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Gebreyesus MS, Dresner A, Wiesner L, Coetzee E, Verschuuren T, Wasmann R, Denti P. Dose optimization of cefazolin in South African children undergoing cardiac surgery with cardiopulmonary bypass. CPT Pharmacometrics Syst Pharmacol 2024. [PMID: 38962872 DOI: 10.1002/psp4.13196] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2023] [Revised: 05/27/2024] [Accepted: 06/18/2024] [Indexed: 07/05/2024] Open
Abstract
Cefazolin is an antibiotic used to prevent surgical site infections. During cardiac surgery with cardiopulmonary bypass (CPB), its efficacy target could be underachieved. We aimed to develop a population pharmacokinetic model for cefazolin in children and optimize the prophylactic dosing regimen. Children under 25 kg undergoing cardiac surgery with CPB and receiving cefazolin at standard doses (50 mg/kg IV every 4-6 h) were included in this analysis. A population pharmacokinetic model and Monte Carlo simulations were used to evaluate the probability of target attainment (PTA) for efficacy and toxicity with the standard regimen and an alternative regimen of continuous infusion, where loading and maintenance doses were calculated from model-derived individual parameters. Twenty-two patients were included, with median (range) age, body weight, and eGFR of 19.5 (1-94) months, 8.7 (2-21) kg, and 116 (48-159) mL/min, respectively. Six patients received an additional dose in the CPB circuit. A two-compartment disposition model with an additional compartment for the CPB was developed, including weight-based allometric scaling and eGFR. For a 10 kg patient with eGFR of 120 mL/min/1.73 m2, clearance was estimated as 0.856 L/h. Simulations indicated that the standard dosing regimen fell short of achieving the efficacy target >40% of the time within a dosing duration and in patients with good renal function, PTA ranged from <20% to 70% for the smallest to the largest patients, respectively, at high MICs. In contrast, the alternative regimen consistently maintained target concentrations throughout the procedure for all patients while using a lower overall dose.
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Affiliation(s)
- Manna Semere Gebreyesus
- Division of Clinical Pharmacology, Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Alexandra Dresner
- Department of Anesthesia and Perioperative Medicine, Red Cross War Memorial Children's Hospital and University of Cape Town, Cape Town, South Africa
| | - Lubbe Wiesner
- Division of Clinical Pharmacology, Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Ettienne Coetzee
- Department of Anesthesia and Perioperative Medicine, Groote Schuur Hospital and University of Cape Town, Cape Town, South Africa
| | - Tess Verschuuren
- Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
| | - Roeland Wasmann
- Division of Clinical Pharmacology, Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Paolo Denti
- Division of Clinical Pharmacology, Department of Medicine, University of Cape Town, Cape Town, South Africa
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Yu Y, Dooley FC, Woods A, Gunnett A, Chandasana H, Amini E, Garvan C, Ihnow S, Blakemore LC, Sangari T, Seubert CN. Dosing Cefazolin for Surgical Site Infection Prophylaxis in Adolescent Idiopathic Scoliosis Surgery: Intermittent Bolus or Continuous Infusion?-A Pilot Study. J Clin Med 2024; 13:3524. [PMID: 38930053 PMCID: PMC11204537 DOI: 10.3390/jcm13123524] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2024] [Revised: 06/10/2024] [Accepted: 06/14/2024] [Indexed: 06/28/2024] Open
Abstract
Background: Cefazolin may minimize the risk of surgical site infection (SSI) following posterior spinal fusion (PSF) for adolescent idiopathic scoliosis (AIS). Cefazolin dosing recommendations vary and there is limited evidence for achieved tissue concentrations. Methods: We performed a randomized, controlled, prospective pharmacokinetic pilot study of 12 patients given cefazolin by either intermittent bolus (30 mg/kg every 3 h) or continuous infusion (30 mg/kg bolus followed by 10/mg/kg per hour) during PSF for AIS. Results: Patients were well matched for demographic and perioperative variables. While total drug exposure, measured as area-under-the-curve (AUC), was similar in plasma for bolus and infusion dosing, infusion dosing achieved greater cefazolin exposure in subcutaneous and muscle tissue. Using the pharmacodynamic metric of time spent above minimal inhibitory concentration (MIC), both bolus and infusion dosing performed well. However, when targeting a bactericidal concentration of 32 µg/mL, patients in the bolus group spent a median of 1/5 and 1/3 of the typical 6 h operative time below target in subcutaneous and muscle tissue, respectively. Conclusions: We conclude that intraoperative determination of cefazolin tissue concentrations is feasible and both bolus and infusion dosing of cefazolin achieve concentrations in excess of typical MICs. Infusion dosing appears to more consistently achieve bactericidal concentrations in subcutaneous and muscle tissues.
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Affiliation(s)
- Yichao Yu
- Department of Pharmaceutics, University of Florida, Gainesville, FL 32610, USA (H.C.); (E.A.)
- Drug Development, Clinical Pharmacology, Boehringer Ingelheim, Ridgefield, CT 06810, USA
| | - F. Cole Dooley
- Department of Anesthesiology, University of Florida College of Medicine, Gainesville, FL 32610, USA
| | - Anna Woods
- Department of Anesthesiology, University of Florida College of Medicine, Gainesville, FL 32610, USA
| | - Amy Gunnett
- Department of Anesthesiology, University of Florida College of Medicine, Gainesville, FL 32610, USA
| | - Hardik Chandasana
- Department of Pharmaceutics, University of Florida, Gainesville, FL 32610, USA (H.C.); (E.A.)
- Clinical Pharmacology, Modeling, and Simulation, Glaxo-Smith-Kline, Collegeville, PA 19426, USA
| | - Elham Amini
- Department of Pharmaceutics, University of Florida, Gainesville, FL 32610, USA (H.C.); (E.A.)
- Department of Clinical Pharmacology, Gilead Sciences, Foster City, CA 94404, USA
| | - Cynthia Garvan
- Department of Anesthesiology, University of Florida College of Medicine, Gainesville, FL 32610, USA
| | - Stephanie Ihnow
- Department of Orthopaedic Surgery & Sports Medicine, University of Florida College of Medicine, Gainesville 32610, FL, USA
| | | | - Taran Sangari
- Department of Anesthesiology, University of California at San Francisco, Oakland, CA 94609, USA
| | - Christoph N. Seubert
- Department of Anesthesiology, University of Florida College of Medicine, Gainesville, FL 32610, USA
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Bardia A, Michel G, Farela A, Fisher C, Mori M, Huttler J, Lang AL, Geirsson A, Schonberger RB. Association of adherence to individual components of Society of Thoracic Surgeons cardiac surgery antibiotic guidelines and postoperative infections. J Thorac Cardiovasc Surg 2024; 167:2170-2176.e5. [PMID: 37075942 PMCID: PMC10579454 DOI: 10.1016/j.jtcvs.2023.03.031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/12/2022] [Revised: 03/02/2023] [Accepted: 03/25/2023] [Indexed: 04/21/2023]
Abstract
OBJECTIVES The study objectives were to measure the association among the 4 components of Society of Thoracic Surgeons antibiotic guidelines and postoperative complications in a cohort of patients undergoing valve or coronary artery bypass grafting requiring cardiopulmonary bypass. METHODS In this retrospective observational study, adult patients undergoing coronary revascularization or valvular surgery who received a Surgical Care Improvement Project-compliant antibiotic from January 1, 2016, to April 1, 2021, at a single, tertiary care hospital were included. The primary exposures were adherence to the 4 individual components of Society of Thoracic Surgeons antibiotic best practice guidelines. The association of each component and a combined metric was tested in its association with the primary outcome of postoperative infection as determined by Society of Thoracic Surgeons data abstractors, controlling for several known confounders. RESULTS Of the 2829 included patients, 1084 (38.3%) received care that was nonadherent to at least 1 aspect of Society of Thoracic Surgeons antibiotic guidelines. The incidence of nonadherence to the 4 individual components was 223 (7.9%) for timing of first dose, 639 (22.6%) for antibiotic choice, 164 (5.8%) for weight-based dose adjustment, and 192 (6.8%) for intraoperative redosing. In adjusted analyses, failure to adhere to first dose timing guidelines was directly associated with Society of Thoracic Surgeons-adjudicated postoperative infection (odds ratio, 1.9; 95% confidence interval, 1.1-3.3; P = .02). Failure of weight-adjusted dosing was associated with both postoperative sepsis (odds ratio, 6.9; 95% confidence interval, 2.5-8.5; P < .01) and 30-day mortality (odds ratio, 4.3; 95% confidence interval, 1.7-11.4; P < .01). No other significant associations among the 4 Society of Thoracic Surgeons metrics individually or as a combination were observed with postoperative infection, sepsis, or 30-day mortality. CONCLUSIONS Nonadherence to Society of Thoracic Surgeons antibiotic best practices is common. Failure of antibiotic timing and weight-adjusted dosing is associated with odds of postoperative infection, sepsis, and mortality after cardiac surgery.
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Affiliation(s)
- Amit Bardia
- Department of Anesthesiology, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, Mass
| | - George Michel
- Yale Center for Analytical Sciences, Yale School of Public Health, New Haven, Conn
| | - Andrea Farela
- Department of Anesthesiology, Yale School of Medicine, New Haven, Conn
| | - Clark Fisher
- Department of Anesthesiology, Yale School of Medicine, New Haven, Conn
| | - Makoto Mori
- Division of Cardiothoracic Surgery, Yale School of Medicine, New Haven, Conn
| | - Joshua Huttler
- Department of Anesthesiology, Yale School of Medicine, New Haven, Conn
| | - Angela Lu Lang
- Department of Anesthesiology, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, Mass
| | - Arnar Geirsson
- Division of Cardiothoracic Surgery, Yale School of Medicine, New Haven, Conn
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Crisafi C, Grant MC, Rea A, Morton-Bailey V, Gregory AJ, Arora RC, Chatterjee S, Lother SA, Cangut B, Engelman DT. Enhanced Recovery After Surgery Cardiac Society turnkey order set for surgical-site infection prevention: Proceedings from the American Association for Thoracic Surgery ERAS Conclave 2023. J Thorac Cardiovasc Surg 2024:S0022-5223(24)00281-2. [PMID: 38574802 DOI: 10.1016/j.jtcvs.2024.03.027] [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: 12/23/2023] [Revised: 02/23/2024] [Accepted: 03/18/2024] [Indexed: 04/06/2024]
Abstract
OBJECTIVES Surgical-site infections (SSIs) after cardiac surgery increase morbidity and mortality, consume health care resources, impair recovery, and diminish patients' quality of life. Numerous guidelines and expert consensus documents have been published to address the prevention and management of SSIs. Our objective is to integrate these documents into an order set that will facilitate the adoption and implementation of evidence-based best practices for preventing and managing SSIs after cardiac surgery. METHODS Subject matter experts were consulted to translate existing guidelines and literature into a sample turnkey order set for SSI reduction. Orders derived from consistent class I, IIA, or equivalent recommendations across referenced guidelines and consensus manuscripts appear in the turnkey order set in bold type. Selected orders that were inconsistent class I or IIA, class IIB or otherwise supported by published evidence, were also included in italicized type. RESULTS Preventative care begins with the preoperative identification of both modifiable and nonmodifiable SSI risks by health care providers. Assessment tools can be used to assist in identifying patients at a high risk of SSI. Preoperative recommendations include screening for and treating Staphylococcus aureus nasal carriage. Intraoperatively, tailored prophylactic intravenous antibiotics and maintaining blood glucose levels below 180 mg/dL are essential elements. Postoperative care includes maintaining normothermia, glucose control and patient engagement. CONCLUSIONS Despite the well-documented advantages of a multidisciplinary care pathway for SSI in cardiac surgery, there are inconsistencies in its adoption and implementation. This article provides an order set that incorporates recommendations from existing guidelines to prevent SSI in the cardiac surgical population.
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Affiliation(s)
- Cheryl Crisafi
- Heart & Vascular Program Baystate Health, University of Massachusetts Chan Medical, School-Baystate, Springfield, Mass.
| | - Michael C Grant
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University, School of Medicine, Baltimore, Md
| | - Amanda Rea
- Division of Cardiac Surgery, University of Maryland St Joseph Medical Center, Towson, Md
| | | | - Alexander J Gregory
- Department of Anesthesiology, Cumming School of Medicine & Libin Cardiovascular Institute, University of Calgary, Calgary, Alberta, Canada
| | - Rakesh C Arora
- Division of Cardiac Surgery, Department of Surgery, Harrington Heart and Vascular, Institute, University Hospitals, Case Western Reserve University, Cleveland, Ohio
| | | | - Sylvain A Lother
- Sections of Infectious Diseases and Critical Care Rady Faculty of Health Sciences, Department of Internal Medicine, Max Rady College of Medicine, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Busra Cangut
- Icahn School of Medicine at Mount Sinai, New York, NY
| | - Daniel T Engelman
- Heart & Vascular Program Baystate Health, University of Massachusetts Chan Medical, School-Baystate, Springfield, Mass
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Zelenitsky SA. Effective Antimicrobial Prophylaxis in Surgery: The Relevance and Role of Pharmacokinetics-Pharmacodynamics. Antibiotics (Basel) 2023; 12:1738. [PMID: 38136772 PMCID: PMC10741006 DOI: 10.3390/antibiotics12121738] [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: 11/19/2023] [Revised: 12/09/2023] [Accepted: 12/11/2023] [Indexed: 12/24/2023] Open
Abstract
Appropriate surgical antimicrobial prophylaxis (SAP) is an important measure in preventing surgical site infections (SSIs). Although antimicrobial pharmacokinetics-pharmacodynamics (PKPD) is integral to optimizing antibiotic dosing for the treatment of infections, there is less research on preventing infections postsurgery. Whereas clinical studies of SAP dose, preincision timing, and redosing are informative, it is difficult to isolate their effect on SSI outcomes. Antimicrobial PKPD aims to explain the complex relationship between antibiotic exposure during surgery and the subsequent development of SSI. It accounts for the many factors that influence the PKs and antibiotic concentrations in patients and considers the susceptibilities of bacteria most likely to contaminate the surgical site. This narrative review examines the relevance and role of PKPD in providing effective SAP. The dose-response relationship i.e., association between lower dose and SSI in cefazolin prophylaxis is discussed. A comprehensive review of the evidence for an antibiotic concentration-response (SSI) relationship in SAP is also presented. Finally, PKPD considerations for improving SAP are explored with a focus on cefazolin prophylaxis in adults and outstanding questions regarding its dose, preincision timing, and redosing during surgery.
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Affiliation(s)
- Sheryl A. Zelenitsky
- College of Pharmacy, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, MB R3E 0T5, Canada;
- Department of Pharmacy, St. Boniface Hospital, Winnipeg, MB R2H 2A6, Canada
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Francois K. Antibiotic Prophylaxis in Congenital Cardiac Surgery: The Jury is still out. Ann Thorac Surg 2022; 114:1441. [PMID: 35346633 DOI: 10.1016/j.athoracsur.2022.03.018] [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: 03/02/2022] [Accepted: 03/05/2022] [Indexed: 11/26/2022]
Affiliation(s)
- Katrien Francois
- Cardiac Surgery, University Hospital Ghent, Belgium, De Pintelaan 185, Gent, 9000, Belgium.
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Suna J, Moloney G, Marathe SP, Bierbach B, Roberts JA, Parker S, Ungerer JPJ, Mcwhinney B, Dorofaeff T, Venugopal P, Alphonso N. Perioperative cefazolin prophylaxis in paediatric cardiac surgery: a prospective, cohort study. Ann Thorac Surg 2022; 114:1434-1440. [PMID: 35292260 DOI: 10.1016/j.athoracsur.2022.02.047] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/22/2021] [Revised: 01/31/2022] [Accepted: 02/09/2022] [Indexed: 11/01/2022]
Abstract
BACKGROUND This study's objective was to determine the effect of age, prolonged bypass, and hypothermia on serum cefazolin concentrations in children undergoing cardiac surgery. METHODS A prospective, single-centre, observational study was conducted. Children undergoing cardiac surgery were examined. Participants received cefazolin intravenously approximately 1 hour before skin incision, 3 hourly intraoperatively and 8 hourly postoperatively. Blood samples were collected at 6-8 timepoints intraoperatively and 6-time points in the first 24 hours postoperatively. Target unbound serum cefazolin concentrations were of 2 mg/L. RESULTS Sixty-eight patients were enrolled in the study, and 64 included in the analysis. All maintained concentrations ≥ 2 mg/L throughout the operation. Nineteen patients (30%) did not maintain concentrations ≥ 2 mg/L in the first 24 hours following surgery. Older, larger children (p < 0.0001) were significantly less likely to achieve target unbound serum cefazolin concentrations. CONCLUSIONS Intraoperative cefazolin concentrations reached the target concentration in all paediatric cardiac surgical cases. Postoperative cefazolin dosing appears insufficient to achieve minimum inhibitory concentrations in many patients.
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Affiliation(s)
- Jessica Suna
- Industry Fellow, University of Queensland, Brisbane, Australia; Deputy Director, Queensland Paediatric Cardiac Research, Queensland Children's Hospital, Brisbane, Australia.
| | - Gregory Moloney
- Senior Medical Officer, Department of Anaesthetics, Queensland Children's Hospital, Brisbane, Australia
| | - Supreet P Marathe
- Lecturer, University of Queensland Clinical School, Queensland Children's Hospital, University of Queensland, Brisbane, Australia; Senior Cardiac Surgery Fellow, Queensland Paediatric Cardiac Service, Queensland Children's Hospital, Brisbane, Australia
| | - Benjamin Bierbach
- Department of Paediatric Cardiac Surgery, University Hospital Bonn, Germany
| | - Jason A Roberts
- NHMRC Practitioner Fellow, University of Queensland Centre for Clinical Research, The University of Queensland, Brisbane, Australia; Consultant Pharmacist, Pharmacy Department and Department of Intensive Care Medicine, Royal Brisbane and Women's Hospital, Brisbane, Australia; Scientific Consultant, Division of Anaesthesiology Critical Care Emergency and Pain Medicine, Nîmes University Hospital, University of Montpellier, Nîmes France
| | - Suzanne Parker
- NHMRC Early Career Research Fellow, University of Queensland Centre for Clinical Research, The University of Queensland, Brisbane, Australia
| | - Jacobus P J Ungerer
- Director Chemical Pathology, Pathology Queensland, Queensland Health, Brisbane Australia; School of Biomedical Sciences, University of Queensland, Brisbane Australia
| | - Brett Mcwhinney
- Supervising Scientist, Pathology Queensland, Queensland Health, Brisbane Australia
| | - Tavey Dorofaeff
- Senior Lecturer, University of Queensland Clinical School Queensland Children's Hospital, University of Queensland, Brisbane, Australia; Senior Medical Officer, Paediatric Intensive Care Unit, Queensland Children's Hospital, Brisbane, Australia
| | - Prem Venugopal
- Senior Lecturer, University of Queensland Clinical School Queensland Children's Hospital, University of Queensland, Brisbane, Australia; Director of Cardiac Surgery, Queensland Paediatric Cardiac Service, Queensland Children's Hospital, Brisbane, Australia
| | - Nelson Alphonso
- Associate Professor, Child Health Research Centre, University of Queensland, Brisbane, Australia; Deputy Director of Cardiac Surgery, Queensland Paediatric Cardiac Service, Queensland Children's Hospital, Brisbane, Australia
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Abstract
Surgical site infection (SSI) can be a significant complication of cardiac surgery, delaying recovery and acting as a barrier to enhanced recovery after cardiac surgery. Several risk factors predisposing patients to SSI including smoking, excessive alcohol intake, hyperglycemia, hypoalbuminemia, hypo- or hyperthermia, and Staphylococcus aureus colonization are discussed. Various measures can be taken to abolish these factors and minimize the risk of SSI. Glycemic control should be optimized preoperatively, and hyperglycemia should be avoided perioperatively with the use of intravenous insulin infusions. All patients should receive topical intranasal Staphylococcus aureus decolonization and intravenous cephalosporin if not penicillin allergic.
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Affiliation(s)
- Shruti Jayakumar
- Department of Cardiothoracic Surgery, St. George's Hospital, Blackshaw Road, London SW17 0QT, UK
| | - Ali Khoynezhad
- MemorialCare Heart and Vascular Institute, MemorialCare Long Beach Medical Center, 2801 Atlantic Avenue, Long Beach, CA 90806, USA
| | - Marjan Jahangiri
- Department of Cardiothoracic Surgery, St. George's Hospital, Blackshaw Road, London SW17 0QT, UK.
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Engelman DT, Ben Ali W, Williams JB, Perrault LP, Reddy VS, Arora RC, Roselli EE, Khoynezhad A, Gerdisch M, Levy JH, Lobdell K, Fletcher N, Kirsch M, Nelson G, Engelman RM, Gregory AJ, Boyle EM. Guidelines for Perioperative Care in Cardiac Surgery. JAMA Surg 2019; 154:755-766. [DOI: 10.1001/jamasurg.2019.1153] [Citation(s) in RCA: 347] [Impact Index Per Article: 69.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Affiliation(s)
- Daniel T. Engelman
- Heart and Vascular Program, Baystate Medical Center, Springfield, Massachusetts
| | | | | | | | - V. Seenu Reddy
- Centennial Heart & Vascular Center, Nashville, Tennessee
| | - Rakesh C. Arora
- St Boniface Hospital, University of Manitoba, Winnipeg, Manitoba, Canada
- Now with Department of Surgery, Max Rady College of Medicine, University of Manitoba, Winnipeg, Canada
| | | | - Ali Khoynezhad
- MemorialCare Heart and Vascular Institute, Los Angeles, California
| | - Marc Gerdisch
- Franciscan Health Heart Center, Indianapolis, Indiana
| | | | - Kevin Lobdell
- Atrium Health, Department of Cardiovascular and Thoracic Surgery, North Carolina
| | - Nick Fletcher
- St Georges University of London, London, United Kingdom
| | - Matthias Kirsch
- Centre Hospitalier Universitaire Vaudois Cardiac Surgery Centre, Lausanne, Switzerland
| | | | | | | | - Edward M. Boyle
- Department of Cardiac Surgery, St Charles Medical Center, Bend, Oregon
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Ing RJ, Twite M. The Year in Review: Anesthesia for Congenital Heart Disease 2018. Semin Cardiothorac Vasc Anesth 2019; 23:205-211. [DOI: 10.1177/1089253219845414] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
This review article surveys the published literature from January 2018 to March 2019. Three themes were identified and articles were selected based on their originality and interest to anesthesiologists caring for patients with congenital heart disease.
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Affiliation(s)
- Richard J. Ing
- Children’s Hospital Colorado, Anschutz Medical Campus, Aurora, CO, USA
- University of Colorado, Aurora, CO, USA
| | - Mark Twite
- Children’s Hospital Colorado, Anschutz Medical Campus, Aurora, CO, USA
- University of Colorado, Aurora, CO, USA
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Staffa SJ, Zurakowski D. Five Steps to Successfully Implement and Evaluate Propensity Score Matching in Clinical Research Studies. Anesth Analg 2018; 127:1066-1073. [DOI: 10.1213/ane.0000000000002787] [Citation(s) in RCA: 83] [Impact Index Per Article: 13.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Pharmacodynamic model for β-lactam regimens used in surgical prophylaxis: model-based evaluation of standard dosing regimens. Int J Clin Pharm 2018; 40:1059-1071. [PMID: 30117081 DOI: 10.1007/s11096-018-0720-y] [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] [Received: 11/03/2017] [Accepted: 08/12/2018] [Indexed: 10/28/2022]
Abstract
Background Continual evolution of resistance among bacteria against methods of surgical prophylaxis may make currently used beta-lactam regimens inadequate. Objective To re-evaluate beta-lactam regimens in surgical prophylaxis. Setting A pharmacodynamic Monte Carlo simulation (MCS) model based on a number of patients in China. Methods Pharmacodynamic profiling using Monte Carlo simulation up to 4 hours postinfusion was conducted for standard-dose, short-term (0.5 h) and prolonged (2 to 4 h) infusions of ampicillin, cefazolin, cefotaxime, cefoxitin, cefuroxime, ertapenem, and piperacillin/tazobactam in adult patients with normal renal function. Microbiological data were incorporated. Cumulative fraction of response (CFR) was determined for each regimen against populations of S. aureus, coagulase-negative staphylococci and E. coli. The optimal CFR was defined as ≥ 90% response. Main Outcome Measure Cumulative fractions of response of pharmacodynamic target attainment. Results During the first 2 hours postinfusion, piperacillin/tazobactam 3.375 g exhibited consistently optimal cumulative fractions against S. aureus, CoNS and E. coli. Ampicillin 2 g (2 h) also displayed optimal CFRs for S. aureus and E. coli but not for coagulase-negative staphylococci. Cefoxitin 2 g didnot achieve any optimal CFRs, even via 2-h prolonged infusion (maximum 72.8% CFR for S. aureus and 64.5% CFR for E. coli). Cefazolin 2 g (4 h) and cefuroxime 1.5 g (4 h) provided desired CFRs across 4 h postinfusion for S. aureus but provided poor CFRs for coagulase-negative staphylococci and E. coli. Only ertapenem 1 g for E. coli and S. aureus and cefotaxime 1 g for E. coli consistently yielded ≥ 90% CFRs for 4 hour postinfusion. Conclusions Certain dosing regimens may warrant adjustment for improved prevention efficiency and enhanced empirical antibiotic regimens for surgical prophylaxis.
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Gertler R, Gruber M, Wiesner G, Grassin-Delyle S, Urien S, Tassani-Prell P, Martin K. Pharmacokinetics of cefuroxime in infants and neonates undergoing cardiac surgery. Br J Clin Pharmacol 2018; 84:2020-2028. [PMID: 29761538 DOI: 10.1111/bcp.13632] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2018] [Revised: 04/22/2018] [Accepted: 04/26/2018] [Indexed: 12/29/2022] Open
Abstract
AIMS Very little data exist regarding the effect of cardiopulmonary bypass (CPB) on cefuroxime (CXM) pharmacokinetics in children less than one year of age. METHODS 50 mg kg-1 CXM i.v. after induction were followed by 75 mg kg-1 into the CPB circuit. In 42 patients undergoing cardiac surgery, 15-20 samples were obtained between 5 and 360 min after the first dose. Total CXM concentrations were measured by high-performance liquid chromatography and a pharmacokinetic/pharmacodynamic (PK/PD) modelling was performed. RESULTS Using a fixed protein binding of 15.6% for CXM, peak plasma concentrations of unbound CXM were 229 ± 52 μg ml-1 after the first bolus and 341 ± 86 μg ml-1 on CPB. Nadir concentrations before CPB were 69 ± 20 μg ml-1 and six hours later decreased to 41 ± 19 μg ml-1 with and 24 ± 14 μg ml-1 without CPB. A two-compartment model was fitted with the main covariates body weight, CPB and postmenstrual age (PMA). PK parameters were as follows: systemic clearance, 5.15 [95% CI 4.5-5.8] l h-1 ; central volume of distribution, 11.25 [9.41-13.09] l; intercompartmental clearance, 18.19 [14.79-21.58] l h-1 ; and peripheral volume, 17.07 [15.7-18.5] L. ƒT > MIC of 32 μg ml-1 for an 8-h time period was between 70 and 100% (2.5-10 kg BW). According to our simulation, 25 mg ml-1 CXM as a primary bolus and into the prime plus a 5 mg kg-1 h-1 infusion maintain CXM concentrations continuously above 32 μg ml-1 . CONCLUSIONS The routine dosing regimen provided was sufficient for prophylaxis, but continuous dosing can provide a higher percentage of ƒT > MIC.
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Affiliation(s)
- Ralph Gertler
- Klinik für Anaesthesie, operative und allgemeine Intensivmedizin, Notfallmedizin, Klinikum Links der Weser, University Medical Center Hamburg-Eppendorf, Bremen, Germany
| | - Michael Gruber
- Department of Anesthesia, University Hospital Regensburg, Germany
| | - Gunther Wiesner
- Institute of Anaesthesiology, German Heart Centre Munich, Technical University Munich, Germany
| | - Stanislas Grassin-Delyle
- Département des Maladies des Voies Respiratoires, Hôpital Foch, Université Versailles Saint Quentin en Yvelines, Université Paris Saclay, F-92150, Suresnes, France.,Plateforme de spectrométrie de masse et INSERM UMR1173, UFR Sciences de la Santé Simone Veil, Université Versailles Saint Quentin en Yvelines, Université Paris Saclay, F-78180, Montigny-le-Bretonneux, France
| | - Saïk Urien
- CIC1419 Inserm Necker-Cochin, URC Paris Descartes Necker Cochin, AP-HP, Paris, France; EAU7323, Université Paris Descartes, Sorbonne Paris Cité, France
| | - Peter Tassani-Prell
- Institute of Anaesthesiology, German Heart Centre Munich, Technical University Munich, Germany
| | - Klaus Martin
- Institute of Anaesthesiology, German Heart Centre Munich, Technical University Munich, Germany
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Sousa-Uva M, Head SJ, Milojevic M, Collet JP, Landoni G, Castella M, Dunning J, Gudbjartsson T, Linker NJ, Sandoval E, Thielmann M, Jeppsson A, Landmesser U. 2017 EACTS Guidelines on perioperative medication in adult cardiac surgery. Eur J Cardiothorac Surg 2017; 53:5-33. [PMID: 29029110 DOI: 10.1093/ejcts/ezx314] [Citation(s) in RCA: 247] [Impact Index Per Article: 35.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
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Shoulders BR, Crow JR, Davis SL, Whitman GJ, Gavin M, Lester L, Barodka V, Dzintars K. Impact of Intraoperative Continuous-Infusion Versus Intermittent Dosing of Cefazolin Therapy on the Incidence of Surgical Site Infections After Coronary Artery Bypass Grafting. Pharmacotherapy 2016; 36:166-73. [PMID: 26799442 DOI: 10.1002/phar.1689] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
STUDY OBJECTIVES To determine whether intraoperative continuous-infusion (CI) cefazolin reduces the incidence of surgical site infections (SSIs) compared with intermittent (INT) cefazolin dosing in patients undergoing coronary artery bypass grafting (CABG) on cardiopulmonary bypass (CPB); safety end points and protocol adherence comparing the two dosing strategies were also explored. DESIGN Retrospective quasi-experimental (pre-post intervention) cohort study. SETTING Large academic medical center. PATIENTS A total of 516 adults who underwent CABG on CPB and received cefazolin intraoperatively between June 1, 2013, and December 31, 2014, were included. The INT cohort included 284 patients who underwent CABG from June 2013 to February 2014. The CI cohort included 232 patients who underwent CABG from April to December 2014, after an intraoperative CI cefazolin protocol for cardiac surgery patients undergoing CPB was adopted in March 2014. MEASUREMENTS AND MAIN RESULTS The primary end point was incidence of SSIs, and safety end points of renal dysfunction and seizures were evaluated. Multivariable logistic regression analysis was used to determine the impact on SSIs when controlling for other risk factors. A subgroup analysis for this study included 2 months within each time period to evaluate protocol adherence. The overall incidence of SSIs was decreased in patients receiving CI cefazolin, although this did not reach statistical significance (4.6% in the INT cohort vs 1.7% in the CI cohort, p=0.116). Superficial SSIs were significantly reduced in the CI cohort (2.8% in the INT cohort vs 0.4% in the CI cohort, p=0.039). In the regression analysis, CI cefazolin decreased the odds of SSI by 66%, although it did not reach statistical significance (p=0.077). Safety end points were not significantly different between groups. Overall protocol adherence did not differ significantly between the cohorts: 77% in the INT cohort and 67% in the CI cohort (p=0.212). CONCLUSION CI cefazolin significantly decreased the incidence of superficial SSIs compared with INT cefazolin in patients undergoing CABG on CPB, without increasing the risk for adverse effects. As this study was underpowered to detect a significant difference in overall SSIs, larger, randomized studies are required to validate the superiority of CI cefazolin.
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Affiliation(s)
| | - Jessica R Crow
- Department of Pharmacy, The Johns Hopkins Hospital, Baltimore, Maryland
| | - Stephanie L Davis
- Department of Pharmacy, The Johns Hopkins Hospital, Baltimore, Maryland
| | - Glenn J Whitman
- Department of Pharmacy, The Johns Hopkins Hospital, Baltimore, Maryland
| | - Melanie Gavin
- Department of Pharmacy, The Johns Hopkins Hospital, Baltimore, Maryland
| | - Laeban Lester
- Anesthesiology and Critical Care Medicine, The Johns Hopkins Hospital, Baltimore, Maryland
| | - Viachaslau Barodka
- Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Kathryn Dzintars
- Department of Pharmacy, The Johns Hopkins Hospital, Baltimore, Maryland
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