Sochet Anthony A, Nyhan Aoibhinn, Spaeder Michael C, Cartron Alexander M, Song Xiaoyan, Klugman Darren, Brown Anna T
1Division of Critical Care Medicine, Department of Pediatrics, Johns Hopkins All Children's Hospital, St. Petersburg, FL. 2The George Washington University, School of Medicine and Health Sciences, Washington, D.C. 3Division of Pediatric Critical Care, Department of Pediatrics, University of Virginia School of Medicine, Charlottesville, VA. 4Division of Critical Care Medicine, Department of Pediatrics, Children's National Health System, Washington, DC. 5Division of Infectious Disease, Department of Pediatrics, Children's National Health System, Washington, DC. 6Division of Cardiology, Department of Pediatrics, Children's National Health System, Washington, DC. 7Division of Anesthesiology, Department of Pediatrics, Children's National Health System, Washington, DC.
Pediatr Crit Care Med. 2017 Aug;18(8):770-778. doi: 10.1097/PCC.0000000000001193.
To determine the impact of cumulative, postoperative thoracostomy output, amount of bolus IV fluids and peak fluid overload on the incidence and odds of developing a deep surgical site infection following pediatric cardiothoracic surgery.
A single-center, nested, retrospective, matched case-control study.
A 26-bed cardiac ICU in a 303-bed tertiary care pediatric hospital.
Cases with deep surgical site infection following cardiothoracic surgery were identified retrospectively from January 2010 through December 2013 and individually matched to controls at a ratio of 1:2 by age, gender, Risk Adjustment for Congenital Heart Surgery score, Society of Thoracic Surgeons-European Association for Cardiothoracic Surgery category, primary cardiac diagnosis, and procedure.
None.
Twelve cases with deep surgical site infection were identified and matched to 24 controls without detectable differences in perioperative clinical characteristics. Deep surgical site infection cases had larger thoracostomy output and bolus IV fluid volumes at 6, 24, and 48 hours postoperatively compared with controls. For every 1 mL/kg of thoracostomy output, the odds of developing a deep surgical site infection increase by 13%. By receiver operative characteristic curve analysis, a cutoff of 49 mL/kg of thoracostomy output at 48 hours best discriminates the development of deep surgical site infection (sensitivity 83%, specificity 83%). Peak fluid overload was greater in cases than matched controls (12.5% vs 6%; p < 0.01). On receiver operative characteristic curve analysis, a threshold value of 10% peak fluid overload was observed to identify deep surgical site infection (sensitivity 67%, specificity 79%). Conditional logistic regression of peak fluid overload greater than 10% on the development of deep surgical site infection yielded an odds ratio of 9.4 (95% CI, 2-46.2).
Increased postoperative peak fluid overload and cumulative thoracostomy output were associated with deep surgical site infection after pediatric cardiothoracic surgery. We suspect the observed increased thoracostomy output, fluid overload, and IV fluid boluses may have altered antimicrobial prophylaxis. Although analysis of additional pharmacokinetic data is warranted, providers may consider modification of antimicrobial prophylaxis dosing or alterations in fluid management and diuresis in response to assessment of peak fluid overload and fluid volume shifts in the immediate postoperative period.
确定小儿心胸外科手术后胸腔闭式引流累计引流量、静脉推注液体量及液体超负荷峰值对深部手术部位感染发生率及发生几率的影响。
一项单中心、嵌套式、回顾性、配对病例对照研究。
一家拥有303张床位的三级儿科医院中一个有26张床位的心脏重症监护病房。
回顾性确定2010年1月至2013年12月心胸外科手术后发生深部手术部位感染的病例，并按年龄、性别、先天性心脏病手术风险调整评分、胸外科医师协会-欧洲心胸外科协会分类、原发性心脏诊断和手术，以1:2的比例与对照个体匹配。
无。
确定12例深部手术部位感染病例，并与24例对照匹配，围手术期临床特征无明显差异。与对照组相比，深部手术部位感染病例术后6、24和48小时胸腔闭式引流量和静脉推注液体量更大。胸腔闭式引流量每增加1 mL/kg，发生深部手术部位感染的几率增加13%。通过受试者工作特征曲线分析，术后48小时胸腔闭式引流量截断值为49 mL/kg时，对深部手术部位感染的发生具有最佳鉴别能力（敏感性83%，特异性83%）。病例组的液体超负荷峰值高于匹配的对照组（12.5%对6%；p<0.01）。通过受试者工作特征曲线分析，观察到液体超负荷峰值阈值为10%时可识别深部手术部位感染（敏感性67%，特异性79%）。深部手术部位感染发生时液体超负荷峰值大于10%的条件逻辑回归分析得出比值比为9.4（95%CI，2-46.2）。
小儿心胸外科手术后液体超负荷峰值增加和胸腔闭式引流累计引流量与深部手术部位感染有关。我们怀疑观察到的胸腔闭式引流量增加、液体超负荷和静脉推注液体可能改变了抗菌药物预防效果。尽管有必要分析更多的药代动力学数据，但临床医生可考虑根据术后早期液体超负荷峰值和液体量变化评估结果，调整抗菌药物预防剂量或改变液体管理及利尿措施。
