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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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Silva TRDA, Ono JN, Miname FCBR, Gowdak LHW, Mioto BM, Santos RBD, Dallan LRP, Machado Cesar LA. Benefits of using a support bra in women undergoing coronary artery bypass graft surgery: A randomized trial. Clinics (Sao Paulo) 2024; 79:100370. [PMID: 38772100 PMCID: PMC11134560 DOI: 10.1016/j.clinsp.2024.100370] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/07/2023] [Revised: 03/28/2024] [Accepted: 04/17/2024] [Indexed: 05/23/2024] Open
Abstract
BACKGROUND Approximately 30 % of cardiac surgeries are conducted on women by median sternotomy, which often causes discomfort such as pain, affects quality of life, and delayed recovery compared with men. Breast size is related to operative wound complications, such as incisional pain, sternum dehiscence, and infection, which may affect hospital costs due to prolonged hospital stays. OBJECTIVE To evaluate breast size and operative wound complications and the effect of breast support on the incidence of pain, infection, and quality of life in women after coronary artery bypass grafting. METHOD Women were randomly assigned to one of three groups: group A (surgical breast support), group B (ordinary breast support), and group C (no-support). Observations were taken daily between the second and seventh postoperative days and at 30, 60, and 180 days. Pain was assessed using the Short-Form 36 Health Survey (SF36) for quality of life and a verbal numerical scale. The authors used the nonparametric Kruskal-Wallis and Friedman tests to examine variance. The authors used the Pearson correlation coefficient or the Spearman correlation for correlations between variables. A multivariate study was conducted to evaluate the occurrence of infection, and the logistic regression model with "stepwise" variable selection was used. A linear regression model with the "stepwise" variable selection was also used for hospitalization. The authors used SPSS 17.0 software for Windows, with a significance level of p < 0.05. RESULTS There was no difference in pain evaluation between the groups in 190 women (p > 0.05). When comparing quality of life, there was a statistically significant difference in the functional capacity domain at 30 and 60 days, with group A having the best functional capacity (p < 0.05). The larger the breast size, the longer the hospital stay (p < 0.001) and the higher the probability of infection (p = 0.032). Patients with a history of stroke had a 3.8 higher incidence of infection (p = 0.040). CONCLUSION The use of surgical support did not affect acute pain or sternal infection rate in the 6-month follow-up. However, it was effective in the functional capacity domain 30 days after surgery and maintained at 60 days.
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Affiliation(s)
| | - Julia Nishida Ono
- Instituto do Coração (InCor), Faculdade de Medicina da Universidade de São Paulo (FMUSP), São Paulo, SP, Brazil
| | | | - Luís Henrique Wolff Gowdak
- Instituto do Coração (InCor), Faculdade de Medicina da Universidade de São Paulo (FMUSP), São Paulo, SP, Brazil
| | - Bruno Maher Mioto
- Instituto do Coração (InCor), Faculdade de Medicina da Universidade de São Paulo (FMUSP), São Paulo, SP, Brazil
| | - Renan Barbosa Dos Santos
- Instituto do Coração (InCor), Faculdade de Medicina da Universidade de São Paulo (FMUSP), São Paulo, SP, Brazil
| | - Luiz Roberto Palma Dallan
- Instituto do Coração (InCor), Faculdade de Medicina da Universidade de São Paulo (FMUSP), São Paulo, SP, Brazil
| | - Luiz Antonio Machado Cesar
- Instituto do Coração (InCor), Faculdade de Medicina da Universidade de São Paulo (FMUSP), São Paulo, SP, Brazil
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Zhang Y, Tan S, Chen S, Fan X. Risk factors associated with surgical site infections in patients undergoing cardiothoracic surgery: A systematic review and meta-analysis. Int Wound J 2024; 21:e14573. [PMID: 38102858 PMCID: PMC10961885 DOI: 10.1111/iwj.14573] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2023] [Revised: 12/02/2023] [Accepted: 12/04/2023] [Indexed: 12/17/2023] Open
Abstract
Surgical site infections (SSIs) following cardiothoracic surgery can pose significant challenges to patient recovery and outcome. This systematic review and meta-analysis aim to identify and quantify the risk factors associated with SSIs in patients undergoing cardiothoracic surgery. A comprehensive literature search adhering to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines and based on the PICO paradigm was conducted across four databases: PubMed, Embase, Web of Science and the Cochrane Library, without any temporal restrictions. The meta-analysis incorporated studies detailing the risk factors for post-operative sternal infections, especially those reporting odds ratios (OR) or relative risks with 95% confidence intervals (CI). Quality assessment of the studies was done using the Newcastle-Ottawa Scale. Statistical analysis was executed using the chi-square tests for inter-study heterogeneity, with further analyses depending on I2 values. Sensitivity analyses were performed, and potential publication bias was also assessed. An initial dataset of 2442 articles was refined to 21 articles after thorough evaluations based on inclusion and exclusion criteria. Patients with diabetes mellitus have an OR of 1.80 (95% CI: 1.40-2.20) for the incidence of SSIs, while obese patients demonstrate an OR of 1.63 (95% CI: 1.40-1.87). Individuals who undergo intraoperative blood transfusion present an OR of 1.13 (95% CI: 1.07-1.18), and smokers manifest an OR of 1.32 (95% CI: 1.03-1.60). These findings unequivocally indicate a pronounced association between these factors and an elevated risk of SSIs post-operatively. This meta-analysis confirms that diabetes, obesity, intraoperative transfusion and smoking heighten the risk of SSIs post-cardiac surgery. Clinicians should be alert to these factors to optimise patient outcomes.
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Affiliation(s)
- Yanfei Zhang
- Department of Cardiovascular SurgeryGuangdong Provincial Hospital of Chinese MedicineGuangzhouGuangdong ProvinceChina
| | - Songtao Tan
- Department of Cardiovascular SurgeryGuangdong Provincial Hospital of Chinese MedicineGuangzhouGuangdong ProvinceChina
| | - Suning Chen
- Department of CardiologyShengjing Hospital of China Medical UniversityShenyangLiaoning ProvinceChina
| | - Xiaoping Fan
- Department of Cardiovascular SurgeryGuangdong Provincial Hospital of Chinese MedicineGuangzhouGuangdong ProvinceChina
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Chen D, Zhang J, Wang Y, Jiang W, Xu Y, Xiong C, Feng Z, Han Y, Chen Y. Risk factors for sternal wound infection after open-heart operations: A systematic review and meta-analysis. Int Wound J 2023; 21:e14457. [PMID: 37909266 PMCID: PMC10898401 DOI: 10.1111/iwj.14457] [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: 08/20/2023] [Accepted: 10/11/2023] [Indexed: 11/03/2023] Open
Abstract
We aimed to quantitatively and systematically elucidate the rationality of the examined variables as independent risk factors for sternal wound infection. We searched databases to screen studies, ascertained the variables to be analysed, extracted the data and applied meta-analysis to each qualified variable. Odds ratios and mean differences were considered to be the effect sizes for binary and continuous variables, respectively. A random-effects model was used for these procedures. The source of heterogeneity was evaluated using a meta-regression. Publication bias was tested by funnel plot and Egger's test, the significant results of which were then calculated using trim and fill analysis. We used a sensitivity analysis and bubble chart to describe their robustness. After screening all variables in the eligible literature, we excluded 55 because only one or no research found them significant after multivariate analysis, leaving 33 variables for synthesis. Two binary variables (age over 65 years, NYHA class >2) and a continuous variable (preoperative stay) were not significant after the meta-analysis. The most robust independent risk factors in our study were diabetes mellitus, obesity, use of bilateral internal thoracic arteries, chronic obstructive pulmonary disease, prolonged surgery time, prolonged ventilation and critical preoperative state, followed by congestive heart failure, atrial fibrillation, renal insufficiency, stroke, peripheral vascular disease and use of an intra-aortic balloon pump. Relatively low-risk factors were emergent/urgent surgery, smoking, myocardial infarction, combined surgery and coronary artery bypass grafting. Sternal wound infection after open-heart surgery is a multifactorial disease. The detected risk factors significantly affected the wound healing process, but some were different in strength. Anything that affects wound healing and antibacterial ability, such as lack of oxygen, local haemodynamic disorders, malnutrition condition and compromised immune system will increase the risk, and this reminds us of comprehensive treatment during the perioperative period.
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Affiliation(s)
- Dongsheng Chen
- Department of Plastic and Reconstructive SurgeryThe First Medical Centre of Chinese PLA General HospitalBeijingChina
| | - Jianghe Zhang
- Department of Plastic and Cosmetic Surgery, Xinqiao HospitalArmy Medical UniversityChongqingChina
| | - Yuting Wang
- Department of Plastic and Reconstructive SurgeryThe First Medical Centre of Chinese PLA General HospitalBeijingChina
| | - Weiqian Jiang
- Department of Plastic and Reconstructive SurgeryThe First Medical Centre of Chinese PLA General HospitalBeijingChina
| | - Yujian Xu
- Department of Plastic and Reconstructive SurgeryThe First Medical Centre of Chinese PLA General HospitalBeijingChina
| | - Chenlu Xiong
- Department of Plastic and Reconstructive SurgeryThe First Medical Centre of Chinese PLA General HospitalBeijingChina
| | - Zekun Feng
- Department of Cardiovascular SurgeryThe First Medical Centre of Chinese PLA General HospitalBeijingChina
| | - Yan Han
- Department of Plastic and Reconstructive SurgeryThe First Medical Centre of Chinese PLA General HospitalBeijingChina
| | - Youbai Chen
- Department of Plastic and Reconstructive SurgeryThe First Medical Centre of Chinese PLA General HospitalBeijingChina
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Bashir A, Holmes M, Suresh N, Panahi P, Atta S, Perkins HT, Lloyd C, Asopa S. The impact of COVID-19 prevention measures on surgical wound infection rates post-cardiac surgery. Monaldi Arch Chest Dis 2023. [PMID: 37823835 DOI: 10.4081/monaldi.2023.2604] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2023] [Accepted: 06/10/2023] [Indexed: 10/13/2023] Open
Abstract
The COVID-19 pandemic had a huge impact on medical services. Several measures have been implemented to reduce the risk of viral transmission. In this paper, we assessed the impact of these measures on surgical wound infection rates in patients post-cardiac surgery. Hypothesis testing was used to compare post-cardiac operation infection rates between the year prior to the COVID-19 pandemic being declared and the first 13 months of the pandemic. The infection rates in 969 patients with operations between 01/03/2019 and 29/02/2020 were compared to those of 925 patients with cardiac surgery between 01/03/2020 and 31/03/2021. Infection rates for various operative urgencies and infection types were analysed. To compare infection rates, a two-tailed pooled z-test using the difference in infection proportions was performed. A 5% significance level was used and only categories with at least 10 patients in both the pre-covid and covid populations were tested. For leg infections, only operations involving coronary artery bypass grafting were included. To ensure that any differences in outcomes were not due to differences in patient demographics resulting in unequal operative risks, Euroscore II values, a measure of cardiac operative risk, were compared between the pre-covid and post-covid cohorts. The Mann-Whitney U-test was used to determine whether the distributions of Euroscore II values were likely to be drawn from the same population. A significance level of 5% was used. A total of 1901 patients (932 during the COVID-19 pandemic) were included in this study. Significant reduction in post-operative infections for all patients undergoing cardiac surgery from 4.3% of patients before COVID to 1.5% during the pandemic. During the pandemic, fewer elective and more urgent operations were performed. This study suggests a significant role of iatrogenic causes in wound infections prior to the pandemic. The implementation of COVID-19 prevention measures in healthcare providers can reduce surgical infection rates. As COVID-19-related restrictions have been eased, we suggest maintaining them in healthcare providers to reduce the incidence of surgical wound infections.
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Affiliation(s)
| | | | | | | | - Sameh Atta
- University Hospitals Plymouth NHS Trust, Plymouth.
| | | | | | - Sanjay Asopa
- University Hospitals Plymouth NHS Trust, Plymouth.
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Gunga Z, Marchese MV, Pfister R, Dulgorov F, Nowacka A, Rancati V, Ltaief Z, Niclaus L, Pretre R, Kirsch M. Topical skin adhesive PRINEO as the ideal wound closure system in cardiac surgery to limit surgical site infection. J Wound Care 2023; 32:S24-S30. [PMID: 37591665 DOI: 10.12968/jowc.2023.32.sup8a.s24] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/19/2023]
Abstract
OBJECTIVE Surgical site infections (SSIs) are a major source of morbidity after cardiac surgery, involving prolonged hospitalisation. Among the numerous techniques of skin closure and dressings available, the optimal method remains undetermined. The DERMABOND-PRINEO (PRINEO) (PRINEO, Ethicon, J&J) is the only skin closure system which combines a topical skin adhesive with a mesh. Other surgical disciplines have highlighted remarkable results with PRINEO. The aim of this study was to evaluate the effects of PRINEO, used as the final layer in sternotomy closure, in the incidence of postoperative SSIs. METHOD This was a retrospective single-centre cohort study including adult patients who underwent cardiac surgery between January 2015 and December 2018. Patients who had undergone heart transplantation or ventricular assist surgery were excluded. Included patients were divided into two groups depending on the type of post-operative wound care technique used. Group 1 consisted of patients who had their sternotomy closed with a standard dressing and group 2 consisted of patients who were treated with PRINEO. The primary endpoint of our study was the occurrence of SSIs and secondary outcomes were the length of hospitalisation and mortality. RESULTS A total of 1603 patients were reviewed with the occurrence of 44 SSIs. Both groups were homogeneous in terms of risk factors. The incidence of SSIs was significantly lower in group 2 (PRINEO) than in group 1 (standard dressing) (n=29, 3.8% vs n=15, 1.8%, respectively; p=0.042). However, there was no significant difference in the duration of hospitalisation and mortality. CONCLUSION In our practice, PRINEO has proven to be a safe wound closure system after sternotomy, with a reduced SSI rate compared to conventional wound care techniques.
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Affiliation(s)
- Ziyad Gunga
- Department of Cardiac Surgery, Centre Hospitalier Universitaire Vaudois, Lausanne University, Lausanne, Switzerland
| | - Mario Verdugo Marchese
- Department of Cardiac Surgery, Centre Hospitalier Universitaire Vaudois, Lausanne University, Lausanne, Switzerland
| | - Raymond Pfister
- Department of Cardiac Surgery, Centre Hospitalier Universitaire Vaudois, Lausanne University, Lausanne, Switzerland
| | - Filip Dulgorov
- Department of Cardiac Surgery, Centre Hospitalier Universitaire Vaudois, Lausanne University, Lausanne, Switzerland
| | - Anna Nowacka
- Department of Cardiac Surgery, Centre Hospitalier Universitaire Vaudois, Lausanne University, Lausanne, Switzerland
| | - Valentina Rancati
- Department of Anesthesiology, Centre Hospitalier Universitaire Vaudois, Lausanne University, Lausanne, Switzerland
| | - Zied Ltaief
- Department of Anesthesiology, Centre Hospitalier Universitaire Vaudois, Lausanne University, Lausanne, Switzerland
| | - Lars Niclaus
- Department of Cardiac Surgery, Centre Hospitalier Universitaire Vaudois, Lausanne University, Lausanne, Switzerland
| | - Rene Pretre
- Department of Cardiac Surgery, Centre Hospitalier Universitaire Vaudois, Lausanne University, Lausanne, Switzerland
| | - Matthias Kirsch
- Department of Cardiac Surgery, Centre Hospitalier Universitaire Vaudois, Lausanne University, Lausanne, Switzerland
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Madsen HJ, Gillette RA, Colborn KL, Henderson WG, Dyas AR, Bronsert MR, Lambert-Kerzner A, Meguid RA. The association between obesity and postoperative outcomes in a broad surgical population: A 7-year American College of Surgeons National Surgical Quality Improvement analysis. Surgery 2023; 173:1213-1219. [PMID: 36872175 DOI: 10.1016/j.surg.2023.02.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2022] [Revised: 01/22/2023] [Accepted: 02/02/2023] [Indexed: 03/06/2023]
Abstract
BACKGROUND The number of obese surgical patients continues to grow, and yet obesity's association with surgical outcomes is not totally clear. This study examined the association between obesity and surgical outcomes across a broad surgical population using a very large sample size. METHODS This was an analysis of the 2012 to 2018 American College of Surgeons National Surgical Quality Improvement database, including all patients from 9 surgical specialties (general, gynecology, neurosurgery, orthopedics, otolaryngology, plastics, thoracic, urology, and vascular). Preoperative characteristics and postoperative outcomes were compared by body mass index class (normal weight 18.5-24.9 kg/m2, overweight 25.0-29.9, obese class I 30.0-34.9, obese II 35.0-39.9, obese III ≥40). Adjusted odds ratios were computed for adverse outcomes by body mass index class. RESULTS A total of 5,572,019 patients were included; 44.6% were obese. Median operative times were marginally higher for obese patients (89 vs 83 minutes, P < .001). Compared to normal weight patients, overweight and obese patients in classes I, II, and III all had higher adjusted odds of developing infection, venous thromboembolism, and renal complications, but they did not exhibit elevated odds of other postoperative complications (mortality, overall morbidity, pulmonary, urinary tract infection, cardiac, bleeding, stroke, unplanned readmission, or discharge not home (except for class III patients). CONCLUSION Obesity was associated with increased odds of postoperative infection, venous thromboembolism, and renal but not the other American College of Surgeons National Surgical Quality Improvement complications. Obese patients need to be carefully managed for these complications.
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Affiliation(s)
- Helen J Madsen
- Surgical Outcomes and Applied Research Program, Department of Surgery, University of Colorado School of Medicine, Aurora, CO.
| | - Riley A Gillette
- Surgical Outcomes and Applied Research Program, Department of Surgery, University of Colorado School of Medicine, Aurora, CO
| | - Kathryn L Colborn
- Surgical Outcomes and Applied Research Program, Department of Surgery, University of Colorado School of Medicine, Aurora, CO; Department of Biostatistics and Informatics, Colorado School of Public Health, Aurora, CO. https://twitter.com/ColbornKathryn
| | - William G Henderson
- Surgical Outcomes and Applied Research Program, Department of Surgery, University of Colorado School of Medicine, Aurora, CO; Adult and Child Center for Health Outcomes Research and Delivery Science, University of Colorado School of Medicine, Aurora, CO; Department of Biostatistics and Informatics, Colorado School of Public Health, Aurora, CO
| | - Adam R Dyas
- Surgical Outcomes and Applied Research Program, Department of Surgery, University of Colorado School of Medicine, Aurora, CO
| | - Michael R Bronsert
- Surgical Outcomes and Applied Research Program, Department of Surgery, University of Colorado School of Medicine, Aurora, CO; Adult and Child Center for Health Outcomes Research and Delivery Science, University of Colorado School of Medicine, Aurora, CO
| | - Anne Lambert-Kerzner
- Surgical Outcomes and Applied Research Program, Department of Surgery, University of Colorado School of Medicine, Aurora, CO; Adult and Child Center for Health Outcomes Research and Delivery Science, University of Colorado School of Medicine, Aurora, CO
| | - Robert A Meguid
- Surgical Outcomes and Applied Research Program, Department of Surgery, University of Colorado School of Medicine, Aurora, CO; Adult and Child Center for Health Outcomes Research and Delivery Science, University of Colorado School of Medicine, Aurora, CO. https://twitter.com/MeguidRobert
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Torre TM, Toto F, Klersy C, Theologou T, Pozzoli A, Ferrari E, Demertzis S. Twenty-year experience with skeletonized bilateral internal thoracic arteries for surgical myocardial revascularization. A single center experience. J Card Surg 2022; 37:4928-4936. [PMID: 36378881 DOI: 10.1111/jocs.17176] [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: 05/05/2022] [Accepted: 10/27/2022] [Indexed: 11/16/2022]
Abstract
BACKGROUND AND AIM OF THE STUDY The mammary artery shows excellent long-term patency and encourages the use of skeletonized bilateral internal thoracic arteries (BITA) for coronary surgery. We analyzed the long-term outcome of patients operated for myocardial revascularization with BITA in a single center. MATERIALS AND METHODS Clinical data and surgical details of patients undergoing coronary surgery with BITA were prospectively collected and retrospectively analyzed. Selected variables were studied as risk factors for sternal wound complication and a subanalysis of clinical outcome for patients aged 70 years or greater was performed. A long-term follow-up of the study group is provided. RESULTS From January 2001 to November 2021, 750 patients underwent myocardial revascularization using BITA grafts (mean age: 61 ± 9.5 years; males: 91%) at our institute. Patients with triple-vessel disease were 81%, 15.3% of all procedures were performed off-pump and 3.6% were urgent cases. Hospital mortality was 0.5%. Sternal wound complication was observed in 67 patients (9.0%) with 7 deep sternal wound infections (0.9%). Female gender (odds ratios [OR]: 3.7, p < 0.01), BMI >30 (OR: 1.8, p = 0.04), smoking (OR: 1.8, p = 0.02), and chronic kidney failure (OR: 3.7, p = 0.05) were independent predictors for sternal complications. During a mean follow-up time of 8.7 ± 5.3 years, 34 patients (4.5%) underwent a repeated myocardial revascularization, and there were 89 all-cause deaths (11.9%) and the cumulative survival at 5, 10, 15, and 20 years was 97%, 89%, 76%, and 60% for the whole study group 92%, 74%, 47%, and 43% for the subgroup of elderly patients (mean age: 74 ± 3.5 years). CONCLUSIONS Use of skeletonized bilateral thoracic arteries shows low-rate of wound infection and good long-term outcome with low risk of repeated revascularizations, regardless of patients' age.
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Affiliation(s)
- Tiziano M Torre
- Cardiac Surgery, Cardiocentro Ticino Institute, Ente Ospedaliero Cantonale, Lugano, Switzerland
| | - Francesca Toto
- Cardiac Surgery, Cardiocentro Ticino Institute, Ente Ospedaliero Cantonale, Lugano, Switzerland
| | - Catherine Klersy
- Service of Clinical Epidemiology & Biometry, IRCCS Fondazione Policlinico San Matteo, Pavia, Italy
| | - Thomas Theologou
- Cardiac Surgery, Cardiocentro Ticino Institute, Ente Ospedaliero Cantonale, Lugano, Switzerland
| | - Alberto Pozzoli
- Cardiac Surgery, Cardiocentro Ticino Institute, Ente Ospedaliero Cantonale, Lugano, Switzerland
| | - Enrico Ferrari
- Cardiac Surgery, Cardiocentro Ticino Institute, Ente Ospedaliero Cantonale, Lugano, Switzerland
| | - Stefanos Demertzis
- Cardiac Surgery, Cardiocentro Ticino Institute, Ente Ospedaliero Cantonale, Lugano, Switzerland
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Soto E, Kumbla PA, Restrepo RD, Patel JJ, Davies J, Aliotta R, Collawn SS, Denney B, Kilic A, Patcha P, Grant JH, Fix RJ, King TW, de la Torre JI, Myers RP. Comorbidity Trends in Patients Requiring Sternectomy and Reconstruction: Updated Data Analysis From 2005 to 2020. Ann Plast Surg 2022; 88:S443-S448. [PMID: 35502943 PMCID: PMC9893917 DOI: 10.1097/sap.0000000000003155] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
INTRODUCTION Comorbidity trends after median sternectomy were studied at our institution by Vasconze et al (Comorbidity trends in patients requiring sternectomy and reconstruction. Ann Plast Surg. 2005;54:5). Although techniques for sternal reconstruction have remained unchanged, the patient population has become more complex in recent years. This study offers insight into changing trends in this patient population. METHODS A retrospective review was performed of patients who underwent median sternectomy followed by flap reconstruction at out institution between 2005 and 2020. Comorbidities, reconstruction method, average laboratory values, and complications were analyzed. RESULTS A total of 105 patients were identified. Comorbidities noted were diabetes (27%), immunosuppression (16%), hypertension (58%), renal insufficiency (23%), chronic obstructive pulmonary disease (16%), and tobacco utilization (24%). The most common reconstruction methods were omentum (45%) or pectoralis major flaps (34%). Thirty-day mortality rates were 10%, and presence of at least 1 complication was 34% (hematoma, seroma, osteomyelitis, dehiscence, wound infection, flap failure, and graft exposure). Univariate analysis demonstrated that sex (P = 0.048), renal insufficiency, surgical site complication, wound dehiscence, and flap failure (P < 0.05) had statistically significant associations with mortality. In addition, body mass index, creatinine, and albumin had a significant univariate association with mortality (P < 0.05). CONCLUSIONS Similar to the original study, there is an association between renal insufficiency and mortality. However, the mortality rate is decreased to 10%, likely because of improved medical management of patients with increasing comorbidities (80% with greater than one comorbidity). This has led to the increased use of omentum as a first-line option. Subsequent wound dehiscence and flap failure demonstrate an association with mortality, suggesting that increasingly complex patients are requiring a method of reconstruction once used a last resort as a first-line option.
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Affiliation(s)
- Edgar Soto
- From the University of Alabama at Birmingham, Heersink School of Medicine, Birmingham
| | - Pallavi A Kumbla
- Department of Surgery, Division of Plastic Surgery, University of Alabama at Birmingham Medical Center
| | - Ryan D Restrepo
- Department of Surgery, Division of Plastic Surgery, University of Alabama at Birmingham Medical Center
| | - Jason J Patel
- From the University of Alabama at Birmingham, Heersink School of Medicine, Birmingham
| | - James Davies
- Department of Surgery, Division of Cardiovascular Surgery, University of Alabama at Birmingham Medical Center, Birmingham, AL
| | - Rachel Aliotta
- Department of Surgery, Division of Plastic Surgery, University of Alabama at Birmingham Medical Center
| | - Sherry S Collawn
- Department of Surgery, Division of Plastic Surgery, University of Alabama at Birmingham Medical Center
| | - Brad Denney
- Department of Surgery, Division of Plastic Surgery, University of Alabama at Birmingham Medical Center
| | - Ali Kilic
- Department of Surgery, Division of Plastic Surgery, University of Alabama at Birmingham Medical Center
| | - Prasanth Patcha
- Department of Surgery, Division of Plastic Surgery, University of Alabama at Birmingham Medical Center
| | - John H Grant
- Department of Surgery, Division of Plastic Surgery, University of Alabama at Birmingham Medical Center
| | - R Jobe Fix
- Department of Surgery, Division of Plastic Surgery, University of Alabama at Birmingham Medical Center
| | - Timothy W King
- Department of Surgery, Division of Plastic Surgery, Loyola University Medical Center, Maywood, Illinois
| | - Jorge I de la Torre
- Department of Surgery, Division of Plastic Surgery, University of Alabama at Birmingham Medical Center
| | - Rene P Myers
- Department of Surgery, Division of Plastic Surgery, University of Alabama at Birmingham Medical Center
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10
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Bouza E, de Alarcón A, Fariñas MC, Gálvez J, Goenaga MÁ, Gutiérrez-Díez F, Hortal J, Lasso J, Mestres CA, Miró JM, Navas E, Nieto M, Parra A, Pérez de la Sota E, Rodríguez-Abella H, Rodríguez-Créixems M, Rodríguez-Roda J, Sánchez Espín G, Sousa D, Velasco García de Sierra C, Muñoz P, Kestler M. Prevention, Diagnosis and Management of Post-Surgical Mediastinitis in Adults Consensus Guidelines of the Spanish Society of Cardiovascular Infections ( SEICAV), the Spanish Society of Thoracic and Cardiovascular Surgery ( SECTCV) and the Biomedical Research Centre Network for Respiratory Diseases ( CIBERES). J Clin Med 2021; 10:5566. [PMID: 34884268 PMCID: PMC8658224 DOI: 10.3390/jcm10235566] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2021] [Revised: 11/19/2021] [Accepted: 11/23/2021] [Indexed: 01/04/2023] Open
Abstract
This is a consensus document of the Spanish Society of Cardiovascular Infections (SEICAV), the Spanish Society of Thoracic and Cardiovascular Surgery (SECTCV) and the Biomedical Research Centre Network for Respiratory Diseases (CIBERES). These three entities have brought together a multidisciplinary group of experts that includes anaesthesiologists, cardiac and cardiothoracic surgeons, clinical microbiologists, infectious diseases and intensive care specialists, internal medicine doctors and radiologists. Despite the clinical and economic consequences of sternal wound infections, to date, there are no specific guidelines for the prevention, diagnosis and management of mediastinitis based on a multidisciplinary consensus. The purpose of the present document is to provide evidence-based guidance on the most effective diagnosis and management of patients who have experienced or are at risk of developing a post-surgical mediastinitis infection in order to optimise patient outcomes and the process of care. The intended users of the document are health care providers who help patients make decisions regarding their treatment, aiming to optimise the benefits and minimise any harm as well as the workload.
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Affiliation(s)
- Emilio Bouza
- Clinical Microbiology and Infectious Diseases Department, Gregorio Marañon University Hospital, Gregorio Marañon Health Research Institute, Complutense University of Madrid, CIBER of Respiratory Diseases—CIBERES, 28007 Madrid, Spain; (E.B.); (M.R.-C.); (P.M.)
| | | | | | - Juan Gálvez
- Virgen Macarena University Hospital, 41009 Seville, Spain;
| | | | - Francisco Gutiérrez-Díez
- Cardiovascular Surgery Department, Marques de Valdecilla University Hospital, 39008 Santander, Cantabria, Spain;
| | - Javier Hortal
- Anesthesia and Intensive Care Department, Gregorio Marañon University Hospital, 28007 Madrid, Spain;
| | - José Lasso
- Plastic Surgery Department, Gregorio Marañon University Hospital, 28007 Madrid, Spain;
| | - Carlos A. Mestres
- Department of Cardiac Surgery, University Hospital Zurich, 8091 Zurich, Switzerland;
| | - José M. Miró
- Infectious Diseases Services, Hospital Clinic-IDIBAPS, University of Barcelona, 08036 Barcelona, Spain;
| | - Enrique Navas
- Infectious Diseases Department, Ramón y Cajal University Hospital, 28034 Madrid, Spain;
| | - Mercedes Nieto
- Cardiovascular Unit, Intensive Care Department, San Carlos Clinical Hospital, 28040 Madrid, Spain;
| | - Antonio Parra
- Department of Radiology, Marquez de Valdecilla University Hospital, 39008 Santander, Cantabria, Spain;
| | | | - Hugo Rodríguez-Abella
- Cardiac Surgery Department, Gregorio Marañon University Hospital, 28007 Madrid, Spain;
| | - Marta Rodríguez-Créixems
- Clinical Microbiology and Infectious Diseases Department, Gregorio Marañon University Hospital, Gregorio Marañon Health Research Institute, Complutense University of Madrid, CIBER of Respiratory Diseases—CIBERES, 28007 Madrid, Spain; (E.B.); (M.R.-C.); (P.M.)
| | | | - Gemma Sánchez Espín
- Heart Clinical Management Unit, Virgen de la Victoria University Hospital, 29006 Malaga, Spain;
| | - Dolores Sousa
- Infectious Diseases Department, A Coruña Hospital Complex, 15006 A Coruña, Spain;
| | | | - Patricia Muñoz
- Clinical Microbiology and Infectious Diseases Department, Gregorio Marañon University Hospital, Gregorio Marañon Health Research Institute, Complutense University of Madrid, CIBER of Respiratory Diseases—CIBERES, 28007 Madrid, Spain; (E.B.); (M.R.-C.); (P.M.)
| | - Martha Kestler
- Clinical Microbiology and Infectious Diseases Department, Gregorio Marañon University Hospital, Gregorio Marañon Health Research Institute, Complutense University of Madrid, CIBER of Respiratory Diseases—CIBERES, 28007 Madrid, Spain; (E.B.); (M.R.-C.); (P.M.)
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11
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Jiang X, Bu F, Xu Y, Jing Z, Jiao G, Li M, Rong X. Antibiotic-loaded bone cement combined with vacuum sealing drainage to treat deep sternal wound infection following cardiac surgery: the first case report. J Cardiothorac Surg 2021; 16:292. [PMID: 34629078 PMCID: PMC8504067 DOI: 10.1186/s13019-021-01673-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2021] [Accepted: 09/25/2021] [Indexed: 11/18/2022] Open
Abstract
Background Deep sternal wound infection (DSWI) is a rare but serious complication after median sternotomy, and treatment success depends mainly on surgical experience. Here we first present a case of a patient successfully treated for antibiotic-loaded bone cement (ALBC) combined with vacuum sealing drainage (VSD) of DSWI. Case presentation This case report presented a patient who underwent open heart surgery, and suffered postoperatively from a DSWI associated with enterococcus cloacae. Focus debridement combined with ALBC filling and VSD was conducted in stage I. Appropriate antibiotics were started according to sensitivity to be continued for 2 weeks until the inflammatory markers decreased to normal. One month after the surgery, patient’s wound was almost healed and was discharged from hospital with a drainage tube. Two months after the stage I surgery procedure, the major step was removing the previous ALBC, and extensive debridement in stage II. The patient fully recovered without further surgical treatment. Conclusions The results of this case suggest that ALBC combined with VSD may be a viable and safe option for deep sternal wound reconstruction.
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Affiliation(s)
- Xia Jiang
- Department of Cardiovascular Surgery, Wuxi People's Hospital/Wuxi Affiliated Hospital of Nanjing Medical University, Wuxi, 214203, China
| | - Fanyu Bu
- Department of Chronic Wound, Wuxi Ninth People's Hospital Affiliated to Soochow University, Wuxi, 214062, China
| | - Yong Xu
- Department of Cardiovascular Surgery, Wuxi People's Hospital/Wuxi Affiliated Hospital of Nanjing Medical University, Wuxi, 214203, China
| | - Zhaohui Jing
- Department of Cardiovascular Surgery, Wuxi People's Hospital/Wuxi Affiliated Hospital of Nanjing Medical University, Wuxi, 214203, China
| | - Guoqing Jiao
- Department of Cardiovascular Surgery, Wuxi People's Hospital/Wuxi Affiliated Hospital of Nanjing Medical University, Wuxi, 214203, China
| | - Mingqiu Li
- Department of Cardiovascular Surgery, Wuxi People's Hospital/Wuxi Affiliated Hospital of Nanjing Medical University, Wuxi, 214203, China.
| | - Xiaosong Rong
- Department of Cardiovascular Surgery, Wuxi People's Hospital/Wuxi Affiliated Hospital of Nanjing Medical University, Wuxi, 214203, China.
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12
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Myllykangas HM, Halonen J, Husso A, Väänänen H, Berg LT. Does Incisional Negative Pressure Wound Therapy Prevent Sternal Wound Infections? Thorac Cardiovasc Surg 2021; 70:65-71. [PMID: 34521138 DOI: 10.1055/s-0041-1731767] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
BACKGROUND Incisional negative pressure wound therapy has been described as an effective method to prevent wound infections after open heart surgery in several publications. However, most studies have examined relatively small patient groups, only a few were randomized, and some have manufacturer-sponsorship. Most of the studies have utilized Prevena; there are only a few reports describing the PICO incisional negative pressure wound therapy system. METHODS We conducted a prospective cohort study involving a propensity score-matched analysis to evaluate the effect of PICO incisional negative pressure wound therapy after coronary artery bypass grafting. A total of 180 high-risk patients with obesity or diabetes were included in the study group. The control group included 772 high-risk patients operated before the initiation of the study protocol. RESULTS The rates of deep sternal wound infections in the PICO group and in the control group were 3.9 and 3.1%, respectively. The rates of superficial wound infections needing operative treatment were 3.1 and 0.8%, respectively. After propensity score matching with two groups of 174 patients, the incidence of both deep and superficial infections remained slightly elevated in the PICO group. None of the infections were due to technical difficulties or early interruption of the treatment. CONCLUSION It seems that incisional negative pressure wound therapy with PICO is not effective in preventing wound infections after coronary artery bypass grafting. The main difference in this study compared with previous reports is the relatively low incidence of infections in our control group.
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Affiliation(s)
- Heidi-Mari Myllykangas
- Department of Plastic Surgery, Kuopio University Hospital, Kuopio, Finland.,University of Eastern Finland School of Medicine, Kuopio, Pohjois-Savo, Finland
| | - Jari Halonen
- University of Eastern Finland School of Medicine, Kuopio, Pohjois-Savo, Finland.,Department of Cardiothoracic Surgery, Kuopio University Hospital, Kuopio, Pohjois-Savo, Finland
| | - Annastiina Husso
- Department of Cardiothoracic Surgery, Kuopio University Hospital, Kuopio, Pohjois-Savo, Finland
| | - Helli Väänänen
- Department of Plastic Surgery, Kuopio University Hospital, Kuopio, Finland
| | - Leena T Berg
- Department of Plastic Surgery, Kainuu Central Hospital, Kajaani, Kainuu, Finland
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13
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An Outcomes Review of 330 Sternal Wound Reconstructions: Timing of Closure Does Make a Difference. Plast Reconstr Surg 2021; 148:429-437. [PMID: 34398095 DOI: 10.1097/prs.0000000000008168] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Sternal wound infection and dehiscence following cardiac surgery remain difficult clinical problems with high morbidity. Older classification systems regarding timing to reconstruction do not take into account recent improvements in critical care, wound vacuum-assisted closure use, or next-generation antibiotic therapies, which may prolong time to reconstruction. METHODS Records of patients undergoing sternal wound reconstruction performed by the senior author (J.A.A.) from 1996 to 2018 at a high-volume cardiac surgery center were reviewed. Indications included sternal wound infection or dehiscence. All patients underwent single-stage removal of hardware, débridement, and flap closure. Patients were divided into two groups based on timing of wound closure after cardiac surgery: less than 30 days or greater than or equal to 30 days. RESULTS Of the 505 patients identified during the study period, 330 had sufficient data for analysis. Mean time to sternal wound surgery was 15.7 days in the early group compared to 64.4 days (p < 0.01) beyond 30 days. Postdébridement cultures were positive in 72 percent versus 62.5 percent of patients (p = 0.11), whereas rates of postoperative infection were significantly higher in the delayed group: 1.9 percent versus 9.5 percent (p < 0.01). Partial wound dehiscence rates were also higher after 30 days (1.9 percent versus 11.3 percent; p < 0.01), whereas total length of stay was decreased. Use of wound vacuum-assisted closure was significantly associated with reconstruction beyond 30 days (p < 0.01). CONCLUSIONS Although performing sternal wound reconstruction more than 30 days after initial cardiac surgery was associated with a shorter overall hospital length of stay and higher extubation rates in the operating room, these patients also had elevated postoperative infection and wound complication rates. The authors thus recommend not delaying definitive surgical reconstruction when possible. CLINICAL QUESTION/LEVEL OF EVIDENCE Therapeutic, III.
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14
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Guglielmi V, Colangeli L, D’Adamo M, Sbraccia P. Susceptibility and Severity of Viral Infections in Obesity: Lessons from Influenza to COVID-19. Does Leptin Play a Role? Int J Mol Sci 2021; 22:ijms22063183. [PMID: 33804765 PMCID: PMC8003928 DOI: 10.3390/ijms22063183] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2021] [Revised: 03/05/2021] [Accepted: 03/18/2021] [Indexed: 12/13/2022] Open
Abstract
The recent pandemic Sars-CoV2 infection and studies on previous influenza epidemic have drawn attention to the association between the obesity and infectious diseases susceptibility and worse outcome. Metabolic complications, nutritional aspects, physical inactivity, and a chronic unbalance in the hormonal and adipocytokine microenvironment are major determinants in the severity of viral infections in obesity. By these pleiotropic mechanisms obesity impairs immune surveillance and the higher leptin concentrations produced by adipose tissue and that characterize obesity substantially contribute to such immune response dysregulation. Indeed, leptin not only controls energy balance and body weight, but also plays a regulatory role in the interplay between energy metabolism and immune system. Since leptin receptor is expressed throughout the immune system, leptin may exert effects on cells of both innate and adaptive immune system. Chronic inflammatory states due to metabolic (i.e., obesity) as well as infectious diseases increase leptin concentrations and consequently lead to leptin resistance further fueling inflammation. Multiple factors, including inflammation and ER stress, contribute to leptin resistance. Thus, if leptin is recognized as one of the adipokines responsible for the low grade inflammation found in obesity, on the other hand, impairments of leptin signaling due to leptin resistance appear to blunt the immunologic effects of leptin and possibly contribute to impaired vaccine-induced immune responses. However, many aspects concerning leptin interactions with inflammation and immune system as well as the therapeutical approaches to overcome leptin resistance and reduced vaccine effectiveness in obesity remain a challenge for future research.
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15
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Storey A, MacDonald B, Rahman MA. The association between preoperative length of hospital stay and deep sternal wound infection: A scoping review. Aust Crit Care 2021; 34:620-633. [PMID: 33750649 DOI: 10.1016/j.aucc.2020.12.010] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2019] [Revised: 12/10/2020] [Accepted: 12/13/2020] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND Deep sternal wound infection (DSWI) is a serious complication of cardiac surgery, associated with a significantly longer hospital stay, an increased mortality, and an almost doubling of treatment costs. The preoperative length of hospital stay has been suggested in a small number of studies as a modifiable risk factor yet is not included in surgical site infection prevention guidelines. The aim of this scoping review was to review the existing evidence on the association between preoperative length of hospital stay and DSWI, and to identify established risk factors for DSWI. METHODS A literature search of six electronic databases yielded 2297 results. Titles concerning risk factors for DSWI, sternal or surgical wound infection, or poststernotomy complications were included. Abstracts relating to preoperative length of stay as a risk factor for DSWI proceeded to full article review. Articles regarding paediatric surgery, DSWI management or unavailable in English were excluded. RESULTS The review identified 11 observational cohort studies. DSWI prevalence was between 0.9% and 6.8%. Preoperative length of stay ranged from 0-15.5 days and was found to be associated with DSWI in all studies. Preoperative length of stay and DSWI were inconsistently defined. Other risk factors for DSWI included diabetes, obesity, respiratory disease, heart failure, renal impairment, complex surgery, and reoperation (p < 0.05). CONCLUSION In this scoping review, an association between preoperative length of stay and the development of DSWI following cardiac surgery was identified. Thus, preoperative length of stay as a modifiable risk factor for DSWI should be considered for inclusion in cardiothoracic surgical infection prevention guidelines.
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Affiliation(s)
- Annmarie Storey
- Alfred Heart & Lung, The Alfred Hospital, 55 Commercial Road, Melbourne, VIC 3004, Australia; School of Nursing and Midwifery, La Trobe University, Plenty Rd & Kingsbury Dr, Bundoora, Melbourne, VIC 3086, Australia.
| | - Brendan MacDonald
- Alfred Heart & Lung, The Alfred Hospital, 55 Commercial Road, Melbourne, VIC 3004, Australia; Ward 2.2, Box Hill Hospital, Eastern Health, 8 Arnold St, Box Hill, Melbourne, Victoria, 3128, Australia
| | - Muhammad Aziz Rahman
- School of Health, Federation University Australia, Berwick, Melbourne, VIC 3806, Australia; Australian Institute of Primary Care and Ageing, La Trobe University, Melbourne, VIC 3086, Australia.
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16
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Shafi AMA, Abuelgasim E, Abuelgasim B, Iddawela S, Harky A. Sternal closure with single compared with double or figure of 8 wires in obese patients following cardiac surgery: A systematic review and meta-analysis. J Card Surg 2021; 36:1072-1082. [PMID: 33476466 DOI: 10.1111/jocs.15339] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2020] [Accepted: 01/05/2021] [Indexed: 11/26/2022]
Abstract
OBJECTIVES Sternal instability and wound infections are major causes of morbidity following cardiac surgery, which is further amplified in high risk patients that include diabetics and patients with high body mass index (BMI). We compare the different outcomes of different sternal wire closure techniques following median sternotomy for cardiac surgery in obese patients. METHODS A comprehensive electronic literature search was undertaken according to PRISMA guidelines from inception to July 2020 to identify all published data comparing single wire sternal closure to either double wire or figure-of-8 techniques following median sternotomy for cardiac surgery in obese patients, defined as a BMI ≥ 30. RESULTS Eight studies met the final inclusion criteria; single wire versus double wire sternal closure (n = 2) and single wire versus figure-of-8 wire closure (n = 6). Higher rate of sternal instability was noted in single wire versus double wire closure (22/150 [14.7%] patients vs. 6/150 [4%] patients, p = 0.003, odd ratio [OR] 0.25 [95% confidence interval [CI] 0.10-0.63]). Similarly, sternal instability was higher in single wire vs figure-of-8 wire closure technique (33/2422 [1.3%] vs. 11/8035 [0.1%], p = 0.04 OR 0.30 [95% CI, 0.09-0.96]), respectively. CONCLUSION There is benefit in the use of either double or figure-of-8 sternal wire closure techniques over single wire closure in terms of sternal instability. However, as the studies were limited, larger scale comparative studies are required to provide a solid evidence base for choosing the optimal sternal closure technique in this high risk group of patients.
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Affiliation(s)
- Ahmed M A Shafi
- Department of Cardiothoracic Surgery, St Bartholomew's Hospital, Barts Heart Centre, London, UK
| | | | | | - Sashini Iddawela
- Department of Respiratory Medicine, University Hospitals Birmingham, Birmingham, UK
| | - Amer Harky
- Department of Cardiothoracic Surgery, Liverpool Heart and Chest Hospital, Liverpool, UK.,Department of Integrative Biology, Faculty of Health and Life Sciences, University of Liverpool, Liverpool, UK
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17
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The Japan Society for Surgical Infection: guidelines for the prevention, detection, and management of gastroenterological surgical site infection, 2018. Surg Today 2020; 51:1-31. [PMID: 33320283 PMCID: PMC7788056 DOI: 10.1007/s00595-020-02181-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/30/2020] [Indexed: 12/27/2022]
Abstract
Background The guidelines for the prevention, detection, and management of gastroenterological surgical site infections (SSIs) were published in Japanese by the Japan Society for Surgical Infection in 2018. This is a summary of these guidelines for medical professionals worldwide. Methods We conducted a systematic review and comprehensive evaluation of the evidence for diagnosis and treatment of gastroenterological SSIs, based on the concepts of the Grading of Recommendations Assessment, Development and Evaluation (GRADE) system. The strength of recommendations was graded and voted using the Delphi method and the nominal group technique. Modifications were made to the guidelines in response to feedback from the general public and relevant medical societies. Results There were 44 questions prepared in seven subject areas, for which 51 recommendations were made. The seven subject areas were: definition and etiology, diagnosis, preoperative management, prophylactic antibiotics, intraoperative management, perioperative management, and wound management. According to the GRADE system, we evaluated the body of evidence for each clinical question. Based on the results of the meta-analysis, recommendations were graded using the Delphi method to generate useful information. The final version of the recommendations was published in 2018, in Japanese. Conclusions The Japanese Guidelines for the prevention, detection, and management of gastroenterological SSI were published in 2018 to provide useful information for clinicians and improve the clinical outcome of patients. Electronic supplementary material The online version of this article (10.1007/s00595-020-02181-6) contains supplementary material, which is available to authorized users.
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18
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Malik VS, Ravindra K, Attri SV, Bhadada SK, Singh M. Higher body mass index is an important risk factor in COVID-19 patients: a systematic review and meta-analysis. ENVIRONMENTAL SCIENCE AND POLLUTION RESEARCH INTERNATIONAL 2020; 27:42115-42123. [PMID: 32710359 PMCID: PMC7380664 DOI: 10.1007/s11356-020-10132-4] [Citation(s) in RCA: 48] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/17/2020] [Accepted: 07/14/2020] [Indexed: 05/07/2023]
Abstract
Globally, both obesity and underweight are severe health risks for various diseases. The current study systematically examined the emerging evidence to identify an association between body mass index (BMI) and COVID-19 disease outcome. Online literature databases (e.g., Google Scholar, PubMed, MEDLINE, EMBASE, Scopus, Medrixv and BioRixv) were screened following standard search strategy having the appropriate keyword such as "Obesity", "Underweight", "BMI", "Body Mass Index", "2019-nCov", "COVID-19, "novel coronavirus", "coronavirus disease". Studies published till 20th April 2020 were included without language restriction. These studies include case reports, case series, cohort, and any other which reported BMI, overweight/obesity or underweight, and its complication with COVID-19 disease. This study observed COVID-19 infection among BMI < 25 kg/m2 with prevalence of 0.60 (95%CI: 0.34-0.86, I2 = - 76.77) as compared to the 0.34 (95%CI: 0.23-0.44, I2 = 53.45% heterogeneity) having BMI > 25 kg/m2. The results of the current study show that BMI plays a significant role in COVID-19 severity in all age groups, especially the older individuals. A panel of doctors and nursing staff should review COVID-19 patients with higher BMI with other co-morbidities (diabetes and hypertension), and they should be given increased vigilance, priority in testing, and treatment to control the associated co-morbidities. Further, the COVID-19 patients whose illness entered 7-10 days, age > 50 years, and elevated CRP levels should be given additional medical considerations. Our finding showed that the population and patients with high BMI have moderate to high risk of medical complications with COVID-19, and hence, their health status should be monitored more frequently including monitoring of blood pressure and blood glucose.
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Affiliation(s)
- Vivek Singh Malik
- Department of Community Medicine and School of Public Health, Post Graduate Institute of Medical Education and Research (PGIMER), Chandigarh, 160012, India
- Department of Pediatrics, Post Graduate Institute of Medical Education and Research (PGIMER), Chandigarh, 160012, India
| | - Khaiwal Ravindra
- Department of Community Medicine and School of Public Health, Post Graduate Institute of Medical Education and Research (PGIMER), Chandigarh, 160012, India.
| | - Savita Verma Attri
- Department of Pediatrics, Post Graduate Institute of Medical Education and Research (PGIMER), Chandigarh, 160012, India
| | - Sanjay Kumar Bhadada
- Department of Endocrinology, Post Graduate Institute of Medical Education and Research (PGIMER), Chandigarh, 160012, India
| | - Meenu Singh
- Department of Pediatrics, Post Graduate Institute of Medical Education and Research (PGIMER), Chandigarh, 160012, India
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19
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Findeisen A, Arefian H, Doenst T, Hagel S, Pletz MW, Hartmann M, Maschmann J. Economic burden of surgical site infections in patients undergoing cardiac surgery†. Eur J Cardiothorac Surg 2020; 55:494-500. [PMID: 30084908 DOI: 10.1093/ejcts/ezy274] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/30/2018] [Revised: 07/05/2018] [Accepted: 07/08/2018] [Indexed: 11/14/2022] Open
Abstract
OBJECTIVES This study aimed to determine the additional costs and length of stay (LOS) due to surgical site infections (SSIs) after coronary artery bypass grafting (CABG) at Jena University Hospital. METHODS The data of 999 consecutive patients who underwent CABG from January 2013 to December 2014 were collected. We extracted the number, type and duration of antimicrobial therapy and V.A.C.® therapy (negative pressure wound therapy) treatments and calculated the additional SSI-related costs based on the hospital's perspective. We also evaluated the prolongation of LOS using a multistate model and calculated the costs due to the additional LOS. RESULTS In total, 983 patients were included in our analysis, and 126 patients with SSIs following CABG were identified during the study period; 124 patients with SSIs (98.4%) were discharged alive. The mean cost of antimicrobial therapy to treat the SSIs was €818 [95% confidence interval (CI) 392-1245], and the mean cost of V.A.C. therapy was €1179 (95% CI 748-1610) per infected patient. The mean additional LOS due to SSIs (±standard error) was estimated to be 9.3 ± 2.6 days. The cost per SSI-infected patient attributable to the additional LOS was €9444 (95% CI 4242-14 645). CONCLUSIONS SSIs following CABG are associated with an additional LOS and a significant economic burden depending on the classification of SSI. A very important component of the additional cost is the prolongation of LOS. Therefore, it is essential to shorten the hospital stay due to SSIs as far as possible.
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Affiliation(s)
- Axel Findeisen
- Faculty of Medicine, Friedrich Schiller University Jena, Jena, Germany
| | - Habibollah Arefian
- Center for Sepsis Control and Care (CSCC), Jena University Hospital, Jena, Germany.,Hospital Pharmacy, Jena University Hospital, Jena, Germany
| | - Torsten Doenst
- Department of Cardiothoracic Surgery, Jena University Hospital, Jena, Germany
| | - Stefan Hagel
- Center for Sepsis Control and Care (CSCC), Jena University Hospital, Jena, Germany.,Institute for Infectious Diseases and Infection Control, Jena University Hospital, Jena, Germany
| | - Mathias W Pletz
- Institute for Infectious Diseases and Infection Control, Jena University Hospital, Jena, Germany
| | - Michael Hartmann
- Center for Sepsis Control and Care (CSCC), Jena University Hospital, Jena, Germany.,Hospital Pharmacy, Jena University Hospital, Jena, Germany
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20
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Lin C, Fu Y, Huang S, Zhou S, Shen C. Rapid thrombelastography predicts perioperative massive blood transfusion in patients undergoing coronary artery bypass grafting: A retrospective study. Medicine (Baltimore) 2020; 99:e21833. [PMID: 32925720 PMCID: PMC7489729 DOI: 10.1097/md.0000000000021833] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
Massive blood transfusion (MBT) is a relatively common complication of cardiac surgery, which is independently associated with severe postoperative adverse events. However, the value of using rapid thrombotomography (r-TEG) to predict MBT in perioperative period of cardiac surgery has not been explored. This study aimed to identify the effect of r-TEG in predicting MBT for patients undergoing coronary artery bypass grafting (CABG).This retrospective study included consecutive patients first time undergoing CABG at the Zhongnan Hospital of Wuhan University between March 2015 and November 2017. All the patients had done r-TEG tests before surgery. The MBT was defined as receiving at least 4 units of red blood cells intra-operatively and 5 units postoperatively (1 unit red blood cells from 200 mL whole blood).Lower preoperative hemoglobin level (P = .001) and longer cardiopulmonary bypass time (P = .001) were the independent risk factors for MBT during surgery, and no components of the r-TEG predicted MBT during surgery. Meanwhile, longer activated clotting time (P < .001), less autologous blood transfusion (P = .001), and older age (P = .008) were the independent risk factors for MBT within 24 hours of surgery.Preoperative r-TEG activated clotting time can predict the increase of postoperative MBT in patients undergoing CABG. We recommend the careful monitoring of coagulation system with r-TEG, which allows rapid diagnosis of coagulation abnormalities even before the start of surgery.
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Affiliation(s)
- Chenyao Lin
- Department of Laboratory Mediciney, Ningbo Medical Treatment Center Lihuili Hospital, Ningbo
- Department of Blood Transfusion, ZhongNan Hospital of Wuhan University, Wuhan, China
| | - Yourong Fu
- Department of Blood Transfusion, ZhongNan Hospital of Wuhan University, Wuhan, China
| | - Shuang Huang
- Department of Blood Transfusion, ZhongNan Hospital of Wuhan University, Wuhan, China
| | - Shuimei Zhou
- Department of Blood Transfusion, ZhongNan Hospital of Wuhan University, Wuhan, China
| | - Changxin Shen
- Department of Blood Transfusion, ZhongNan Hospital of Wuhan University, Wuhan, China
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Magboo R, Drey N, Cooper J, Byers H, Shipolini A, Sanders J. Predicting cardiac surgical site infection: development and validation of the Barts Surgical Infection Risk tool. J Clin Epidemiol 2020; 128:57-65. [PMID: 32853763 DOI: 10.1016/j.jclinepi.2020.08.015] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2020] [Revised: 07/28/2020] [Accepted: 08/19/2020] [Indexed: 11/30/2022]
Abstract
OBJECTIVES The objective of this study was to develop and validate a new risk tool (Barts Surgical Infection Risk (B-SIR)) to predict surgical site infection (SSI) risk after all types of adult cardiac surgery, and compare its predictive ability against existing (but procedure-specific) tools: Brompton-Harefield Infection Score (BHIS), Australian Clinical Risk Index (ACRI), National Nosocomial Infection Surveillance (NNIS). STUDY DESIGN AND SETTING Single-center retrospective analysis of prospectively collected data including 2,449 patients undergoing cardiac surgery between January 2016 and December 2017 in a European tertiary hospital. Thirty-four variables associated with SSI risk after cardiac surgery were collated from three local databases. Independent predictors were identified using stepwise multivariable logistic regression. Bootstrap resampling was conducted to validate the model. Hosmer-Lemeshow goodness-of-fit test was performed to assess calibration of scores. RESULTS The B-SIR model was constructed from six independent predictors female gender, body mass index >30, diabetes, left ventricular ejection fraction <45%, peripheral vascular disease and operation type, and the risk estimates were derived. The receiver operating characteristics curve for B-SIR was 0.682, vs. 0.603 for BHIS, 0.618 for ACRI, and 0.482 for the NNIS tool. CONCLUSION B-SIR provides greater predictive power of SSI risk after cardiac surgery compared with existing tools in our population.
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Affiliation(s)
- Rosalie Magboo
- Department of Perioperative Medicine, St. Bartholomew's Hospital, Barts Health NHS Trust, West Smithfield, London EC1A 7B, UK.
| | - Nicholas Drey
- Division of Nursing, City University of London, Northampton Square, Clerkenwell, London EC1V 0HB, UK
| | - Jackie Cooper
- William Harvey Research Institute, Queen Mary's University of London, Charterhouse Square, London EC1M 6BQ, UK
| | - Heather Byers
- Department of Perioperative Medicine, St. Bartholomew's Hospital, Barts Health NHS Trust, West Smithfield, London EC1A 7B, UK
| | - Alex Shipolini
- Department of Cardiothoracic Surgery, St. Bartholomew's Hospital, Barts Health NHS Trust, West Smithfield, London EC1A 7B, UK
| | - Julie Sanders
- William Harvey Research Institute, Queen Mary's University of London, Charterhouse Square, London EC1M 6BQ, UK; St. Bartholomew's Hospital, Barts Health NHS Trust, West Smithfield, London EC1A 7B, UK
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Phoon PHY, Hwang NC. Deep Sternal Wound Infection: Diagnosis, Treatment and Prevention. J Cardiothorac Vasc Anesth 2020; 34:1602-1613. [DOI: 10.1053/j.jvca.2019.09.019] [Citation(s) in RCA: 30] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/20/2019] [Revised: 08/28/2019] [Accepted: 09/12/2019] [Indexed: 12/18/2022]
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Zia A, Hasan M, Ilyas S, Siddiqui HU, Tappuni B, Marsia S, Zubair MM, Raza S, Mustafa RR, Baloch ZQ, Deo SV, Sharma UM, Sheikh MA. Reining in Sternal Wound Infections: The Achilles' Heel of Bilateral Internal Thoracic Artery Grafting. Surg Infect (Larchmt) 2020; 21:323-331. [DOI: 10.1089/sur.2018.142] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Affiliation(s)
- Aisha Zia
- Department of Thoracic & Cardiovascular Surgery, Heart & Vascular Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Marium Hasan
- Department of Urology, The Kidney Centre, Karachi, Pakistan
| | - Sidra Ilyas
- Department of Medicine, Detroit Medical Center/Wayne State University, Detroit, Michigan, USA
| | - Hafiz Umair Siddiqui
- Department of Thoracic & Cardiovascular Surgery, Heart & Vascular Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Bassman Tappuni
- Department of Thoracic & Cardiovascular Surgery, Heart & Vascular Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Shayan Marsia
- Dow Medical College, Dow University of Health Sciences, Karachi, Pakistan
| | - M. Mujeeb Zubair
- Methodist DeBakey Heart & Vascular Center, Houston Methodist Hospital, Houston, Texas, USA
| | - Sajjad Raza
- University Hospitals Cleveland Medical Center, Cleveland, Ohio, USA
| | - Rami R. Mustafa
- University Hospitals Cleveland Medical Center, Cleveland, Ohio, USA
| | | | - Salil V. Deo
- University Hospitals Cleveland Medical Center, Cleveland, Ohio, USA
| | - Umesh M. Sharma
- Community Division of Hospital Medicine, Mayo Clinic Health System, Rochester, Minnesota, USA
| | - Mohammad Adil Sheikh
- Department of Medicine, Detroit Medical Center/Wayne State University, Detroit, Michigan, USA
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Nozawa E, Gonçalves CD, Almeida POD, Hajjar LA, Galas FRG, Feltrim MIZ. Infra-Abdominal Muscles Activation Brings Benefits to the Pulmonary Function of Patients with Sternal Instability after Cardiac Surgery. Braz J Cardiovasc Surg 2020; 35:41-49. [PMID: 32270959 PMCID: PMC7089742 DOI: 10.21470/1678-9741-2018-0365] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
Objective To compare physical therapy strategies involving abdominal muscle stabilization, with and without upper limb movement, in patients with sternal instability after heart surgery and during in-hospital care. Methods This prospective, longitudinal, randomized, and comparative clinical study included 20 patients, which were divided into two groups: ARM, the arm group (n=10), and LEG, the leg group (n=10). The study involved the evaluation of scores of visual analog scales for sternal instability, pain, discomfort, functional impairment, lung function, and maximum inspiratory pressure (MIP) and maximum expiratory pressure (MEP) before and after the interventions. Two protocols consisting of abdominal exercises in both groups with upper limb movements (ARM) and just abdominal activation with leg movements (LEG) were used for three weeks. Results There were statistically significant (P≤0.01) improvements in pain, discomfort, and functional impairment scores, and in MIP (P=0.04) and MEP (P≤0.01) after intervention in both groups and just LEG showed improvement in forced vital capacity (P=0.043) and forced expiratory volume in one second (P=0.011). Conclusion Both strategies promoted improvement in pain, discomfort, and functional impairment scores and in the values of inspiratory and expiratory pressures. Perhaps they were influenced by the time and resolution of the infection process, although exercises with upper limb movements seem to be safe in this population. The activation of the infra-abdominal muscles through leg movements seems to bring more benefits to lung function.
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Affiliation(s)
- Emilia Nozawa
- Universidade de São Paulo Faculdade de Medicina Hospital das Clínicas São Paulo SP Brazil Department of Physiotherapy of the Instituto do Coração do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (InCor/HC-FMUSP), São Paulo, SP, Brazil
| | - Cristiane Domingues Gonçalves
- Universidade de São Paulo Faculdade de Medicina Hospital das Clínicas São Paulo SP Brazil Department of Physiotherapy of the Instituto do Coração do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (InCor/HC-FMUSP), São Paulo, SP, Brazil
| | - Patricia Oliva de Almeida
- Universidade de São Paulo Faculdade de Medicina Hospital das Clínicas São Paulo SP Brazil Department of Physiotherapy of the Instituto do Coração do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (InCor/HC-FMUSP), São Paulo, SP, Brazil
| | - Ludhmila Abrahão Hajjar
- Universidade de São Paulo Faculdade de Medicina Hospital das Clínicas São Paulo SP Brazil Department of Critical Patients of the Instituto do Coração do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (InCor/HC-FMUSP), São Paulo, SP, Brazil
| | - Filomena Regina Gomes Galas
- Universidade de São Paulo Faculdade de Medicina Hospital das Clínicas São Paulo SP Brazil Department of Anesthesia and Surgical Intensive Care of the Instituto do Coração do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (InCor/HC-FMUSP), São Paulo, SP, Brazil
| | - Maria Ignêz Zanetti Feltrim
- Universidade de São Paulo Faculdade de Medicina Hospital das Clínicas São Paulo SP Brazil Department of Physiotherapy of the Instituto do Coração do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (InCor/HC-FMUSP), São Paulo, SP, Brazil
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Theodore DA, Goodwin RD, Zhang YV, Schneider N, Gordon RJ. History of Depression and Increased Risk of Sternal Wound Infection After Cardiothoracic Surgery: A Novel and Potentially Modifiable Risk Factor. Open Forum Infect Dis 2019; 6:ofz083. [PMID: 30949529 PMCID: PMC6440688 DOI: 10.1093/ofid/ofz083] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2018] [Accepted: 02/14/2019] [Indexed: 12/11/2022] Open
Abstract
Background Sternal wound infection (SWI) is a leading cause of postoperative disease and death; the risk factors for SWI remain incompletely understood. The goal of the current study was to investigate the relationship between a preoperative history of depression and the risk of SWI after cardiothoracic surgery. Methods Among patients undergoing cardiothoracic surgery in a major academic medical center between 2007 and 2012, those in whom SWI developed (n = 129) were matched, by date of surgery, with those in whom it did not (n = 258). Multivariable logistic regression was used to examine the strength of relationships between risk factors and development of infection. History of depression was defined as a composite variable to increase the sensitivity of detection. Results History of depression as defined by our composite variable was associated with increased risk of SWI (adjusted odds ratio, 2.4; 95% confidence interval, 1.2–4.7; P = .01). Staphylococcus aureus was the most common organism isolated. Conclusions History of depression was associated with increased risk of SWI. Future prospective studies are warranted to further investigate this relationship. Depression is highly treatable, and increased efforts to identify and treat depression preoperatively may be a critical step toward preventing infection-related disease and death.
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Affiliation(s)
- Deborah A Theodore
- Department of Medicine, Columbia University Medical Center, New York, New York
| | - Renee D Goodwin
- Department of Epidemiology, Columbia University Mailman School of Public Health, New York, New York
| | - Yuan Vivian Zhang
- Department of Biostatistics, Columbia University Mailman School of Public Health, New York, New York
| | - Nancy Schneider
- Department of Infection Prevention and Control, New York-Presbyterian Hospital, New York, New York
| | - Rachel J Gordon
- Department of Epidemiology, Columbia University Mailman School of Public Health, New York, New York.,Department of Medicine, Columbia University College of Physicians and Surgeons, New York, New York
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Comparing Negative Pressure Wound Therapy with Instillation and Conventional Dressings for Sternal Wound Reconstructions. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2019; 7:e2087. [PMID: 30859044 PMCID: PMC6382248 DOI: 10.1097/gox.0000000000002087] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2018] [Accepted: 10/09/2018] [Indexed: 01/08/2023]
Abstract
Background: Muscle flap reconstruction has become a mainstay of therapy following treatment of sternal wound complications; however, success depends on removing wound exudate and infectious material from the wound before reconstruction and closure. Importantly, time to closure is a key factor affecting morbidity/mortality and cost-to-treat for this wound type. Methods: A retrospective analysis of 30 patients who were treated for sternal wound complications between June 2015 and October 2017 was performed. After surgical debridement, group 1 patients (n = 15) received negative pressure wound therapy (NPWT) with instillation and dwell time (NPWTi-d), instilling 1/8-strength Dakin’s solution with a 20-minute dwell time followed by 2 hours of NPWT (-125 mm Hg); group 2 patients (n = 15) were treated with wet-to-moist dressings soaked in 1/8-strength Dakin’s solution. After muscle flap reconstruction and closure with sutures, group 1 patients received closed incision negative pressure therapy, and group 2 patients received Benzoin and wound closure strips. Data collected included time to closure, therapy duration, number of debridements/dressing changes, drain duration, and complications. Results: There was a significantly shorter time to closure (P < 0.0001) for group 1 when compared with group 2. In addition, there were fewer therapy days (P = 0.0041), fewer debridements/dressing changes (P = 0.0011), and shorter drain duration (P = 0.0001) for group 1 when compared with group 2. Conclusions: We describe a novel regimen consisting of adjunctive NPWTi-d, along with debridement and systemic antibiotics, followed by closed incision negative pressure therapy after muscle flap reconstruction and closure, to help manage preexisting sternal wounds that had failed to close following a previous cardiac procedure.
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Cotogni P, Barbero C, Rinaldi M. Incidence and risk factors for potentially suboptimal serum concentrations of vancomycin during cardiac surgery. World J Cardiol 2018; 10:234-241. [PMID: 30510640 PMCID: PMC6259028 DOI: 10.4330/wjc.v10.i11.234] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/08/2018] [Revised: 09/02/2018] [Accepted: 10/11/2018] [Indexed: 02/06/2023] Open
Abstract
AIM To investigate the incidence and risk factors for vancomycin concentrations less than 10 mg/L during cardiac surgery.
METHODS In this prospective study, patients undergoing cardiac surgery received a single dose of 1000 mg of vancomycin. Multiple arterial samples were drawn during surgery. Exclusion criteria were hepatic dysfunction; renal dysfunction; ongoing infectious diseases; solid or hematologic tumors; severe insulin-dependent diabetes; body mass index of < 17 or > 40 kg/m2; pregnancy or lactation; antibiotic, corticosteroid, or other immunosuppressive therapy; vancomycin or nonsteroidal anti-inflammatory drug therapy in the previous 2 wk; chemotherapy or radiation therapy in the previous 6 mo; allergy to vancomycin or cefazolin; drug abuse; cardiac surgery in the previous 6 mo; previous or scheduled organ transplantation; preoperative stay in the intensive care unit for more than 24 h; emergency procedure or lack of adequate preparation for surgery; and participation in another trial.
RESULTS Over a 1-year period, 236 patients were enrolled, and a total of 1682 serum vancomycin concentrations (median 7/patient) were measured. No vancomycin levels under 10 mg/L were recorded in 122 out of 236 patients (52%), and 114 out of 236 patients (48%) were found to have at least 1 serum sample with a vancomycin level < 10 mg/L; 54 out of 236 patients (22.9%) had at least 5 serum samples with a vancomycin level lower than 10 mg/L. Vancomycin infusion was administered for 60 min in 97 out of 236 patients (41%). In 47 patients (20%), the duration of infusion was longer than 60 min, and in 92 patients (39%) the duration of infusion was shorter than 60 min. The maximum concentration and area under the concentration-time curve were significantly higher in patients with no vancomycin levels less than 10 mg/L (P < 0.001). The multivariate analysis identified female gender, body mass index (BMI) > 25 kg/m2, and creatinine clearance above 70 mL/min as risk factors for vancomycin levels less than 10 mg/L.
CONCLUSION Results of this study identified female gender, BMI > 25 kg/m2, and creatinine clearance above 70 mL/min as risk factors for suboptimal vancomycin serum concentration during cardiac surgery; no relationship was found between infusion duration and vancomycin levels less than 10 mg/L. These findings call attention to the risk of facilitating the emergence of vancomycin-resistant methicillin-resistant Staphylococcus aureus strains.
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Affiliation(s)
- Paolo Cotogni
- Department of Anesthesia, Intensive Care and Emergency, Molinette Hospital, University of Turin, Turin 10126, Italy
| | - Cristina Barbero
- Cardiovascular Surgery, Department of Surgical Sciences, Molinette Hospital, University of Turin, Turin 10126, Italy
| | - Mauro Rinaldi
- Cardiovascular Surgery, Department of Surgical Sciences, Molinette Hospital, University of Turin, Turin 10126, Italy
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Allen KB, Icke KJ, Thourani VH, Naka Y, Grubb KJ, Grehan J, Patel N, Guy TS, Landolfo K, Gerdisch M, Bonnell M. Sternotomy closure using rigid plate fixation: a paradigm shift from wire cerclage. Ann Cardiothorac Surg 2018; 7:611-620. [PMID: 30505745 DOI: 10.21037/acs.2018.06.01] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Background Rigid plate fixation (RPF) is the cornerstone in managing fractures and osteotomies except for sternotomy, where most cardiac surgeons continue to use wire cerclage (WC). Results of a multicenter randomized trial evaluating sternal healing, sternal complications, patient reported outcome measures (PROMs), and costs after sternotomy closure with RPF or WC are summarized here. Methods Twelve US centers randomized 236 patients to either RPF (n=116) or WC (n=120). The primary endpoint, sternal healing at 6 months, was evaluated by a core laboratory using computed tomography and a validated 6-point scale (greater scores represent greater healing). Secondary endpoints assessed through 6 months included sternal complications and PROMs. Costs from the time of sternal closure through 90 days and 6 months were analyzed by a health economic core laboratory. Results RPF compared to WC resulted in better sternal healing scores at 3 (2.6±1.1 vs. 1.8±1.0; P<0.0001) and 6 months (3.8±1.0 vs. 3.3±1.1; P=0.0007) and higher sternal union rates at 3 [41% (42/103) vs. 16% (16/102); P<0.0001] and 6 months [80% (81/101) vs. 67% (67/100); P=0.03]. There were fewer sternal complications with RPF through 6 months [0% (0/116) vs. 5% (6/120); P=0.03] and a trend towards fewer sternal wound infections [0% (0/116) vs. 4.2% (5/120); P=0.06]. All PROMs including sternal pain, upper extremity function (UEF), and quality-of-life scores were numerically better in RPF patients compared to WC patients at all follow-up time points. Although RPF was associated with a trend toward higher index hospitalization costs, a trend towards lower follow-up costs resulted in total costs that were $1,888 less at 90 days in RPF patients compared to WC patients (95% CI: -$8,889 to $4,273; P=0.52) and $1,646 less at 6 months (95% CI: -$9,127 to $4,706; P=0.61). Conclusions Sternotomy closure with RPF resulted in significantly better sternal healing, fewer sternal complications, improved PROMs and was cost neutral through 90 days and 6 months compared to WC.
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Affiliation(s)
- Keith B Allen
- Saint Luke's Mid America Heart Institute, Kansas City, MO, USA
| | | | | | | | | | | | | | | | | | - Marc Gerdisch
- Franciscan St. Francis Health, Indianapolis, IN, USA
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Abdi H, Elzayat E, Cagiannos I, Lavallée LT, Cnossen S, Flaman AS, Mallick R, Morash C, Breau RH. Female radical cystectomy patients have a higher risk of surgical site infections. Urol Oncol 2018; 36:400.e1-400.e5. [PMID: 30064934 DOI: 10.1016/j.urolonc.2018.05.023] [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: 02/07/2018] [Revised: 04/13/2018] [Accepted: 05/21/2018] [Indexed: 11/27/2022]
Abstract
INTRODUCTION Surgical site infections (SSI) are common after radical cystectomy. The objectives of this study were to evaluate if female sex is associated with postoperative SSI and if experiencing an SSI was associated with subsequent adverse events. METHODS This was a historical cohort study of radical cystectomy patients from the American College of Surgeons' National Surgical Quality Improvement Program database between 2006 and 2016. The primary outcome was development of a SSI (superficial, deep, or organ/abdominal space) within 30 days of surgery. Multivariable logistic regression analyses were performed to determine the association between sex and other patient/procedural factors with SSI. Female patients with SSI were also compared to those without SSI to determine risk of subsequent adverse events. RESULTS A total of 9,275 radical cystectomy patients met the inclusion criteria. SSI occurred in 1,277(13.7%) patients, 308 (16.4%) females and 969 (13.1%) males (odds ratio = 1.27; 95% confidence interval 1.10-1.47; P = 0.009). Infections were superficial in 150 (8.0%) females versus 410 (5.5%) males (P < 0.0001), deep in 40 (2.1%) females versus 114 (1.5%) males (P = 0.07), and organ/abdominal space in 118 (6.2%) females versus 445 (6.0%) males (P = 0.66). On multivariable analysis, female sex was independently associated with SSI (odds ratio = 1.21 confidence interval 1.01-1.43 P = 0.03). Females who experience SSI had higher probability of developing other complications including wound dehiscence, septic shock, and need for reoperation (all P < 0.05). CONCLUSIONS Female sex is an independent risk factor for SSI following radical cystectomy. More detailed study of patient factors, pathogenic microbes, and treatment factors are needed to prescribe the best measures for infection prophylaxis.
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Affiliation(s)
- Hamidreza Abdi
- Division of Urology, The Ottawa Hospital, University of Ottawa and the Ottawa Hospital Research Institute, 501 Smyth Road, Box 222, Ottawa, ON, Canada
| | - Ehab Elzayat
- Division of Urology, The Ottawa Hospital, University of Ottawa and the Ottawa Hospital Research Institute, 501 Smyth Road, Box 222, Ottawa, ON, Canada
| | - Ilias Cagiannos
- Division of Urology, The Ottawa Hospital, University of Ottawa and the Ottawa Hospital Research Institute, 501 Smyth Road, Box 222, Ottawa, ON, Canada
| | - Luke T Lavallée
- Division of Urology, The Ottawa Hospital, University of Ottawa and the Ottawa Hospital Research Institute, 501 Smyth Road, Box 222, Ottawa, ON, Canada
| | - Sonya Cnossen
- Division of Urology, The Ottawa Hospital, University of Ottawa and the Ottawa Hospital Research Institute, 501 Smyth Road, Box 222, Ottawa, ON, Canada
| | - Anathea S Flaman
- Division of Urology, The Ottawa Hospital, University of Ottawa and the Ottawa Hospital Research Institute, 501 Smyth Road, Box 222, Ottawa, ON, Canada
| | - Ranjeeta Mallick
- Division of Urology, The Ottawa Hospital, University of Ottawa and the Ottawa Hospital Research Institute, 501 Smyth Road, Box 222, Ottawa, ON, Canada
| | - Chris Morash
- Division of Urology, The Ottawa Hospital, University of Ottawa and the Ottawa Hospital Research Institute, 501 Smyth Road, Box 222, Ottawa, ON, Canada
| | - Rodney H Breau
- Division of Urology, The Ottawa Hospital, University of Ottawa and the Ottawa Hospital Research Institute, 501 Smyth Road, Box 222, Ottawa, ON, Canada.
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Cefazolin tissue concentrations with a prophylactic dose administered before sleeve gastrectomy in obese patients: a single centre study in 116 patients. Br J Anaesth 2017; 120:1202-1208. [PMID: 29793587 DOI: 10.1016/j.bja.2017.10.023] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2016] [Revised: 10/19/2017] [Accepted: 10/24/2017] [Indexed: 10/18/2022] Open
Abstract
BACKGROUND In obese patients undergoing sleeve gastrectomy, the blood and fatty-tissue concentrations of cefazolin required for adequate antibiotic prophylaxis are uncertain. METHODS This was a single centre prospective study in obese (Group A: 40≤ BMI ≤50 kg m-2) and severely obese (Group B: 50< BMI ≤65 kg m-2) patients undergoing bariatric surgery. Blood and fatty-tissue samples were collected after a cefazolin 4 g i.v. injection. The primary aim was to compare cefazolin concentrations in subcutaneous fatty tissue with a targeted tissue concentration of 4 μg g-1 according to Staphylococcus aureus resistance breakpoint. RESULTS One hundred and sixteen patients were included: 79 in Group A and 37 in Group B. At the beginning of the surgery, cefazolin concentration in subcutaneous fatty tissue was 12.2 (5.4) μg g-1 in Group A and 12 (6.1) μg g-1 in Group B (P=0.7). At the end, cefazolin concentrations in subcutaneous fatty tissue were 9.0 (4.9) and 7.8 (4.2) μg g-1 in Groups A and B, respectively (P=0.2). The plasma concentration of free cefazolin during surgery was higher in Group A than in Group B (P<0.0001). Fatty-tissue concentrations of 95% and 83% patients in Groups A and B, respectively, were above S. aureus resistance breakpoint. CONCLUSIONS After a 4 g dose, the concentrations of cefazolin in fatty tissue were above the 4 μg g-1 tissue concentration target, providing adequate antibiotic tissue concentrations during bariatric surgery. As cefazolin concentration in fatty tissue is a surrogate endpoint, the results should be considered in conjunction with the results on free cefazolin concentrations in subcutaneous tissue. CLINICAL TRIAL REGISTRATION NCT01537380.
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Affiliation(s)
- Siew S.C. Goh
- Department of Cardiothoracic Surgery; Liverpool Hospital; NSW Australia
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Abu-Omar Y, Kocher GJ, Bosco P, Barbero C, Waller D, Gudbjartsson T, Sousa-Uva M, Licht PB, Dunning J, Schmid RA, Cardillo G. European Association for Cardio-Thoracic Surgery expert consensus statement on the prevention and management of mediastinitis. Eur J Cardiothorac Surg 2017; 51:10-29. [PMID: 28077503 DOI: 10.1093/ejcts/ezw326] [Citation(s) in RCA: 101] [Impact Index Per Article: 14.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/23/2016] [Revised: 08/10/2016] [Accepted: 08/11/2016] [Indexed: 12/24/2022] Open
Abstract
Mediastinitis continues to be an important and life-threatening complication after median sternotomy despite advances in prevention and treatment strategies, with an incidence of 0.25-5%. It can also occur as extension of infection from adjacent structures such as the oesophagus, airways and lungs, or as descending necrotizing infection from the head and neck. In addition, there is a chronic form of 'chronic fibrosing mediastinitis' usually caused by granulomatous infections. In this expert consensus, the evidence for strategies for treatment and prevention of mediatinitis is reviewed in detail aiming at reducing the incidence and optimizing the management of this serious condition.
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Affiliation(s)
- Yasir Abu-Omar
- Department of Cardiothoracic Surgery, Papworth Hospital NHS Foundation Trust, Cambridge, UK
| | - Gregor J Kocher
- Division of General Thoracic Surgery, Bern University Hospital / Inselspital, Switzerland
| | - Paolo Bosco
- Department of Cardiothoracic Surgery, Papworth Hospital NHS Foundation Trust, Cambridge, UK
| | - Cristina Barbero
- Department of Cardiovascular and Thoracic Surgery, University of Turin-Italy, Città della Salute e della Scienza-San Giovanni Battista Hospital, Torino, Italy
| | - David Waller
- Department of Thoracic Surgery, Glenfield Hospital, Leicester, UK
| | - Tomas Gudbjartsson
- Department of Cardiothoracic Surgery, Landspitali University Hospital and Faculty of Medicine, University of Iceland, Reykjavík, Iceland
| | - Miguel Sousa-Uva
- Unit of Cardiac Surgery, Hospital Cruz Vermelha, Lisbon, Portugal
| | - Peter B Licht
- Department of Cardiothoracic Surgery, Odense University Hospital, Odense, Denmark
| | - Joel Dunning
- Department of Cardiothoracic Surgery, James Cook University Hospital, Middlesbrough, UK
| | - Ralph A Schmid
- Department of Cardiothoracic Surgery, Papworth Hospital NHS Foundation Trust, Cambridge, UK
| | - Giuseppe Cardillo
- Unit of Thoracic Surgery, Azienda Ospedaliera S. Camillo Forlanini, Lazzaro Spallanzani Hospital, Rome, Italy
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Allen KB, Thourani VH, Naka Y, Grubb KJ, Grehan J, Patel N, Guy TS, Landolfo K, Gerdisch M, Bonnell M, Cohen DJ. Randomized, multicenter trial comparing sternotomy closure with rigid plate fixation to wire cerclage. J Thorac Cardiovasc Surg 2017; 153:888-896.e1. [DOI: 10.1016/j.jtcvs.2016.10.093] [Citation(s) in RCA: 64] [Impact Index Per Article: 9.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/24/2016] [Revised: 10/11/2016] [Accepted: 10/12/2016] [Indexed: 11/26/2022]
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Dobner J, Kaser S. Body mass index and the risk of infection - from underweight to obesity. Clin Microbiol Infect 2017; 24:24-28. [PMID: 28232162 DOI: 10.1016/j.cmi.2017.02.013] [Citation(s) in RCA: 201] [Impact Index Per Article: 28.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2016] [Revised: 02/11/2017] [Accepted: 02/12/2017] [Indexed: 01/21/2023]
Abstract
BACKGROUND Nutritional status is a well-known risk factor for metabolic and endocrine disorders. Recent studies suggest that dietary intake also affects immune function and as a consequence infection risk. AIMS This reviews aims to give an overview on the effect of body weight on infection rate at different periods of life. SOURCES Clinically relevant prospective, cross-sectional and case-control community-based studies are summarized. CONTENT In children and adolescents underweight is a significant risk factor for infection especially in developing countries, probably reflecting malnutrition and poor hygienic standards. Data from industrialized countries suggest that infection rate is also increased in obese children and adolescents. Similarly, several studies suggest a U-shaped increased infection rate in both underweight and obese adults. In the latter, infections of the skin and respiratory tract as well as surgical-site infections have consistently been reported to be more common than in normal-weight participants. Paradoxically, mortality of critically ill patients was reduced in obesity in some studies. IMPLICATIONS Several studies in children or adults suggest that both underweight and obesity are associated with increased infection risk. However, confounding factors such as malnutrition, hygienic status and underlying disease or co-morbidities might aggravate accurate assessment of the impact of body weight on infection risk.
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Affiliation(s)
- J Dobner
- Christian Doppler Laboratory for Metabolic Research, Medical University Innsbruck, Innsbruck, Austria
| | - S Kaser
- Christian Doppler Laboratory for Metabolic Research, Medical University Innsbruck, Innsbruck, Austria; Department of Internal Medicine 1, Medical University Innsbruck, Austria.
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Balachandran S, Lee A, Denehy L, Lin KY, Royse A, Royse C, El-Ansary D. Risk Factors for Sternal Complications After Cardiac Operations: A Systematic Review. Ann Thorac Surg 2016; 102:2109-2117. [DOI: 10.1016/j.athoracsur.2016.05.047] [Citation(s) in RCA: 47] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/05/2016] [Revised: 04/27/2016] [Accepted: 05/09/2016] [Indexed: 11/28/2022]
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Cutrell JB, Barros N, McBroom M, Luby J, Minhajuddin A, Ring WS, Greilich PE. Risk factors for deep sternal wound infection after cardiac surgery: Influence of red blood cell transfusions and chronic infection. Am J Infect Control 2016; 44:1302-1309. [PMID: 27179393 DOI: 10.1016/j.ajic.2016.03.027] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2015] [Revised: 03/28/2016] [Accepted: 03/28/2016] [Indexed: 01/08/2023]
Abstract
BACKGROUND Deep sternal wound infection (DSWI) following cardiac surgery is a serious complication, but risk factors associated with DSWI have not been fully elucidated. METHODS We analyzed all DSWI cases at our institution from 2010-2013 in adult cardiac median sternotomy cases, based on Society of Thoracic Surgeons or National Healthcare Safety Network definitions, but with 1-year surveillance postsurgery. Controls were matched 3:1 per case for procedure, age, and year of surgery. Demographic and operative data were pulled from Society of Thoracic Surgeons database and chart review. Potential variables were evaluated using univariate and multivariate conditional logistic regression. RESULTS Out of 1,894 surgeries performed, 39 DSWI cases (2%) and 117 controls were identified. In univariate analyses, patients with red blood cell (RBC) transfusion ≥ 4 units, any platelet transfusion, previous infections, and chronic infections were associated with higher DSWI. RBC transfusion ≥ 4 units (P = .037) and chronic infections (P = .029) remained significant risk factors for DSWI in multivariate analysis. Preoperative anemia alone was not associated with more DSWI, but its interaction with RBC transfusion ≥ 4 units was significant. CONCLUSIONS High-volume RBC transfusions and chronic infections were strongly associated with DSWI in our population and represent potentially modifiable areas for improvement.
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Santos KAQ, Berto B, Sousa AG, Costa FAAD. Prognosis and Complications of Diabetic Patients Undergoing Isolated Coronary Artery Bypass Surgery. Braz J Cardiovasc Surg 2016; 31:7-14. [PMID: 27074269 PMCID: PMC5062695 DOI: 10.5935/1678-9741.20160002] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2015] [Accepted: 12/30/2015] [Indexed: 01/04/2023] Open
Abstract
Objective: Compare the prognosis and complications of diabetic and non-diabetic patients
undergoing isolated coronary artery bypass surgery at a hospital with a high
surgical volume. Methods: Data of patients who underwent coronary artery bypass surgery from June 2009
to July 2010 were analyzed. We selected diabetic and non-diabetic patients
and evaluated their postoperative and long-term prognosis based on clinical
complications. To reduce the disparity within the sample, statistical
analyses were performed using propensity scores. Results: We included 2,688 patients who underwent coronary artery bypass surgery; 36%
of them had diabetes, their mean age was 62.1±9.49 years and 70%
(1,884) of them were men. Patients with diabetes were older (63±9
years vs. 61±10 years; P<0.001),
more often obese (BMI>25 kg/m2: 70.7% vs.
64.5%; P<0.001), dyslipidemic (50.4%
vs. 41.1%; P<0.001), hypertensive
(89.2% vs. 78.7%; P<0.001), and
presented chronic renal failure (8.3% vs. 3.8%;
P<0.001). They also presented higher rates of acute
renal failure (5.6% vs. 2.7%, P<0.001),
infection (11.4% vs. 7.2%, P<0.001) and
mortality after one year (9.1% vs. 5.6%,
P<0.001). Pneumonia was more common among patients with
diabetes (7.7% vs. 4.0%, P<0.001).
According to propensity scoring, 430 patients (215 diabetics and 215
non-diabetics) had a mean age of 61.3±8.97 years, and 21.2% (91 of
430) were women. However, diabetes was not an independent factor for poor
prognosis. Conclusion: Patients with diabetes were at higher risk for postoperative complications
and mortality after undergoing coronary artery bypass surgery. However,
diabetes did not explain the poor prognosis of these patients after pairing
this factor with the propensity score.
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Eton V, Sinyavskaya L, Langlois Y, Morin JF, Suissa S, Brassard P. Effect of Pre-Operative Use of Medications on the Risk of Surgical Site Infections in Patients Undergoing Cardiac Surgery. Surg Infect (Larchmt) 2016; 17:557-62. [DOI: 10.1089/sur.2016.007] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
- Vic Eton
- Center for Clinical Epidemiology, Department of Cardiac Surgery, Jewish General Hospital, Montreal, Quebec, Canada
| | - Liliya Sinyavskaya
- Center for Clinical Epidemiology, Department of Cardiac Surgery, Jewish General Hospital, Montreal, Quebec, Canada
| | - Yves Langlois
- Department of Medicine, McGill University, Montreal, Quebec, Canada
| | | | - Samy Suissa
- Center for Clinical Epidemiology, Department of Cardiac Surgery, Jewish General Hospital, Montreal, Quebec, Canada
- Department of Epidemiology, Biostatistics, and Occupational Health, McGill University, Montreal, Quebec, Canada
| | - Paul Brassard
- Center for Clinical Epidemiology, Department of Cardiac Surgery, Jewish General Hospital, Montreal, Quebec, Canada
- Department of Epidemiology, Biostatistics, and Occupational Health, McGill University, Montreal, Quebec, Canada
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Schimmer C, Gross J, Ramm E, Morfeld BC, Hoffmann G, Panholzer B, Hedderich J, Leyh R, Cremer J, Petzina R. Prevention of surgical site sternal infections in cardiac surgery: a two-centre prospective randomized controlled study. Eur J Cardiothorac Surg 2016; 51:67-72. [PMID: 27365077 DOI: 10.1093/ejcts/ezw225] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/15/2016] [Revised: 05/25/2016] [Accepted: 06/01/2016] [Indexed: 12/20/2022] Open
Abstract
OBJECTIVES Surgical site infection (SSI) of the sternum is a devastating complication in cardiac surgery. The aim of this prospective randomized controlled two-centre clinical study was to compare the use of a gentamicin-collagen sponge (Genta-Coll® resorb) and of a cyanoacrylate-based microbial skin sealant (InteguSeal®) on the SSI rate of the sternum. METHODS We analysed data from 996 consecutive patients following isolated coronary artery bypass grafting between 2012 and 2014. The patients were randomized into three groups: standard group (S-group), Genta-Coll group (G-group) and InteguSeal group (I-group). The primary study end-point was to analyse the incidence of superficial and deep sternal SSI. The secondary study end-point was to determine independent risk factors for an increased SSI rate. RESULTS Of the 996 patients investigated, 332 patients were in S-group, 336 patients in G-group and 328 patients in I-group. The mean age was 67.7 ± 9.4 years, 18.6% were women and the overall SSI rate was 6.2% with 2.2% deep sternal wound infections. SSI rates were 8.3% (S-group), 5.4% (G-group) and 4.9% (I-group) (P 0.16). Multiple regression analysis demonstrated a preoperative body mass index (BMI) of >30 kg/m2 (P 0.047), re-thoracotomy for postoperative bleeding (P < 0.001) and sternum instability (P < 0.001) as independent predictors for an increased SSI rate. CONCLUSIONS The application of InteguSeal® or Genta-Coll® resorb had no significant influence on the incidence of the sternal SSI rate in 996 consecutive cardiac surgery patients but demonstrated a trend towards a benefit from using these prophylactic approaches. Multiple regression analysis demonstrated a preoperative BMI of >30 kg/m2, re-thoracotomy for bleeding and sternum instability as independent predictors for an increased sternal SSI rate.
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Affiliation(s)
- Christoph Schimmer
- Department of Cardiothoracic and Thoracic Vascular Surgery, University Hospital Würzburg, Würzburg, Germany
| | - Justus Gross
- Department of Cardiovascular Surgery, University Hospital Schleswig-Holstein, Campus Kiel, Kiel, Germany
| | - Elena Ramm
- Department of Cardiovascular Surgery, University Hospital Schleswig-Holstein, Campus Kiel, Kiel, Germany
| | - Björn-Carsten Morfeld
- Department of Cardiothoracic and Thoracic Vascular Surgery, University Hospital Würzburg, Würzburg, Germany
| | - Grischa Hoffmann
- Department of Cardiovascular Surgery, University Hospital Schleswig-Holstein, Campus Kiel, Kiel, Germany
| | - Bernd Panholzer
- Department of Cardiovascular Surgery, University Hospital Schleswig-Holstein, Campus Kiel, Kiel, Germany
| | - Jürgen Hedderich
- Institute of Medical Informatics and Statistics, University Hospital Schleswig-Holstein, Campus Kiel, Kiel, Germany
| | - Rainer Leyh
- Department of Cardiothoracic and Thoracic Vascular Surgery, University Hospital Würzburg, Würzburg, Germany
| | - Jochen Cremer
- Department of Cardiovascular Surgery, University Hospital Schleswig-Holstein, Campus Kiel, Kiel, Germany
| | - Rainer Petzina
- Department of Cardiovascular Surgery, University Hospital Schleswig-Holstein, Campus Kiel, Kiel, Germany
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Gudbjartsson T, Jeppsson A, Sjögren J, Steingrimsson S, Geirsson A, Friberg O, Dunning J. Sternal wound infections following open heart surgery – a review. SCAND CARDIOVASC J 2016; 50:341-348. [DOI: 10.1080/14017431.2016.1180427] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Affiliation(s)
- Tomas Gudbjartsson
- Department of Cardiothoracic Surgery, Landspitali University Hospital, Faculty of Medicine, University of Iceland, Reykjavik, Iceland
| | - Anders Jeppsson
- Department of Cardiothoracic Surgery, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Johan Sjögren
- Department of Cardiothoracic Surgery, Skane University Hospital, Lund, Sweden
| | - Steinn Steingrimsson
- Department of Cardiothoracic Surgery, Landspitali University Hospital, Faculty of Medicine, University of Iceland, Reykjavik, Iceland
| | - Arnar Geirsson
- Department of Cardiothoracic Surgery, Landspitali University Hospital, Faculty of Medicine, University of Iceland, Reykjavik, Iceland
| | - Orjan Friberg
- Department of Cardiothoracic Surgery, Orebro University Hospital, Orebro, Sweden
| | - Joel Dunning
- Department of Cardiothoracic Surgery, James Cook University Hospital, Middlesbrough, UK
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Adams J, Lotshaw A, Exum E, Campbell M, Spranger CB, Beveridge J, Baker S, McCray S, Bilbrey T, Shock T, Lawrence A, Hamman BL, Schussler JM. An alternative approach to prescribing sternal precautions after median sternotomy, "Keep Your Move in the Tube". Proc (Bayl Univ Med Cent) 2016; 29:97-100. [PMID: 26722187 DOI: 10.1080/08998280.2016.11929379] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023] Open
Abstract
Traditional sternal precautions, given to sternotomy patients as part of their discharge education, are intended to help prevent sternal wound complications. They vary widely but generally include arbitrary load and time restrictions (lifting no more than a specified weight for up to 12 weeks) and may prohibit common shoulder joint and shoulder girdle movements. Having observed the negative effects of restrictive sternal precautions for many years, our research team performed a series of studies that measured the forces exerted during various common activities and their relationship to the sternum. The results, though informative, led us to realize that the goal of identifying "the" appropriate load restriction to prescribe for sternotomy patients was futile. The alternative approach that we introduce applies standard kinesiological principles and teaches patients how to perform load-bearing movements in a way that avoids excessive stress to the sternum.
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Affiliation(s)
- Jenny Adams
- Baylor Heart and Vascular Hospital (Adams, McCray, Bilbrey, Shock, Lawrence, Schussler); Baylor University Medical Center at Dallas (Lotshaw, Exum, Beveridge, Hamman, Schussler); Baylor Institute for Rehabilitation (Baker); Darwen Leisure Centre, Darwen, UK (Campbell); and Seton Medical Center Austin, Austin, Texas (Spranger)
| | - Ana Lotshaw
- Baylor Heart and Vascular Hospital (Adams, McCray, Bilbrey, Shock, Lawrence, Schussler); Baylor University Medical Center at Dallas (Lotshaw, Exum, Beveridge, Hamman, Schussler); Baylor Institute for Rehabilitation (Baker); Darwen Leisure Centre, Darwen, UK (Campbell); and Seton Medical Center Austin, Austin, Texas (Spranger)
| | - Emelia Exum
- Baylor Heart and Vascular Hospital (Adams, McCray, Bilbrey, Shock, Lawrence, Schussler); Baylor University Medical Center at Dallas (Lotshaw, Exum, Beveridge, Hamman, Schussler); Baylor Institute for Rehabilitation (Baker); Darwen Leisure Centre, Darwen, UK (Campbell); and Seton Medical Center Austin, Austin, Texas (Spranger)
| | - Mark Campbell
- Baylor Heart and Vascular Hospital (Adams, McCray, Bilbrey, Shock, Lawrence, Schussler); Baylor University Medical Center at Dallas (Lotshaw, Exum, Beveridge, Hamman, Schussler); Baylor Institute for Rehabilitation (Baker); Darwen Leisure Centre, Darwen, UK (Campbell); and Seton Medical Center Austin, Austin, Texas (Spranger)
| | - Cathy B Spranger
- Baylor Heart and Vascular Hospital (Adams, McCray, Bilbrey, Shock, Lawrence, Schussler); Baylor University Medical Center at Dallas (Lotshaw, Exum, Beveridge, Hamman, Schussler); Baylor Institute for Rehabilitation (Baker); Darwen Leisure Centre, Darwen, UK (Campbell); and Seton Medical Center Austin, Austin, Texas (Spranger)
| | - Jim Beveridge
- Baylor Heart and Vascular Hospital (Adams, McCray, Bilbrey, Shock, Lawrence, Schussler); Baylor University Medical Center at Dallas (Lotshaw, Exum, Beveridge, Hamman, Schussler); Baylor Institute for Rehabilitation (Baker); Darwen Leisure Centre, Darwen, UK (Campbell); and Seton Medical Center Austin, Austin, Texas (Spranger)
| | - Shawn Baker
- Baylor Heart and Vascular Hospital (Adams, McCray, Bilbrey, Shock, Lawrence, Schussler); Baylor University Medical Center at Dallas (Lotshaw, Exum, Beveridge, Hamman, Schussler); Baylor Institute for Rehabilitation (Baker); Darwen Leisure Centre, Darwen, UK (Campbell); and Seton Medical Center Austin, Austin, Texas (Spranger)
| | - Stephanie McCray
- Baylor Heart and Vascular Hospital (Adams, McCray, Bilbrey, Shock, Lawrence, Schussler); Baylor University Medical Center at Dallas (Lotshaw, Exum, Beveridge, Hamman, Schussler); Baylor Institute for Rehabilitation (Baker); Darwen Leisure Centre, Darwen, UK (Campbell); and Seton Medical Center Austin, Austin, Texas (Spranger)
| | - Tim Bilbrey
- Baylor Heart and Vascular Hospital (Adams, McCray, Bilbrey, Shock, Lawrence, Schussler); Baylor University Medical Center at Dallas (Lotshaw, Exum, Beveridge, Hamman, Schussler); Baylor Institute for Rehabilitation (Baker); Darwen Leisure Centre, Darwen, UK (Campbell); and Seton Medical Center Austin, Austin, Texas (Spranger)
| | - Tiffany Shock
- Baylor Heart and Vascular Hospital (Adams, McCray, Bilbrey, Shock, Lawrence, Schussler); Baylor University Medical Center at Dallas (Lotshaw, Exum, Beveridge, Hamman, Schussler); Baylor Institute for Rehabilitation (Baker); Darwen Leisure Centre, Darwen, UK (Campbell); and Seton Medical Center Austin, Austin, Texas (Spranger)
| | - Anne Lawrence
- Baylor Heart and Vascular Hospital (Adams, McCray, Bilbrey, Shock, Lawrence, Schussler); Baylor University Medical Center at Dallas (Lotshaw, Exum, Beveridge, Hamman, Schussler); Baylor Institute for Rehabilitation (Baker); Darwen Leisure Centre, Darwen, UK (Campbell); and Seton Medical Center Austin, Austin, Texas (Spranger)
| | - Baron L Hamman
- Baylor Heart and Vascular Hospital (Adams, McCray, Bilbrey, Shock, Lawrence, Schussler); Baylor University Medical Center at Dallas (Lotshaw, Exum, Beveridge, Hamman, Schussler); Baylor Institute for Rehabilitation (Baker); Darwen Leisure Centre, Darwen, UK (Campbell); and Seton Medical Center Austin, Austin, Texas (Spranger)
| | - Jeffrey M Schussler
- Baylor Heart and Vascular Hospital (Adams, McCray, Bilbrey, Shock, Lawrence, Schussler); Baylor University Medical Center at Dallas (Lotshaw, Exum, Beveridge, Hamman, Schussler); Baylor Institute for Rehabilitation (Baker); Darwen Leisure Centre, Darwen, UK (Campbell); and Seton Medical Center Austin, Austin, Texas (Spranger)
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Kato S, Chikuda H, Ohya J, Oichi T, Matsui H, Fushimi K, Takeshita K, Tanaka S, Yasunaga H. Risk of infectious complications associated with blood transfusion in elective spinal surgery-a propensity score matched analysis. Spine J 2016; 16:55-60. [PMID: 26499767 DOI: 10.1016/j.spinee.2015.10.014] [Citation(s) in RCA: 54] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/11/2015] [Revised: 08/10/2015] [Accepted: 10/12/2015] [Indexed: 02/03/2023]
Abstract
BACKGROUND CONTEXT Although the negative aspects of blood transfusion are increasingly recognized, less is known about transfusion-related risks in spinal surgery. PURPOSE This study was designed to determine whether perioperative allogeneic blood transfusion is associated with increased risk of infectious complications after elective spinal surgery. STUDY DESIGN A retrospective cohort study with propensity score matched analysis was carried out. PATIENT SAMPLE Data of patients with spinal canal stenosis and spondylolisthesis who underwent elective lumbar surgeries (decompression or fusion) were obtained from the Diagnosis Procedure Combination database, a nationwide administrative inpatient database in Japan. OUTCOME MEASURES Clinical outcomes included in-hospital death and the occurrence of infectious complications (surgical site infection [SSI], respiratory tract infection, urinary tract infection, and sepsis). METHODS Patients' clinical information, including sex, age, type of hospital, preoperative comorbidities, duration of anesthesia, cell saver use, and volume of allogeneic blood transfused, were investigated. Patients transfused with >840 mL (6 units) were excluded. Propensity scores for receiving transfusion were calculated, with one-to-one matching based on estimated propensity scores to adjust for patients' baseline characteristics. The proportions of complications were compared in patients with and without transfusions. This study was funded by grants from the Ministry of Health, Labour and Welfare, Japan. RESULTS Of the 84,650 patients identified, 5,289 patients (6.1%) received transfusions, with 4,436 (5.2%) receiving up to 840 mL. One-to-one propensity score matching resulted in 4,275 pairs with and without transfusion. Patients transfused were at increased risk of SSI (odds ratio [OR], 1.9; 95% confidence interval [CI], 1.4-2.5; p<.001) and urinary tract infection (OR, 2.5; 95% CI, 1.5-4.2; p<.001) than those not transfused. CONCLUSIONS Allogeneic blood transfusion after elective lumbar surgery was associated with increased risks of SSI and urinary tract infection.
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Affiliation(s)
- So Kato
- Department of Orthopaedic Surgery, Sensory and Motor System Medicine, Surgical Sciences, Graduate School of Medicine, The University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 113-8655, Japan.
| | - Hirotaka Chikuda
- Department of Orthopaedic Surgery, Sensory and Motor System Medicine, Surgical Sciences, Graduate School of Medicine, The University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 113-8655, Japan
| | - Junichi Ohya
- Department of Orthopaedic Surgery, Sensory and Motor System Medicine, Surgical Sciences, Graduate School of Medicine, The University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 113-8655, Japan
| | - Takeshi Oichi
- Department of Orthopaedic Surgery, Sensory and Motor System Medicine, Surgical Sciences, Graduate School of Medicine, The University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 113-8655, Japan
| | - Hiroki Matsui
- Department of Clinical Epidemiology and Health Economics, School of Public Health, The University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 113-0033, Japan
| | - Kiyohide Fushimi
- Department of Health Policy and Informatics, Tokyo Medical and Dental University Graduate School, 1-5-45 Yushima, Bunkyo-ku, Tokyo 113-8519, Japan
| | - Katsushi Takeshita
- Department of Orthopaedic Surgery, Sensory and Motor System Medicine, Surgical Sciences, Graduate School of Medicine, The University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 113-8655, Japan
| | - Sakae Tanaka
- Department of Orthopaedic Surgery, Sensory and Motor System Medicine, Surgical Sciences, Graduate School of Medicine, The University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 113-8655, Japan
| | - Hideo Yasunaga
- Department of Clinical Epidemiology and Health Economics, School of Public Health, The University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 113-0033, Japan
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Patel NN, Avlonitis VS, Jones HE, Reeves BC, Sterne JAC, Murphy GJ. Indications for red blood cell transfusion in cardiac surgery: a systematic review and meta-analysis. LANCET HAEMATOLOGY 2015; 2:e543-53. [DOI: 10.1016/s2352-3026(15)00198-2] [Citation(s) in RCA: 87] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/04/2015] [Revised: 09/15/2015] [Accepted: 09/16/2015] [Indexed: 01/23/2023]
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Cossin S, Malavaud S, Jarno P, Giard M, L'Hériteau F, Simon L, Bieler L, Molinier L, Marcheix B, Venier AG, Simon L, Ali-Brandmeyer O, Neels C, Jarno P, Aupée M, Perennec M, Astagneau P, L'Hériteau F, Daniel F, Campion C, Giard M, Bernet C, Caillat-Vallet E, Venier AG, Bervas C, Reyreaud E, Baillet P, Costa Y, Jost JL, Merle V, Merlo L, Seguier JC, Malavaud S, Bruyere F, Thiolet JM, Barquin-Guichard S. Surgical site infection after valvular or coronary artery bypass surgery: 2008–2011 French SSI national ISO-RAISIN surveillance. J Hosp Infect 2015; 91:225-30. [DOI: 10.1016/j.jhin.2015.07.001] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2014] [Accepted: 07/16/2015] [Indexed: 11/17/2022]
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Case report of a rare complication of open-heart surgery masquerading as a gunshot wound: an autopsy diagnosis. Am J Forensic Med Pathol 2015; 36:66-70. [PMID: 25828033 DOI: 10.1097/paf.0000000000000144] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
INTRODUCTION Poststernotomy mediastinitis is a rare feared sequelae of open-heart surgery with low incidence of 1% to 3% but a high mortality rate (10%-35%). Poststernotomy mediastinitis can in uncommon instances give rise to sternocutaneous fistulas in 0.25% to 10% of cases. Although scant reports have documented prosthetic valve endocarditis occurring in a setting of deep sternal wire infections, it is an infrequent but well-documented fatal complication of valvular replacement surgery. CASE REPORT A 52-year-old male smoker with aortic valve replacement (2011), on Coumadin and Monocor, was found dead on September 2013 with a hole along a surgical scar over the sternum, masquerading as a gunshot wound. Chest radiograph revealed no foreign body, and no evidence of homicidal/suicidal or accidental cause was found at autopsy. Examination revealed a chronic fistulous tract from a deep sternal wire infection to the skin, in addition to a chronic sinus tract eroding into the root of the aorta with recent prosthetic valve endocarditis. DISCUSSION To our knowledge, this is the first case report documenting poststernotomy mediastinitis causing a simultaneous occurrence of sternocutaneous fistula and prosthetic valve endocarditis. Either of these 2 exceptional but lethal complications would have sufficed as the cause of death.
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Sajja LR. Strategies to reduce deep sternal wound infection after bilateral internal mammary artery grafting. Int J Surg 2015; 16:171-8. [DOI: 10.1016/j.ijsu.2014.11.017] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2014] [Revised: 11/10/2014] [Accepted: 11/11/2014] [Indexed: 01/04/2023]
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Kozlow JH, Patel SP, Jejurikar S, Pannucci CJ, Cederna PS, Brown DL. Complications after sternal reconstruction: a 16-y experience. J Surg Res 2015; 194:154-60. [DOI: 10.1016/j.jss.2014.09.044] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2014] [Revised: 09/22/2014] [Accepted: 09/22/2014] [Indexed: 11/24/2022]
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Glycopeptides Versus β-Lactams for the Prevention of Surgical Site Infections in Cardiovascular and Orthopedic Surgery. Ann Surg 2015; 261:72-80. [DOI: 10.1097/sla.0000000000000704] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
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Coronary Artery Bypass Surgery and Percutaneous Coronary Revascularization: Impact on Morbidity and Mortality in Patients with Coronary Artery Disease. Coron Artery Dis 2015. [DOI: 10.1007/978-1-4471-2828-1_26] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
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