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ABSTRACT: Guidelines exist for prevention of sternal wound infections (SWI) in adults. There are no guidelines for pediatric patients and limited reports on SWI incidence. The purpose of this study was to determine the incidence of, and preventative practice regarding pediatric SWIs with a long-term aim to develop best practice guidelines.
Eighty-nine congenital heart programs were sent a 31 question on-line survey regarding pediatric SWI.
Thirty eight (43%) of the 89 programs responded. They reported 8,774 pediatric congenital procedures with a mean SWI rate of 1.53% (range, 0 to 9.09). Mean yearly volume was 237 operations (range, 50 to 720). Neither program size nor delayed sternal closure was associated with increased incidence of SWI. Variations in preoperative measures, antibiotic regimens, and wound care did not statistically impact incidence of SWI. Programs with protocols to monitor and control blood glucose levels postoperatively had statistically lower infection rates (1.04 vs 2.35, p = 0.03), and those that sent mediastinal cultures at time of delayed sternal closure reported lower infection rates (1.34 vs 1.74, p = 0.051).
This report provides a multiinstitutional SWI incidence from pediatric programs of 1.53%. Despite variations in clinical practice between programs, this survey revealed two strategies resulting in reduced SWIs; protocol-based management of glucose levels and mediastinal wound cultures sent at time of closure. Pediatric programs do not consistently follow adult preventative guidelines. Multicenter randomized research is needed to formulate preventative guidelines to reduce the incidence of pediatric SWI.
The Annals of thoracic surgery 03/2011; 91(3):799-804. · 3.74 Impact Factor
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Jorge D Salazar,
Ryan D Coleman,
Stephen Griffith,
Jeffrey D McNeil,
Megan Steigelman,
Haven Young,
Bart Hensler,
Patricia Dixon, John Calhoon,
Faridis Serrano,
Robert DiGeronimo
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ABSTRACT: Deep hypothermic circulatory arrest (DHCA) is commonly used for complex cardiac operations in children, often with selective cerebral perfusion (SCP). Little data exist concerning the real-time effects of DHCA with or without SCP on cerebral metabolism. Our objective was to better define these effects, focusing on brain oxygenation and energy metabolism.
Piglets undergoing cardiopulmonary bypass were assigned to either 60 minutes of DHCA at 18 degrees C (n = 9) or DHCA with SCP at 18 degrees C (n = 8), using pH-stat management. SCP was administered at 10 mL/kg/min. A cerebral microdialysis catheter was implanted into the cortex for monitoring of cellular ischemia and energy stores. Cerebral oxygen tension and intracranial pressure also were monitored. After DHCA with or without SCP, animals were recovered for 4 hours off cardiopulmonary bypass.
With SCP, brain oxygen tension was preserved in contrast to DHCA alone (p < 0.01). Deep hypothermic circulatory arrest was associated with marked elevations of lactate (p < 0.01), glycerol (p < 0.01), and the lactate to pyruvate ratio (p < 0.001), as well as profound depletion of the energy substrates glucose (p < 0.001) and pyruvate (p < 0.001). These changes persisted well into recovery. With SCP, no significant cerebral microdialysis changes were observed. A strong correlation was demonstrated between cerebral oxygen levels and cerebral microdialysis markers (p < 0.001).
Selective cerebral perfusion preserves cerebral oxygenation and attenuates derangements in cerebral metabolism associated with DHCA. Cerebral microdialysis provides real-time metabolic feedback that correlates with changes in brain tissue oxygenation. This model enables further study and refinement of strategies aiming to limit brain injury in children requiring complex cardiac operations.
The Annals of thoracic surgery 07/2009; 88(1):162-9. · 3.74 Impact Factor
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ABSTRACT: Hypothermic circulatory arrest (HCA) is employed for aortic arch and other complex operations, often with selective cerebral perfusion (SCP). Our previous work has demonstrated real-time evidence of improved brain protection using SCP at 18 degrees C. The purpose of this study was to evaluate the utility of SCP at warmer temperatures (25 degrees C) and its impact on operating times.
Piglets undergoing cardiopulmonary bypass (CPB) and 60 min of HCA were assigned to three groups: 18 degrees C without SCP, 18 degrees C with SCP and 25 degrees C with SCP (n=8 animals per group). CPB flows were 100 ml kg(-1) min(-1) using pH-stat management. SCP flows were 10 ml kg(-1) min(-1) via the innominate artery. Cerebral oxygenation was monitored using NIRS (near-infrared spectroscopy). A microdialysis probe placed into the cerebral cortex had samples collected every 15 min. Animals were recovered for 4h after separation from CPB. All data are presented as mean+/-standard deviation (SD; p<0.05, significant).
Cerebral oxygenation was preserved during deep and tepid HCA with SCP, in contrast to deep HCA without SCP (p<0.05). Deep HCA at 18 degrees C without SCP resulted in significantly elevated brain lactate (p<0.01) and glycerol (p<0.01), while the energy substrates glucose (p<0.001) and pyruvate (p<0.001) were significantly depleted. These derangements were prevented with SCP at 18 degrees C and 25 degrees C. The lactate/pyruvate ratio (L/P) was profoundly elevated following HCA alone (p<0.001) and remained persistently elevated throughout recovery (p<0.05). Piglets given SCP during HCA at 18 degrees C and 25 degrees C maintained baseline L/P ratios. Mean operating times were significantly shorter in the 25 degrees C group compared to both 18 degrees C groups (p<0.05) without evidence of significant acidemia.
HCA results in cerebral hypoxia, energy depletion and ischaemic injury, which are attenuated with the use of SCP at both 18 degrees C and 25 degrees C. Procedures performed at 25 degrees C had significantly shorter operating times while preserving end organs.
European journal of cardio-thoracic surgery: official journal of the European Association for Cardio-thoracic Surgery 05/2009; 36(3):524-31. · 2.40 Impact Factor
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ABSTRACT: Fibronectin (FN), a key component of the extracellular matrix, is upregulated in cardiac tissue during myocardial hypertrophy and failure. Here we show that interleukin (IL)-18, a proinflammatory and pro-hypertrophic cytokine, stimulates FN expression in adult human cardiac fibroblasts (HCF), an effect blocked by either the IL-18BP:Fc chimera or IL-18 neutralizing antibodies. IL-18 stimulated FN promoter-reporter activity in HCF, a response attenuated by mutation of an NF-kappaB binding site in the FN promoter. Overexpression of p65 stimulated FN transcription. IL-18 stimulated in vitro (p65, p50) and in vivo NF-kappaB DNA binding activities, and induced kappaB-dependent reporter gene activity. These effects were inhibited by adenoviral transduction of dominant negative (dn) p65 (Ad.dnp65) and dnIKK2 (Ad.dnIKK2). Investigation of signaling intermediates revealed that IL-18 stimulated PI3 kinase activity (blocked by wortmannin, LY294002, or Ad.dnPI3Kp85), and Akt phosphorylation and kinase activity (blocked by SH-5 or Ad.dnAkt). Furthermore, targeting MyD88, IRAK1, TRAF6, PI3K, Akt, and NF-kappaB by RNA interference or dn expression vectors blunted IL-18 mediated FN transcription and mRNA expression. Conversely, FN stimulated IL-18 expression. These data provide the first evidence that IL-18 and FN stimulate each other's expression in HCF, and suggest a role for IL-18, FN and their crosstalk in myocardial hypertrophy and remodeling, disease states characterized by enhanced FN expression and fibrosis.
Journal of Cellular Physiology 07/2008; 215(3):697-707. · 3.87 Impact Factor
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ABSTRACT: Applications to cardiothoracic surgery training programs have steadily declined. The application cycle for 2004 marked the first time the number of applicants was lower than the positions offered. This survey reflects on this trend in applications and the perspectives of current and graduating residents.
In June 2004, the Thoracic Surgery Residents Association, in conjunction with CTSNet, surveyed residents completing accredited cardiothoracic training or additional subspecialization. Participation was anonymous and voluntary.
Of the 140 graduates, 88 responded. Most were male (92%) and married (72%). Their average age was 35.7 years, and 56% had children. The mean educational debt was less than $50,000. Of the 88 respondents, 69 (78%) had plans to seek jobs whereas 15 (17%) sought additional training. Among job-seeking residents, 12% received no offers. Also, 59% of graduates initially sought a position in academics and 41% in private practice. Nearly one quarter (23%) reported that they would not choose a career in cardiothoracic surgery again, and more than half (52%) would not strongly recommend cardiothoracic surgery to potential trainees. Almost all (90%) of the graduates believed that the number of cardiothoracic training spots should be decreased, and 92% believed that a reduction in training positions should be achieved by closing marginal training programs. Additionally, 91% believed reimbursement for cardiothoracic surgery was inadequate, and 88% thought low reimbursement resulted in restricted patient access and decreased quality of care.
Cardiothoracic training programs are having difficulty in both applicant recruitment and in suitable job placement. This frustration in the job search coupled with reimbursement and lifestyle issues most likely contributes to the general dissatisfaction conveyed by the graduates. If these trends continue, the field will be faced with a crisis of unfilled residency programs and unemployed graduates.
The Annals of thoracic surgery 10/2006; 82(3):1160-5. · 3.74 Impact Factor
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Luis F Angel,
Deborah J Levine,
Marcos I Restrepo,
Scott Johnson,
Edward Sako,
Andrea Carpenter, John Calhoon,
John E Cornell,
Sandra G Adams,
Gary B Chisholm,
Joe Nespral,
Ann Roberson,
Stephanie M Levine
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ABSTRACT: One of the limitations associated with lung transplantation is the lack of available organs.
To determine whether a lung donor-management protocol could increase the number of lungs for transplantation without affecting the survival rates of the recipients.
We implemented the San Antonio Lung Transplant protocol for managing potential lung donors according to modifications of standard criteria for donor selection and strategies for donor management. We then compared information gathered during a 4-yr period, during which the protocol was used with information gathered during a 4-yr period before protocol implementation. Primary outcome measures were the procurement rate of lungs and the 30-d and 1-yr survival rates of recipients.
We reviewed data from 711 potential lung donors. The mean rate of lung procurement was significantly higher (p < 0.0001) during the protocol period (25.5%) than during the pre-protocol period (11.5%), with an estimated risk ratio of 2.2 in favor of the protocol period. More patients received transplants during the protocol period (n = 121) than during the pre-protocol period (n = 53; p < 0.0001). Of 98 actual lung donors during the protocol period, 53 (54%) had initially been considered poor donors; these donors provided 64 (53%) of the 121 lung transplants. The type of donor was not associated with significant differences in recipients' 30-d and 1-yr survival rates or any clinical measures of adequate graft function.
The protocol was associated with a significant increase in the number of lung donors and transplant procedures without compromising pulmonary function, length of stay, or survival of the recipients.
American Journal of Respiratory and Critical Care Medicine 10/2006; 174(6):710-6. · 11.08 Impact Factor
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The Annals of thoracic surgery 07/2005; 79(6):1878. · 3.74 Impact Factor
