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Ferrari F, Nacoti M, Carobbio A, Favarato M, Di Dedda GB, Bonanomi E. The impact of a standardized perioperative management on hospital mortality after the Norwood procedure in a low volume center: results and perspectives. Minerva Pediatr (Torino) 2024; 76:498-506. [PMID: 34128601 DOI: 10.23736/s2724-5276.21.06133-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND Mortality of newborns with Hypoplastic Left Heart Syndrome (HLHS) is mainly concentrated after Norwood procedure (NP) stage 1 palliation (S1P) and between S1P and stage 2 palliation (S2P). Standardized management of these patients may help to control hospital mortality. Aim of the study was to evaluate the impact on hospital mortality of a standardized perioperative management (SPM) for newborns requiring S1P in a low volume center for NP. METHODS A consecutive series of patients undergoing S1P from January 1, 2002 to December 31, 2006 were retrospectively compared, by a "before and after" design, with those receiving a SPM (i.e. use of selective cerebral perfusion, near infrared spectroscopy, delayed sternal closure, modified ultrafiltration) from January 1st, 2007 to December 31st, 2018. Demographic, intraoperative and postoperative characteristics were collected. Univariate and multivariate analyses assessed differences before and after SPM. RESULTS Ninety-one newborns underwent S1P in the considered period; of 74 eligible patients, 25 did not receive SPM, while 49 received SPM. Hospital mortality after S1P was 31% (CI 21-44%). The introduction of a SPM did not affect hospital mortality both at the univariate-(28% vs. 29%, P=0.959) and at the multivariate analysis (HR 1.85, P=0.62). Mortality was 12% (CI 6-25%) between hospital discharge after S1P and S2P and 8% (CI 3-22%) between S2P and S3P. CONCLUSIONS The use of a SPM for HLHS newborns requiring S1P was not effective in reducing hospital mortality in a low volume center. We suggest a collaboration between Italian Pediatric Cardiac Centers to manage HLHS patients.
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Affiliation(s)
- Floriana Ferrari
- Pediatric Intensive Care Unit, Department of Anesthesia and Intensive Care, ASST Papa Giovanni XXIII, Bergamo, Italy -
| | - Mirco Nacoti
- Pediatric Intensive Care Unit, Department of Anesthesia and Intensive Care, ASST Papa Giovanni XXIII, Bergamo, Italy
| | | | - Moreno Favarato
- Pediatric Intensive Care Unit, Department of Anesthesia and Intensive Care, ASST Papa Giovanni XXIII, Bergamo, Italy
| | - Giovanni B Di Dedda
- Pediatric Intensive Care Unit, Department of Anesthesia and Intensive Care, ASST Papa Giovanni XXIII, Bergamo, Italy
| | - Ezio Bonanomi
- Pediatric Intensive Care Unit, Department of Anesthesia and Intensive Care, ASST Papa Giovanni XXIII, Bergamo, Italy
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Abdelrehim AA, Stephens EH, Pochettino A, Wittwer ED, Ashikhmina EA, Todd AL, Daly RC, Crestanello JA, Schaff HV, Dearani JA. Delayed Sternal Closure vs Emergency Sternal Reopening in Adults With Congenital Heart Disease. Ann Thorac Surg 2024:S0003-4975(24)00373-4. [PMID: 38763220 DOI: 10.1016/j.athoracsur.2024.04.031] [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] [Received: 11/05/2023] [Revised: 04/17/2024] [Accepted: 04/22/2024] [Indexed: 05/21/2024]
Abstract
BACKGROUND Limited data exist regarding outcomes of delayed sternal closure (DSC) in adults with congenital heart disease (ACHD). METHODS We reviewed 159 ACHD patients undergoing cardiac operation from 1993 to 2023 who required DSC (open sternum at the end of operation, n = 112) or sternum emergently reopened (n = 47). Regression models were performed to determine factors associated with outcomes. RESULTS Of 112 patients undergoing DSC, 87 patients (77.6%) underwent DSC ≤4 days and 25 patients (22.3%) >4 days. The most common operations were valve (n = 35 [31.2%]), aortic (n = 33 [29.4%]), and right ventricular outflow tract procedures (n = 23 [20.5%]). Median time to chest closure was 2 days (interquartile range, 1-5 days). Apart from sex, baseline characteristics were similar between DSC groups. A stepwise increase in early mortality was observed from DSC ≤4 days to DSC >4 days (6.8% vs 32%), as well as the incidence of early complications, except sternal infection. Risk factors associated with early mortality were age (P = .02), DSC >4 days (P < .001), hemodynamic indication (P = .03), and single ventricle (P = .02). On multivariable analysis, lower ejection fraction (P = .04), hemodynamic indication (P = .02), single ventricle (P = .004), and diabetes mellitus (P = .03) were predictors of prolonged time to chest closure. Among hospital survivors, late survival was similar between patients undergoing DSC ≤4 days vs >4 days (P = .48). CONCLUSIONS A brief duration of DSC in ACHD patients is associated with low morbidity and mortality. Higher early mortality and complications were observed among patients who did not achieve chest closure within 4 days.
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Affiliation(s)
| | | | | | - Erica D Wittwer
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, Minnesota
| | - Elena A Ashikhmina
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, Minnesota
| | - Austin L Todd
- Department of Clinical Trials and Biostatistics, Mayo Clinic, Rochester, Minnesota
| | - Richard C Daly
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, Minnesota
| | | | - Hartzell V Schaff
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, Minnesota
| | - Joseph A Dearani
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, Minnesota
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Zürn C, Hübner D, Ziesenitz VC, Höhn R, Schuler L, Schlange T, Gorenflo M, Kari FA, Kroll J, Loukanov T, Klemm R, Stiller B. Model-driven survival prediction after congenital heart surgery. INTERDISCIPLINARY CARDIOVASCULAR AND THORACIC SURGERY 2023; 37:ivad089. [PMID: 37279735 PMCID: PMC10493173 DOI: 10.1093/icvts/ivad089] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/11/2023] [Accepted: 06/03/2023] [Indexed: 06/08/2023]
Abstract
OBJECTIVES The objective of the study was to improve postoperative risk assessment in congenital heart surgery by developing a machine-learning model based on readily available peri- and postoperative parameters. METHODS Our bicentric retrospective data analysis from January 2014 to December 2019 of established risk parameters for dismal outcome was used to train and test a model to predict postoperative survival within the first 30 days. The Freiburg training data consisted of 780 procedures; the Heidelberg test data comprised 985 procedures. STAT mortality score, age, aortic cross-clamp time and postoperative lactate values over 24 h were considered. RESULTS Our model showed an area under the curve (AUC) of 94.86%, specificity of 89.48% and sensitivity of 85.00%, resulting in 3 false negatives and 99 false positives.The STAT mortality score and the aortic cross-clamp time each showed a statistically highly significant impact on postoperative mortality. Interestingly, a child's age was barely statistically significant. Postoperative lactate values indicated an increased mortality risk if they were either constantly at a high level or low during the first 8 h postoperatively with an increase afterwards.When considering parameters available before, at the end of and 24 h after surgery, the predictive power of the complete model achieved the highest AUC. This, compared to the already high predictive power alone (AUC 88.9%) of the STAT mortality score, translates to an error reduction of 53.5%. CONCLUSIONS Our model predicts postoperative survival after congenital heart surgery with great accuracy. Compared with preoperative risk assessments, our postoperative risk assessment reduces prediction error by half. Heightened awareness of high-risk patients should improve preventive measures and thus patient safety.
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Affiliation(s)
- Christoph Zürn
- Department of Congenital Heart Defects and Paediatric Cardiology, University Heart Center Freiburg—Bad Krozingen, Medical Center—University of Freiburg, Faculty of Medicine, University of Freiburg, Germany
| | - David Hübner
- Machine learning for medical applications, Averbis GmbH, Freiburg, Germany
| | - Victoria C Ziesenitz
- Department of Paediatric Cardiology and Congenital Heart Disease Center for Child and Adolescent Health, Medical Center—University of Heidelberg, Faculty of Medicine, University of Heidelberg, Germany
| | - René Höhn
- Department of Congenital Heart Defects and Paediatric Cardiology, University Heart Center Freiburg—Bad Krozingen, Medical Center—University of Freiburg, Faculty of Medicine, University of Freiburg, Germany
| | - Lena Schuler
- Department of Congenital Heart Defects and Paediatric Cardiology, University Heart Center Freiburg—Bad Krozingen, Medical Center—University of Freiburg, Faculty of Medicine, University of Freiburg, Germany
| | - Tim Schlange
- Faculty of Psychology, Ruhr University, Bochum, Germany
| | - Matthias Gorenflo
- Department of Paediatric Cardiology and Congenital Heart Disease Center for Child and Adolescent Health, Medical Center—University of Heidelberg, Faculty of Medicine, University of Heidelberg, Germany
| | - Fabian A Kari
- Department of Cardiovascular Surgery, University Heart Center Freiburg—Bad Krozingen, Medical Center—University of Freiburg, Faculty of Medicine, University of Freiburg, Germany
| | - Johannes Kroll
- Department of Cardiovascular Surgery, University Heart Center Freiburg—Bad Krozingen, Medical Center—University of Freiburg, Faculty of Medicine, University of Freiburg, Germany
| | - Tsvetomir Loukanov
- Department of Cardiothoracic Surgery, Medical Center—University of Heidelberg, Faculty of Medicine, University of Heidelberg, Germany
| | - Rolf Klemm
- Department of Cardiovascular Surgery, University Heart Center Freiburg—Bad Krozingen, Medical Center—University of Freiburg, Faculty of Medicine, University of Freiburg, Germany
| | - Brigitte Stiller
- Department of Congenital Heart Defects and Paediatric Cardiology, University Heart Center Freiburg—Bad Krozingen, Medical Center—University of Freiburg, Faculty of Medicine, University of Freiburg, Germany
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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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Asfari A, Jacobs JP, Byrnes JW, Borasino S, Prodhan P, Zaccagni H, Dabal RJ, Sorabella RA, Hammel JM, Smith-Parrish M, Zhang W, Banerjee M, Schumacher KR, Tabbutt S. Norwood Operation: Immediate vs Delayed Sternal Closure. Ann Thorac Surg 2023; 115:649-654. [PMID: 35863395 DOI: 10.1016/j.athoracsur.2022.06.046] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/03/2022] [Revised: 06/06/2022] [Accepted: 06/27/2022] [Indexed: 11/19/2022]
Abstract
BACKGROUND The Norwood operation is a complex neonatal surgery. There are limited data to inform the timing of sternal closure. After the Norwood operation, delayed sternal closure (DSC) is frequent. We aimed to examine the association of DSC with outcomes, with a particular interest in how sternal closure at the time of surgery compared with the timing of DSC. Our outcomes included mortality, length of ventilation, length of stay, and postoperative complications. METHODS This retrospective study included neonates who underwent a Norwood operation reported in the Pediatric Cardiac Critical Care Consortium registry from February 2019 through April 2021. Outcomes of patients with closed sternum were compared to those with sternal closure prior to postoperative day 3 (early closure) and prior to postoperative day 6 (intermediate closure). RESULTS The incidence of DSC was 74% (500 of 674). The median duration of open sternum was 4 days (interquartile range 3-5 days). Comparing patients with closed sternum to patients with early sternal closure, there was no statistical difference in mortality rate (1.1% vs 0%) and the median hospital postoperative stay (30 days vs 31 days). Compared with closed sternum, patients with intermediate sternal closure required longer mechanical ventilation (5.9 days vs 3.9 days) and fewer subsequent sternotomies (3% vs 7.5%). CONCLUSIONS For important outcomes following the Norwood operation there is no advantage to chest closure at the time of surgery if the chest can be closed prior to postoperative day 3.
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Affiliation(s)
- Ahmed Asfari
- Division of Cardiology, Department of Pediatrics, University of Alabama at Birmingham, Birmingham, Alabama.
| | - Jeffrey P Jacobs
- Department of Cardiovascular Surgery, University of Florida, Gainesville, Florida
| | - Jonathan W Byrnes
- Division of Cardiology, Department of Pediatrics, University of Alabama at Birmingham, Birmingham, Alabama
| | - Santiago Borasino
- Division of Cardiology, Department of Pediatrics, University of Alabama at Birmingham, Birmingham, Alabama
| | - Parthak Prodhan
- Division of Cardiology, Department of Pediatrics, University of Arkansas for Medical Sciences, Arkansas Children's Hospital, Little Rock, Arkansas
| | - Hayden Zaccagni
- Division of Cardiology, Department of Pediatrics, University of Alabama at Birmingham, Birmingham, Alabama
| | - Robert J Dabal
- Department of Cardiovascular Surgery, University of Alabama at Birmingham, Birmingham, Alabama
| | - Robert A Sorabella
- Department of Cardiovascular Surgery, University of Alabama at Birmingham, Birmingham, Alabama
| | - James M Hammel
- Department of Cardiovascular Surgery, University of Nebraska, Omaha, Nebraska
| | - Melissa Smith-Parrish
- Divisions of Pediatric Critical Care Medicine and Pediatric Cardiology, Department of Pediatrics, Vanderbilt University School of Medicine and Monroe Carrell Jr. Children's Hospital at Vanderbilt, Nashville, Tennessee
| | - Wenying Zhang
- Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor, Michigan
| | - Mousumi Banerjee
- Department of Biostatistics, University of Michigan School of Public Health, Ann Arbor, Michigan
| | - Kurt R Schumacher
- Division of Cardiology, Department of Pediatrics and Communicable Diseases, C.S. Mott Children's Hospital and University of Michigan Medical School, Ann Arbor, Michigan
| | - Sarah Tabbutt
- Division of Critical Care Medicine, Department of Pediatrics, University of California San Francisco Benioff Children's Hospitals, San Francisco, California
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Desai KD, Yuan I, Padiyath A, Goldsmith MP, Tsui FC, Pratap JN, Nelson O, Simpao AF. A Narrative Review of Multiinstitutional Data Registries of Pediatric Congenital Heart Disease in Pediatric Cardiac Anesthesia and Critical Care Medicine. J Cardiothorac Vasc Anesth 2023; 37:461-470. [PMID: 36529633 DOI: 10.1053/j.jvca.2022.11.034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/18/2022] [Accepted: 11/23/2022] [Indexed: 11/29/2022]
Abstract
Congenital heart disease (CHD) is one of the most common birth anomalies. While the care of children with CHD has improved over recent decades, children with CHD who undergo general anesthesia remain at increased risk for morbidity and mortality. Electronic health record systems have enabled institutions to combine data on the management and outcomes of children with CHD in multicenter registries. The application of descriptive analytics methods to these data can improve clinicians' understanding and care of children with CHD. This narrative review covers efforts to leverage multicenter data registries relevant to pediatric cardiac anesthesia and critical care to improve the care of children with CHD.
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Affiliation(s)
- Krupa D Desai
- Department of Anesthesiology, Perioperative Care, and Pain Medicine at NYU Grossman School of Medicine, NYU Langone Health, New York, NY
| | - Ian Yuan
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia and University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | - Asif Padiyath
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia and University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | - Michael P Goldsmith
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia and University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | - Fu-Chiang Tsui
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia and University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | - Jayant Nick Pratap
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia and University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | - Olivia Nelson
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia and University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | - Allan F Simpao
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia and University of Pennsylvania Perelman School of Medicine, Philadelphia, PA.
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Iguidbashian J, Feng Z, Colborn KL, Barrett CS, Newman SR, Harris M, Campbell DN, Mitchell MB, Jaggers J, Stone ML. Open Chest Duration Following Congenital Cardiac Surgery Increases Risk for Surgical Site Infection. Pediatr Cardiol 2022:10.1007/s00246-022-03088-4. [PMID: 36583758 DOI: 10.1007/s00246-022-03088-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/16/2022] [Accepted: 12/21/2022] [Indexed: 12/31/2022]
Abstract
Surgical site infections (SSI) following congenital heart surgery (CHS) remain a significant source of morbidity. Delayed sternal closure (DSC) is often required to minimize the potential for hemodynamic instability. The purpose of this study was to determine the incidence of SSI among patients undergoing DSC versus primary chest closure (PCC) and to define a potential inflection point for increased risk of SSI as a function of open chest duration (OCD).A retrospective review of our institutional Society of Thoracic Surgeons dataset is to identify patients undergoing CHS at our institution between 2015 and 2020. Incidences of SSI were compared between DSC and PCC patients. DSC patients were evaluated to determine the association of OCD and the incidence of SSI.2582 operations were performed at our institution between 2015 and 2020, including 195 DSC and 2387 PCC cases. The incidence of SSI within the cohort was 1.8% (47/2,582). DSC patients had significantly higher incidences of SSI (17/195, 8.7%) than PCC patients (30/2387, 1.3%, p < 0.001). Further, patients with an OCD of four or more days had a significantly higher incidence of SSI (11/62, 17.7%, p = 0.006) than patients with an OCD less than 4 days (6/115, 5.3%).The incidence of SSI following CHS is higher in DSC patients compared to PCC patients. Prolonged OCD of 4 days or more significantly increases the risk of SSI and represents a potentially modifiable risk factor for SSI predisposition. These data support dedicated, daily post-operative assessment of candidacy for chest closure to minimize the risk of SSI.
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Affiliation(s)
- John Iguidbashian
- Department of Surgery, University of Colorado School of Medicine, 12605 E 16th Ave, Aurora, CO, 80045, USA.
| | - Zihan Feng
- Department of Surgery, University of Colorado School of Medicine, 12605 E 16th Ave, Aurora, CO, 80045, USA
| | - Kathryn L Colborn
- Department of Surgery, University of Colorado School of Medicine, 12605 E 16th Ave, Aurora, CO, 80045, USA
| | - Cindy S Barrett
- Department of Cardiology and Cardiothoracic Surgery, Children's Hospital of Colorado, Aurora, CO, USA
| | - Shanna R Newman
- Department of Cardiology and Cardiothoracic Surgery, Children's Hospital of Colorado, Aurora, CO, USA
| | - Marisa Harris
- Department of Cardiology and Cardiothoracic Surgery, Children's Hospital of Colorado, Aurora, CO, USA
| | - David N Campbell
- Department of Cardiology and Cardiothoracic Surgery, Children's Hospital of Colorado, Aurora, CO, USA
| | - Max B Mitchell
- Department of Cardiology and Cardiothoracic Surgery, Children's Hospital of Colorado, Aurora, CO, USA
| | - James Jaggers
- Department of Cardiology and Cardiothoracic Surgery, Children's Hospital of Colorado, Aurora, CO, USA
| | - Matthew L Stone
- Department of Cardiology and Cardiothoracic Surgery, Children's Hospital of Colorado, Aurora, CO, USA
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8
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Cooper DS, Hill KD, Krishnamurthy G, Sen S, Costello JM, Lehenbauer D, Twite M, James L, Mah KE, Taylor C, McBride ME. Acute Cardiac Care for Neonatal Heart Disease. Pediatrics 2022; 150:189882. [PMID: 36317971 DOI: 10.1542/peds.2022-056415j] [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] [Accepted: 08/29/2022] [Indexed: 11/07/2022] Open
Abstract
This manuscript is one component of a larger series of articles produced by the Neonatal Cardiac Care Collaborative that are published in this supplement of Pediatrics. In this review article, we summarize the contemporary physiologic principles, evaluation, and management of acute care issues for neonates with complex congenital heart disease. A multidisciplinary team of authors was created by the Collaborative's Executive Committee. The authors developed a detailed outline of the manuscript, and small teams of authors were assigned to draft specific sections. The authors reviewed the literature, with a focus on original manuscripts published in the last decade, and drafted preliminary content and recommendations. All authors subsequently reviewed and edited the entire manuscript until a consensus was achieved. Topics addressed include cardiopulmonary interactions, the pathophysiology of and strategies to minimize the development of ventilator-induced low cardiac output syndrome, common postoperative physiologies, perioperative bleeding and coagulation, and common postoperative complications.
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Affiliation(s)
- David S Cooper
- Department of Pediatrics, University of Cincinnati College of Medicine, The Heart Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Kevin D Hill
- Division of Cardiology, Duke Children's Hospital, Durham, North Carolina
| | - Ganga Krishnamurthy
- Division of Neonatology, Columbia University Medical Center, New York, New York
| | - Shawn Sen
- Department of Pediatrics, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - John M Costello
- Division of Cardiology, Medical University of South Carolina, Charleston, South Carolina
| | - David Lehenbauer
- Department of Pediatrics, University of Cincinnati College of Medicine, The Heart Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Mark Twite
- Department of Anesthesia, Colorado Children's Hospital, Aurora, Colorado
| | - Lorraine James
- Department of Pediatrics, Children's Hospital of Los Angeles, Los Angeles, California
| | - Kenneth E Mah
- Department of Pediatrics, University of Cincinnati College of Medicine, The Heart Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Carmen Taylor
- Department of Pediatric Cardiothoracic Surgery, The Children's Hospital, Oklahoma City, Oklahoma
| | - Mary E McBride
- Department of Pediatrics, Northwestern University Feinberg School of Medicine, Chicago, Illinois
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9
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Chen H, Yan Y, Li C, Zheng X, Wang G, Jin Z, Shi G, He X, Tong X, Chen H, Zhu Z. Inattention and hyperactivity in children and adolescents with repaired D-transposition of the great arteries: Prevalence, perioperative risk factors, and clinical outcomes. Front Cardiovasc Med 2022; 9:937311. [PMID: 36204574 PMCID: PMC9530033 DOI: 10.3389/fcvm.2022.937311] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2022] [Accepted: 08/11/2022] [Indexed: 11/13/2022] Open
Abstract
ObjectiveThe present study objectives were to determine the prevalence of attention-deficit/hyperactivity disorder symptoms (ADHD-like symptoms) in children and adolescent with d-transposition of great artery (D-TGA) after arterial switch operation (ASO) and examine associated risk factors and adverse personal, family dysfunctions.MethodsThis cohort study included 103 patients with D-TGA who underwent ASO in early infancy at Shanghai Children’s Medical Center between 2011 and 2016 and then follow-up. Data analysis was conducted from September 2020 to April 2022. A standardized Swanson, Nolan, and Pelham IV (SNAP-IV) questionnaire is used to evaluate inattention and hyperactivity symptoms. Demographic, preoperative, intraoperative, and postoperative factor were collected. Univariate and multivariable regression analyses were performed with odds ratios (OR) and 95% confidence intervals (CIs).ResultsPrevalence of ADHD-like symptoms was 27.18% (28/103). Attention-deficit (18/28, 64.29%) symptom was the predominant subphenotype. After underwent TGA surgery, 39% of patients with ADHD-like symptoms receive remedial special academic services. There is none had repeated grade. Univariate analysis showed that, positive inotropic drug score (P = 0.03) and delayed sternal closure (P = 0.02) were risk factors of ADHD-like symptoms; increased preoperative oxygen saturation (SpO2) (P = 0.01) and surgical height (P = 0.01) and TGA subtype (VSD) (P = 0.02) were protective factor of ADHD-like symptoms. Multivariable analysis showed that delayed sternal closure (DSC) (OR, 1.50; 95% CI, 1.02–2.18) is a risk factor for the occurrence of ADHD-like symptom while increased preoperative oxygen saturation [odds ratio (OR), 0.95; 95% confidence interval (CI), 0.92–0.99] is a protective factor of ADHD-like symptom.ConclusionThe children and adolescents with D-TGA after ASO were at high risk of ADHD-like symptoms. Preoperative hypoxic status and postoperative DSC became predominant risk factors. Modification of the risk factors may be helpful to relieve ADHD-like symptoms for these patients.
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Affiliation(s)
- Hongtong Chen
- Department of Cardiothoracic Surgery, Heart Center, Shanghai Children’s Medical Center, Shanghai Jiao Tong University School of Medicine, Shanghai, China
- Center for Brain Science, Shanghai Children’s Medical Center, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Yichen Yan
- Department of Cardiothoracic Surgery, Heart Center, Shanghai Children’s Medical Center, Shanghai Jiao Tong University School of Medicine, Shanghai, China
- Center for Brain Science, Shanghai Children’s Medical Center, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Cong Li
- Department of Cardiothoracic Surgery, Heart Center, Shanghai Children’s Medical Center, Shanghai Jiao Tong University School of Medicine, Shanghai, China
- Center for Brain Science, Shanghai Children’s Medical Center, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Xiangyu Zheng
- Peking University Sixth Hospital, Peking University Institute of Mental Health, Beijing, China
| | - Guanghai Wang
- Center for Brain Science, Shanghai Children’s Medical Center, Shanghai Jiao Tong University School of Medicine, Shanghai, China
- Department of Developmental and Behavioral Pediatrics, Shanghai Children’s Medical Center, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Zhijuan Jin
- Department of Developmental and Behavioral Pediatrics, Shanghai Children’s Medical Center, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Guocheng Shi
- Department of Cardiothoracic Surgery, Heart Center, Shanghai Children’s Medical Center, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Xiaomin He
- Department of Cardiothoracic Surgery, Heart Center, Shanghai Children’s Medical Center, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Xiaoping Tong
- Center for Brain Science, Shanghai Children’s Medical Center, Shanghai Jiao Tong University School of Medicine, Shanghai, China
- Department of Anatomy and Physiology, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Huiwen Chen
- Department of Cardiothoracic Surgery, Heart Center, Shanghai Children’s Medical Center, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Zhongqun Zhu
- Department of Cardiothoracic Surgery, Heart Center, Shanghai Children’s Medical Center, Shanghai Jiao Tong University School of Medicine, Shanghai, China
- Center for Brain Science, Shanghai Children’s Medical Center, Shanghai Jiao Tong University School of Medicine, Shanghai, China
- *Correspondence: Zhongqun Zhu,
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von Stumm M, Leps Y, Jochheim L, van Rüth V, Gottschalk U, Mueller G, Kozlik-Feldmann R, Hazekamp MG, Sachweh JS, Biermann D. Impact of delayed sternal closure on wound infections following neonatal and infant cardiac surgery. PLoS One 2022; 17:e0267985. [PMID: 35604953 PMCID: PMC9126390 DOI: 10.1371/journal.pone.0267985] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2022] [Accepted: 04/19/2022] [Indexed: 11/23/2022] Open
Abstract
Objectives Delayed sternal closure is a routine procedure to reduce hemodynamic and respiratory instability in pediatric patients following cardiac surgery, particularly in neonates and infants. In this setting, the possible links between sternal wound infection and delayed sternal closure are still a matter of debate. As a part of our routine, there was a low threshold for delayed sternal closure, so we reviewed our experience with sternal wound infections with a focus on potentially related perioperative risk factors, particularly delayed sternal closure. Methods We retrospectively identified 358 operated neonates (37%) and infants (mean age 3.6 months) in our local congenital heart disease database between January 2013 and June 2017. Potential risk factors for sternal wound infections, such as age, gender, complexity (based on Aristotle- and STS-EACTS mortality category), reoperation, use of cardiopulmonary bypass, extracorporeal membrane oxygenation, mortality and delayed sternal closure (163/358, 46%), were subjected to uni- and multivariate analysis. Results A total of 26/358 patients (7.3%) developed a superficial sternal wound infection. There were no deep sternal wound infections, no mediastinitis or sepsis. Applying univariate analysis, the prevalence of sternal wound infections was related to younger age, more complex surgery and delayed sternal closure. However, in multivariate analysis, sternal wound infection was only associated with delayed sternal closure (p = 0.013, odds ratio 8.6). Logistic regression revealed the prevalence of delayed sternal closure to be related to younger age, complexity, and the use of extracorporeal membrane oxygenation. Conclusion In patients younger than one year, sternal wound infections are clearly related to delayed sternal closure. However, in our cohort, all sternal wound infections were superficial and acceptable, considering the improved postoperative hemodynamic stability.
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Affiliation(s)
- Maria von Stumm
- Department of Congenital and Pediatric Heart Surgery, Children‘s Heart Clinic, University Heart & Vascular Center, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Yola Leps
- Department of Congenital and Pediatric Heart Surgery, German Heart Center Munich, Technical University of Munich, Munich, Germany
| | - Luca Jochheim
- Department of Congenital and Pediatric Heart Surgery, German Heart Center Munich, Technical University of Munich, Munich, Germany
| | - Victoria van Rüth
- Department of Congenital and Pediatric Heart Surgery, German Heart Center Munich, Technical University of Munich, Munich, Germany
| | - Urda Gottschalk
- Department of Pediatric Cardiology, Children‘s Heart Clinic, University Heart & Vascular Center, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Goetz Mueller
- Department of Pediatric Cardiology, Children‘s Heart Clinic, University Heart & Vascular Center, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Rainer Kozlik-Feldmann
- Department of Pediatric Cardiology, Children‘s Heart Clinic, University Heart & Vascular Center, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Mark G. Hazekamp
- Department of Cardiothoracic Surgery, Leiden University Medical Center, Leiden, The Netherlands
| | - Joerg S. Sachweh
- Department of Congenital and Pediatric Heart Surgery, German Heart Center Munich, Technical University of Munich, Munich, Germany
| | - Daniel Biermann
- Department of Congenital and Pediatric Heart Surgery, German Heart Center Munich, Technical University of Munich, Munich, Germany
- * E-mail:
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11
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Chew JD, Hill KD, Soslow JH, Jacobs ML, Jacobs JP, Eghtesady P, Thibault D, Chiswell K, Bichell DP, Godown J. Congenitally Corrected Transposition Cardiac Surgery: Society of Thoracic Surgeons Database Analysis. Ann Thorac Surg 2022; 114:1715-1722. [DOI: 10.1016/j.athoracsur.2022.03.063] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/02/2021] [Revised: 03/02/2022] [Accepted: 03/22/2022] [Indexed: 11/17/2022]
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12
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Pan Y, Li P, Liang F, Zhang J, Yuan J, Yin M. A Nano-Silver Loaded PVA/Keratin Hydrogel With Strong Mechanical Properties Provides Excellent Antibacterial Effect for Delayed Sternal Closure. Front Bioeng Biotechnol 2021; 9:733980. [PMID: 34692656 PMCID: PMC8534296 DOI: 10.3389/fbioe.2021.733980] [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] [Received: 07/16/2021] [Accepted: 09/22/2021] [Indexed: 12/13/2022] Open
Abstract
Delayed chest closure (DSC) is widely performed during the treatment of congenital heart diseases. However, the high prevalence of surgical site infection (SSI) in patients undergoing DSC affects prognosis negatively. Herein, we designed a suturable poly (vinyl alcohol)/keratin film loaded with silver nanoparticles (AgNPs) as an alternative material for DSC, which was named PVA/Keratin/AgNPs. The PVA/Keratin/AgNPs films exhibited significantly enhanced mechanical strength after crosslinking by sodium trimetaphosphate (STMP). These films were non-toxic, and cells proliferated with good morphology after 1 week of culture. In addition, PVA/Keratin/AgNPs films provided superior antibacterial ability, as evidenced by the eradication and lower growth rate of Staphylococcus aureus and Escherichia coli. Finally, the PVA/Keratin/AgNPs films were demonstrated to successfully cover the chest cavity temporarily and protect the chest cavity from bacterial infection. These results indicated that the PVA/Keratin/AgNPs films have great prospects to be further exploited for clinical applications in DSC.
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Affiliation(s)
- Yanjun Pan
- Department of Cardiothoracic Surgery, Shanghai Children's Medical Center, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Pengfei Li
- Jiangsu Key Laboratory of Biofunctional Materials, School of Chemistry and Materials Science, Nanjing Normal University, Nanjing, China
| | - Fubang Liang
- Department of Cardiothoracic Surgery, Shanghai Children's Medical Center, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Jingyi Zhang
- Department of Cardiothoracic Surgery, Shanghai Children's Medical Center, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Jiang Yuan
- Jiangsu Key Laboratory of Biofunctional Materials, School of Chemistry and Materials Science, Nanjing Normal University, Nanjing, China
| | - Meng Yin
- Department of Cardiothoracic Surgery, Shanghai Children's Medical Center, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
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13
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Asfari A, Clark MG, Hock KM, Huskey JL, Rahman AKMF, Dabal RJ, Borasino S. Early Versus Late Sternal Closure in Infants-Perioperative Associations and Outcomes. World J Pediatr Congenit Heart Surg 2021; 12:589-596. [PMID: 34597200 DOI: 10.1177/21501351211022413] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND Delayed sternal closure (DSC) has been used for patients who develop bleeding, chest wall edema, and malignant arrhythmia following cardiopulmonary bypass. Multiple factors can influence the timing of when to perform DSC. We aimed to describe our DSC experience in neonates and infants by comparing outcomes between patients undergoing early (<48 hours) versus late DSC (> 48 hours). We explored the associations between specific clinical and laboratory variables and the timing of DSC. METHODS Retrospective chart review of neonates and infants (<one-year-old) with DSC after heart surgery from December 2012 to December 2018. Patients requiring extracorporeal membrane oxygenation were excluded. RESULTS A total of 121 patients were included in the analysis, 34% (n = 41) met late DSC criteria. The overall cohort had a 75% survival rate and a median time for open sternum of 42.5 hours (Q1:23-Q3:65). The median time for open sternum in the early and late DSC groups was 24 hours (Q1:21-Q3:43) and 93 hours (Q1:65-Q3:141), respectively (P < .01). There was no statistical difference in mortality rate between groups. Patients with late DSC endured longer intensive care unit stays (median 24.3 days [Q1:13-Q3:35.3] vs 36.8 [Q1:23.9, 73.6]; P< .01) and a two-fold longer hospital stay compared to the early DSC group (multivariable analysis: relative risk = 2, 95% CI: 1.5-2.7; P < .01). Univariate analysis revealed patients with late DSC had higher median lactates both intraoperatively (7.6 [Q1:5.9-Q3:10.7] vs 9.3 [Q1:7.5-Q3:12.1]; P < .01) and 24 hours postoperatively (6.5 [Q1:4.3-Q3:10.3] vs 8.7 [Q1:5.7-Q3:14.70]; P = .03). A higher vasoactive inotrope score at 36 hours was associated with late DSC (odds ratio = 1.1, 95% CI: 1.01-1.2; P = .02). CONCLUSIONS Future research that explores additional clinical and laboratory variables that can help guide DSC decision-making and timing is needed.
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Affiliation(s)
- Ahmed Asfari
- Department of Pediatric Cardiac Critical Care Medicine, University of Alabama at Birmingham, AL, USA
| | - Matthew G Clark
- Department of Pediatric Cardiac Critical Care Medicine, University of Alabama at Birmingham, AL, USA
| | - Kristal M Hock
- Department of Pediatric Cardiac Critical Care Medicine, University of Alabama at Birmingham, AL, USA
| | - Jordan L Huskey
- Department of Pediatric Cardiac Critical Care Medicine, University of Alabama at Birmingham, AL, USA
| | - A K M F Rahman
- Department of Biostatistics, University of Alabama at Birmingham, AL, USA
| | - Robert J Dabal
- Department of Cardiothoracic Surgery, University of Alabama at Birmingham, AL, USA
| | - Santiago Borasino
- Department of Pediatric Cardiac Critical Care Medicine, University of Alabama at Birmingham, AL, USA
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Prendin A, Tabacco B, Fazio PC, De Barbieri I. Management of pediatric cardiac surgery wound: a literature review. ACTA BIO-MEDICA : ATENEI PARMENSIS 2021; 92:e2021203. [PMID: 34487083 PMCID: PMC8477079 DOI: 10.23750/abm.v92i4.11269] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/25/2021] [Accepted: 03/22/2021] [Indexed: 12/04/2022]
Abstract
Background: Sternal wound infection is a severe complication of cardiac surgery in the pediatric population (0-18 years old) that can lead to increased morbidity, mortality, and prolonged hospitalization. Health professionals have the ability to perform some interventions during the pre, intra and post-surgery to correctly manage sternal wounds, with the goal of preventing infections. Objectives: To identify and discuss current best practice in the prevention, incidence, and treatment of infections of the cardiac surgery site in the pediatric population. Methods: Between February 20th 2021 and February 28th 2021 we consulted the PubMed database adopting full text, 20 years, Humans, English, Child aged 0 to 18 years as criteria. Twenty articles out of sixty-six were considered relevant to this study. These were divided into four themes. Results: All studies highlight the lack of standard guidelines for managing pediatric patients undergoing cardiac surgery. Some centers developed protocols for managing antibiotic prophylaxis supported by measurable interventions; others implemented infection surveillance systems involving families taking care of patients after hospital discharge. Discussions: the identification of healthcare-associated infections in the pediatric population after cardiac surgery is useful in all peri-operative phases. The limited and restricted literature connected to single centers, with relatively small sample sizes, the use of a single database. Conclusion: There is a lack of standard guidelines. The prevention of site infection ought to the goal of reducing surgical site infections. Building a network between the multidisciplinary staff and the pediatric patient’s family improves the infection surveillance system, reducing the incidence of infections. (www.actabiomedica.it)
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15
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Yilmaz Ferhatoglu S, Yurdakok O, Yurtseven N. Malnutrition on admission to the paediatric cardiac intensive care unit increases the risk of mortality and adverse outcomes following paediatric congenital heart surgery: A prospective cohort study. Aust Crit Care 2021; 35:550-556. [PMID: 34462193 DOI: 10.1016/j.aucc.2021.07.004] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2020] [Revised: 06/27/2021] [Accepted: 07/03/2021] [Indexed: 12/01/2022] Open
Abstract
BACKGROUND Malnutrition is a common problem in children with congenital heart disease, and it increases the risk of adverse outcomes in the postoperative period. OBJECTIVES We aimed to assess the association between malnutrition and cardiac surgery outcomes in paediatric patients aged 0-36 months. METHODS This prospective cohort study was performed in a hospital specialising in paediatric cardiothoracic surgery. Children aged 0-36 months admitted to the paediatric cardiac intensive care unit after elective cardiac surgery between January 2018 and July 2018 were included in the study. We evaluated the patients' demographics and clinical variables, nutritional status, adverse outcomes, and 30-day mortality rates. RESULTS A total of 124 cases met the inclusion criteria. Results showed that the Risk Adjustment for Congenital Heart Surgery score ≥5, underweight status (weight-for-age Z score ≤-2), and stunting (length-for-age Z score ≤-2) were all indicators for increased mortality following congenital heart surgery. Underweight children also spent a prolonged stay in the intensive care unit. Stunting (length-for-age Z score ≤-2) was the most strongly associated variable with mortality. CONCLUSION The results confirm the impact of malnutrition on mortality, postoperative infection, and length of hospitalisation in children undergoing surgery for congenital heart disease.
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Affiliation(s)
- Sibel Yilmaz Ferhatoglu
- University of Health Sciences, Istanbul Siyami Ersek Cardiothoracic Surgery Training and Research Hospital, Department of Anesthesiology and Reanimation, Istanbul, Turkey.
| | - Okan Yurdakok
- University of Health Sciences, Istanbul Siyami Ersek Cardiothoracic Surgery Training and Research Hospital, Department of Pediatric Cardiovascular Surgery, Istanbul, Turkey.
| | - Nurgul Yurtseven
- University of Health Sciences, Istanbul Siyami Ersek Cardiothoracic Surgery Training and Research Hospital, Department of Anesthesiology and Reanimation, Istanbul, Turkey.
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16
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Fuller S, Kumar SR, Roy N, Mahle WT, Romano JC, Nelson JS, Hammel JM, Imamura M, Zhang H, Fremes SE, McHugh-Grant S, Nicolson SC. The American Association for Thoracic Surgery Congenital Cardiac Surgery Working Group 2021 consensus document on a comprehensive perioperative approach to enhanced recovery after pediatric cardiac surgery. J Thorac Cardiovasc Surg 2021; 162:931-954. [PMID: 34059337 DOI: 10.1016/j.jtcvs.2021.04.072] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Key Words] [MESH Headings] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/26/2021] [Revised: 04/26/2021] [Accepted: 04/26/2021] [Indexed: 12/22/2022]
Affiliation(s)
- Stephanie Fuller
- Division of Cardiothoracic Surgery, Department of Surgery, The Children's Hospital of Philadelphia, and Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pa
| | - S Ram Kumar
- Division of Cardiac Surgery, Department of Surgery, and Department of Pediatrics, Keck School of Medicine of the University of Southern California, Heart Institute, Children's Hospital Los Angeles, Los Angeles, Calif.
| | - Nathalie Roy
- Department of Cardiac Surgery, Boston Children's Hospital, Department of Surgery, Harvard Medical School, Boston, Mass
| | - William T Mahle
- Division of Cardiology, Department of Pediatrics, Emory University, Children's Healthcare of Atlanta, Atlanta, Ga
| | - Jennifer C Romano
- Departments of Cardiac Surgery and Pediatrics, University of Michigan, CS Mott Children's Hospital, Ann Arbor, Mich
| | - Jennifer S Nelson
- Department of Cardiovascular Services, Nemours Children's Hospital, and Department of Surgery, University of Central Florida College of Medicine, Orlando, Fla
| | - James M Hammel
- Department of Cardiothoracic Surgery, Children's Hospital and Medical Center of Omaha, Omaha, Neb
| | - Michiaki Imamura
- Division of Congenital Heart Surgery, Texas Children's Hospital, Baylor College of Medicine, Houston, Tex
| | - Haibo Zhang
- Department of Cardiothoracic Surgery, Shanghai Children's Medical Center, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Stephen E Fremes
- Division of Cardiac Surgery, Department of Surgery, Schulich Heart Centre, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
| | - Sara McHugh-Grant
- Division of Cardiothoracic Surgery, The Children's Hospital of Philadelphia, Philadelphia, Penn
| | - Susan C Nicolson
- Division of Cardiothoracic Anesthesiology, Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Penn
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18
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Long JB, Engorn BM, Hill KD, Feng L, Chiswell K, Jacobs ML, Jacobs JP, Goswami D. Postoperative Hematocrit and Adverse Outcomes in Pediatric Cardiac Surgery Patients: A Cross-Sectional Study From the Society of Thoracic Surgeons and Congenital Cardiac Anesthesia Society Database Collaboration. Anesth Analg 2021; 133:1077-1088. [PMID: 33721876 DOI: 10.1213/ane.0000000000005416] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND We sought to examine potential associations between pediatric postcardiac surgical hematocrit values and postoperative complications or mortality. METHODS A retrospective, cross-sectional study from the Society of Thoracic Surgeons Congenital Heart Surgery Database (STS-CHSD) and Congenital Cardiac Anesthesia Society Database Module (2014-2019) was completed. Multivariable logistic regression models, adjusting for covariates in the STS-CHSD mortality risk model, were used to assess the relationship between postoperative hematocrit and the primary outcomes of operative mortality or any major complication. Hematocrit was assessed as a continuous variable using linear splines to account for nonlinear relationships with outcomes. Operations after which the oxygen saturation is typically observed to be <92% were classified as cyanotic and ≥92% as acyanotic. RESULTS In total, 27,462 index operations were included, with 4909 (17.9%) being cyanotic and 22,553 (82.1%) acyanotic. For cyanotic patients, each 5% incremental increase in hematocrit over 42% was associated with a 1.31-fold (95% confidence interval [CI], 1.10-1.55; P = .003) increase in the odds of operative mortality and a 1.22-fold (95% CI, 1.10-1.36; P < .001) increase in the odds of a major complication. For acyanotic patients, each 5% incremental increase in hematocrit >38% was associated with a 1.45-fold (95% CI, 1.28-1.65; P < .001) increase in the odds of operative mortality and a 1.21-fold (95% CI, 1.14-1.29; P < .001) increase in the odds of a major complication. CONCLUSIONS High hematocrit on arrival to the intensive care unit (ICU) is associated with increased operative mortality and major complications in pediatric patients following cardiac surgery.
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Affiliation(s)
- Justin B Long
- From the Department of Pediatric Anesthesiology, Children's Healthcare of Atlanta, Emory University School of Medicine, Atlanta, Georgia
| | - Branden M Engorn
- Department of Anesthesiology and Critical Care Medicine, Rady Children's Hospital, San Diego, California
| | | | - Liqi Feng
- Duke Clinical Research Institute, Duke University, Durham, North Carolina
| | - Karen Chiswell
- Duke Clinical Research Institute, Duke University, Durham, North Carolina
| | - Marshall L Jacobs
- Department of Surgery, Johns Hopkins Hospital, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Jeffrey P Jacobs
- Division of Thoracic and Cardiovascular Surgery, Department of Surgery, Congenital Heart Center, University of Florida, Gainesville, Florida
| | - Dheeraj Goswami
- Department of Anesthesiology and Critical Care Medicine, Bloomberg Children's Hospital, Johns Hopkins University School of Medicine, Baltimore, Maryland
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Doğan A, Ada ET, Türköz R. Using eye speculum as a sternal retractor for delayed sternal closure after pediatric heart surgery. J Card Surg 2021; 36:2179-2181. [PMID: 33651427 DOI: 10.1111/jocs.15468] [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: 02/14/2021] [Accepted: 02/19/2021] [Indexed: 11/29/2022]
Abstract
Sternal closure can lead to hemodynamic and respiratory instability after some complex pediatric cardiac surgeries. In such cases, delayed sternal closure is applied to facilitate postoperative recovery. During open sternum several instruments have been defined to prevent the sternum from compressing the heart; however, most of them have limitations. We, therefore, have attempted to use a new instrument to keep the sternum open in neonates and infants. This instrument has been used as an adult eye speculum which is made of a flexible metal wire. It is delicate, ready to use, easily placed, and good fitted to the pediatric sternal edges.
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Affiliation(s)
- Abdullah Doğan
- Department of Cardiovascular Surgery, Acibadem Bakirkoy Hospital, Istanbul, Turkey
| | - Elif Tekin Ada
- Department of Cardiovascular Surgery, Acibadem Bakirkoy Hospital, Istanbul, Turkey
| | - Rıza Türköz
- Department of Cardiovascular Surgery, Acibadem Bakirkoy Hospital, Istanbul, Turkey
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20
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Elsisy MF, Dearani JA, Crestanello JA, Ashikhmina EA, Van Dorn CS, Stephens EH. Outcomes of Primary vs Secondary Delayed Sternal Closure in Pediatric Cardiac Surgery. Ann Thorac Surg 2021; 113:1231-1237. [PMID: 33662305 DOI: 10.1016/j.athoracsur.2021.02.029] [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] [Received: 11/09/2020] [Revised: 02/11/2021] [Accepted: 02/16/2021] [Indexed: 11/01/2022]
Abstract
BACKGROUND Delayed sternal closure (DSC) is a management strategy for hemodynamic instability and severe coagulopathy after complex congenital heart surgery. We hypothesized that DSC results in better outcomes than perioperative sternal reopening. METHODS We reviewed patients aged <18 years old undergoing cardiac surgery 2007-2017 at our institution. A total of 179 patients (3.8%) had primary DSC (PDSC, sternum left open after initial operation) and 45 patients (0.9%) had secondary DSC (SDSC, sternum closed primarily and reopened perioperatively). Perioperative characteristics and outcomes among PDSC ≤2 days (98 patients), PDSC >2 days (81 patients), and SDSC (45 patients) were analyzed. RESULTS Median age was 120 days (range, 3-6553 days) and median DSC duration was 2 days (range, 1-60 days). The PDSC >2 days group was the youngest group, and the distribution of procedures was different between groups. Indications for DSC were hemodynamic instability in 152 patients (67.9%) and severe coagulopathy in 33 patients (14.7%), with no difference between groups (P = .141). Extracorporeal membrane oxygenation use was higher in the PDSC >2 days group than the other groups (47.5% vs 7.1%, P < .01 and 47.5% vs 28.9%, P = .02), respectively. Operative mortality was higher in SDSC compared to the other groups (17.8% vs 0% for PDSC ≤2 and 6.2% for PDSC >2 days, P < .01). Hospital stay was longer in SDSC (57 ± 7 days) than PDSC ≤2 days (22 ± 5 days) and PDSC >2 days (44 ± 6, P = .01). Survival was better in PDSC regardless of duration than SDSC. CONCLUSIONS PDSC demonstrated better outcomes than SDSC. Sternal reopening can be life-saving, but, when anticipated, PDSC can yield better outcomes.
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Affiliation(s)
- Mohamed F Elsisy
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, Minnesota
| | - Joseph A Dearani
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, Minnesota
| | | | - Elena A Ashikhmina
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, Minnesota
| | - Charlotte S Van Dorn
- Department of Pediatric and Adolescent Medicine, Division of Pediatric Critical Care Medicine, Mayo Clinic, Rochester, Minnesota; Department of Pediatric and Adolescent Medicine, Division of Pediatric Cardiology, Mayo Clinic, Rochester, Minnesota
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21
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Woodward C, Taylor R, Son M, Taeed R, Husain SA. Efforts to Reduce Infections in Delayed Sternal Closure Patients: A Survey of Pediatric Practice. World J Pediatr Congenit Heart Surg 2021; 11:310-315. [PMID: 32294002 DOI: 10.1177/2150135120907372] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND Pediatric patients with sternum left open after cardiac surgery experience a higher risk for sternal wound infection (SWI). These infections are costly for programs, payers, and patients and their families. Despite efforts by individual programs to reduce infections in patients undergoing delayed sternal closure (DSC), there are no established guidelines that address preventive procedures. The purpose of this study was to determine the practice of pediatric cardiac surgery programs to prevent infection in their DSC patients and if preventive measures were associated with less infections. METHODS A 33 question survey on institutional practices was sent to chief surgeons at pediatric cardiac surgery programs in the United States. RESULTS Twenty-eight (35%) surgical programs responded. The mean number of pediatric cardiac bypass operations performed by programs in 2016 was 227 (range: 69-872). Data represented 6,484 patients <18 years of age who underwent cardiac surgery with 807 (12%) of those undergoing DSC. One hundred fifty-eight (2.4%) of all patients and 51 (6.3%) of the DSC patients developed a SWI. Patients with DSC who received preoperative baths were less likely to become infected (5.9% vs 15.8%; P = .015). Patients in programs with feeding protocols had fewer infections (5.7% vs 14.8%; P = .008). CONCLUSIONS The results of this survey of children's cardiac surgery programs describe their practices to reduce infection rates in DSC patients. A multicenter project on wound care and closure techniques that might impact this costly complication is needed.
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Affiliation(s)
- Cathy Woodward
- Pediatric Critical Care, Department of Pediatrics, UT Health San Antonio, TX, USA
| | - Richard Taylor
- Pediatric Critical Care, Department of Pediatrics, UT Health San Antonio, TX, USA
| | - Minnette Son
- Pediatric Critical Care, UMKC School of Medicine, Kansas City, MO, USA
| | - Roozbeh Taeed
- Surgery and Perioperative Care, Dell Medical School, University of Texas at Austin, TX, USA
| | - S Adil Husain
- Pediatric Cardiothoracic Surgery, University of Utah Health/Primary Children's Hospital, Salt Lake City, UT, USA
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Vaswani P, Sahu MK, Bipin C, Singh SP, Rajashekar P, Devagourou V, Talwar S. Outcomes of Delayed Sternal Closure in Paediatric Cardiac Surgical Patients–A Prospective Single Centre Study. JOURNAL OF CARDIAC CRITICAL CARE TSS 2020. [DOI: 10.1055/s-0040-1721229] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022] Open
Abstract
Abstract
Background Delayed sternal closure (DSC) is being increasingly used as an interim support to help the dysfunctional heart in the road to recovery after complex pediatric cardiac surgeries. The purpose of this study was to assess the conduct of DSC at a tertiary care center.
Methods Between 2018 and 2019, 185 consecutive pediatric patients (below 12 years of age) underwent cardiac surgery at a tertiary care center. The incidence and causes of DSC were noted. The various pre, intra and postoperative factors till discharge or demise were noted and analyzed.
Results In this study, DSC was done in 63 patients (34.05%) with a median age and weight of 29 days (18–100 days) and 4 kg (2–12.3 kg), respectively. Transposition of great arteries (TGA) (41.27%) constituted the majority, followed by total anomalous pulmonary venous connection (TAPVC) (26.98%). Myocardial edema (49.21%) was the most common indication for DSC. Mean duration of open chest was 40.75 ± 18.58 hours. All-cause mortality was 19.05% (12/63). On multivariate analysis by logistic regression, the independent predictors of mortality were needed for preoperative mechanical ventilation (OR 42.82, 95% CI = 4.52–406.03, p < 0.001) and development of postoperative sepsis (OR 20.07, 95% CI = 2.12–189.80, p = 0.002).
Conclusions DSC is a safe and effective technique in the management of complex pediatric cardiac surgeries. It provides assistance to the severely dysfunctional myocardium soon after the surgery and helps in stabilization of hemodynamics with avoidance of postoperative mediastinal compression. Early sternal closure should be considered on the basis of cardiovascular function and/or resolution of primary indication for DSC.
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Affiliation(s)
- Prateek Vaswani
- Department of Cardiothoracic and Vascular Surgery, Cardiothoracic and Neurosciences Centre, All India Institute of Medical Sciences, New Delhi, India
| | - Manoj Kumar Sahu
- Intensive Care for CTVS, CT Centre, Cardiothoracic and Neurosciences Centre, All India Institute of Medical Sciences, New Delhi, India
| | - Challatil Bipin
- Intensive Care for CTVS, CT Centre, Cardiothoracic and Neurosciences Centre, All India Institute of Medical Sciences, New Delhi, India
| | - Sarvesh Pal Singh
- Intensive Care for CTVS, CT Centre, Cardiothoracic and Neurosciences Centre, All India Institute of Medical Sciences, New Delhi, India
| | - Palleti Rajashekar
- Department of Cardiothoracic and Vascular Surgery, Cardiothoracic and Neurosciences Centre, All India Institute of Medical Sciences, New Delhi, India
| | - Velayoudam Devagourou
- Department of Cardiothoracic and Vascular Surgery, Cardiothoracic and Neurosciences Centre, All India Institute of Medical Sciences, New Delhi, India
| | - Sachin Talwar
- Department of Cardiothoracic and Vascular Surgery, Cardiothoracic and Neurosciences Centre, All India Institute of Medical Sciences, New Delhi, India
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Abstract
BACKGROUND The perioperative complications rate in paediatric cardiac surgery, as well as the failure-to-rescue impact, is less known in low- and middle-income countries. AIM To evaluate perioperative complications rate, mortality related to complications, different patients' demographics, and procedural risk factors for perioperative complication and post-operative death. METHODS Risk factors for perioperative complications and operative mortality were assessed in a retrospective single-centre study which included 296 consecutive children undergoing cardiac surgery. RESULTS Overall mortality was 5.7%. Seventy-three patients (24.7%) developed 145 perioperative complications and had 17 operative mortalities (23.3%). There was a strong association between the number of perioperative complications and mortality - 8.1% among patients with only 1 perioperative complication, 35.3% - with 2 perioperative complications, and 42.1% - with 3 or more perioperative complications (p = 0.007). Risk factors of perioperative complications were younger age (odds ratio 0.76; (95% confidence interval 0.61, 0.93), previous cardiac surgery (odds ratio 3.5; confidence interval 1.33, 9.20), extracardiac structural anomalies (odds ratio 3.03; confidence interval 1.27, 7.26), concomitant diseases (odds ratio 3.23; confidence interval 1.34, 7.72), and cardiopulmonary bypass (odds ratio 6.33; confidence interval 2.45, 16.4), whereas the total number of perioperative complications per patient was the only predictor of operative death (odds ratio 1.89; confidence interval 1.06, 3.37). CONCLUSIONS In a program with limited systemic resources, failure-to-rescue is a major contributor to operative mortality in paediatric cardiac surgery. Despite the comparable crude mortality, the operative mortality among patients with perioperative complications in our series was significantly higher than in the developed world. A number of initiatives are needed in order to improve failure-to-rescue rates in low- and middle-income countries.
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Kundan S, Tailor K, Radhakrishnan HB, Mohanty SR, Bhavsar K, Kadam S, Joshi P, Joshi V, Karande T, Bobhate P, Kulkarni S, Rao SG. Elective delayed sternal closure portends better outcomes in congenital heart surgery: a retrospective observational study. Indian J Thorac Cardiovasc Surg 2020; 35:530-538. [PMID: 33061048 DOI: 10.1007/s12055-019-00830-1] [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: 10/21/2018] [Revised: 03/07/2019] [Accepted: 05/02/2019] [Indexed: 11/28/2022] Open
Abstract
Introduction Delayed sternal closure is used in paediatric cardiac surgery as a management strategy for patients with unstable hemodynamics or postoperative bleeding routinely. We hypothesise that planned postponement of sternal closure leads to better outcomes than emergent reopening in the intensive care unit (ICU) in patients exhibiting some hemodynamic indication for the same. Methods We retrospectively analysed the outcomes of delayed sternal closure 220/2111 (10.42%) out of which 14 sternums were opened in the ICU after shifting the patients. Results A total of 220/2111 (10.42%) sternums were left open postoperatively, out of which 14 were opened after shifting to the ICU. Total mortality of the delayed sternal closure was 33/220, i.e. 15%. The patients whose sternums were left open from the theatre had a mortality of 23/206, i.e. 11.16%, whereas those patients whose sternums were opened in the ICU had a mortality of 10/14, i.e. 71.42%. Conclusion In doubtful postoperatively hemodynamic, the choice of leaving the sternum open electively has better outcomes, rather than opening the sternum as a terminal bail out procedure.
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Affiliation(s)
- Simran Kundan
- Pediatric and Congenital Heart Surgery, Kokilaben Dhirubai Ambani Hospital, Mumbai, India
| | - Kamlesh Tailor
- Pediatric Cardiac Anesthesiologist and Intensivist, Kokilaben Dhirubai Ambani Hospital, Mumbai, India
| | | | - Smruti Ranjan Mohanty
- Pediatric and Congenital Heart Surgery, Kokilaben Dhirubai Ambani Hospital, Mumbai, India
| | - Keyur Bhavsar
- Pediatric Cardiac Anesthesiologist and Intensivist, Kokilaben Dhirubai Ambani Hospital, Mumbai, India
| | - Shankar Kadam
- Pediatric Cardiac Anesthesiologist and Intensivist, Kokilaben Dhirubai Ambani Hospital, Mumbai, India
| | - Preetha Joshi
- Pediatric and Neonatal Intensivist, Kokilaben Dhirubai Ambani Hospital, Mumbai, India
| | - Vinay Joshi
- Pediatric and Neonatal Intensivist, Kokilaben Dhirubai Ambani Hospital, Mumbai, India
| | - Tanuja Karande
- Pediatric Cardiologist, Kokilaben Dhirubai Ambani Hospital, Mumbai, India
| | - Prashant Bobhate
- Pediatric Cardiologist, Kokilaben Dhirubai Ambani Hospital, Mumbai, India
| | - Snehal Kulkarni
- Pediatric Cardiologist, Kokilaben Dhirubai Ambani Hospital, Mumbai, India
| | - Suresh Gururaja Rao
- Pediatric and Congenital Heart Surgery, Kokilaben Dhirubai Ambani Hospital, Mumbai, India
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Jha P, Woodward CS, Gardner H, Pietz C, Husain SA. A Quality Improvement Initiative to Reduce Surgical Site Infections in Patients Undergoing Delayed Sternal Closure After Pediatric Cardiac Surgery. Pediatr Cardiol 2020; 41:1402-1407. [PMID: 32556486 DOI: 10.1007/s00246-020-02396-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/28/2020] [Accepted: 06/12/2020] [Indexed: 11/30/2022]
Abstract
Sternal wound infections (SWI) in delayed sternal closure (DSC) patients are a healthcare burden after congenital heart surgery. There are no guidelines specific for pediatric DSC patients to prevent this costly complication. The hypothesis was that the modifications to a bundled approach for DSC patients would decrease the SWI rate. For this prospective cohort study, DSC patients were postoperatively admitted to a pediatric cardiac care unit from February 2017 to January 2018. Using a modified protocol for prevention of SWI, the infection rates pre- and post-modified protocol were compared. The primary outcome measure was SWI. Secondary outcome measures were compliance with modifications. Retrospective review of cases in pre-protocol modification era from January 1, 2014 to December 31, 2016 showed 377 pediatric cardiopulmonary bypass cases and 39 (10.4%) underwent DSC. During the post-protocol modification era, there were 129 cardiopulmonary bypass cases and 17 (13%) DSC cases. The SWI rate in DSC were 7.7% and 0% for pre-intervention and post-intervention, respectively (p = 0.52). The Bayesian confidence interval with Jeffreys prior gives a 95% confidence interval of 1.5% to 18.3% for pre-intervention and 0 to 13.5% for post-intervention. Compliance with the protocol bundle during the post protocol era was 93-100%. Although preliminary results are not statistically significant due to cohort size, the economic burden and increased LOS for each SWI is clinically significant. The early results of reduced infections for DSC patients using a modified bundle approach appear promising. Continued study and a multicenter project would be beneficial.
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Affiliation(s)
- Prashant Jha
- Division of Critical Care, Department of Pediatrics, Children's Hospital of Nevada, University Medical Center, 1800 W Charleston Blvd, Las Vegas, NV, 89128, USA.
- Department of Pediatrics, University of Nevada at Las Vegas, Las Vegas, NV, USA.
| | - Cathy S Woodward
- Pediatric Services, University Hospital - University Health System, 4502 Medical Dr, San Antonio, TX, 78229, USA
- Division of Pediatric Critical Care, Department of Pediatrics, The University of Texas Health Science Center at San Antonio, San Antonio, TX, USA
| | - Heather Gardner
- Pediatric Services, University Hospital - University Health System, 4502 Medical Dr, San Antonio, TX, 78229, USA
- Division of Pediatric Critical Care, Department of Pediatrics, The University of Texas Health Science Center at San Antonio, San Antonio, TX, USA
| | - Clinton Pietz
- Pediatric Services, University Hospital - University Health System, 4502 Medical Dr, San Antonio, TX, 78229, USA
- Division of Pediatric Critical Care, Department of Pediatrics, The University of Texas Health Science Center at San Antonio, San Antonio, TX, USA
| | - S Adil Husain
- Division of Pediatric Cardiothoracic Surgery, The University of Utah's School of Medicine, Salt Lake City, UT, USA
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Hosokawa T, Shibuki S, Tanami Y, Sato Y, Ko Y, Nomura K, Oguma E. Extracardiac Complications in Intensive Care Units after Surgical Repair for Congenital Heart Disease: Imaging Review with a Focus on Ultrasound and Radiography. J Pediatr Intensive Care 2020; 10:85-105. [PMID: 33884209 DOI: 10.1055/s-0040-1715483] [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: 06/03/2020] [Accepted: 06/24/2020] [Indexed: 12/24/2022] Open
Abstract
Pediatric patients show various extracardiac complications after cardiovascular surgery, and radiography and ultrasound are routinely performed in the intensive care unit to detect and evaluate these complications. This review presents images of these complications, sonographic approach, and timing of occurrence that are categorized based on their extracardiac locations and include complications pertaining to the central nervous system, mediastinum, thorax and lung parenchyma, diaphragm, liver and biliary system, and kidney along with pleural effusion and iatrogenic complications. This pictorial review will make it easier for medical doctors in intensive care units to identify and manage various extracardiac complications in pediatric patients after cardiovascular surgery.
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Affiliation(s)
- Takahiro Hosokawa
- Department of Radiology, Saitama Children's Medical Center, Saitama, Japan
| | - Saki Shibuki
- Department of Radiology, Saitama Children's Medical Center, Saitama, Japan
| | - Yutaka Tanami
- Department of Radiology, Saitama Children's Medical Center, Saitama, Japan
| | - Yumiko Sato
- Department of Radiology, Saitama Children's Medical Center, Saitama, Japan
| | - Yoshihiro Ko
- Department of Cardiovascular Surgery, Saitama Children's Medical Center, Saitama, Japan
| | - Koji Nomura
- Department of Cardiovascular Surgery, Saitama Children's Medical Center, Saitama, Japan
| | - Eiji Oguma
- Department of Radiology, Saitama Children's Medical Center, Saitama, Japan
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27
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Kennedy JT, DiLeonardo O, Hurtado CG, Nelson JS. A Systematic Review of Antibiotic Prophylaxis for Delayed Sternal Closure in Children. World J Pediatr Congenit Heart Surg 2020; 12:93-102. [PMID: 32783516 DOI: 10.1177/2150135120947685] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Antibiotic prophylaxis following delayed sternal closure in pediatric cardiac surgery is not standardized. We systematically reviewed relevant literature published between 1990 and 2019 to aid future trial design. Patient characteristics, antimicrobial prophylaxis regimens, and postoperative incidence of infection were collected. Twenty-eight studies described 36 different regimens in over 3,000 patients. There were 11 single-drug regimens and 25 multidrug regimens. Cefazolin-only was the most common regimen (9/36, 25%). The overall incidence of surgical site infection was 7.5% (217/2,910 patients) and bloodstream infection was 7.4% (123/1,667 patients). In the 2010s, multidrug regimens were associated with a significantly lower incidence of both surgical site infections (4.6% vs. 20%, P < .001) and bloodstream infections (6.0% vs. 50%, P < .001) compared to single-drug regimens.
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Affiliation(s)
- John T Kennedy
- 124506University of Central Florida College of Medicine, Orlando, FL, USA
- Department of Surgery, 124506University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Olivia DiLeonardo
- Department of Medical Education, Nemours Children's Hospital, Orlando, FL, USA
- Nemours Children's Hospital Medical Library, Orlando, FL, USA
| | | | - Jennifer S Nelson
- 124506University of Central Florida College of Medicine, Orlando, FL, USA
- Department of Cardiovascular Services, Nemours Children's Hospital, Orlando, FL, USA
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28
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Ross FJ, Radman M, Jacobs ML, Sassano-Miguel C, Joffe DC, Hill KD, Chiswell K, Feng L, Jacobs JP, Vener DF, Latham GJ. Associations between anthropometric indices and outcomes of congenital heart operations in infants and young children: An analysis of data from the Society of Thoracic Surgeons Database. Am Heart J 2020; 224:85-97. [PMID: 32353587 DOI: 10.1016/j.ahj.2020.03.012] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/20/2019] [Accepted: 03/15/2020] [Indexed: 11/30/2022]
Abstract
BACKGROUND Children with congenital heart disease are at risk for growth failure due to inadequate nutrient intake and increased metabolic demands. We examined the relationship between anthropometric indices of nutrition (height-for-age z-score [HAZ], weight-for-age z-score [WAZ], weight-for-height z-score [WHZ]) and outcomes in a large sample of children undergoing surgery for congenital heart disease. METHODS Patients in the Society of Thoracic Surgeons Congenital Heart Surgery Database having index cardiac surgery at age 1 month to 10 years were included. Indices were calculated by comparing patients' weight and height to population norms from the World Health Organization and Centers for Disease Control and Prevention. Outcomes included operative mortality, composite mortality or major complication, major postoperative infection, and postoperative length of stay. For each outcome and index, the adjusted odds ratio (aOR) (for mortality, composite outcome, and infection) and adjusted relative change in median (for postoperative length of stay) for a 1-unit decrease in index were estimated using mixed-effects logistic and log-linear regression models. RESULTS Every unit decrease in HAZ was associated with 1.40 aOR of mortality (95% CI 1.32-1.48), and every unit decrease in WAZ was associated with 1.33 aOR for mortality (95% CI 1.25-1.41). The relationship between WHZ and outcome was nonlinear, with aOR of mortality of 0.84 (95% CI 0.76-0.93) for 1-unit decrease when WHZ ≥ 0 and a nonsignificant association for WHZ < 0. Trends for other outcomes were similar. Overall, the incidence of low nutritional indices was similar for 1-ventricle and 2-ventricle patients. Children between the age of 1 month and 1 year and those with lesions associated with pulmonary overcirculation had the highest incidence of low nutritional indices. CONCLUSIONS Lower HAZ and WAZ, suggestive of malnutrition, are associated with increased mortality and other adverse outcomes after cardiac surgery in infants and young children. Higher WHZ over zero, suggestive of obesity, is also associated with adverse outcomes.
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Affiliation(s)
- Faith J Ross
- Anesthesiology and Pain Medicine, Seattle Children's Hospital, University of Washington, 4800 Sandpoint Way NE, Seattle, WA.
| | - Monique Radman
- Critical Care, Seattle Children's Hospital, University of Washington, 4800 Sandpoint Way NE, Seattle, WA
| | - Marshall L Jacobs
- Cardiac Surgery, Johns Hopkins School of Medicine, 1800 Orleans St, Zayed Tower 7107, Baltimore, MD
| | - Claudia Sassano-Miguel
- Clinical Nutrition, Seattle Children's Hospital, University of Washington, 4800 Sandpoint Way NE, Seattle, WA
| | - Denise C Joffe
- Anesthesiology and Pain Medicine, Seattle Children's Hospital, University of Washington, 4800 Sandpoint Way NE, Seattle, WA
| | - Kevin D Hill
- Pediatrics, Duke University, DUMC Box 3090, Durham, NC; Duke Clinical Research Institute, Duke University, 200, Morris, St, Durham, NC
| | - Karen Chiswell
- Duke Clinical Research Institute, Duke University, 200, Morris, St, Durham, NC
| | - Liqi Feng
- Duke Clinical Research Institute, Duke University, 200, Morris, St, Durham, NC
| | - Jeffrey P Jacobs
- Cardiothoracic Surgery, Johns Hopkins All Children's Heart Institute, 501 6th Ave S, OCC Suite 607, JHACH Box 6500000606, St Petersburg, FL
| | - David F Vener
- Anesthesiology, Perioperative, and Pain Medicine, Texas Children's Hospital, 6651 Main St, Houston, TX
| | - Gregory J Latham
- Anesthesiology and Pain Medicine, Seattle Children's Hospital, University of Washington, 4800 Sandpoint Way NE, Seattle, WA
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Iyer KS. Deferring sternal closure after complex congenital heart surgery-to do or not to do is the question! Indian J Thorac Cardiovasc Surg 2019; 35:528-529. [PMID: 33061047 PMCID: PMC7525364 DOI: 10.1007/s12055-019-00825-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2019] [Revised: 03/11/2019] [Accepted: 03/19/2019] [Indexed: 11/28/2022] Open
Affiliation(s)
- Krishna Subramony Iyer
- Pediatric and Congenital Heart Surgery, Fortis Escorts Heart Institute, Okhla Road, New Delhi, 110025 India
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30
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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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32
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Silvetti S, Landoni G, Castagnola E, Nuri H, Pomé G, Moscatelli A. Antibiotic Management for Delayed Sternal Closure Following Pediatric Cardiac Surgery: A Systematic Review of Recent Literature. J Cardiothorac Vasc Anesth 2019; 34:1333-1340. [PMID: 31420313 DOI: 10.1053/j.jvca.2019.07.134] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/13/2019] [Revised: 07/02/2019] [Accepted: 07/16/2019] [Indexed: 12/21/2022]
Abstract
Delayed sternal closure after pediatric cardiac surgery is a management option for the treatment of patients with severely impaired heart function. The optimal antimicrobial treatment strategy for this condition is unknown. The aim of this systematic review was to evaluate the current antibiotic administration attitudes in pediatric cardiac surgery patients needing an open chest in terms of infection with a focus on surgical site infection rate. The authors performed a systematic review and meta-analysis of all articles, which described the antibiotic administration strategy and surgical site infection rate in pediatric patients with an open chest after cardiac surgery. The authors performed a subgroup analysis on "standard" versus "non-standard" (defined as any antimicrobial drugs different from the adult guidelines recommendations) therapy for one-proportion meta-analysis with a random effect model. The authors identified 12 studies published from January 1, 2000 to July 1, 2019 including a total of 2,203 patients requiring an open chest after cardiac surgery, 350 of whom (15.9%) developed infections and 182 (8.3%) developed a surgical site infection. The surgical site infection rate in patients with "non-standard" strategy was higher than in patients with "standard" strategy: 8.8% (140 reported infections/1,582 patients) versus 6.8% (42 reported infections/621 patients), p = 0.001. The "standard" antibiotic management proposed by guidelines for adult cardiac surgery patients could be used an acceptable strategy to treat pediatric patients with an open chest after cardiac surgery.
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Affiliation(s)
- Simona Silvetti
- Neonatal and Pediatric Intensive Care Unit, Department of Surgery and Critical Care, IRCCS Istituto Giannina Gaslini, Genova, Italy
| | - Giovanni Landoni
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, University Vita-Salute San Raffaele, Milano, Italy.
| | - Elio Castagnola
- Infectious Disease Unit, Department of Pediatrics, IRCCS Istituto Giannina Gaslini, Genova, Italy
| | - Halkawt Nuri
- Cardiac Surgery Unit, Department of Surgery and Critical Care, IRCCS Istituto Giannina Gaslini, Genova, Italy
| | - Giuseppe Pomé
- Cardiac Surgery Unit, Department of Surgery and Critical Care, IRCCS Istituto Giannina Gaslini, Genova, Italy
| | - Andrea Moscatelli
- Neonatal and Pediatric Intensive Care Unit, Department of Surgery and Critical Care, IRCCS Istituto Giannina Gaslini, Genova, Italy
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Chew JD, Hill KD, Jacobs ML, Jacobs JP, Killen SAS, Godown J, Wallace AS, Thibault D, Chiswell K, Bichell DP, Soslow JH. Congenital Heart Surgery Outcomes in Turner Syndrome: The Society of Thoracic Surgeons Database Analysis. Ann Thorac Surg 2019; 108:1430-1437. [PMID: 31299232 DOI: 10.1016/j.athoracsur.2019.05.047] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/18/2019] [Revised: 05/03/2019] [Accepted: 05/20/2019] [Indexed: 12/26/2022]
Abstract
BACKGROUND Turner syndrome (TS) is a genetic syndrome characterized by monosomy X (45,XO) in phenotypic females and is commonly associated with congenital heart disease. We sought to describe the distribution, mortality, and morbidity of congenital heart surgery in TS and compare outcomes to individuals without genetic syndromes. METHODS The Society of Thoracic Surgeons Congenital Heart Surgery Database was used to evaluate index cardiovascular operations performed from 2000 to 2017 in pediatric patients (aged 0-18 years) with and without TS. Analyses were stratified by the most common operations, including coarctation repair, aortic arch repair, partial anomalous pulmonary venous return repair, Norwood, superior cavopulmonary anastomosis (Glenn), and Fontan. RESULTS Included were 780 operations in TS and 62,659 operations in controls. The most common TS operations were coarctation repair in 274 (35%), aortic arch repair in 116 (15%), and Norwood in 59 (8%). Compared with controls, TS patients had lower weight-for-age Z-scores across all operations (P < .01 for all); however, operative mortality rates did not differ significantly. The chylothorax rate was higher in TS after coarctation repair (8.8% vs 2.8%, P < .001) and Norwood (22% vs 8.1%, P < .001). The median (interquartile range) postoperative length of stay was longer in TS for coarctation repair (6.5 [5.0-15.5] days vs 5.0 [4.0-9.0] days, P < .001), aortic arch repair (15.0 [8.0-27.5] days vs 11.0 [7.0-21.0] days, P = .004), and Glenn (9.0 [6.0-16.0] days vs 6.0 [5.0-11.0] days, P = .013). CONCLUSIONS Turner syndrome patients most commonly underwent operations for left-sided obstructive lesions. Despite increased morbidity for select operations, TS was not associated with increased operative mortality.
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Affiliation(s)
- Joshua D Chew
- Division of Pediatric Cardiology, Vanderbilt University Medical Center, Nashville, Tennessee.
| | - Kevin D Hill
- Division of Pediatric Cardiology, Duke University Medical Center, Durham, North Carolina
| | - Marshall L Jacobs
- Division of Cardiac Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Jeffrey P Jacobs
- Division of Cardiovascular Surgery, Johns Hopkins All Children's Heart Institute, St Petersburg, Florida
| | - Stacy A S Killen
- Division of Pediatric Cardiology, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Justin Godown
- Division of Pediatric Cardiology, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Amelia S Wallace
- Division of Pediatric Cardiology, Duke University Medical Center, Durham, North Carolina
| | - Dylan Thibault
- Division of Pediatric Cardiology, Duke University Medical Center, Durham, North Carolina
| | - Karen Chiswell
- Division of Pediatric Cardiology, Duke University Medical Center, Durham, North Carolina
| | - David P Bichell
- Division of Pediatric Cardiac Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Jonathan H Soslow
- Division of Pediatric Cardiology, Vanderbilt University Medical Center, Nashville, Tennessee
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Philip J, Kegg C, Lopez-Colon D, Kelly BJ, Lawrence RM, Robinson MA, Samraj RS, Bleiweis MS. Safety of a 2-Day Antibiotic Regimen After Delayed Chest Closure Post Pediatric Cardiac Surgery. J Intensive Care Med 2018; 35:805-809. [PMID: 30089431 DOI: 10.1177/0885066618792849] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND There is no consensus for the length of prophylactic antibiotics after delayed chest closure (DCC) postcardiac surgery in pediatrics. In September 2014, our institution's pediatric cardiac intensive care unit changed the policy on length of prophylactic antibiotics after DCC from 5 days (control) to 2 days (study group). The objective of the study was to determine whether a 2-day course of antibiotics is as effective as a 5-day course in preventing blood stream and sternal wound infections in pediatric DCC. METHODS Retrospective and prospective study. Primary end points included incidence of sternal wound infections and positive sternal imaging for infection. Surrogate markers of infection were collected at 4 time points. RESULTS During the study period, 139 patients had DCC postcardiac surgery of which 110 patients were included for analysis, 54 patients in the control and 56 in the study group. There was no difference in total number of positive wound cultures/chest computed tomography (CT) findings (4/54 [7.5%] control vs 5/56 [8.9%] study group, P = .3), positive blood cultures (P = .586), median postsurgical length of stay (P = .4), or readmissions within 30 days postsurgery (P = .6). All secondary end points were similar in both groups except peak heart rate between weeks 2 and 4 (P = .041). CONCLUSION Two days of prophylactic antibiotics is not inferior to 5 days of prophylactic antibiotics after DCC following pediatric cardiac surgery.
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Affiliation(s)
- Joseph Philip
- Congenital Heart Center, UF Health Shands Children's Hospital, University of Florida, Gainesville, FL, USA
| | - Christian Kegg
- Congenital Heart Center, UF Health Shands Children's Hospital, University of Florida, Gainesville, FL, USA
| | - Dalia Lopez-Colon
- Congenital Heart Center, UF Health Shands Children's Hospital, University of Florida, Gainesville, FL, USA
| | - Brian J Kelly
- Congenital Heart Center, UF Health Shands Children's Hospital, University of Florida, Gainesville, FL, USA
| | - Robert M Lawrence
- Congenital Heart Center, UF Health Shands Children's Hospital, University of Florida, Gainesville, FL, USA
| | - Matthew A Robinson
- Congenital Heart Center, UF Health Shands Children's Hospital, University of Florida, Gainesville, FL, USA
| | - Ravi S Samraj
- Congenital Heart Center, UF Health Shands Children's Hospital, University of Florida, Gainesville, FL, USA
| | - Mark S Bleiweis
- Congenital Heart Center, UF Health Shands Children's Hospital, University of Florida, Gainesville, FL, USA
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Kumar SR, Scott N, Wells WJ, Starnes VA. Liberal Use of Delayed Sternal Closure in Children Is Not Associated With Increased Morbidity. Ann Thorac Surg 2018; 106:581-586. [DOI: 10.1016/j.athoracsur.2018.03.053] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/11/2017] [Revised: 03/18/2018] [Accepted: 03/26/2018] [Indexed: 10/17/2022]
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Boulemden A, Speggiorin S, Pelella G, Lotto AA. Use of an Extracellular Matrix Patch for Sternal Wound Dehiscence after Cardiac Surgery in a Neonate. Tex Heart Inst J 2018; 45:176-178. [PMID: 30072858 DOI: 10.14503/thij-17-6239] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Management of sternal wound dehiscence in newborns after cardiac operations can be a slow and lengthy process, during which the risk of progression to deep sternal wound infection and mediastinitis remains a concern. We report the case of a neonate born with single-ventricle physiology who underwent a Damus-Kaye-Stansel procedure as first-stage palliation toward creating Fontan circulation. The postoperative period was characterized by sterile wound dehiscence of the subcutaneous layers. We used a CorMatrix extracellular matrix patch as an adjunct to repair the wound defect. After 7 weeks, the wound had healed with excellent results. To our knowledge, this is the first report of extracellular matrix patch implantation for sternal wound reconstruction in a neonate.
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Parikh R, Eisses M, Latham GJ, Joffe DC, Ross FJ. Perioperative and Anesthetic Considerations in Truncus Arteriosus. Semin Cardiothorac Vasc Anesth 2018; 22:285-293. [PMID: 29808750 DOI: 10.1177/1089253218778826] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Truncus arteriosus is a congenital cardiac lesion in which failure of embryonic truncal septation results in a single semilunar valve and single arterial trunk providing both pulmonary and systemic circulations. Most patients with this lesion are symptomatic in the neonatal period with cyanosis and/or congestive heart failure and undergo complete repair in the first weeks of life. This review will focus on the anatomy, physiology, and perioperative anesthetic management of patients with truncus arteriosus.
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Affiliation(s)
| | - Michael Eisses
- 2 University of Washington, Seattle, WA, USA.,3 Seattle Children's Hospital, Seattle, WA, USA
| | - Gregory J Latham
- 2 University of Washington, Seattle, WA, USA.,3 Seattle Children's Hospital, Seattle, WA, USA
| | - Denise C Joffe
- 2 University of Washington, Seattle, WA, USA.,3 Seattle Children's Hospital, Seattle, WA, USA.,4 University of Washington Medical Center, Seattle, WA, USA
| | - Faith J Ross
- 2 University of Washington, Seattle, WA, USA.,3 Seattle Children's Hospital, Seattle, WA, USA
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Outcomes of Delayed Sternal Closure in Pediatric Heart Surgery: Single-Center Experience. BIOMED RESEARCH INTERNATIONAL 2018; 2018:3742362. [PMID: 29850507 PMCID: PMC5933025 DOI: 10.1155/2018/3742362] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/17/2017] [Accepted: 03/14/2018] [Indexed: 11/18/2022]
Abstract
Background Delayed sternal closure (DSC) after cardiac surgery is a therapeutic option in the treatment of the severely impaired heart in pediatric cardiac surgery. Methods A single-center retrospective review of all bypass surgeries performed over a 10-year period (2003–2012). Results Of a total of 2325 patients registered in our database, the DSC group included 259 cases (11%), and the remaining 2066 cases (89%) constituted the control group (PSC). RACHS-1 risk was higher for the DSC group (74% had a score of 3 or 4) than for the PSC group (82% had a score of 2 or 3). The most frequent diagnosis for the DSC group was transposition of the great arteries (28%). We found out that hemodynamic instability was the main indication observed in patients aged ≤ 8 years (63%), while bleeding was the principal indication for patients aged ≥ 8 years (94%) (p ≤ 0.001). The average time between surgery and sternal closure was 2.3 ± 1.4 days. Overall mortality rates were higher for patients of the DSC group (22%) than for the PSC group (8.7%) (OR: 0.4 (95% CI: 0.4 to 0.5), p < 0.05). There were six patients with DSC who developed mediastinitis (2.3%). The risk of mediastinitis was significantly higher when DSC was performed 4 days after the primary surgery. Conclusions DSC is an important management strategy for congenital cardiac surgery in infants and children. The prolonged sternal closure time is associated with an increased rate of postoperative mediastinitis.
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Durable Benefit of Particle Occlusion of Systemic to Pulmonary Collaterals in Select Patients After Superior Cavopulmonary Connection. Pediatr Cardiol 2018; 39:245-253. [PMID: 28988309 PMCID: PMC5799020 DOI: 10.1007/s00246-017-1748-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/03/2017] [Accepted: 10/04/2017] [Indexed: 10/18/2022]
Abstract
Systemic to pulmonary arterial collaterals (SPC) are commonly found in patients undergoing staged operative palliation for single ventricle heart disease. Occlusion of SPC as part of pre-Fontan catheterization has been shown to improve hemodynamics acutely. Anecdotally, the effect of this intervention appears to be transient, and to our knowledge there is no data supporting its durability in these patients. Between 1/1/2016 and 5/1/2017, 24 children underwent Glenn operations at our institution. Of these, 3 patients had signs and symptoms deteriorating clinical status suggestive of volume overload in the period between their Glenn operation and Fontan completion, prompting heart catheterization. SPC were occluded with a combination of polyvinyl alcohol embolization particles, and in some cases coils or vascular plugs. Clinical course and data from echocardiograms and serial catheterizations are presented. SPC occlusion was performed over 6 procedures in 3 subjects with technical success in each case. Hemodynamic evaluation was repeated in 2/3 patients with improvement in collateral burden and hemodynamics in both cases. One patient previously thought to be unsuitable for Fontan completion improved sufficiently to undergo late Fontan completion, which was ultimately successful. In all patients, there was improvement in clinical status. In patients with severe SPC collateral durable benefit was seen, suggesting that in certain cases intervention on SPC remote from Fontan completion may have clinical benefit.
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Woodward C, Taylor R, Son M, Taeed R, Jacobs ML, Kane L, Jacobs JP, Husain SA. Multicenter Quality Improvement Project to Prevent Sternal Wound Infections in Pediatric Cardiac Surgery Patients. World J Pediatr Congenit Heart Surg 2017; 8:453-459. [PMID: 28696877 DOI: 10.1177/2150135117713741] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND Children undergoing cardiac surgery are at risk for sternal wound infections (SWIs) leading to increased morbidity and mortality. Single-center quality improvement (QI) initiatives have demonstrated decreased infection rates utilizing a bundled approach. This multicenter project was designed to assess the efficacy of a protocolized approach to decrease SWI. METHODS Pediatric cardiac programs joined a collaborative effort to prevent SWI. Programs implemented the protocol, collected compliance data, and provided data points from local clinical registries using Society of Thoracic Surgery Congenital Heart Surgery Database harvest-compliant software or from other registries. RESULTS Nine programs prospectively collected compliance data on 4,198 children. Days between infections were extended from 68.2 days (range: 25-82) to 130 days (range: 43-412). Protocol compliance increased from 76.7% (first quarter) to 91.3% (final quarter). Ninety (1.9%) children developed an SWI preprotocol and 64 (1.5%) postprotocol, P = .18. The 657 (15%) delayed sternal closure patients had a 5% infection rate with 18 (5.7%) in year 1 and 14 (4.3%) in year 2 P = .43. Delayed sternal closure patients demonstrated a trend toward increased risk for SWI of 1.046 for each day the sternum remained open, P = .067. Children who received appropriately timed preop antibiotics developed less infections than those who did not, 1.9% versus 4.1%, P = .007. CONCLUSION A multicenter QI project to reduce pediatric SWIs demonstrated an extension of days between infections and a decrease in SWIs. Patients who received preop antibiotics on time had lower SWI rates than those who did not.
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Affiliation(s)
- Cathy Woodward
- 1 Department of Pediatrics, University of Texas Health Science Center-San Antonio, San Antonio, TX, USA
| | - Richard Taylor
- 1 Department of Pediatrics, University of Texas Health Science Center-San Antonio, San Antonio, TX, USA
| | - Minnette Son
- 1 Department of Pediatrics, University of Texas Health Science Center-San Antonio, San Antonio, TX, USA
| | - Roozbeh Taeed
- 1 Department of Pediatrics, University of Texas Health Science Center-San Antonio, San Antonio, TX, USA
| | - Marshall L Jacobs
- 2 Department of Surgery, Johns Hopkins School of Medicine, Broadway, Baltimore, MD, USA
| | - Lauren Kane
- 3 Division of Congenital Heart Surgery, Baylor College of Medicine, Houston, TX, USA
| | - Jeffrey P Jacobs
- 4 Division of Cardiovascular Surgery, Johns Hopkins All Children's Heart Institute, St Petersburg, FL, USA
| | - S Adil Husain
- 5 Division of Cardiothoracic Surgery, University of Texas Health Science Center-San Antonio, San Antonio, TX, USA
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Jacobs ML, Jacobs JP, Hill KD, Hornik C, O’Brien SM, Pasquali SK, Vener D, Kumar SR, Habib RH, Shahian DM, Edwards FH, Fernandez FG. The Society of Thoracic Surgeons Congenital Heart Surgery Database: 2017 Update on Research. Ann Thorac Surg 2017; 104:731-741. [DOI: 10.1016/j.athoracsur.2017.07.001] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/05/2017] [Accepted: 07/07/2017] [Indexed: 02/04/2023]
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Ing RJ, Twite M, Barrett C. Review of the Society of Thoracic Surgeons Congenital Heart Surgery Database: 2017 Update on Outcomes and Quality Implications for the Anesthesiologist. J Cardiothorac Vasc Anesth 2017; 31:1934-1938. [PMID: 29107588 DOI: 10.1053/j.jvca.2017.06.027] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/30/2017] [Indexed: 11/11/2022]
Affiliation(s)
- Richard J Ing
- Department of Anesthesiology, Children's Hospital Colorado, University of Colorado Anschutz Medical Campus, Aurora, CO.
| | - Mark Twite
- Department of Anesthesiology, Children's Hospital Colorado, University of Colorado Anschutz Medical Campus, Aurora, CO
| | - Cindy Barrett
- Department of Cardiology and Critical Care, Children's Hospital Colorado, University of Colorado Anschutz Medical Campus, Aurora, CO
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Perioperative antibiotics in pediatric cardiac surgery: protocol for a systematic review. Syst Rev 2017; 6:107. [PMID: 28558846 PMCID: PMC5450342 DOI: 10.1186/s13643-017-0502-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/08/2017] [Accepted: 05/18/2017] [Indexed: 12/05/2022] Open
Abstract
BACKGROUND Post-operative infections in pediatric cardiac surgery are an ongoing clinical challenge, with rates between 1 and 20%. Perioperative antibiotics remain the standard for prevention of surgical-site infections, but the type of antibiotic and duration of administration remain poorly defined. Current levels of practice variation through informal surveys are very high. Rates of antibiotic-resistant organisms are increasing steadily around the world. METHODS/DESIGN We will identify all controlled observational studies and randomized controlled trials examining prophylactic antibiotic use in pediatric cardiac surgery. Data sources will include MEDLINE, EMBASE, CENTRAL, and proceedings from recent relevant scientific meetings. For each included study, we will conduct duplicate independent data extraction, risk of bias assessment, and evaluation of quality of evidence using the GRADE approach. DISCUSSION We will report the results of this review in agreement with the PRISMA statement and disseminate our findings at relevant critical care and cardiology conferences and through publication in peer-reviewed journals. We will use this systematic review to inform clinical guidelines, which will be disseminated in a separate stand-alone publication. STUDY REGISTRATION NUMBER PROSPERO CRD42016052978C.
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