Healthcare-associated infections (HAIs) are responsible for many deaths of hospitalized patients each year. Patients with prolonged hospitalization are at high risk for HAIs. Increased efforts have ...been made to decrease these infections, but a recent report from the Centers for Disease Control suggests that some HAIs may be increasing. We hypothesized that HAIs would remain frequent among cardiac surgery patients with prolonged intensive care unit stay and would be associated with increased mortality.
We performed a retrospective cohort study of adult cardiac surgery patients with prolonged intensive care unit stay (more than 7 days) over a 3-year period. Mortality differences were calculated based on whether particular HAIs occurred. Multivariable logistic regression was used to examine risk factors associated with the development of HAI. The relationship between HAI and mortality was estimated using propensity score adjusted logistic regression analysis.
Of 2,595 patients, 388 (15.0%) had a prolonged intensive care unit stay. Of these patients, 48.5% had at least one HAI. Unadjusted inhospital mortality for patients with HAI was 28.7%, versus 13.0% for patients without. Red blood cell transfusion was associated with increased HAI risk. After propensity score adjustment, surgical site infection and central line associated blood stream infection were associated with increased mortality. The HAIs caused by vancomycin-resistant Enterococcus sp, methicillin-resistant Stapholococcus aureus, and multidrug-resistant organisms appeared to be associated with disproportionally high mortality.
Healthcare-associated infections remain frequent among cardiac surgery patients with prolonged intensive care unit stay and are associated with increased mortality. Evidence-based strategies are needed to reduce these infections.
Abstract Background The role of extracorporeal cardiopulmonary resuscitation (ECPR) in adult cardiac surgery patients with refractory cardiac arrest is uncertain. We hypothesized that ECPR would be ...associated with better than expected outcomes in this group of patients. Methods We conducted a single-center retrospective cohort study of adult cardiac surgery patients who underwent ECPR for refractory cardiac arrest during a 6-year period (2010 to 2015). In-hospital mortality, survival at last follow-up, and cerebral performance category (CPC) were examined as outcomes, and potential risk factors for mortality were explored. Results Twenty-three patients underwent ECPR when spontaneous circulation did not return with conventional resuscitation. Thirty-day mortality was 65.2%, and in-hospital mortality was 69.6%. Six of the 23 patients (26.1%) were discharged with a favorable neurologic outcome, defined as CPC 1 or 2. Most patients who died had multiple organ dysfunction syndrome (43.8%), and a smaller number had severe brain injury (25.0%). Kaplan-Meier survival analysis suggested age as a critical factor affecting survival ( P = .04, log-rank test). Conclusions ECPR may have a role in younger adult cardiac surgery patients who experience refractory cardiac arrest. Future studies are needed to identify patients who will benefit most from ECPR.
Observational studies suggest that transfusion of high ratios of fresh frozen plasma (FFP) to red blood cells (RBCs) reduces mortality in severe hemorrhage. There are no studies examining the impact ...of the FFP to RBC transfusion ratio on mortality in massively transfused patients undergoing cardiac operations.
A single-center retrospective cohort study was performed over an 8.5-year period. Massive transfusion was defined as at least 8 RBC units administered during the operation. Patients were classified as having received a high FFP/RBC ratio (greater than 1:1), a moderate ratio (between 1:1 and 1:2), or a low ratio (<1:2). Thirty-day survival was compared between groups using Kaplan-Meier analysis, and Cox proportional hazards modeling was used to identify variables associated with 30-day mortality. In-hospital mortality and postoperative morbidities were also compared between groups using regression analyses.
Of 7,492 patients undergoing cardiac operations, 452 (6%) were massively transfused. Thirty-day mortality was 25.4% and in-hospital mortality was 30.6%. Patients with a high transfusion ratio had improved 30-day survival when compared with those with a low ratio (hazard ratio HR for death, 0.339; p = 0.002). High transfusion ratios were also associated with fewer reoperations for bleeding, less renal failure, more prolonged ventilation, and more atrial fibrillation compared with low ratios.
A high transfusion ratio may improve survival in patients undergoing cardiac operations with massive intraoperative transfusion but may increase the risk for prolonged ventilation and atrial fibrillation.
Bleeding may occur frequently during adult extracorporeal life support; however, there are no detailed investigations of bleeding events, red blood cell transfusion, and their impact on mortality. ...The purpose of our study was to characterize the incidence of bleeding and red blood cell transfusion during adult extracorporeal life support and examine the impact on mortality.
We performed a retrospective analysis of adult extracorporeal life support patients over approximately a 3-year period. The incidence of bleeding events and transfusions were recorded. Unadjusted and adjusted multivariate logistic regression analyses were performed to estimate the odds of inhospital mortality among patients with bleeding and for each red blood cell unit transfused. Ninety-day survival was compared between patients who bled and those who did not.
Serious bleeding events occurred in 74 of 132 patients (56.1%), and the rate of bleeding was 10 events per 100 days. The crude odds ratio for inhospital mortality in patients who bled was 2.22 (95% confidence interval CI: 1.00 to 4.94, p = 0.05); and for each unit of red blood cells transfused, it was 1.03 (95% CI: 1.01 to 1.04, p = 0.005). The adjusted odds ratios for bleeding and red blood cell transfusions were 0.90 (95% CI: 0.37 to 2.19, p = 0.82) and 1.03 (95% CI: 1.00 to 1.06, p = 0.04). There was a trend toward decreased 90-day survival among patients who bled compared with patients who did not (46.7% versus 64.9%, p = 0.08).
Bleeding and red blood cell transfusion occur frequently during adult extracorporeal life support, but only the amount of red blood cell transfusion is associated with inhospital mortality after controlling for confounding variables.
It is important to characterize in-hospital mortality after cardiac surgery and understand the relationships between postoperative length of intensive care unit stay, postoperative length of hospital ...stay, and the likelihood of in-hospital mortality.
We retrospectively identified all cardiac surgery cases that resulted in in-hospital mortality over an 8-year period at a single center. For these subjects we collected demographic data, preoperative comorbidities, and postoperative complications. We performed stepwise multivariate linear regression to determine which postoperative complications were associated with mortality timing. We also analyzed the relationships between postoperative length of intensive care unit stay, postoperative length of hospital stay, and in-hospital mortality in all patients (including survivors) who had cardiac surgery during the same time period. Finally, we calculated the daily incremental observed mortality rate for patients in the hospital up to postoperative day 50.
Six hundred twenty-one in-hospital mortalities occurred among 18,348 patients during the study period (3.4%). Four postoperative complications were associated with mortality timing. Cardiac arrest had a negative association with the number of days until mortality, while deep sternal wound infection, stroke, and pneumonia had a positive association (all p<0.05). Postoperative complications explained 15% of the variability in mortality timing (R2 model=0.15). The odds ratio for in-hospital mortality was 1.033 for each postoperative day in the hospital and 1.071 for each postoperative day in the intensive care unit (both p<0.05).
Most in-hospital mortality occurs during the first week after cardiac surgery with few mortalities occurring after a protracted hospital course. Postoperative complications have a limited ability to explain the variability in mortality timing. Increased length of postoperative intensive care unit stay and hospital stay after cardiac surgery are associated with an increased likelihood of in-hospital mortality.
Objective To determine the incidence of intra-abdominal hypertension (IAH) in adult cardiac surgery patients and its association with postoperative kidney dysfunction. Design Prospective cohort ...study. Setting Single tertiary-care university hospital. Participants Forty-two adult patients having cardiac surgery with cardiopulmonary bypass. Interventions Intra-abdominal pressure (IAP) was measured preoperatively, immediately after surgery, and at the following time points after surgery: 3 hours, 6 hours, 12 hours, and 24 hours. Urine neutrophil gelatinase-associated lipocalin (NGAL) levels were measured as a marker of kidney dysfunction at the following time points: prior to surgery, immediately after surgery, 4 to 6 hours after surgery, and 16-to-18 hours after surgery. Measurements and Main Results Two hundred fifty-two IAPs were measured, and 90 (35.7%) showed IAH. Thirty-five of 42 patients (83.3%) had IAH at 1 time point or more. Peak urine NGAL levels were lower in patients with normal IAP (mean difference = –130.6 ng/mL 95% CI = –211.2 to –50.1, p = 0.002). There was no difference in postoperative kidney dysfunction by risk, injury, failure, loss of kidney function, and end-stage kidney disease (RIFLE) criteria in patients with normal IAP (mean difference = –31.4% 95% CI = –48.0 to 6.3, p = 0.09). IAH was 100% sensitive for predicting postoperative kidney dysfunction by RIFLE criteria, but had poor specificity (54.8%). Conclusions IAH occurs frequently during the perioperative period in cardiac surgery patients and may be associated with postoperative kidney dysfunction.
PDF
