Clinical evaluation of two adult oxygenator systems in terms of mortality and major adverse events

Purpose The primary aim of this study was to examine the effects of two oxygenator systems on major adverse events and mortality. Methods A total of 181 consecutive patients undergoing coronary artery bypass grafting in our clinic were retrospectively analyzed. The patients were divided into two groups according to the oxygenator used: Group M, in which a Medtronic Affinity (Medtronic Operational Headquarters, Minneapolis, MN, USA) oxygenator was used, and Group S, in which a Sorin Inspire (Sorin Group Italia, Mirandola, Italy) oxygenator was used. Results Group S consisted of 89 patients, whereas Group M included 92 patients. No statistically significant differences were found between the two groups in terms of age ( p = .112), weight ( p = .465), body surface area ( p = .956), or gender ( p = .484). There was no statistically significant difference in hemorrhage on the first or second postoperative day ( p = .318 and p = .455, respectively). No statistically significant differences were observed in terms of red blood cell ( p = .468), fresh frozen plasma ( p = .116), or platelet concentrate transfusion ( p = .212). Infections, wound complications, and delayed sternal closure were significantly more common in Group M ( p = .006, p = .023, and p = .019, respectively). Extracorporeal membrane oxygenators and intra-aortic balloon pumps were required significantly more frequently in Group S ( p = .025 and p = .013, respectively). Major adverse events occurred in 16 (18%) patients in Group S and 14 (15.2%) patients in Group M ( p = .382). Mortality was observed in six (6.7%) patients in Group S and three (3.3%) patients in Group M ( p = .232). No statistically significant difference was found between the two groups in terms of length of hospital stay ( p = .451). Conclusion The clinical outcomes of the two oxygenator systems, including mortality, major adverse events, hemorrhage, erythrocyte and platelet transfusions, and length of hospital stay, were similar.

808. Appropriate Use of Cephalotin Before and After Implementation of a Cardiac Surgery Antibiotic Prophylaxis Protocol in Guatemala

Background The appropriate use of Surgical Antibiotic Prophylaxis (SAP) contributes to reducing the prevalence of Surgical Site Infections (SSI). Inappropriate use increases the risk of SSIs, hospitalization costs and potentially contributes to the emergence of antimicrobial resistance. We aimed to compare the appropriate use before and after implementing a SAP protocol in our institution Methods We conducted a retrospective chart review in patients older than 18 undergoing elective cardiac surgery with cardiopulmonary bypass using cephalotin as SSI prophylaxis. We excluded patients who received other antimicrobials for prophylaxis, those undergoing non-elective surgery, and patients with delayed sternal closure. We identified SSIs according to the Centers for Disease Prevention and Control criteria. We evaluated if appropriate dosing (2g-3g) and timing ( >60 min.) occurred before the surgical incision, if redosing was administered, and if prophylaxis was administered > 48 hours. We evaluated before and after implementation of the protocol (August 2016-July 2017; October 2017-2018) Results The study included 262 and 285 patients before and after protocol implementation, respectively. Patient characteristics were similar between comparator groups (Table 1). We found that 1.1% of patients vs. 63% of patients had appropriate dosing before the surgical incision, before and after protocol implementation, respectively (p < 0.05). There was no difference in appropriate redosing when the duration of surgery was greater than 4 hours and no difference in inappropriate prophylaxis administration > 48 hours after protocol implementation. A total of 8 SSIs were identified in each group, with no statistical difference in the incidence, length of stay, or clinical outcome between comparator groups Table 1. Patient Characteristics and Appropriate use of Cephalotin Before and After Implementation of a Cardiac Surgery Antibiotic Prophylaxis Protocol in Guatemala Conclusion Based on our findings, implementing a local guideline-protocol for SAP resulted in significant improvement of pre-surgical antimicrobial dosing. We observed continual unnecessary administration of antibiotic prophylaxis in the postoperative period that needs more proactive interventional pharmacy-guided strategies such as automatic stops or audits width feedback. Disclosures Lourdes A. Sandoval, Master of Science in Pharmacovigilance and Pharmacoepidemiology, Abbott (Employee)

A Nano-Silver Loaded PVA/Keratin Hydrogel With Strong Mechanical Properties Provides Excellent Antibacterial Effect for Delayed Sternal Closure

Delayed chest closure (DSC) is widely performed during the treatment of congenital heart diseases. However, the high prevalence of surgical site infection (SSI) in patients undergoing DSC affects prognosis negatively. Herein, we designed a suturable poly (vinyl alcohol)/keratin film loaded with silver nanoparticles (AgNPs) as an alternative material for DSC, which was named PVA/Keratin/AgNPs. The PVA/Keratin/AgNPs films exhibited significantly enhanced mechanical strength after crosslinking by sodium trimetaphosphate (STMP). These films were non-toxic, and cells proliferated with good morphology after 1 week of culture. In addition, PVA/Keratin/AgNPs films provided superior antibacterial ability, as evidenced by the eradication and lower growth rate of Staphylococcus aureus and Escherichia coli. Finally, the PVA/Keratin/AgNPs films were demonstrated to successfully cover the chest cavity temporarily and protect the chest cavity from bacterial infection. These results indicated that the PVA/Keratin/AgNPs films have great prospects to be further exploited for clinical applications in DSC.

Early Versus Late Sternal Closure in Infants—Perioperative Associations and Outcomes

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.

Deep Wound Infection in Pediatrics after Open Cardiac Surgery

Surgical site infection (SSI) is a serious complication requiring prolonged hospitalization, intravenous antibiotics, wound care and dressings resulting in increased cost and resistant bacteria. In pediatric cardiac surgery, Median sternotomy is the most frequently used incision for the correction of congenital anomalies. Sternal wound infections (SWIs) are well described complications of cardiac surgery and can occur in 3% to 8% of children. Furthermore, the mortality rate can increase 2-fold after SSIs. Also, SSIs are associated with an increased length of hospital stay, readmissions, and higher health care expenditures. Mediastinitis is a retrosternal wound infection frequently associated with a macroscopically sternal osteomyelitis. Mediastinitis is uncomfortable for patients, is poorly accepted by parents, leads to a prolonged hospital stay repeated surgery and prolonged antibiotic therapy. Mediastinitis are costly for patients, providers, and health-care institutions. In A recent survey among congenital heart programs, the incidence of mediastinitis has been reported to occur in 0.2–1.4%. Gram-positive cocci are the most common pathogen. Gram negative organisms are increasingly recognized, especially in neonates, and are related to delayed sternal closure. Fungal organisms are not infrequently found. Mediastinitis generally presents 2–3 weeks after cardiac surgery. Child often appear irritable, tired, and febrile. The incision is erythematous and painful. Wound separation and purulent drainage from the incision are frequent. Some but not all will also have sternal instability or dehiscence. Associated bacteremia is not uncommon, present in up to 40% of patients. Postoperative mediastinitis is a life-threatening infection and increase health expenditure. Young age, malnutrition, hypothermia, hyperglycemia, longer duration of surgery, long time of delayed sternal closure, postoperative low cardiac output and long ICU stay were a risk factor of mediastinitis. Stick to1999 CDC's Guideline for prevention of surgical site infection and their update in 2017 especially proper timing of antibiotic prophylaxis and post-operative blood glucose management is important in prevention of these life-threatening complication. procalcitonin can be useful biologic marker of infection. Management of mediastinitis consist of debridement and culture-based antibiotics. Primary closure over mediastinal drain or high vacuum drain gave good result, less time consuming, more economic and more cosmetic. Vacuum assisted closure gave excellent result, but more time consuming, less economic and delayed closure is necessary. Larger studies are needed to compare both techniques in effectiveness and coast benefit.

Surgical site infection after delayed sternal closure in neonates with congenital heart disease: retrospective case-control study

Objectives To determine the prevalence of surgical site infections (SSIs) in neonatal congenital heart disease patients undergoing delayed sternal closure (DSC) and evaluate risk factors for SSI. Methods Hospital records of 483 consecutive neonates who underwent surgical intervention between January 2013 and December 2017 were reviewed, and perioperative variables were recorded. Results We found that the prevalence of SSI was 87.5% when the body weight was less than 1500 g. When the operative age was between seven and 14 days, the probability of no SSI is about 93.9%. When the duration of the aortic cross-clamp was more than 60 min, the prevalence of SSI was 91.2%. The prevalence without SSI was 96.6% when the duration of DSC was less than 24 h. However, when the duration of DSC was more than 120 h, the prevalence of SSI was 88.9% (p = 0.000). Conclusions With the prolongation of aortic clamping duration, the probability of occurrence of SSI increased in neonatal CHD with DSC. The age at operation and body weight are closely related to the occurrence of SSI in neonatal CHD patients with DSC.

Risk factors for prolonged ventilation after the modified Fontan procedure

Objective: To investigate the risk factors associated with prolonged ventilation after Fontan surgery. Design: Retrospective case series. Setting: Tertiary childrens hospital. Patients: We included 123 children who underwent Fontan surgery without delayed sternal closure or extracorporeal membrane oxygenation between 2011 and 2017. Intervention: Fontan surgery. Measurements and main results: Prolonged ventilation was defined as intubation for more than 24 hours after surgery. Preoperative, intraoperative, and perioperative data were collected retrospectively from medical records. Multivariate logistic regression analysis was used to identify risk factors for prolonged ventilation. The median age and weight of patients were 2.2 years and 10.0 kg, respectively. Seventeen per cent of the patients (n = 21) received prolonged mechanical ventilation, and the median intubation period was 2.9 days. There were no 90-day or in-hospital deaths. The independent predictors of prolonged ventilation identified were fenestration (p < 0.01), low pulmonary artery index (p = 0.02), and advanced atrioventricular regurgitation (p < 0.01). The duration of ICU stay was significantly longer in the prolonged ventilation group than in the early extubation group (10 days versus 6 days, p < 0.01). Conclusion: Fenestration, low pulmonary artery index, and significant atrioventricular regurgitation are risk factors for prolonged ventilation after Fontan surgery. Careful preoperative and perioperative management that considers the risk factors for prolonged ventilation in each individual is important.

Pulmonary Vein Index Is Associated With Early Prognosis of Surgical Treatment for Tetralogy of Fallot

Objectives: To evaluate the predictive value of the pulmonary vein index (PVI) in the early prognosis of patients who received total tetralogy of Fallot (TOF) repair.Methods: We retrospectively reviewed 286 patients who underwent TOF repair in our institution between July 2013 and May 2020. The PVI, McGoon ratio, and Nakata index were measured and calculated. Logistic regression, linear stepwise regression, receiver operating characteristic (ROC) curve analysis, and Cox proportional hazards modeling were performed to evaluate the predictive value of PVI in the early prognosis after TOF repair surgery.Results: The median age and body weight were 1.23 (0.22–15.02) years and 9.00 (3.00–44.00) kg, respectively. There were five early deaths. The areas under the ROC curve for death were 0.89, 0.79, and 0.88 for the McGoon ratio, Nakata index, and PVI, respectively. A lower PVI better predicted prolonged postoperative hospital stay, cardiac intensive care unit stay, and ventilator time (Hazard Ratio, HR [95% Confidence intervals, CI]: 1.003 [1.002–1.004], p &lt; 0.001; 1.002 [1.001–1.004], p &lt; 0.001; 1.002 [1.001–1.003], p &lt; 0.001, respectively) and was a significant risk factor for high 24 h max Vasoactive inotropic score (Crude Odds Ratio [OR] [95% CI]: −0.015 [−0.022, −0.007], p &lt; 0.001), serous effusion (Crude OR [95% CI]: 0.996 [0.992–0.999], p = 0.020), delayed sternal closure (Crude OR [95% CI]: 0.983 [0.971–0.996], p = 0.010), and the need for peritoneal dialysis (Crude OR [95% CI]: 0.988 [0.980–0.996], p = 0.005). The area under the ROC curve of PVI for delayed postoperative recovery was 0.722 (p &lt; 0.001), and the estimated cutoff point was 300.3 mm2/m2.Conclusion: PVI is a good predictor of early prognosis for surgical treatment of TOF patients.