Ventilator-associated pneumonia is an important risk factor for mortality after major cardiac surgery

Risk Factors, Pathogens, and Outcomes of Ventilator-Associated Pneumonia in Non-Cardiac Surgical Patients: A Retrospective Analysis

Ventilator-associated pneumonia (VAP) is a critical hospital-acquired infection following non-cardiac surgeries, leading to poor outcomes. This study identifies VAP risk factors in non-cardiac surgical patients and determines the causative pathogens. A retrospective analysis with 1:4 propensity-score matching was conducted on patients in a surgical intensive care unit (ICU) from 2010 to 2020 at a private tertiary medical center. Among 99 VAP patients, the mortality rate was 64.7%. VAP risk factors included prolonged mechanical ventilation (odds ratio [OR] 6.435; p < 0.001), repeat intubation (OR 6.438; p < 0.001), lower oxygenation levels upon ICU admission (OR 0.950; p < 0.001), and undergoing gastrointestinal surgery (OR 2.257; p = 0.021). The 30-day mortality risk factors in the VAP group were late-onset VAP (OR 3.450; p = 0.022), inappropriate antibiotic treatment (OR 4.083; p = 0.041), and undergoing gastrointestinal surgeries (OR 4.776; p = 0.019). Nearly half of the Gram-negative infections were resistant strains, and a third were polymicrobial infections. Non-cardiac surgical patients with VAP face adverse hospital outcomes. Identifying high-risk patients and understanding VAP's resistant and microbial nature are crucial for appropriate treatment and improved health outcomes.

Influence of Renal Dysfunction on the Differential Behaviour of Procalcitonin for the Diagnosis of Postoperative Infection in Cardiac Surgery

Background: procalcitonin is a valuable marker in the diagnosis of bacterial infections; however, the impairment of renal function can influence its diagnostic precision. The objective of this study is to evaluate the differential behaviour of procalcitonin, as well as its usefulness in the diagnosis of postoperative pulmonary infection after cardiac surgery, depending on the presence or absence of impaired renal function. Materials and methods: A total of 805 adult patients undergoing cardiac surgery with extracorporeal circulation (CBP) were prospectively recruited, comparing the behaviour of biomarkers between the groups with and without postoperative pneumonia and according to the presence or absence of renal dysfunction. Results: Pulmonary infection was diagnosed in 42 patients (5.21%). In total, 228 patients (28.32%) presented postoperative renal dysfunction. Procalcitonin was significantly higher in infected patients, even in the presence of renal dysfunction. The optimal procalcitonin threshold differed markedly in patients with renal dysfunction compared to patients without renal dysfunction (1 vs. 0.78 ng/mL p < 0.05). The diagnostic accuracy of procalcitonin increased significantly when the procalcitonin threshold was adapted to renal function. Conclusions: Procalcitonin is an accurate marker of postoperative infection in cardiac surgery, even in the presence of renal dysfunction. Renal function is an important determinant of procalcitonin levels and, therefore, its diagnostic thresholds must be adapted in the presence of renal dysfunction.

Sex Disparities in Failure to Rescue After Cardiac Surgery in California and New York

BACKGROUND

Women have a higher risk of mortality than men after cardiac surgery independent of other risk factors. The reason for this may not be limited to patient-specific variables. Failure to rescue (FTR) patients from death after a postoperative complication is a nationally endorsed quality care metric. We aimed to identify whether sex disparities exist in the quality of care after cardiac surgery using FTR rates.

METHODS

A retrospective analysis of 30 973 men (70.4%) and 13 033 women (29.6%) aged over 18 years undergoing coronary artery bypass graft or valve surgery in New York (2016-2019) and California (2016-2018) who experienced at least one serious postoperative complication. The primary outcome was the FTR. Multivariable logistic regression was used to identify predictors of death after complication. Propensity matching was used to adjust for baseline differences between sexes and yielded 12 657 pairs.

RESULTS

Female patients that experienced complications were older (mean age 67.8 versus 66.7, P<0.001), more frail (median frailty score 0.1 versus 0.07, P<0.001), and had more comorbidities (median Charlson score 2.5 versus 2.3, P<0.001) than male patients. The overall FTR rate was 5.7% (2524), men were less likely to die after a complication than women (4.8% versus 8%, P<0.001). Independent predictors of FTR included female sex (relative risk [RR]: 1.46 [CI, 1.30-1.62]), area-level poverty rate >20% (RR, 1.21 [CI, 1.01-1.59]), higher frailty (RR, 2.83 [CI, 1.35-5.93]), undergoing concomitant coronary artery bypass graft and valve surgeries (RR, 1.69 [CI, 1.49-1.9]), and higher number of postoperative complications (RR, 16.28 [CI, 14-18.89]). In the propensity-matched cohorts, the FTR rate remained significantly lower among men than women (6.0% versus 8.0%, P<0.001).

CONCLUSIONS

Women are less likely to be rescued from death following postoperative complications, independent of socioeconomic and clinical characteristics. Further research is warranted to investigate the clinical practices contributing to this disparity in quality of care following cardiac surgery.

Risk factors for ventilator-associated pneumonia due to multi-drug resistant organisms after cardiac surgery in adults

Background

Ventilator-associated pneumonia (VAP) is one of the most common intensive care unit (ICU)-acquired infections, which can cause multiple adverse events. Due to bacterial mutation and overuse of antimicrobial drugs, multidrug-resistant organisms (MDRO) has become one of the major causes of postoperative VAP infections in cardiac patients. Therefore, this study aims to explore the risk factors for VAP with MDRO following cardiac surgery in adults.

Methods

The clinical data of adult VAP patients following cardiac surgery in the hospital from Jan 2017 to May 2021 were analyzed retrospectively, and the patients were divided into the MDRO VAP group and the non-MDRO VAP group. Univariable and multivariable logistic regression analyses were performed on risk factors in patients with MDRO VAP. The species and drug sensitivity of pathogens isolated from the VAP patients were also analyzed.

Results

A total of 61 VAP cases were involved in this study, with 34 cases in the MDRO VAP group (55.7%) and 27 cases in the non-MDRO VAP group (44.3%). Multivariable logistic regression analysis showed that independent risk factors for MDRO VAP included preoperative creatinine clearance rate (CCR) ≥ 86.6ml, intraoperative cardiopulmonary bypass (CPB) time ≥ 151 min, postoperative acute kidney injury (AKI) and nasal feeding. Gram-negative bacilli were the main pathogens in VAP patients (n = 54, 90.0%), with the highest rate of Acinetobacter baumannii (n = 24, 40.0%). Additionally, patients with MDRO VAP had a significantly longer postoperative intensive care unit (ICU) duration and higher hospitalization costs than non-MDRO VAP patients, but there was no notable difference in the 28-day mortality rate between the two groups.

Conclusion

Based on implementing measures to prevent VAP, clinicians should pay more attention to patients with kidney disease, longer intraoperative CPB time, and postoperative nasal feeding to avoid MDRO infections.

Pneumonia After Cardiovascular Surgery: Incidence, Risk Factors and Interventions

Postoperative pneumonia (POP) is prevalent in patients undergoing cardiovascular surgery, associated with poor clinical outcomes, prolonged hospital stay and increased medical costs. This article aims to clarify the incidence, risk factors, and interventions for POP after cardiovascular surgery. A comprehensive literature search was performed to identify previous reports involving POP after cardiovascular surgery. Current situation, predictors and preventive measures on the development of POP were collected and summarized. Many studies showed that POP was prevalent in various cardiovascular surgical types, and predictors varied in different studies, including advanced age, smoking, chronic lung disease, chronic kidney disease, cardiac surgery history, cardiac function, anemia, body mass index, diabetes mellitus, surgical types, cardiopulmonary bypass time, blood transfusion, duration of mechanical ventilation, repeated endotracheal intubation, and some other risk factors. At the same time, several targeted interventions have been widely reported to be effective to reduce the risk of POP and improve prognosis, including preoperative respiratory physiotherapy, oral care and subglottic secretion drainage. Through the review of the current status, risk factors and intervention measures, this article may play an important role in clinical prevention and treatment of POP after cardiovascular surgery.

Development and Validation of Nomogram Models for Postoperative Pneumonia in Adult Patients Undergoing Elective Cardiac Surgery

Background: Postoperative pneumonia (POP) is a frequent complication following cardiac surgery, related to increased morbidity, mortality and healthcare costs. The objectives of this study were to investigate the risk factors associated with POP in adults undergoing elective cardiac surgery and to develop and validate nomogram models.

Methods: We conducted a multicenter retrospective study in four cardiac centers in China. Adults operated with elective open-heart surgery from 2016 to 2020 were included. Patients were randomly allocated to training and validation sets by 7:3 ratio. Demographics, comorbidities, laboratory data, surgical factors, and postoperative outcomes were collected and analyzed. Risk factors for POP were identified by univariate and multivariate analysis. Nomograms were constructed based on the multivariate logistic regression models and were evaluated with calibration, discrimination and decision curve analysis.

Results: A total of 13,380 patients meeting the criteria were included and POP developed in 882 patients (6.6%). The mortality was 2.0%, but it increased significantly in patients with POP (25.1 vs. 0.4%, P < 0.001). Using preoperative and intraoperative variables, we constructed a full nomogram model based on ten independent risk factors and a preoperative nomogram model based on eight preoperative factors. Both nomograms demonstrated good calibration, discrimination, and were well validated. The decision curves indicated significant clinical usefulness. Finally, four risk intervals were defined for better clinical application.

Conclusions: We developed and validated two nomogram models for POP following elective cardiac surgery using preoperative and intraoperative factors, which may be helpful for individualized risk evaluation and prevention decisions.

Plasma and Lung Tissue Pharmacokinetics of Ceftaroline Fosamil in Patients Undergoing Cardiac Surgery with Cardiopulmonary Bypass: an In Vivo Microdialysis Study

Ceftaroline fosamil, a fifth-generation cephalosporin antibiotic with activity against methicillin-resistant Staphylococcus aureus (MRSA), is currently approved for the treatment of pneumonia and complicated skin and soft tissue infections. However, pharmacokinetics data on free lung tissue concentrations in critical patient populations are lacking. The aim of this study was to evaluate the pharmacokinetics of the high-dose regimen of ceftaroline in plasma and lung tissue in cardiac surgery patients during intermittent and continuous administration. Nine patients undergoing elective cardiac surgery on cardiopulmonary bypass were included in this study and randomly assigned to intermittent or continuous administration. Eighteen hundred milligrams of ceftaroline fosamil was administered intravenously as either 600 mg over 2 h every 8 h (q8h) (intermittent group) or 600 mg over 2 h (loading dose) plus 1,200 mg over 22 h (continuous group). Interstitial lung tissue concentrations were measured by in vivo microdialysis. Relevant pharmacokinetics parameters were calculated for each group. Plasma exposure levels during intermittent and continuous administration were comparable to those of previously published studies and did not differ significantly between the two groups. In vivo microdialysis demonstrated reliable and adequate penetration of ceftaroline into lung tissue during intermittent and continuous administration. The steady-state area under the concentration-time curve from 0 to 8 h (AUCss 0-8) and the ratio of AUCSS 0-8 in lung tissue and AUC in plasma (AUClung/plasma) were descriptively higher in the continuous group. Continuous administration of ceftaroline fosamil achieved a significantly higher proportion of time for which the free drug concentration remained above 4 times the minimal inhibitory concentration (MIC) during the dosing interval (% fT>4xMIC) than intermittent administration for pathogens with a MIC of 1 mg/liter. Ceftaroline showed adequate penetration into interstitial lung tissue of critically ill patients undergoing major cardiothoracic surgery, supporting its use for pneumonia caused by susceptible pathogens.

Clinical risk score for postoperative pneumonia following heart valve surgery

Background:

Postoperative pneumonia (POP) is one of the most common infections following heart valve surgery (HVS) and is associated with a significant increase in morbidity, mortality, and health care costs. This study aimed to identify the major risk factors associated with the occurrence of POP following HVS and to derive and validate a clinical risk score.

Methods:

Adults undergoing open HVS between January 2016 and December 2019 at a single institution were enrolled in this study. Patients were randomly assigned to the derivation and validation sets at 1:1 ratio. A prediction model was developed with multivariable logistic regression analysis in the derivation set. Points were assigned to independent risk factors based on their regression coefficients.

Results:

POP occurred in 316 of the 3853 patients (8.2%). Multivariable analysis identified ten significant predictors for POP in the derivation set, including older age, smoking history, chronic obstructive pulmonary disease, diabetes mellitus, renal insufficiency, poor cardiac function, heart surgery history, longer cardiopulmonary bypass, blood transfusion, and concomitant coronary and/or aortic surgery. A 22-point risk score based on the multivariable model was then generated, demonstrating good discrimination (C-statistic: 0.81), and calibration (Hosmer-Lemeshow χ² = 8.234, P = 0.312). The prediction rule also showed adequate discriminative power (C-statistic: 0.83) and calibration (Hosmer-Lemeshow χ² = 5.606, P = 0.691) in the validation set. Three risk intervals were defined as low-, medium-, and high-risk groups.

Conclusion:

We derived and validated a 22-point risk score for POP following HVS, which may be useful in preventive interventions and risk management.

Trial Registration:

Chictr.org, ChiCTR1900028127; http://www.chictr.org.cn/showproj.aspx?proj=46932

Risk factors for postoperative pneumonia after cardiac surgery: a prediction model

Background

Postoperative pneumonia is the main infectious complication following cardiac surgery and is associated with significant increases in morbidity, mortality and health care costs. The aim of this study was to identify potential risk factors related to the occurrence of postoperative pneumonia in adult patients undergoing cardiac surgery and to develop a predictive system.

Methods

Adult patients who underwent open heart surgery in our institution between 2016 and 2019 were enrolled in this study. Preoperative and intraoperative variables were collected and analyzed. A multivariate prediction model for evaluating the risk of postoperative pneumonia was established using logistic regression analysis via forward stepwise selection, and points were assigned to significant risk factors based on their regression coefficient values.

Results

Postoperative pneumonia occurred in 530 of the 5,323 patients (9.96%). Prolonged stays in the postoperative intensive care unit (ICU) and hospital, as well as higher mortality (25.66% versus 0.65%), were observed in patients with postoperative pneumonia. Multivariate analysis identified 13 independent risk factors including patient demographics, comorbidities, cardiac function, cardiopulmonary bypass (CPB) duration, and blood transfusion. The prediction model showed good discrimination (C-statistic: 0.80) and was well calibrated (Hosmer-Lemeshow χ²=7.907, P value =0.443). A 32-point risk score was generated, and then three risk intervals were defined.

Conclusions

We derived and validated a prediction model for postoperative pneumonia after cardiac surgery incorporating 13 easily discernible risk factors. The scoring system may be helpful for individualized risk estimations and clinical decision-making.

Postoperative Pneumonia Following Open Heart Surgery

Objectives

This study aimed to measure the incidence and record the relations between risk factors of postoperative pneumonia (POP) among patients who underwent open heart surgery in a single hospital in Saudi Arabia. 

Methods

This retrospective cohort study was conducted in June 2019 at King Abdulaziz University hospital in Saudi Arabia. Data including general information, comorbidities, lab investigations, preoperative risk factors, intraoperative considerations, and postoperative elements were collected and analyzed.

Results

A total of 255 cardiac surgeries were performed from November 2014 to June 2019. Two hundred of the 255 cardiac surgeries were analyzed as open-heart surgeries. Only five patients were diagnosed with POP after open heart surgery with an incidence of 2.5%. The mean age of these patients was 47±18 years, more than half of them were smokers, three were hypertensive, four were classified as ASA 4, and three underwent the operation electively. The mean bypass time was 100.3 ± 24.5 min, the mean duration of operation was 199 ± 86.2 min, the mean postoperative intensive care unit (ICU) stay was 97.4 ± 83.4 hours, and the mean overall hospital stay was 10.4 ± 7.2 days. We observed significant differences in only the following correlations: amount of blood transfusion with ICU stay and with the overall hospital stay.

Conclusion

The incidence of developing postoperative pneumonia in patients undergoing open heart surgery in the King Abdulaziz University hospital from November 2014 to June 2019 was 2.5%, indicating a high-quality level of surgical technique and proper infection control.

"Risk factors for ventilator-associated pneumonia following cardiac surgery: case-control study"

BACKGROUND

Ventilator-associated pneumonia (VAP) following cardiac surgery is a preventable complication associated with adverse outcomes.

AIMS

We aimed to assess risk factors and outcomes of VAP following cardiac surgery.

METHODS

A matched 1:3 case:control study, including adult patients undergoing cardiac surgery through sternotomy between Sep-2014 to Mar-2017 was conducted in a tertiary-care hospital in Israel. Cases included all patients developing VAP within 30 days after surgery, defined using consensus criteria. Controls were matched for age, gender and surgery type. Operative data were collected prospectively, other data were collected retrospectively. Cox regression was used for adjusted analysis of matched data.

FINDINGS

Out of 946 operated patients, we identified 57 patients with VAP after cardiac surgery (17.7 episodes per 1000 ventilator-days) matched to 149 controls. Significant independent risk factors for VAP included congestive heart failure (OR 2.357 95%CI 1.052-5.281), Chest re-exploration in ICU (OR 10.213 95%CI: 2.235-46.678), preoperative glucose levels (OR 1.1010 per 1 mg/dl increase 95%CI: 1.004-1.019) intraoperative red blood cell transfusions (OR 1.542 per 1 unit 95%CI: 1.109-2.094) and pulmonary hypertension (OR 2.261 95%CI 1.048-6.554). VAP was most commonly caused by Gram-negative pathogens. VAP was associated with higher mortality, longer length of stay, longer need for ventilator support and longer stay in ICU setting.

CONCLUSIONS

Postoperative VAP in cardiac surgery patients is associated with severe clinical outcomes. We identified risk factors that can aid in preventive measures implementation for high risk patients.

Gradient diffusion antibiogram used directly on bronchial aspirates for a rapid diagnosis of ventilator-associated pneumonia

Background

In patients with suspected ventilator-associated pneumonia, a rapid etiological diagnosis is crucial as incorrect or delayed treatment in the first few hours leads to a worse prognosis and a higher mortality rate. This study examines the efficacy of a rapid antibiogram on bronchial aspirates in patients with suspected ventilator-associated pneumonia (VAP).

Methods

The direct gradient diffusion susceptibility testing method (GDM) on respiratory samples was compared with a standard broth microdilution method (BMD) after quantitative cultures in patients with suspicion of VAP. Samples were preselected by Gram staining (for good quality microbiological samples with a predominant single bacterial morphotype). The antibiotics tested were ceftazidime, ceftobiprole, ceftolozane-tazobactam, meropenem, doripenem, and tedizolid.

Results

Over a 16-month study period, 445 bronchial aspirate samples were selected from 1376 samples received at our laboratory from 672 adult patients. By direct plating on Mueller-Hinton agar, we recovered 504 (95.5%) of the 528 microorganisms identified by the standard semiquantitative method. Antimicrobial susceptibility testing by GDM was compared with the BMD method in 472 strains (216 Enterobacteriaceae, 138 P. aeruginosa and 118 S. aureus.) and 1652 individual microorganism-antimicrobial agent combinations. There was total agreement between both methods in 98% of combinations. The Kappa index between both techniques was excellent (over 80%). There was only one potential major error for P. aeruginosa susceptibility to ceftazidime.

Conclusions

The six GDM strips directly placed on plated bronchial aspirates obtained from patients with a suspicion of VAP provided accurate and reliable susceptibility results within 24 h.

Prophylactic Noninvasive Ventilation Versus Conventional Care in Patients After Cardiac Surgery

BACKGROUND

Cardiac surgery can be accompanied by postoperative complications, which are associated with increased postoperative morbidity and mortality. Therefore, it is necessary to investigate the effect of prophylactic noninvasive ventilation (NIV) after extubation versus conventional pulmonary care on complications after cardiac surgery.

MATERIALS AND METHODS

An electronic search of PubMed, Cochrane Library, Ovid, and EMBASE was conducted to find randomized controlled trials which compared the effect of prophylactic NIV with controlled strategies on complications and which were published before April 2018.

RESULTS

Ten studies (1011 patients) were included in the final analysis. The atelectasis rate was 32.6% in the prophylactic-NIV group, which was lower than that in the control group (48.71%). Prophylactic NIV could lower the rate of atelectasis, reintubation, and other respiratory complications (pleural effusion, pneumonia, and hypoxia) (odds ratio = 0.43, 0.33, and 0.45; 95% confidence interval: 0.21-0.88, 0. 13-0.84, 0.27-0.75; P = 0.02, 0.02, and 0.002, respectively). The effect on cardiac and distal organ complications (P = 0.07) and hospital mortality (P = 0.62) might be limited.

CONCLUSIONS

Prophylactic NIV is associated with a lower rate of postoperative pulmonary complications. The effect on the other complications and hospital mortality might be limited. Further evidence with randomized controlled trials can discern the benefits.

The Overlooked Immune State in Candidemia: A Risk Factor for Mortality

Lymphopenia has been related to increased mortality in septic patients. Nonetheless, the impact of lymphocyte count on candidemia mortality and prognosis has not been addressed. We conducted a retrospective study, including all admitted patients with candidemia from 2007 to 2016. We examined lymphocyte counts during the first 5 days following the diagnosis of candidemia. Multivariable logistic regression analysis was performed to determine the relationship between lymphocyte count and mortality. Classification and Regression Tree analysis was used to identify the best cut-off of lymphocyte count for mortality associated with candidemia. From 296 cases of candidemia, 115 died, (39.8% 30-day mortality). Low lymphocyte count was related to mortality and poor outcome (p < 0.001). Lymphocyte counts <0.703 × 10⁹ cells/L at diagnosis (area under the curve (AUC)-ROC, 0.783 ± 0.042; 95% confidence interval (CI), 0.700-0.867, p < 0.001), and lymphocyte count <1.272 × 10⁹ cells/L five days later (AUC-ROC, 0.791 ± 0.038; 95%CI, 0.716-0.866, p < 0.001) increased the odds of mortality five-fold (odds ratio (OR), 5.01; 95%CI, 2.39-10.93) at time of diagnosis, and three-fold (OR, 3.27; 95%CI, 1.24-8.62) by day 5, respectively. Low lymphocyte count is an independent predictor of mortality in patients with candidemia and might serve as a biomarker for predicting candidemia-associated mortality and poor outcome.

Predictive value of C-reactive protein and the Pediatric Risk of Mortality III Score for occurrence of postoperative ventilator-associated pneumonia in pediatric patients with congenital heart disease

IMPORTANCE

Ventilator-associated pneumonia (VAP) is one of the most common complications after cardiac surgery in children with congenital heart disease (CHD). Early prediction of the incidence of VAP is important for clinical prevention and treatment.

OBJECTIVE

To determine the value of serum C-reactive protein (CRP) levels and the Pediatric Risk of Mortality III (PRISM III) score in predicting the risk of postoperative VAP in pediatric patients with CHD.

METHODS

We performed a retrospective review of clinical data of 481 pediatric patients with CHD who were admitted to our pediatric intensive care unit. These patients received mechanical ventilation for 48 hours or longer after corrective surgery. On the basis of their clinical manifestations and laboratory results, patients were separated into two groups of those with VAP and those without VAP. CRP levels were measured and PRISM III scores were collected within 12 hours of admission to the pediatric intensive care unit. The Pearson correlation coefficient was used to evaluate the association of CRP levels and the PRISM score with the occurrence of postoperative VAP. A linear regression model was constructed to obtain a joint function and receiver operating curves were used to assess the predictive value.

RESULTS

CRP levels and the PRISM III score in the VAP group were significantly higher than those in the non-VAP group (P < 0.05). Receiver operating curves suggested that using CRP + the PRISM III score to predict the incidence of VAP after congenial heart surgery was more accurate than using either of them alone (CRP + the PRISM III score: sensitivity: 53.2%, specificity: 85.7%). When CRP + the PRISM III score was greater than 45.460, patients were more likely to have VAP.

INTERPRETATION

Although using CRP levels plus the PRISM III score to predict the incidence of VAP after congenial heart surgery is more accurate than using either of them alone, its predictive value is still limited.

The relationship between ventilator-associated pneumonia and chronic obstructive pulmonary disease: what is the current evidence?

Chronic obstructive pulmonary disease (COPD) affects approximately 65 million people from which > 25% will require intensive care unit (ICU) admission. Ventilator-associated pneumonia (VAP) is the commonest ICU infection and results in increased morbidity/mortality and costs. The literature on the interaction between COPD and VAP is scarce and controversial. The project aimed to search the literature in order to address the following: (i) Is COPD a risk factor for VAP development? (ii) Does COPD impact the outcome of patients with VAP? (iii) Does VAP development impact the outcome of COPD patients? (iv) Does COPD impact the aetiology of VAP? Current evidence on the topic is controversial. Regarding the impact of VAP on COPD patients, the majority of the existing limited number of studies suggests that VAP development results in higher mortality and longer duration of mechanical ventilation and ICU stay. Also, the majority of the studies exploring the impact of COPD on VAP outcomes suggest that COPD is independently associated with a decrease in survival, although the number of such studies is limited. Regarding the aetiology, Pseudomonas aeruginosa is the most frequent pathogen in VAP patients with COPD. Noteworthy, one study suggests that P. aeruginosa is higher in COPD patients even in the early-onset VAP subgroup. This manuscript provides a comprehensive overview of the available literature on the interaction between COPD and VAP, highlighting the differences and limitations that may have led to controversial results, and it may act as a platform for further research with important clinical implications.

Postoperative kidney oxygen saturation as a novel marker for acute kidney injury after adult cardiac surgery

OBJECTIVE

Acute kidney injury is a severe complication and one of the stronger risk factors for death in patients undergoing cardiac surgery. The relationship between postoperative brain oxygen saturation and kidney oxygen saturation with acute kidney injury in adults undergoing cardiac surgery has not been determined. We designed a single-center prospective study to determine if the continuous monitoring of postoperative brain oxygen saturation and kidney oxygen saturation could predict postoperative acute kidney injury.

METHODS

We conducted a prospective open cohort study from January to September 2017. The primary outcome was postoperative acute kidney injury using the Kidney Disease: Improving Global Outcomes criteria. Brain oxygen saturation and kidney oxygen saturation, the metrics of which were area measurements (%-min), were recorded during the surgery and the first 48 hours after the cardiac procedure. Receiver operating characteristic curve analysis was used to evaluate the predictive power of kidney oxygen saturation for acute kidney injury.

RESULTS

A total of 121 consecutive patients were enrolled. Thirty-five patients (28.9%) developed acute kidney injury. Brain oxygen saturation showed no statistical difference in both groups; however, kidney oxygen saturation was related to acute kidney injury (P = .001). Receiver operating characteristic curve analysis showed that kidney oxygen saturation could predict the risk of acute kidney injury. Kidney oxygen saturation less than 65% (area under the curve-receiver operating characteristic, 0.679 ± 0.054, 95% confidence interval, 0.573-0.785, P = .002) and 20% decrease from baseline (area under the curve-receiver operating characteristic, 0.639 ± 0.059, 95% confidence interval, 0.523-0.755, P = .019) showed the better performance, respectively.

CONCLUSIONS

Postoperative kidney oxygen saturation is related to the development of cardiac surgery-associated acute kidney injury. Continuous kidney saturation monitoring might be a promising, noninvasive tool for predicting acute kidney injury during the postoperative period for adult patients after cardiac surgery.

Impact of an ultraviolet air sterilizer on cardiac surgery patients, a randomized clinical trial

BACKGROUND

Numerous studies have evaluated the use of ultraviolet-C devices for terminal disinfection in hospitals, however, to date there is little information about the device's final impact on patients. We investigated the effect of an ultraviolet air sterilizer (UVAS) on the clinical outcomes of cardiac surgery patients.

MATERIALS AND METHODS

This random, prospective and non-interventional study included 1097 adult patients undergoing elective cardiac surgery: 522 stayed in an ICU room with UVAS (Medixair^®) and 575 patients ICU room without UVAS and were used as a control. The primary outcome measure was to evaluate the effect of a UVAS on the overall prevalence of nosocomial infections in postoperative cardiac patients in ICUs.

RESULTS

No significant differences in ventilator-associated pneumonia (4.6% vs. 5.0%, p=0.77) and total infection (14.0% vs. 15.5%, p=0.45) rates were detected in patients with and without the UVAS. The length of stay in the intensive care unit and at the hospital was similar in both groups, UVAS (4.6 (8.2) days and 18.3 (5.5) days) and without UVAS (4.6 (7.3) days and 19.2 (18.6) days). The 30-day in-hospital mortality rate was 5.3%, no significant differences between groups were observed (p=0.053).

CONCLUSION

Novel ultraviolet-C technology has not been shown to significantly reduce nosocomial infections or mortality rates in cardiac surgery patients.

World-Wide Variation in Incidence of Staphylococcus aureus Associated Ventilator-Associated Pneumonia: A Meta-Regression

Staphylococcus aureus (S. aureus) is a common Ventilator-Associated Pneumonia (VAP) isolate. The objective here is to define the extent and possible reasons for geographic variation in the incidences of S. aureus-associated VAP, MRSA-VAP and overall VAP. A meta-regression model of S. aureus-associated VAP incidence per 1000 Mechanical Ventilation Days (MVD) was undertaken using random effects methods among publications obtained from a search of the English language literature. This model incorporated group level factors such as admission to a trauma ICU, year of publication and use of bronchoscopic sampling towards VAP diagnosis. The search identified 133 publications from seven worldwide regions published over three decades. The summary S. aureus-associated VAP incidence was 4.5 (3.9–5.3) per 1000 MVD. The highest S. aureus-associated VAP incidence is amongst reports from the Mediterranean (mean; 95% confidence interval; 6.1; 4.1–8.5) versus that from Asian ICUs (2.1; 1.5–3.0). The incidence of S. aureus-associated VAP varies by up to three-fold (for the lowest versus highest incidence) among seven geographic regions worldwide, whereas the incidence of VAP varies by less than two-fold. Admission to a trauma unit is the most important group level correlate for S. aureus-associated VAP.

Procalcitonin and white blood cells, combined predictors of infection in cardiac surgery patients

BACKGROUND

Sepsis is strongly associated with an increased risk of postoperative mortality, longer length of hospital stay, and elevated health care costs. Early clinical symptoms overlap with those of systemic inflammatory response syndrome, a response that commonly occurs after cardiac surgery with cardiopulmonary bypass. Since a combination of biomarkers has been demonstrated to improve the prediction of postoperative infection, the objective of the present study was to test whether the combination of C-reactive protein (CRP), white blood cells (WBC), and procalcitonin (PCT) is able to predict postoperative infection in a large cohort of cardiac surgery patients.

MATERIAL AND METHODS

Case-control study involving 423 patients who underwent cardiac surgery with cardiopulmonary bypass. Patients were retrospectively classified into two groups based on whether they developed severe sepsis or septic shock during the postoperative period. Blood samples for biological measurements (PCT, CRP, and WBC) were drawn on the first day in the intensive care unit, then once daily in the morning until the 10th postoperative day.

RESULTS

CRP median values were similar in both groups. WBC and PCT median values were significantly higher in patients with infection than without during the first 10 postoperative days. With elevation cutoffs ≤3 times (OR: 4.058; 95% CI: 2.206-7.463; P = 0.001) and ≥4 times (OR: 10.274, 95% CI: 3.690-28.604; P < 0.001), the median value for PCT (1.7 ng/mL) and/or WBC (13,000 cells/mm³) on the second postoperative day was significantly associated with the development of infection.

CONCLUSIONS

The goal of this study was to use a large cohort of cardiac surgery patients to ensure that the results were representative of this population. The combination of PCT and WBC levels over the first three postoperative days was able to predict postoperative infection within the 30 d following cardiac surgery.

World-wide variation in incidence of Acinetobacter associated ventilator associated pneumonia: a meta-regression

Background

Acinetobacter species such as Acinetobacter baumanii are of increasing concern in association with ventilator associated pneumonia (VAP). In the ICU, Acinetobacter infections are known to be subject to seasonal variation but the extent of geographic variation is unclear. The objective here is to define the extent and possible reasons for geographic variation for Acinetobacter associated VAP whether or not these isolates are reported as Acinetobacter baumanii.

Methods

A meta-regression model of VAP associated Acinetobacter incidence within the published literature was undertaken using random effects methods. This model incorporated group level factors such as proportion of trauma admissions, year of publication and reporting practices for Acinetobacter infection.

Results

The search identified 117 studies from seven worldwide regions over 29 years. There is significant variation in Acinetobacter species associated VAP incidence among seven world-wide regions. The highest incidence is amongst reports from the Middle East (mean; 95 % confidence interval; 8.8; 6 · 2–12 · 7 per 1000 mechanical ventilation days) versus that from North American ICU’s (1 · 2; 0 · 8–2 · 1). There is a similar geographic related disparity in incidence among studies reporting specifically as Acinetobacter baumanii. The incidence in ICU’s with a majority of admission being for trauma is >2.5 times that of other ICU’s.

Conclusion

There is greater than fivefold variation in Acinetobacter associated VAP among reports from various geographic regions worldwide. This variation is not explainable by variations in rates of VAP overall, admissions for trauma, publication year or Acinetobacter reporting practices as group level variables.

Electronic supplementary material

The online version of this article (doi:10.1186/s12879-016-1921-4) contains supplementary material, which is available to authorized users.

Pneumonia after Major Cancer Surgery: Temporal Trends and Patterns of Care

Rationale. Pneumonia is a leading cause of postoperative complication. Objective. To examine trends, factors, and mortality of postoperative pneumonia following major cancer surgery (MCS). Methods. From 1999 to 2009, patients undergoing major forms of MCS were identified using the Nationwide Inpatient Sample (NIS), a Healthcare Cost and Utilization Project (HCUP) subset, resulting in weighted 2,508,916 patients. Measurements. Determinants were examined using logistic regression analysis adjusted for clustering using generalized estimating equations. Results. From 1999 to 2009, 87,867 patients experienced pneumonia following MCS and prevalence increased by 29.7%. The estimated annual percent change (EAPC) of mortality after MCS was −2.4% (95% CI: −2.9 to −2.0, P < 0.001); the EAPC of mortality associated with pneumonia after MCS was −2.2% (95% CI: −3.6 to 0.9, P = 0.01). Characteristics associated with higher odds of pneumonia included older age, male, comorbidities, nonprivate insurance, lower income, hospital volume, urban, Northeast region, and nonteaching status. Pneumonia conferred a 6.3-fold higher odd of mortality. Conclusions. Increasing prevalence of pneumonia after MCS, associated with stable mortality rates, may result from either increased diagnosis or more stringent coding. We identified characteristics associated with pneumonia after MCS which could help identify at-risk patients in order to reduce pneumonia after MCS, as it greatly increases the odds of mortality.

[Mortality from postoperative complications (failure to rescue) after cardiac surgery in a university hospital]

OBJECTIVE

This study analyses the rate of post-operative complications after cardiac surgery, the incidence of the failure to rescue (FR), and the relationship between complications and survival.

METHODS

The study included a total of 2,750 adult patients operated of cardiac surgery between January 2003 and December 2009. An analysis was made of 9 post-operative complications. Multiple logistic regression analysis was used to find independent variables associated with any of the selected complications. Survival was analysed with Kaplan-Meyer survival estimates. A risk-adjusted Cox proportional regression model was used to find out which complications were associated with mid-term survival.

RESULTS

Hospital mortality rate was 1.4% (95% CI: 1.0%-1.9%). Postoperative complications rate was 38.5% (36.7%-40.4%), and FR 3.6% (2.5%-4.9%). Urgent surgery (OR = 2.03; 1.52-2.72), chronic renal failure (OR = 1.50, 95%.CI: 1.25-1.80), and age ≥70 years (OR = 1.42; 1.20-1.68) were the variables that showed the highest strength of association with the selected complications. Survival at 5 years in the group of patients without complications was 93%, and in the group of patients with complications it was 83% (P<.0001). Postoperative complications associated with mid-term survival were pneumonia (HR = 2.6, 95% CI; 1.27-5.50), acute myocardial infarction (HR = 1.9; 1.10-2.30), and acute renal failure (HR = 1.7; 1.30-2.26).

CONCLUSIONS

The incidence of complications after cardiac surgery is around 40%, and was associated with an increase in hospital mortality, although FR was very low (3.6%; 95% CI: 2.5-4.9).

Impact of ventilator-associated pneumonia on mortality and epidemiological features of patients with secondary peritonitis

Background

Despite the significant impact of nosocomial infections on the morbidity and mortality of patients staying in the intensive care unit (ICU), no study over the past 20 years has focused specifically on VAP following secondary peritonitis. The objective of the present study was to determine in-hospital mortality and epidemiological features attributed to ventilator-associated pneumonia (VAP) following secondary peritonitis.

Methods

Prospective observational study involved 418 consecutive patients admitted in the ICU. Univariate and multivariate analyses were performed to identify risk factors associated with mortality and development of VAP.

Results

The incidence of VAP following secondary peritonitis was 9.6 %. Risk factors associated with the development of VAP were hospital-acquired peritonitis, requiring >48 h of mechanical ventilation, and SOFA score. The onset of VAP was late in majority of patients. VAP was developed about 16.8 days after the initiation of the peritonitis. Etiological microorganisms responsible for the peritonitis were different than for VAP. The 90-day in-hospital mortality rate was 47.5 % of VAP patients. Independent factors associated with 30- to 90-day in-hospital mortality were VAP and SOFA.

Conclusions

In light of the impact on morbidity and mortality in the ICU, more attention should be given to the concurrent features among VAP and secondary peritonitis.

Is type 2 diabetes mellitus in mechanically ventilated adult trauma patients potentially related to the occurrence of ventilator-associated pneumonia?

BACKGROUND

Ventilator-associated pneumonia (VAP) is a type of lung infection that typically affects critically ill patients undergoing mechanical ventilation (MV) in the intensive care unit (ICU). Patients with type 2 diabetes mellitus (T2DM) are considered to be more susceptible to several types of infections including community-acquired pneumonia. However, it is not clear whether T2DM is a risk factor for the development of VAP. The purpose of this study was to determine the risk of VAP for diabetic and nondiabetic mechanically ventilated trauma patients.

MATERIALS AND METHODS

This study is a secondary analysis of a prospective observational study of the history of T2DM in the ICU over a period of 1 year at Imam Khomeini Hospital in Iran. A total of 186 critically ill trauma patients who required at least 48 h of MV were monitored for the occurrence of VAP by their clinical pulmonary infection score (CPIS) until ICU discharge, VAP diagnosis, or death.

RESULTS

Forty-one of the 186 patients developed VAP. The median time from hospitalization to VAP was 29.09 days (95% CI: 26.27-31.9). The overall incidence of VAP was 18.82 cases per 1,000 days of intubation (95% CI: 13.86-25.57). Risk of VAP in diabetic patients was greater than nondiabetic patients after adjustments for other potential factors [hazard ratio (HR): 10.12 [95% confidence interval (CI): 5.1-20.2); P < 0.0001)].

CONCLUSION

The findings show that T2DM is associated with a significant increase in the occurrence of VAP in mechanically ventilated adult trauma patients.

Procalcitonin cannot be used as a biomarker of infection in heart surgery patients with acute kidney injury

PURPOSE

We intended to assess how acute kidney injuy impacts on procalcitonin levels in cardiac surgery patients, with or without infection, and whether procalcitonin might be used as a biomarker of infection in acute kidney injuy.

MATERIAL AND METHODS

A case-control study was designed which included patients that had had cardiac surgery between January 2011 and January 2015. Every patient developing severe sepsis or septic shock (n = 122; 5.5%) was enrolled. In addition, consecutive cardiac surgery patients during 2013 developing systemic inflammatory response syndrome (n = 318) were enrolled. Those recruited 440 patients were divided into 2 groups, according to renal function.

RESULTS

Median procalcitonin levels were significantly higher during the 10 postoperative days in the acute kidney injury patients. Regression analysis showed that postoperatory day, creatinine, white blood cells and infection were significantly (P < .0001) associated to serum procalcitonin level. In patients with creatinine ≥2, median procalcitonin levels were similar in infected and non-infected patients. Only when creatinine was less than 2 mg/L, the median procalcitonin levels were significantly higher in patients with infection, as compared to those with no infection.

CONCLUSIONS

In acute kidney injuy patients, high procalcitonin levels are a marker of acute kidney injuy but will not be able to differentiate infected from non-infected patients.

Impact of increasing overnight intensive care unit registrar staffing on duration of intubation of elective cardiac surgery patients

It is unclear whether increases to overnight junior medical staffing levels can improve ICU patient outcomes. We conducted a retrospective cohort study before and after the introduction of a third overnight ICU registrar at a 24-bed metropolitan ICU in February 2012. We hypothesised that this change would be associated with decreased intubation time for elective cardiac surgery patients and an increase in the proportion of these patients being extubated during the overnight period. All elective cardiac surgery patients were included from two temporally matched six-month periods (May to October) in 2011 and 2012. The primary outcome was median duration of intubation, and the secondary outcome was proportion of patients extubated during the 'overnight' period (2200 to 0700). A total of 142 and 188 patients were included in the control and intervention cohorts, respectively. Median (IQR) intubation time was 8.7 (6.6 to 14.5) hours in the control cohort and 8.2 (6.0 to 13.4) hours in the intervention cohort, with no significant difference between groups (P=0.40). The proportion of elective cardiac surgery patients extubated during the overnight period was similar, 54.2% in the control group compared to 50.0% in intervention group (P=0.45). In our unit, increasing overnight ICU registrar staffing levels was not associated with a significant reduction in duration of intubation for elective cardiac surgery patients or a reduction in the proportion of these patients extubated overnight. This is likely due to factors other than medical staffing levels influencing timing of extubation of these patients.

The role of Octenidol(®), Glandomed(®) and chlorhexidine mouthwash in the prevention of mucositis and in the reduction of the oropharyngeal flora: a double-blind randomized controlled trial

AIM

The oropharyngeal flora is of importance for the development of oral mucositis, which is a frequent complication in oncologic practice. It also plays a role in the pathogenesis of ventilator-associated pneumonia. Mucositis is associated with significantly worse clinical and economic outcomes. The aim of our study was to assess the efficacy of Octenidol(®), Glandomed(®) and chlorhexidine mouthwash in the prevention of mucositis and reduction of the oropharyngeal flora.

METHODS

A prospective, double-blinded RCT including two strata was conducted between October 2008 and November 2010. Stratum i consisted of ventilated cardiothoracic surgical patients. Stratum ii consisted of medical patients with haemato-oncological malignancies requiring stem cell transplantation. The primary outcome measures were development of mucositis regarding to OMAS/WHO score and reduction of the oropharyngeal flora.

RESULTS

Both strata showed low OMAS/WHO scores which did not differ significantly between the groups. The overall mean reduction of colony forming units was significantly higher in the Octenidol(®) group compared to the chlorhexidine and the Glandomed(®) groups.

CONCLUSIONS

No significant differences in the development of mucositis were found, thus all solutions proved successful in the prevention of mucositis. However, Octenidol(®) was superior in the reduction of the oropharyngeal flora. Hence, the preventive effect on nosocomial infections might be higher in patients using Octenidol(®) rather than chlorhexidine or Glandomed(®).

The role of Octenidol(®), Glandomed(®) and chlorhexidine mouthwash in the prevention of mucositis and in the reduction of the oropharyngeal flora: a double-blind randomized controlled trial

AIM

The oropharyngeal flora is of importance for the development of oral mucositis, which is a frequent complication in oncologic practice. It also plays a role in the pathogenesis of ventilator-associated pneumonia. Mucositis is associated with significantly worse clinical and economic outcomes. The aim of our study was to assess the efficacy of Octenidol(®), Glandomed(®) and chlorhexidine mouthwash in the prevention of mucositis and reduction of the oropharyngeal flora.

METHODS

A prospective, double-blinded RCT including two strata was conducted between October 2008 and November 2010. Stratum i consisted of ventilated cardiothoracic surgical patients. Stratum ii consisted of medical patients with haemato-oncological malignancies requiring stem cell transplantation. The primary outcome measures were development of mucositis regarding to OMAS/WHO score and reduction of the oropharyngeal flora.

RESULTS

Both strata showed low OMAS/WHO scores which did not differ significantly between the groups. The overall mean reduction of colony forming units was significantly higher in the Octenidol(®) group compared to the chlorhexidine and the Glandomed(®) groups.

CONCLUSIONS

No significant differences in the development of mucositis were found, thus all solutions proved successful in the prevention of mucositis. However, Octenidol(®) was superior in the reduction of the oropharyngeal flora. Hence, the preventive effect on nosocomial infections might be higher in patients using Octenidol(®) rather than chlorhexidine or Glandomed(®).

Procalcitonin as a diagnostic marker of ventilator-associated pneumonia in cardiac surgery patients

The aim of the present study was to assess whether procalcitonin (PCT) can be used as a diagnostic marker for ventilator-associated pneumonia (VAP) in cardiac surgery patients. Between January 2012 and June 2013, a total of 92 patients were recruited and divided into non-VAP (59 patients) and VAP (33 patients) groups. The preoperative and postoperative characteristics of the patients were recorded. Serum levels of PCT, interleukin (IL)-6 and C-reactive protein (CRP) were measured using an electrochemiluminescence immunoassay. Subsequently, receiver operating characteristic curves of the PCT, IL-6 and CRP levels were constructed. In addition, associations between the sequential organ failure assessment (SOFA) scores and the serum levels of PCT, IL-6 and CRP in the VAP patients were analyzed. No statistically significant difference was observed between the non-VAP and VAP patients in the occurrence of postoperative complications. However, the SOFA scores (days 1 and 7), the duration of stay in the intensive care unit and the mechanical ventilation time were all significantly higher in the VAP group when compared with the non-VAP group (P<0.05). The optimum PCT cut-off value for VAP diagnosis on day 1 was 5.0 ng/ml, with a sensitivity of 91% and a specificity of 71%. The serum PCT levels on days 1 and 7 were found to correlate positively with the SOFA scores (r=0.54 and r=0.66 for days 1 and 7, respectively). Therefore, the results suggested that serum PCT may be used as diagnostic marker for VAP in patients following cardiac surgery.

Mitochondrial DNA haplogroups are associated with severe sepsis and mortality in patients who underwent major surgery

OBJECTIVE

To analyse whether mitochondrial DNA (mtDNA) haplogroups are associated with severe sepsis and mortality after major surgery.

METHODS

We performed a case-control study on 240 cardiac or abdominal surgery patients developing severe sepsis (Case-group) and 267 cardiac or abdominal surgery patients without severe sepsis and with systemic inflammatory response syndrome (SIRS, Control-group). Furthermore, a longitudinal substudy was performed for analysing the survival in septic patients. Only European white patients within the N macro-cluster were included.

RESULTS

Case-group underwent cardiac surgery had lower frequencies of cluster HV (p = 0.005) and haplogroup H (p = 0.005) and higher frequencies of cluster JT (p = 0.028) than Control-group; but no significant differences were found for abdominal surgery. Besides, both cluster HV and haplogroup H were associated with decreased odds of severe sepsis (adjusted odds ratio (aOR) = 0.45 (95%CI = 0.25; 0.82); p = 0.009 and aOR = 0.48 (95%CI = 0.26; 0.87); p = 0.015, respectively) among patients underwent cardiac surgery. In Case-group, 45.4% (109/240) patients died with a survival median of 39 (95%CI = 31.4; 46.62) days. When the clusters were examined, 41% (55/134) patients within cluster HV died versus 71.4% (10/14) patients within cluster IWX (p = 0.018). Additionally, patients within cluster IWX had an increased risk of death (adjusted hazard ratio (aHR) = 2.22; (95%CI = 1.14; 4.34); p = 0.019).

CONCLUSIONS

European mitochondrial haplogroups might be related to the onset of severe sepsis in patients who underwent major cardiac surgery, but not in patients underwent major abdominal surgery. Besides, mtDNA haplogroups could have influence on mortality in septic patients.

Impact of four sequential measures on the prevention of ventilator-associated pneumonia in cardiac surgery patients

Introduction

Ventilator-associated pneumonia (VAP) is the most frequent infection in patients admitted to intensive care units.

The efficacy of individual measures for the prevention of VAP is well documented, and data on the impact of implementing bundle measures have usually been reported from studies in which several measures are implemented simultaneously in the general intensive care unit (ICU).

The objective of our work was to evaluate the impact of four sequentially implemented measures for preventing VAP in a major heart surgery ICU. The measures were a specific training program, aspiration of subglottic secretions (ASSs), introduction of an inclinometer to improve the semirecumbent position, and reinforcement of oral care with chlorhexidine.

Methods

We compared rates of VAP, days on mechanical ventilation (MV), and cost of antimicrobial agents before and during implementation.

Results

We collected data from 401 patients before the intervention and from 1,534 patients during the intervention. Both groups were comparable. No significant differences in EuroSCORE were observed between the patients of both periods (6.4 versus 6.3; P = 0.7). The rates of VAP (episodes/1,000 days of ventilation) were, respectively, 23.9 versus 13.5 (P = 0.005). Mean number of days of MV/1,000 days of stay was 507 versus 375 (P = 0.001), and the cost of antimicrobial therapy (Euros/1,000 days of stay) was €70,612 versus €52,775 (P = 0.10). The main effect of sequential application of preventive measures in time achieved a relative-rate reduction of VAP of 41% (IRR, 0.41; 95% CI, 0.28 to 0.62). The mortality rate before and during the intervention was 13.0% and 10.2%, respectively.

VAP rate was most significantly reduced by training and the use of the inclinometer.

Conclusions

A sequentially applied bundle of four preventive measures reduces VAP rates, days of MV, and the cost of antimicrobial therapy in patients admitted to the major heart surgery ICU.

Trial registration

Clinical Trials.gov: NCT02060045. Registered 4 February 2014.

Long-Term Mortality After Pneumonia in Cardiac Surgery Patients

Background:

The role that intensive care unit (ICU)-acquired pneumonia plays in the long-term outcomes of cardiac surgery patients is not well known. This study examined the association of pneumonia with in-hospital mortality and long-term mortality after adult cardiac surgery.

Methods:

A total of 2750 patients admitted to our ICU after cardiac surgery from January 2003 to December 2009 are the basis for this observational study. Patients who developed ICU-acquired pneumonia were matched with patients without it in a 1:2 ratio. The matching criteria were age, urgent or scheduled surgery, surgical procedure, and the propensity score for pneumonia. Multiple regression analysis was used to find predictors of hospital mortality. The relationship between pneumonia and long-term survival was analyzed with Kaplan-Meier survival estimates and a risk-adjusted Cox proportional regression model for patients discharged alive from hospital.

Results:

Pneumonia was diagnosed in 32 (1.2%) patients and there were 19 cases per 1000 days of mechanical ventilation. Patients with pneumonia had a significantly higher hospital mortality rate (28% vs 6.2%, P = .003) and a higher mortality at the end of follow-up (53% vs 19%, P < .0001) than those without it. Regression analysis showed that pneumonia was a strong predictor of hospital mortality. Five-year survival was as follows: pneumonia, 62%; control, 81%; and cohort patients, 91%. The Cox model showed that, after adjusting for confounding factors, patients with pneumonia (hazard ratio = 3.96, 95% confidence interval [CI]: 1.41-11.14) had poorer long-term survival.

Conclusion:

Pneumonia remains a serious complication in patients operated for cardiac surgery and is associated with increased hospital mortality and reduced long-term survival.

Influence of Remifentanil/Propofol Anesthesia on Ventilator-associated Pneumonia Occurence After Major Cardiac Surgery

The study is designed to evaluate the influence of remifentanil/propofol anesthesia on ventilator-associated pneumonia (VAP) occurrence and respiratory support (RS) time after major cardiac surgery.

MATERIAL AND METHODS

In retrospective-prospective study we investigated the respiratory support time and VAP occurrence in group of 47 patients with remifentanil/propofol and 35 patients with fentanil/midazolam anesthesia after major cardiac surgery in period June 2009-December 2011. Groups are divided in subgroups depending of who underwent cardiac surgery with or without cardiopulmonary by pass (CPB).

RESULTS

The time of respiratory support (RS) was the shortest in remifentanil group without CPB (R/Off 63min ± 44.3 vs R/On 94min ± 49.2 p=0,22), but was longer in fentanil group (F/Off 142 min ± 102.2 vs F/On 212 min ± 102.2 p=0.0014). The duration of RS of ON pump remifentanil group was shorter than in ON pump fentanil group (R/On 94 min vs F/On 212 min p=0.0011). The time of RS of OFF pump remifentanil group was lower than in Off pump entangle group (R/Off 63min ± 44,3 vs F/Off 142min ± 102.2 p=0,021) with statistically significance. Ventilator-associated pneumonia was detected in 7 patients (8.5 %). Six patients (17.1%) were from entangle group and one patient (2.1%) from remifentanil group. The most common isolates were Pseudomonas aeruginosa in all patients and both Pseudomonas aeruginosa and Klebsiella pneumonia in one patient.

CONCLUSION

The remifentanil anesthesia regimen in cardiac surgery decreases length of respiratory support duration and can prevent development of VAP. The role of remifentanil anesthesia in preventing VAP, as one of the most important risk factor of in-hospital mortality after cardiac surgery is still incompletely understood and should be investigated further.

Routine aspiration of subglottic secretions after major heart surgery: impact on the incidence of ventilator-associated pneumonia

Aspiration of subglottic secretions (ASS) is recommended in patients requiring mechanical ventilation for ≥48h. We assessed the impact of the introduction of ASS routinely in all patients after major heart surgery in an ecological study comparing ventilator-acquired pneumonia (VAP) incidence, days of mechanical ventilation, and cost of antimicrobial agents before and after the implementation of ASS. Before and after the intervention the results (per 1000 days) were: VAP incidence, 23.92 vs 16.46 (P = 0.04); cost of antimicrobials, €71,384 vs €63,446 (P = 0.002); and days of mechanical ventilation, 507.5 vs 377.5 (P = 0.009). From the moment of induction of anaesthesia all patients undergoing major heart surgery should routinely receive ASS.