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Fox MT, Meyer-Macaulay C, Roberts H, Lipsitz S, Siegel BD, Mastropietro C, Graham RJ, Moynihan KM. Tracheostomy Timing During Pediatric Cardiac Intensive Care: Single Referral Center Retrospective Cohort. Pediatr Crit Care Med 2023; 24:e556-e567. [PMID: 37607094 DOI: 10.1097/pcc.0000000000003345] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/24/2023]
Abstract
OBJECTIVES To describe associations between the timing of tracheostomy and patient characteristics or outcomes in the cardiac ICU (CICU). DESIGN Single-institution retrospective cohort study. SETTING Freestanding academic children's hospital. PATIENTS CICU patients with tracheostomy placed between July 1, 2011, and July 1, 2020. INTERVENTIONS We compared patient characteristics and outcomes between early and late tracheostomy based on the duration of positive pressure ventilation (PPV) before tracheostomy placement, fitting a receiver operating characteristic curve for current survival to define a cutoff. MEASUREMENTS AND MAIN RESULTS Sixty-one patients underwent tracheostomy placement (0.5% of CICU admissions). Median age was 7.8 months. Eighteen patients (30%) had single ventricle physiology and 13 patients (21%) had pulmonary vein stenosis (PVS). Primary indications for tracheostomy were pulmonary/lower airway (41%), upper airway obstruction (UAO) (31%), cardiac (15%), neuromuscular (4%), or neurologic (4%). In-hospital mortality was 26% with 41% survival at the current follow-up (median 7.8 [interquartile range, IQR 2.6-30.0] mo). Late tracheostomy was defined as greater than or equal to 7 weeks of PPV which was equivalent to the median PPV duration pre-tracheostomy. Patients with late tracheostomy were more likely to be younger, have single ventricle physiology, and have greater respiratory severity. Patients with early tracheostomy were more likely to have UAO or genetic comorbidities. In multivariable analysis, late tracheostomy was associated with 4.2 times greater mortality (95% CI, 1.9-9.0). PVS was associated with higher mortality (adjusted hazard ratio [HR] 5.2; 95% CI, 2.5-10.9). UAO was associated with lower mortality (adjusted HR 0.2; 95% CI, 0.1-0.5). Late tracheostomy was also associated with greater cumulative opioid exposure. CONCLUSIONS CICU patients who underwent tracheostomy had high in-hospital and longer-term mortality rates. Tracheostomy timing decisions are influenced by indication, disease, genetic comorbidities, illness severity, and age. Earlier tracheostomy was associated with lower sedative use and improved adjusted survival. Tracheostomy placement is a complex decision demanding individualized consideration of risk-benefit profiles and thoughtful family counseling.
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Affiliation(s)
- Miriam T Fox
- Department of Pediatrics, Harvard Medical School, Boston, MA
- Department of Pediatrics, Boston Medical Center, Boston, MA
- Department of Cardiology, Boston Children's Hospital, Boston, MA
| | - Colin Meyer-Macaulay
- Division of Cardiac Critical Care, Department of Pediatrics, Nemours Children's Health, Delaware Valley, Wilmington, DE
- Department of Pediatrics, Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, PA
| | - Hanna Roberts
- Department of Cardiology, Boston Children's Hospital, Boston, MA
| | - Stuart Lipsitz
- Division of General Internal Medicine, Brigham and Women's Hospital, Boston, MA
| | - Bryan D Siegel
- Department of Pediatrics, Harvard Medical School, Boston, MA
- Department of Cardiology, Boston Children's Hospital, Boston, MA
| | - Chris Mastropietro
- Division of Critical Care, Department of Pediatrics, Indiana University School of Medicine, Riley Hospital for Children at Indiana University Health, Indianapolis, IN
| | - Robert J Graham
- Department of Pediatrics, Harvard Medical School, Boston, MA
- Department of Anesthesia and Critical Care, Boston Children's Hospital, Boston, MA
| | - Katie M Moynihan
- Department of Pediatrics, Harvard Medical School, Boston, MA
- Department of Cardiology, Boston Children's Hospital, Boston, MA
- Department of Pediatrics, Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, PA
- Faculty of Medicine and Health, Children's Hospital at Westmead Clinical School, The University of Sydney, Sydney, NSW, Australia
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Asfari A, Jacobs JP, Byrnes JW, Borasino S, Prodhan P, Zaccagni H, Dabal RJ, Sorabella RA, Hammel JM, Smith-Parrish M, Zhang W, Banerjee M, Schumacher KR, Tabbutt S. Norwood Operation: Immediate vs Delayed Sternal Closure. Ann Thorac Surg 2023; 115:649-654. [PMID: 35863395 DOI: 10.1016/j.athoracsur.2022.06.046] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/03/2022] [Revised: 06/06/2022] [Accepted: 06/27/2022] [Indexed: 11/19/2022]
Abstract
BACKGROUND The Norwood operation is a complex neonatal surgery. There are limited data to inform the timing of sternal closure. After the Norwood operation, delayed sternal closure (DSC) is frequent. We aimed to examine the association of DSC with outcomes, with a particular interest in how sternal closure at the time of surgery compared with the timing of DSC. Our outcomes included mortality, length of ventilation, length of stay, and postoperative complications. METHODS This retrospective study included neonates who underwent a Norwood operation reported in the Pediatric Cardiac Critical Care Consortium registry from February 2019 through April 2021. Outcomes of patients with closed sternum were compared to those with sternal closure prior to postoperative day 3 (early closure) and prior to postoperative day 6 (intermediate closure). RESULTS The incidence of DSC was 74% (500 of 674). The median duration of open sternum was 4 days (interquartile range 3-5 days). Comparing patients with closed sternum to patients with early sternal closure, there was no statistical difference in mortality rate (1.1% vs 0%) and the median hospital postoperative stay (30 days vs 31 days). Compared with closed sternum, patients with intermediate sternal closure required longer mechanical ventilation (5.9 days vs 3.9 days) and fewer subsequent sternotomies (3% vs 7.5%). CONCLUSIONS For important outcomes following the Norwood operation there is no advantage to chest closure at the time of surgery if the chest can be closed prior to postoperative day 3.
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Affiliation(s)
- Ahmed Asfari
- Division of Cardiology, Department of Pediatrics, University of Alabama at Birmingham, Birmingham, Alabama.
| | - Jeffrey P Jacobs
- Department of Cardiovascular Surgery, University of Florida, Gainesville, Florida
| | - Jonathan W Byrnes
- Division of Cardiology, Department of Pediatrics, University of Alabama at Birmingham, Birmingham, Alabama
| | - Santiago Borasino
- Division of Cardiology, Department of Pediatrics, University of Alabama at Birmingham, Birmingham, Alabama
| | - Parthak Prodhan
- Division of Cardiology, Department of Pediatrics, University of Arkansas for Medical Sciences, Arkansas Children's Hospital, Little Rock, Arkansas
| | - Hayden Zaccagni
- Division of Cardiology, Department of Pediatrics, University of Alabama at Birmingham, Birmingham, Alabama
| | - Robert J Dabal
- Department of Cardiovascular Surgery, University of Alabama at Birmingham, Birmingham, Alabama
| | - Robert A Sorabella
- Department of Cardiovascular Surgery, University of Alabama at Birmingham, Birmingham, Alabama
| | - James M Hammel
- Department of Cardiovascular Surgery, University of Nebraska, Omaha, Nebraska
| | - Melissa Smith-Parrish
- Divisions of Pediatric Critical Care Medicine and Pediatric Cardiology, Department of Pediatrics, Vanderbilt University School of Medicine and Monroe Carrell Jr. Children's Hospital at Vanderbilt, Nashville, Tennessee
| | - Wenying Zhang
- Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor, Michigan
| | - Mousumi Banerjee
- Department of Biostatistics, University of Michigan School of Public Health, Ann Arbor, Michigan
| | - Kurt R Schumacher
- Division of Cardiology, Department of Pediatrics and Communicable Diseases, C.S. Mott Children's Hospital and University of Michigan Medical School, Ann Arbor, Michigan
| | - Sarah Tabbutt
- Division of Critical Care Medicine, Department of Pediatrics, University of California San Francisco Benioff Children's Hospitals, San Francisco, California
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Akay MH, Jezovnik MK, Salas De Armas IA, Ilic M, Karabulut MN, Alagoz M, Patel M, Radovancevic R, Kar B, Gregoric ID. Delayed versus primary sternal closure for left ventricular assist device implantation: Impact on mechanical circulatory support infections. J Heart Lung Transplant 2022; 42:645-650. [PMID: 36641296 DOI: 10.1016/j.healun.2022.12.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2021] [Revised: 10/31/2022] [Accepted: 12/06/2022] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND Delayed sternal closure may be required after left ventricular assist device (LVAD) implantation due to coagulopathy or hemodynamic instability. There is conflicting data regarding infection risk. METHODS We performed a single-center, retrospective analysis of patients who received their first LVAD between May 2012 and January 2021. Patients were divided into delayed sternal closure (DSC) and primary sternal closure (PSC) groups. We used chi-squared or Fisher Exact tests, as appropriate, to compare the incidence of postoperative LVAD-related infections (mediastinal/sternal wound) and LVAD-specific infections (driveline and pump pocket) after definitive chest closure between these two groups. RESULTS A total of 327 patients met eligibility criteria, including 127 (39%) patients that underwent DSC and 200 (61%) patients that had a PSC. Demographic and clinical characteristics were similar except for an overrepresentation of men (87% vs. 75%, p = .016), Interagency Registry of Mechanically Assisted Circulatory Support class I-II patients (89% vs 66%, p < .001), patients with a previous sternotomy (43% vs 13%, p < .001), and patients with chronic kidney disease (55% vs 43%, p = .030) in the DSC group. The median DSC time was 24 (IQR: 24-48) hours. The incidence of LVAD-related mediastinal/sternal wound infection was similar between the DSC and PSC groups (4.7% vs 3.0%, p = .419). There was no difference between DSC and PSC groups in the incidence of driveline infection (6.3% vs 9%, p = .411) and pump pocket infection (1.6% vs 1.5%, p =.901), respectively. CONCLUSIONS DSC does not seem to increase the incidence of LVAD-related or LVAD-specific infection rates in heart failure patients undergoing device implantation surgery.
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Affiliation(s)
- Mehmet H Akay
- Department of Advanced Cardiopulmonary Therapies and Transplantation, Center for Advanced Heart Failure, The University of Texas Health Science Center-Houston/Memorial Hermann Hospital-Texas Medical Center, Houston, TX
| | - Mateja K Jezovnik
- Department of Advanced Cardiopulmonary Therapies and Transplantation, Center for Advanced Heart Failure, The University of Texas Health Science Center-Houston/Memorial Hermann Hospital-Texas Medical Center, Houston, TX
| | - Ismael A Salas De Armas
- Department of Advanced Cardiopulmonary Therapies and Transplantation, Center for Advanced Heart Failure, The University of Texas Health Science Center-Houston/Memorial Hermann Hospital-Texas Medical Center, Houston, TX
| | - Milica Ilic
- Department of Advanced Cardiopulmonary Therapies and Transplantation, Center for Advanced Heart Failure, The University of Texas Health Science Center-Houston/Memorial Hermann Hospital-Texas Medical Center, Houston, TX
| | - Mehmet N Karabulut
- Department of Advanced Cardiopulmonary Therapies and Transplantation, Center for Advanced Heart Failure, The University of Texas Health Science Center-Houston/Memorial Hermann Hospital-Texas Medical Center, Houston, TX
| | - Mehmet Alagoz
- Department of Advanced Cardiopulmonary Therapies and Transplantation, Center for Advanced Heart Failure, The University of Texas Health Science Center-Houston/Memorial Hermann Hospital-Texas Medical Center, Houston, TX
| | - Manish Patel
- Department of Advanced Cardiopulmonary Therapies and Transplantation, Center for Advanced Heart Failure, The University of Texas Health Science Center-Houston/Memorial Hermann Hospital-Texas Medical Center, Houston, TX
| | - Rajko Radovancevic
- Department of Advanced Cardiopulmonary Therapies and Transplantation, Center for Advanced Heart Failure, The University of Texas Health Science Center-Houston/Memorial Hermann Hospital-Texas Medical Center, Houston, TX
| | - Biswajit Kar
- Department of Advanced Cardiopulmonary Therapies and Transplantation, Center for Advanced Heart Failure, The University of Texas Health Science Center-Houston/Memorial Hermann Hospital-Texas Medical Center, Houston, TX
| | - Igor D Gregoric
- Department of Advanced Cardiopulmonary Therapies and Transplantation, Center for Advanced Heart Failure, The University of Texas Health Science Center-Houston/Memorial Hermann Hospital-Texas Medical Center, Houston, TX.
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von Stumm M, Leps Y, Jochheim L, van Rüth V, Gottschalk U, Mueller G, Kozlik-Feldmann R, Hazekamp MG, Sachweh JS, Biermann D. Impact of delayed sternal closure on wound infections following neonatal and infant cardiac surgery. PLoS One 2022; 17:e0267985. [PMID: 35604953 PMCID: PMC9126390 DOI: 10.1371/journal.pone.0267985] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2022] [Accepted: 04/19/2022] [Indexed: 11/23/2022] Open
Abstract
Objectives Delayed sternal closure is a routine procedure to reduce hemodynamic and respiratory instability in pediatric patients following cardiac surgery, particularly in neonates and infants. In this setting, the possible links between sternal wound infection and delayed sternal closure are still a matter of debate. As a part of our routine, there was a low threshold for delayed sternal closure, so we reviewed our experience with sternal wound infections with a focus on potentially related perioperative risk factors, particularly delayed sternal closure. Methods We retrospectively identified 358 operated neonates (37%) and infants (mean age 3.6 months) in our local congenital heart disease database between January 2013 and June 2017. Potential risk factors for sternal wound infections, such as age, gender, complexity (based on Aristotle- and STS-EACTS mortality category), reoperation, use of cardiopulmonary bypass, extracorporeal membrane oxygenation, mortality and delayed sternal closure (163/358, 46%), were subjected to uni- and multivariate analysis. Results A total of 26/358 patients (7.3%) developed a superficial sternal wound infection. There were no deep sternal wound infections, no mediastinitis or sepsis. Applying univariate analysis, the prevalence of sternal wound infections was related to younger age, more complex surgery and delayed sternal closure. However, in multivariate analysis, sternal wound infection was only associated with delayed sternal closure (p = 0.013, odds ratio 8.6). Logistic regression revealed the prevalence of delayed sternal closure to be related to younger age, complexity, and the use of extracorporeal membrane oxygenation. Conclusion In patients younger than one year, sternal wound infections are clearly related to delayed sternal closure. However, in our cohort, all sternal wound infections were superficial and acceptable, considering the improved postoperative hemodynamic stability.
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Affiliation(s)
- Maria von Stumm
- Department of Congenital and Pediatric Heart Surgery, Children‘s Heart Clinic, University Heart & Vascular Center, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Yola Leps
- Department of Congenital and Pediatric Heart Surgery, German Heart Center Munich, Technical University of Munich, Munich, Germany
| | - Luca Jochheim
- Department of Congenital and Pediatric Heart Surgery, German Heart Center Munich, Technical University of Munich, Munich, Germany
| | - Victoria van Rüth
- Department of Congenital and Pediatric Heart Surgery, German Heart Center Munich, Technical University of Munich, Munich, Germany
| | - Urda Gottschalk
- Department of Pediatric Cardiology, Children‘s Heart Clinic, University Heart & Vascular Center, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Goetz Mueller
- Department of Pediatric Cardiology, Children‘s Heart Clinic, University Heart & Vascular Center, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Rainer Kozlik-Feldmann
- Department of Pediatric Cardiology, Children‘s Heart Clinic, University Heart & Vascular Center, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Mark G. Hazekamp
- Department of Cardiothoracic Surgery, Leiden University Medical Center, Leiden, The Netherlands
| | - Joerg S. Sachweh
- Department of Congenital and Pediatric Heart Surgery, German Heart Center Munich, Technical University of Munich, Munich, Germany
| | - Daniel Biermann
- Department of Congenital and Pediatric Heart Surgery, German Heart Center Munich, Technical University of Munich, Munich, Germany
- * E-mail:
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Asfari A, Clark MG, Hock KM, Huskey JL, Rahman AKMF, Dabal RJ, Borasino S. Early Versus Late Sternal Closure in Infants-Perioperative Associations and Outcomes. World J Pediatr Congenit Heart Surg 2021; 12:589-596. [PMID: 34597200 DOI: 10.1177/21501351211022413] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND Delayed sternal closure (DSC) has been used for patients who develop bleeding, chest wall edema, and malignant arrhythmia following cardiopulmonary bypass. Multiple factors can influence the timing of when to perform DSC. We aimed to describe our DSC experience in neonates and infants by comparing outcomes between patients undergoing early (<48 hours) versus late DSC (> 48 hours). We explored the associations between specific clinical and laboratory variables and the timing of DSC. METHODS Retrospective chart review of neonates and infants (<one-year-old) with DSC after heart surgery from December 2012 to December 2018. Patients requiring extracorporeal membrane oxygenation were excluded. RESULTS A total of 121 patients were included in the analysis, 34% (n = 41) met late DSC criteria. The overall cohort had a 75% survival rate and a median time for open sternum of 42.5 hours (Q1:23-Q3:65). The median time for open sternum in the early and late DSC groups was 24 hours (Q1:21-Q3:43) and 93 hours (Q1:65-Q3:141), respectively (P < .01). There was no statistical difference in mortality rate between groups. Patients with late DSC endured longer intensive care unit stays (median 24.3 days [Q1:13-Q3:35.3] vs 36.8 [Q1:23.9, 73.6]; P< .01) and a two-fold longer hospital stay compared to the early DSC group (multivariable analysis: relative risk = 2, 95% CI: 1.5-2.7; P < .01). Univariate analysis revealed patients with late DSC had higher median lactates both intraoperatively (7.6 [Q1:5.9-Q3:10.7] vs 9.3 [Q1:7.5-Q3:12.1]; P < .01) and 24 hours postoperatively (6.5 [Q1:4.3-Q3:10.3] vs 8.7 [Q1:5.7-Q3:14.70]; P = .03). A higher vasoactive inotrope score at 36 hours was associated with late DSC (odds ratio = 1.1, 95% CI: 1.01-1.2; P = .02). CONCLUSIONS Future research that explores additional clinical and laboratory variables that can help guide DSC decision-making and timing is needed.
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Affiliation(s)
- Ahmed Asfari
- Department of Pediatric Cardiac Critical Care Medicine, University of Alabama at Birmingham, AL, USA
| | - Matthew G Clark
- Department of Pediatric Cardiac Critical Care Medicine, University of Alabama at Birmingham, AL, USA
| | - Kristal M Hock
- Department of Pediatric Cardiac Critical Care Medicine, University of Alabama at Birmingham, AL, USA
| | - Jordan L Huskey
- Department of Pediatric Cardiac Critical Care Medicine, University of Alabama at Birmingham, AL, USA
| | - A K M F Rahman
- Department of Biostatistics, University of Alabama at Birmingham, AL, USA
| | - Robert J Dabal
- Department of Cardiothoracic Surgery, University of Alabama at Birmingham, AL, USA
| | - Santiago Borasino
- Department of Pediatric Cardiac Critical Care Medicine, University of Alabama at Birmingham, AL, USA
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Elsisy MF, Dearani JA, Crestanello JA, Ashikhmina EA, Van Dorn CS, Stephens EH. Outcomes of Primary vs Secondary Delayed Sternal Closure in Pediatric Cardiac Surgery. Ann Thorac Surg 2021; 113:1231-1237. [PMID: 33662305 DOI: 10.1016/j.athoracsur.2021.02.029] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/09/2020] [Revised: 02/11/2021] [Accepted: 02/16/2021] [Indexed: 11/01/2022]
Abstract
BACKGROUND Delayed sternal closure (DSC) is a management strategy for hemodynamic instability and severe coagulopathy after complex congenital heart surgery. We hypothesized that DSC results in better outcomes than perioperative sternal reopening. METHODS We reviewed patients aged <18 years old undergoing cardiac surgery 2007-2017 at our institution. A total of 179 patients (3.8%) had primary DSC (PDSC, sternum left open after initial operation) and 45 patients (0.9%) had secondary DSC (SDSC, sternum closed primarily and reopened perioperatively). Perioperative characteristics and outcomes among PDSC ≤2 days (98 patients), PDSC >2 days (81 patients), and SDSC (45 patients) were analyzed. RESULTS Median age was 120 days (range, 3-6553 days) and median DSC duration was 2 days (range, 1-60 days). The PDSC >2 days group was the youngest group, and the distribution of procedures was different between groups. Indications for DSC were hemodynamic instability in 152 patients (67.9%) and severe coagulopathy in 33 patients (14.7%), with no difference between groups (P = .141). Extracorporeal membrane oxygenation use was higher in the PDSC >2 days group than the other groups (47.5% vs 7.1%, P < .01 and 47.5% vs 28.9%, P = .02), respectively. Operative mortality was higher in SDSC compared to the other groups (17.8% vs 0% for PDSC ≤2 and 6.2% for PDSC >2 days, P < .01). Hospital stay was longer in SDSC (57 ± 7 days) than PDSC ≤2 days (22 ± 5 days) and PDSC >2 days (44 ± 6, P = .01). Survival was better in PDSC regardless of duration than SDSC. CONCLUSIONS PDSC demonstrated better outcomes than SDSC. Sternal reopening can be life-saving, but, when anticipated, PDSC can yield better outcomes.
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Affiliation(s)
- Mohamed F Elsisy
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, Minnesota
| | - Joseph A Dearani
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, Minnesota
| | | | - Elena A Ashikhmina
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, Minnesota
| | - Charlotte S Van Dorn
- Department of Pediatric and Adolescent Medicine, Division of Pediatric Critical Care Medicine, Mayo Clinic, Rochester, Minnesota; Department of Pediatric and Adolescent Medicine, Division of Pediatric Cardiology, Mayo Clinic, Rochester, Minnesota
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Abstract
BACKGROUND The perioperative complications rate in paediatric cardiac surgery, as well as the failure-to-rescue impact, is less known in low- and middle-income countries. AIM To evaluate perioperative complications rate, mortality related to complications, different patients' demographics, and procedural risk factors for perioperative complication and post-operative death. METHODS Risk factors for perioperative complications and operative mortality were assessed in a retrospective single-centre study which included 296 consecutive children undergoing cardiac surgery. RESULTS Overall mortality was 5.7%. Seventy-three patients (24.7%) developed 145 perioperative complications and had 17 operative mortalities (23.3%). There was a strong association between the number of perioperative complications and mortality - 8.1% among patients with only 1 perioperative complication, 35.3% - with 2 perioperative complications, and 42.1% - with 3 or more perioperative complications (p = 0.007). Risk factors of perioperative complications were younger age (odds ratio 0.76; (95% confidence interval 0.61, 0.93), previous cardiac surgery (odds ratio 3.5; confidence interval 1.33, 9.20), extracardiac structural anomalies (odds ratio 3.03; confidence interval 1.27, 7.26), concomitant diseases (odds ratio 3.23; confidence interval 1.34, 7.72), and cardiopulmonary bypass (odds ratio 6.33; confidence interval 2.45, 16.4), whereas the total number of perioperative complications per patient was the only predictor of operative death (odds ratio 1.89; confidence interval 1.06, 3.37). CONCLUSIONS In a program with limited systemic resources, failure-to-rescue is a major contributor to operative mortality in paediatric cardiac surgery. Despite the comparable crude mortality, the operative mortality among patients with perioperative complications in our series was significantly higher than in the developed world. A number of initiatives are needed in order to improve failure-to-rescue rates in low- and middle-income countries.
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Kundan S, Tailor K, Radhakrishnan HB, Mohanty SR, Bhavsar K, Kadam S, Joshi P, Joshi V, Karande T, Bobhate P, Kulkarni S, Rao SG. Elective delayed sternal closure portends better outcomes in congenital heart surgery: a retrospective observational study. Indian J Thorac Cardiovasc Surg 2020; 35:530-538. [PMID: 33061048 DOI: 10.1007/s12055-019-00830-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2018] [Revised: 03/07/2019] [Accepted: 05/02/2019] [Indexed: 11/28/2022] Open
Abstract
Introduction Delayed sternal closure is used in paediatric cardiac surgery as a management strategy for patients with unstable hemodynamics or postoperative bleeding routinely. We hypothesise that planned postponement of sternal closure leads to better outcomes than emergent reopening in the intensive care unit (ICU) in patients exhibiting some hemodynamic indication for the same. Methods We retrospectively analysed the outcomes of delayed sternal closure 220/2111 (10.42%) out of which 14 sternums were opened in the ICU after shifting the patients. Results A total of 220/2111 (10.42%) sternums were left open postoperatively, out of which 14 were opened after shifting to the ICU. Total mortality of the delayed sternal closure was 33/220, i.e. 15%. The patients whose sternums were left open from the theatre had a mortality of 23/206, i.e. 11.16%, whereas those patients whose sternums were opened in the ICU had a mortality of 10/14, i.e. 71.42%. Conclusion In doubtful postoperatively hemodynamic, the choice of leaving the sternum open electively has better outcomes, rather than opening the sternum as a terminal bail out procedure.
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Affiliation(s)
- Simran Kundan
- Pediatric and Congenital Heart Surgery, Kokilaben Dhirubai Ambani Hospital, Mumbai, India
| | - Kamlesh Tailor
- Pediatric Cardiac Anesthesiologist and Intensivist, Kokilaben Dhirubai Ambani Hospital, Mumbai, India
| | | | - Smruti Ranjan Mohanty
- Pediatric and Congenital Heart Surgery, Kokilaben Dhirubai Ambani Hospital, Mumbai, India
| | - Keyur Bhavsar
- Pediatric Cardiac Anesthesiologist and Intensivist, Kokilaben Dhirubai Ambani Hospital, Mumbai, India
| | - Shankar Kadam
- Pediatric Cardiac Anesthesiologist and Intensivist, Kokilaben Dhirubai Ambani Hospital, Mumbai, India
| | - Preetha Joshi
- Pediatric and Neonatal Intensivist, Kokilaben Dhirubai Ambani Hospital, Mumbai, India
| | - Vinay Joshi
- Pediatric and Neonatal Intensivist, Kokilaben Dhirubai Ambani Hospital, Mumbai, India
| | - Tanuja Karande
- Pediatric Cardiologist, Kokilaben Dhirubai Ambani Hospital, Mumbai, India
| | - Prashant Bobhate
- Pediatric Cardiologist, Kokilaben Dhirubai Ambani Hospital, Mumbai, India
| | - Snehal Kulkarni
- Pediatric Cardiologist, Kokilaben Dhirubai Ambani Hospital, Mumbai, India
| | - Suresh Gururaja Rao
- Pediatric and Congenital Heart Surgery, Kokilaben Dhirubai Ambani Hospital, Mumbai, India
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Yabrodi M, Hermann JL, Brown JW, Rodefeld MD, Turrentine MW, Mastropietro CW. Minimization of Surgical Site Infections in Patients With Delayed Sternal Closure After Pediatric Cardiac Surgery. World J Pediatr Congenit Heart Surg 2019; 10:400-406. [PMID: 31307311 DOI: 10.1177/2150135119846040] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Delayed sternal closure (DSC) following pediatric cardiac surgery is commonly implemented at many centers. Infectious complications occur in 18.7% of these patients based on recent multicenter data. We aimed to describe our experience with DSC, hypothesizing that our practices surrounding the implementation and maintenance of the open sternum during DSC minimize the risk of infectious complications. METHODS We reviewed patients less than 365 days who underwent DSC between 2012 and 2016 at our institution. Infectious complications as defined by the Society of Thoracic Surgeons Congenital Heart Surgery Database were recorded. Patients with and without infectious complications were compared using Wilcoxon rank sum tests or Fisher exact tests as appropriate. RESULTS We identified 165 patients less than 365 days old who underwent DSC, 135 (82%) of whom had their skin closed over their open sternum. Median duration of open sternum was 3 days (range: 1-32 days). Infectious complications occurred in 15 (9.1%) patients-13 developed clinical sepsis with positive blood cultures, one patient developed ventilator-associated pneumonia, and one patient developed wound infection (0.6%). No cases of mediastinitis occurred. No statistical differences in characteristics between patients with and without infectious complications could be identified. CONCLUSION Infectious complications after DSC at our institution were notably less than reported in recent literature, primarily due to minimization of surgical site infections. Practices described in the article, including closing skin over the open sternum whenever possible, could potentially aid other institutions aiming to reduce infectious complications associated with DSC.
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Affiliation(s)
- Mouhammad Yabrodi
- 1 Division of Critical Care, Department of Pediatrics, Riley Hospital for Children at Indiana University Health, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Jeremy L Hermann
- 2 Division of Cardiothoracic Surgery, Department of Surgery, Riley Hospital for Children at Indiana University Health, Indiana University School of Medicine, Indianapolis, IN, USA
| | - John W Brown
- 2 Division of Cardiothoracic Surgery, Department of Surgery, Riley Hospital for Children at Indiana University Health, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Mark D Rodefeld
- 2 Division of Cardiothoracic Surgery, Department of Surgery, Riley Hospital for Children at Indiana University Health, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Mark W Turrentine
- 2 Division of Cardiothoracic Surgery, Department of Surgery, Riley Hospital for Children at Indiana University Health, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Christopher W Mastropietro
- 1 Division of Critical Care, Department of Pediatrics, Riley Hospital for Children at Indiana University Health, Indiana University School of Medicine, Indianapolis, IN, USA
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Silvetti S, Landoni G, Castagnola E, Nuri H, Pomé G, Moscatelli A. Antibiotic Management for Delayed Sternal Closure Following Pediatric Cardiac Surgery: A Systematic Review of Recent Literature. J Cardiothorac Vasc Anesth 2019; 34:1333-1340. [PMID: 31420313 DOI: 10.1053/j.jvca.2019.07.134] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/13/2019] [Revised: 07/02/2019] [Accepted: 07/16/2019] [Indexed: 12/21/2022]
Abstract
Delayed sternal closure after pediatric cardiac surgery is a management option for the treatment of patients with severely impaired heart function. The optimal antimicrobial treatment strategy for this condition is unknown. The aim of this systematic review was to evaluate the current antibiotic administration attitudes in pediatric cardiac surgery patients needing an open chest in terms of infection with a focus on surgical site infection rate. The authors performed a systematic review and meta-analysis of all articles, which described the antibiotic administration strategy and surgical site infection rate in pediatric patients with an open chest after cardiac surgery. The authors performed a subgroup analysis on "standard" versus "non-standard" (defined as any antimicrobial drugs different from the adult guidelines recommendations) therapy for one-proportion meta-analysis with a random effect model. The authors identified 12 studies published from January 1, 2000 to July 1, 2019 including a total of 2,203 patients requiring an open chest after cardiac surgery, 350 of whom (15.9%) developed infections and 182 (8.3%) developed a surgical site infection. The surgical site infection rate in patients with "non-standard" strategy was higher than in patients with "standard" strategy: 8.8% (140 reported infections/1,582 patients) versus 6.8% (42 reported infections/621 patients), p = 0.001. The "standard" antibiotic management proposed by guidelines for adult cardiac surgery patients could be used an acceptable strategy to treat pediatric patients with an open chest after cardiac surgery.
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Affiliation(s)
- Simona Silvetti
- Neonatal and Pediatric Intensive Care Unit, Department of Surgery and Critical Care, IRCCS Istituto Giannina Gaslini, Genova, Italy
| | - Giovanni Landoni
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, University Vita-Salute San Raffaele, Milano, Italy.
| | - Elio Castagnola
- Infectious Disease Unit, Department of Pediatrics, IRCCS Istituto Giannina Gaslini, Genova, Italy
| | - Halkawt Nuri
- Cardiac Surgery Unit, Department of Surgery and Critical Care, IRCCS Istituto Giannina Gaslini, Genova, Italy
| | - Giuseppe Pomé
- Cardiac Surgery Unit, Department of Surgery and Critical Care, IRCCS Istituto Giannina Gaslini, Genova, Italy
| | - Andrea Moscatelli
- Neonatal and Pediatric Intensive Care Unit, Department of Surgery and Critical Care, IRCCS Istituto Giannina Gaslini, Genova, Italy
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