critical Care, University of Utah School of Medicine, Salt Lake City, UT
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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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Sochet AA, Cartron AM, Nyhan A, Spaeder MC, Song X, Brown AT, Klugman D. Surgical Site Infection After Pediatric Cardiothoracic Surgery. World J Pediatr Congenit Heart Surg 2017; 8:7-12. [PMID: 28033082 DOI: 10.1177/2150135116674467] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
BACKGROUND Surgical site infection (SSI) occurs in 0.25% to 6% of children after cardiothoracic surgery (CTS). There are no published data regarding the financial impact of SSI after pediatric CTS. We sought to determine the attributable hospital cost and length of stay associated with SSI in children after CTS. METHODS We performed a retrospective, matched cohort study in a 26-bed cardiac intensive care unit (CICU) from January 2010 through December 2013. Cases with SSI were identified retrospectively and individually matched to controls 2:1 by age, gender, Risk Adjustment for Congenital Heart Surgery score, Society of Thoracic Surgeons-European Association for Cardiothoracic Surgery category, and primary cardiac diagnosis and procedure. RESULTS Of the 981 cases performed during the study period, 12 with SSI were identified. There were no differences in demographics, clinical characteristics, or intraoperative data. Median total hospital costs were higher in participants with SSI as compared to controls (US$219,573 vs US$82,623, P < .01). Children with SSI had longer median CICU length of stay (9 vs 3 days, P < .01), hospital length of stay (18 vs 8.5 days, P < .01), and duration of mechanical ventilation (2 vs 1 day, P < .01) and vasoactive administration (4.5 vs 1 day, P < .01). CONCLUSIONS Children with SSI after CTS have an associated increase in hospital costs of US$136,950/case and hospital length of stay of 9.5 days/case. The economic burden posed by SSI stress the importance of infection control surveillance, exhaustive preventative measures, and identification of modifiable risk factors.
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Affiliation(s)
- Anthony A Sochet
- 1 Division of Critical Care Medicine, Department of Pediatrics, Johns Hopkins All Children's Hospital, St Petersburg, FL, USA.,2 School of Medicine and Health Sciences, The George Washington University, Washington, DC, USA
| | - Alexander M Cartron
- 3 Division of Critical Care Medicine, Department of Pediatrics, Children's National Health System, Washington, DC, USA
| | - Aoibhinn Nyhan
- 2 School of Medicine and Health Sciences, The George Washington University, Washington, DC, USA
| | - Michael C Spaeder
- 4 Division of Pediatric Critical Care Medicine, Department of Pediatrics, University of Virginia School of Medicine, Charlottesville, VA, USA
| | - Xiaoyan Song
- 2 School of Medicine and Health Sciences, The George Washington University, Washington, DC, USA.,5 Division of Infectious Disease, Department of Pediatrics, Children's National Health System, Washington, DC, USA
| | - Anna T Brown
- 2 School of Medicine and Health Sciences, The George Washington University, Washington, DC, USA.,6 Division of Anesthesiology, Department of Pediatrics, Children's National Health System, Washington, DC, USA
| | - Darren Klugman
- 2 School of Medicine and Health Sciences, The George Washington University, Washington, DC, USA.,7 Division of Cardiology, Department of Pediatrics, Children's National Health System, Washington, DC, USA
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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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Heydarpour F, Rahmani Y, Heydarpour B, Asadmobini A. Nosocomial infections and antibiotic resistance pattern in open-heart surgery patients at Imam Ali Hospital in Kermanshah, Iran. GMS HYGIENE AND INFECTION CONTROL 2017; 12:Doc07. [PMID: 28584733 PMCID: PMC5447783 DOI: 10.3205/dgkh000292] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
Background: Patients undergoing open heart surgery have a relatively high risk of acquiring nosocomial infections. The development of antibiotic-resistant infections is associated with prolonged hospital stays and mortalities. Objectives: The present study was conducted to investigate nosocomial infections and the antibiotic resistance pattern in bacteria causing these infections in open heart surgery patients at Imam Ali Hospital in Kermanshah in the west of Iran over a 4-year period from March 2011 to March 2014. Materials and methods: The present cross-sectional study was conducted on 135 cases of nosocomial infection among open heart surgery patients. The demographic characteristics and the risk factors of each case of infection were recorded. The antibiotic susceptibility test was carried out using the Minimum Inhibitory Concentration (MIC) method based on the Clinical and Laboratory Standards Institute (CLSI) protocol. The data collected were then analyzed in SPSS-16. Results: Out of the 6,000 patients who underwent open heart surgery during this 4-year period at the selected hospital, nosocomial infections developed in 135 patients (2.25%), 59.3% of whom were female and 40.7% male. Surgery site infection (SSI), pneumonia (PNEU), urinary tract infection (UTI) and blood stream infection (BSI) affected 52.6%, 37%, 9.6% and 0.8% of the cases, respectively. E.coli, Klebsiella spp. and S. aureus were the most common bacteria causing the nosocomial infections. E. coli was most frequently resistant to imipenem (23.3%) Klebsiella spp. to gentamicin (38.5%) S. aureus to co-trimoxazole (54.2%). Conclusion: SSI had a high prevalence in this study. Further studies should therefore be conducted to examine the risk factors associated with SSI in open heart surgery. Various studies have shown that antibiotic resistance patterns are different in different regions. Finding a definitive treatment therefore requires an antibiogram.
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Affiliation(s)
- Fatemeh Heydarpour
- Cardiovascular Research Center, Kermanshah University of Medical Sciences, Kermanshah, Iran
| | - Youssef Rahmani
- Cardiovascular Research Center, Kermanshah University of Medical Sciences, Kermanshah, Iran
| | - Behzad Heydarpour
- Cardiovascular Research Center, Kermanshah University of Medical Sciences, Kermanshah, Iran
| | - Atefeh Asadmobini
- Cardiovascular Research Center, Kermanshah University of Medical Sciences, Kermanshah, Iran
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