DOI 10.1007/s00246-013-0830-1 ORIGINAL ARTICLE Ventilator-Associated Pneumonia in Children After Cardiac Surgery Ghassan A. Shaath Abdulraouf Jijeh Fawaz Faruqui Lily Bullard Akhter Mehmood Mohamed S. Kabbani Received: 15 Aril 2013 / Acceted: 26 October 2013 Ó Sringer Science+Business Media New York 2013 Abstract Ventilator-associated neumonia () is a nosocomially acquired infection that has a significant burden on intensive care units (ICUs). We investigated the incidence of in children after cardiac surgery and its imact on morbidity and mortality. A rosective cross-sectional review was erformed in the ostoerative cardiac in ediatric cardiac intensive care unit (PCICU) from March 2010 until the end of Setember 2010. The were divided into two grous: the grou and the non- grou, Demograhic data and erioerative risk variables were collected for all. One hundred thirty-seven were recruited, 65 (48 %) female and 72 (52 %) male. occurred in 9 (6.6 %). Average body weights in the and non- grous were G. A. Shaath (&) A. Jijeh F. Faruqui L. Bullard A. Mehmood M. S. Kabbani Pediatric Cardiac Intensive Care Unit, King Abdulaziz Cardiac Center, King Abdulaziz Medical City, National Guard Health Affairs, Khurais Road, Mail code 1413, PO Box 22490, Riyadh 11426, Saudi Arabia e-mail: shaathg@gmail.com; shaathg@ngha.med.sa A. Jijeh e-mail: ajijeh@yahoo.com F. Faruqui e-mail: f_faruqi@hotmail.com L. Bullard e-mail: bullardl@ngha.med.sa A. Mehmood e-mail: mehmooda@ngha.med.sa M. S. Kabbani e-mail: kabbanim@ngha.med.sa M. S. Kabbani King Saud University for Health Sciences (KSU-HS), National Guard Health Affairs, Riyadh, Saudi Arabia 5.9 ± 1.24 and 7.3 ± 0.52 kg, resectively. In our PCICU, the mechanical ventilation (MV) use ratio was 26 % with a -density rate of 29/1000 ventilator days. Univariate analyses showed that the risk variables to develo are as follows: rolonged cardioulmonary byass (CPB) time, use of total arenteral nutrition (TPN), and rolonged ICU stay ( \ 0.002 for all). Thirty-three ercent of had Gram-negative bacilli (GNB). Patients require more MV hours, longer stay, and more inhaled nitric oxide. Mortality in the grou was 11 % and in the non- grou was 0.7 % ( = 0.28). incidence is high in children after cardiac surgery mainly by GNB. increases with longer CPB time, administration of TPN, and longer PCICU stay. increases morbidity in ostoerative cardiac. Keywords Pediatric cardiac surgery Hositalacquired infection Introduction Hosital-acquired infection (HAI) is considered one of the most imortant bench-marking indexes for any hosital. It occurs in 12 % of [2], which hinders outcome and influences the atient morbidity and ossible mortality [1, 2, 10]. Ventilator-associated neumonia () is the second most common form of HAI [1, 9, 12, 20] after blood stream infection (BSI). is defined as a nosocomially acquired neumonia in the mechanically ventilated [48 h er Centers for Disease Control (CDC) criteria for the diagnosis of clinically defined neumonia [8, 15, 20]. has a significant imact on atient morbidity and mortality. in the ediatric intensive care unit (PICU) increases mechanical ventilation
(MV) hours by 10 to 20 times [1, 5, 10, 16, 18, 19], which subsequently increases the length of stay in the PICU [1, 2, 7, 19]. Some reorts have shown a significant increase in mortality in who had [19]. It was reorted to be as high as 20 % in some studies [1, 5]. In ediatric, the incidence rate in the PICU setting was found to be in a range between 3 and 10 % of the mechanically ventilated children [1, 5, 18]. From United States National Healthcare Safety Network data in general PICUs, was reorted across many PICUs as being 1.8 cases/1000 device days (ventilator days). In contrast, the International Nosocomial Infection Control Consortium reorted a much higher rate of 6.5 cases/1000 device days in general PICUs from 36 develoing countries [17]. Both reorts, however, reflect general PICUs. There is aucity of information about after ediatric cardiac surgery. In one study, the investigators documented in ostoerative cardiac children a incidence of 9.6 %, but it was not indexed er device days [6]. Many risk factors contribute to increased rate in the PICU, such as genetic syndromes, transortation [5], reintubation [1, 5], and suine osition in the adult oulation [3]. In children undergoing cardiac surgery, the subject of after surgery has not been well investigated. We erformed this study to investigate the incidence, etiology, risk factors, and outcome of who develoed after ediatric cardiac surgery in our PCICU. Methods A rosective surveillance was erformed for children admitted to the PCICU for cardiac surgery at King Abdulaziz Cardiac Center in King Abdulaziz Medical City, Riyadh, Saudi Arabia. Our institution is a tertiary-care unit receiving with congenital heart disease (CHD) from the entire Arabian Gulf region. Our PCICU has 9 beds dedicated for critical medical and surgical ediatric cardiac. During 2010, we admitted 462, 346 of whom underwent cardiac surgery wherein 84 % of cases were subjected to CPB. The study was aroved by the Institutional Research Committee. All children \14 years who underwent cardiac surgery and were subsequently admitted to the PCICU were included. We collected atient demograhics, which included the following: age, body weight, sex, resence of syndrome, and tye of admission (from community or from other health care facility) (Table 1). Tye of CHD, surgical reair, and surgical risk scoring, as reorted by Jenkins et al. were also recorded [13]. In this study, we considered with surgical risk categories 1 and 2 as the low-risk grou and categories 3 and 4 as the high-risk grou. Other risk factors analyzed, including duration of CPB, cross-clam time, and status of closed or delayed chest closure, were also investigated as ossible risk factors to develo (Table 2). Other variables, Table 1 Demograhics of and Non- grous such as tye of antacids for stress ulcer rohylaxis, evidence of BSI, and duration of antibiotics, were also reviewed (Table 3). Patients were divided in two grous: the grou and the non- grou. was defined according to the CDC definitions guidelines. No secific bundle was alied in either grou of during the study eriod. We calculated the ventilation days to evaluate PCICU -density rate/ 1000 ventilator days, and MV use ratio according to the atient s length of stay in the PCICU was also assessed [8, 15]. Results Non- Total no. 128 9 Male/female 66/62 6/3 Average age 19.7 ± 2.5 9.8 ± 4 0.3 (months) ± SEM Average weight 7.3 ± 0.5 5.9 ± 1.2 0.49 (kg) ± SEM Presence of a syndrome 18 % 44 % 0.053 Table 2 Intraoerative data of in the and non- grous Non- Oen heart surgery 84 % 89 % 0.68 Oen sternum 4 % 11 % 0.85 CPB time (min) 100 ± 6.5 205 ± 49 0.0002 Cross-clam time (min) 62 ± 5 84 ± 16 0.28 Presence of reoerative 2% 0% 0.7 Average surgical-risk 2.3 ± 0.1 2.4 ± 0.4 0.65 category Low surgical-risk category 55 % 44 % 0.29 1&2 High surgical risk category 3&4 45 % 56 % 0.42 One hundred thirty seven were recruited during the study eriod; there were 65 (48 %) females and 72 (52 %) males. Average body weight in the and non- grous was 5.9 ± 1.24 and 7.3 ± 0.52 kg, resectively (Table 1). was diagnosed in 9 (6.6 %) at an average age of 9.8 ± 4 months. The cardiac anomalies in cases included two cases with truncus arteriosus, two with ventricular setal defect (VSD), one with coarctation of the aorta, one with rimum atrial setal defect, one with transosition of the great arteries, and one arterial tortuosity syndrome with sura aortic stenosis. All cases had a rimary tye of reair.
Table 3 Postoerative variables in and non- All with survived excet one (11 %) atient with truncus arteriosus who develoed ostoerative multile sesis eisodes in addition to and died afterward. We had 306 ventilator days with a -density rate of 29/1000 ventilator days, and MV use was 26 % (Table 2). A review of variables using univariate analysis showed statistically a significant difference in CPB time, TPN use, and rolonged ICU stay. Furthermore, lower body weight, use of muscle relaxants, younger age grou, oen-chest surgery, and BSI showed a trend toward increased rate of, but this did not reach statistical significance. The organisms encountered were GNB in 33 % of the cases. We observed an increase in ventilation hours ( \ 0.0001), longer stay in the PCICU ( \ 0.0027), and more use of inhaled nitric oxide (ino) ( \ 0.0001) in the grou. Desite the obvious difference in mortality between the grou at 11 % and the non- grou at 0.7 %, that difference did not reach statistical significance ( = 0.28) (Table 3). Discussion Non- Average LOS in PCICU (hour) 192 ± 17 400 ± 59 0.0027 Continuous feeding 36 % 44 % 0.91 No. of extubation trials 1.05 ± 0.02 1.4 ± 0.4 0.0001 Use of muscle relaxant 23 % 55 % 0.08 Associated BSI 5 % 11 % 0.48 Previous antibiotic use 14 % 10 % 0.85 Presence of aralyzed 0.07 % 0 % 0.79 diahragm (hour) Need for ino 6 % 55 % 0.0001 Average time of intubation 40 ± 5 247 ± 70 0.0001 (hour) Use of rokinetics 28 % 44 % 0.5 Use of ranitidine 77 % 67 % 0.65 Use of TPN 1.5 % 33 % 0.0001 Presence of chylothorax 1.5 % 0 % 0.7 Need for O 2 on discharge from 41 % 67 % 0.23 PCICU Tracheostomy 2 % 0 % 0.7 Mortality 0.7 % 11 % 0.28 Average length on ventilator (hour) 40 247 0.0001 ventilator-associated neumonia, LOS length of stay, PCICU Pediatric Cardiac Intensive Care Unit, BSI blood stream infection, ino inhaled nitric oxide, TPN total arenteral nutrition, O 2 oxygen CPB and cardiac surgery induces many changes in the body that may include hemodynamic instability, ulmonary edema, as well as a surge of cytotoxins with resultant caillary leak syndrome, which varies from mild to severe. These changes affects body defense and increases the risk of in children. The incidence of in children after heart surgery has been rarely reorted in the medical literatures because the majority of the ublished data described density rate and incidence in the general PICU oulation. In one study that analyzed in selected children after heart surgery, the investigators reorted an incidence of 9.6 % in a grou of similar to our atient oulation [6]. Our incidence was slightly lower (7 %) comared with the former study. However, when we comared rate between general PICU and selected ostoerative cardiac children in a PCICU setting, we observed a much higher density rate in the PCICU, which was close to 10 times greater than what has been reorted in general PICUs [1, 15]. The average -density rate was reorted to be 3/1000 ventilator days from general PICU reorts [1, 2, 17]. The increase in incidence rate in children after heart surgery may be due to multile factors that include the following: young age, lower body weight, heart failure, failure to thrive, and oor general condition. Furthermore, who develoed were noted to be younger because[50 % of them are\6 months of age, and their body weight was\6 kg, reflecting oor general nutritional status with ossible increase vulnerability to infection. In addition, our cardiac required more invasive devices and longer invasive monitoring. An additional factor that also may lay a role and may contribute to increase risk of resiratory infection in cardiac children is the effects of heart disease on the lungs. Increase ulmonary blood flow, lung lethora, significant leftto-right shunt, or ulmonary venous obstruction are common erioerative roblems that can affect lung vasculature and ulmonary blood flow, which may also increase the risk of resiratory infection after surgery. Intrinsic factors related to our PCICU in articular cannot be ruled out because many of our PCICU cases were referred to us late for logistic reasons and resented with severe heart failure, oor nutritional status, or other subotimal conditions that could have otentially increased their risk of nosocomial infection and after surgery. We found a significant correlation between CPB time and. Our results linking and CPB duration were in concordance with a revious reort by Medrano et al. [14]in Sain about resiratory infection develoment in hositalized cardiac children. CPB is known to induce inflammatory reactions and alter body immunity with an increased risk of infection. In contrast, our results of there being no link between surgical-comlexity risk categories and incidence of were artially in discordance with what Fischer et al. [6] reorted in their review.
Although we did not find a statistically significant difference in rate between the low- and high-risk surgical-comlexity grous, we noted a trend toward in high-risk (56 %) comared with low-risk cases (45 %). This difference may become significant with a larger samle size. In addition, TPN was noticed to be associated with, which concurs with Singh-Naz et al. [18]. GNB were frequently encountered organisms in our, which has also been reorted by other investigators [1, 2, 19]. We observed tendency toward increased mortality in the grou, which might need a larger samle to be statistically significant. Other reviews described similar findings with an increase trend toward mortality with [19]. Some variables have been described to be correlated with, such as delayed sternal closure [21], BSI [11], chylothorax [4], and diahragm aralysis. In our analysis, those variable were resent more frequently in ; however, statistical analysis failed to show a significant difference ossibly due to small samle size. Our study has limitations, such as small samle size, limited duration, difficulty of determining the exact timing to develo, and single-center exerience. Nevertheless, the results highlights the high incidence of in children after cardiac surgery with the emergence of gramnegative organisms as one of the frequent causes of. Conclusion incidence in children after cardiac surgery is significantly higher than the exected in PICU, esecially in the who require longer CPB time, TPN, or longer PCICU stay. Gram-negative organisms are frequently the etiology of. has a significant imact on ediatric morbidity and mortality after cardiac surgery. Introducing a bundle in the PCICU may decrease the rate. Further study to evaluate the benefit and the imact of such revention in children after cardiac surgery is required. Acknowledgment We acknowledge all PCICU nurses and resiratory theraists for their hel in this study. References 1. Almuneef M, Memish ZA, Balkhy HH, Alalem H, Abutaleb A (2004) Ventilator-associated neumonia in a ediatric intensive care unit in Saudi Arabia: a 30-month rosective surveillance. Infect Control Hos Eidemiol 25(9):753 758 2. Bigham MT, Amato R, Bondurrant P, Fridriksson J, Krawczeski CD, Raake J, Ryckman S, Schwartz S, Shaw J, Wells D, Brilli RJ (2009) Ventilator-associated neumonia in the ediatric intensive care unit: characterizing the roblem and imlementing a sustainable solution. J Pediatr 154(4):582 587.e2 3. Black SR, Lo E, Madriaga M, Zimmerman M, Segreti J (2002) Nosocomial neumonia in the PICU. In: 40th interscience conference on antimicrobial agents chermotheraeutics, abstract K-452 4. Bond SJ, Guzzetta PC, Snyder ML, Randolh JG (1993) Management of ediatric ostoerative chylothorax. Ann Thorac Surg 56(3):469 472 discussion 472 473 5. Elward AM, Warren DK, Fraser VJ (2002) Ventilator-associated neumonia in ediatric intensive care unit : Risk factors and outcomes. Pediatrics 109(5):758 764 6. Fischer JE, Allen P, Fanconi S (2000) Delay of extubation in neonates and children after cardiac surgery: imact of ventilatorassociated neumonia. Intensive Care Med 26(7):942 949 7. Foglia E, Hollenbeak C, Fraser V, Elward A (2006) Costs associated with nosocomial bloodstream infections and ventilatorassociated neumonia in ediatric intensive care unit. In: abstracts of the 16th annual scientific meeting of the Society for Healthcare Eidemiology of America, Chicago, 109 8. Garner JS, Jarvis WR, Emori TG, Horan TC, Hughes JM (1988) CDC definitions for nosocomial infections. Am J Infect Control 16(3):128 140 9. Gaynes RP, Edwards JR, Jarvis WR, Culver DH, Tolson JS, Martone WJ (1996) Nosocomial infections among neonates in high-risk nurseries in the United States. National Nosocomial Infections Surveillance System. Pediatrics 98(3 Pt 1): 357 361 10. Grohskof LA, Sinkowitz-Cochran RL, Garrett DO, Sohn AH, Levine GL, Siegel JD, Siegel JD, Stover BH, Jarvis WR, Pediatric Prevention Network (2002) A national oint-revalence survey of ediatric intensive care unit-acquired infections in the United States. J Pediatr 140(4):432 438 11. Hauser GJ, Chan MM, Casey WF, Midgley FM, Holbrook PR (1991) Immune dysfunction in children after corrective surgery for congenital heart disease. Crit Care Med 19(7):874 881 12. Jarvis WR, Edwards JR, Culver DH, Hughes JM, Horan T, Emori TG, Banerjee S, Tolson J, Henderson T, Gaynes RP et al (1991) Nosocomial infection rates in adult and ediatric intensive care units in the United States. National Nosocomial Infections Surveillance System. Am J Med 91(3B):185S 191S 13. Jenkins KJ, Newburger JW, Lock JE, Davis RB, Coffman GA, Iezzoni LI (1995) In-hosital mortality for surgical reair of congenital heart defects: reliminary observations of variation by hosital caseload. Pediatrics 95(3):323 330 14. Medrano C, Garcia-Guereta L, Grueso J, Insa B, Insa B, Ballesteros F, Casaldaliga J (2007) Resiratory infection in congenital cardiac disease. Hositalizations in young children in Sain during 2004 and 2005: the CIVIC Eidemiologic Study. Cardiol Young 17(4):360 371 15. National Nosocomial Infections Surveillance System (2004) National Nosocomial Infections Surveillance (NNIS) System Reort, data summary from January 1992 through June 2004, issued October 2004. Am J Infect Control 32(8):470 485 16. Richards MJ, Edwards JR, Culver DH, Gaynes RP (1999) Nosocomial infections in ediatric intensive care units in the United States. National Nosocomial Infections Surveillance System. Pediatrics 103(4):e39 17. Rosenthal VD, Bijie H, Maki DG, Mehta Y, Aisarnthanarak A, Medeiros EA et al (2012) International Nosocomial Infection Control Consortium (INICC) reort, data summary of 36 countries, for 2004 2009. Am J Infect Control 40(5):396 407 18. Singh-Naz N, Srague BM, Patel KM, Pollack MM (1996) Risk factors for nosocomial infection in critically ill children: a rosective cohort study. Crit Care Med 24(5):875 878 19. Srinivasan R, Asselin J, Gildengorin G, Wiener-Kronish J, Flori HR (2009) A rosective study of ventilator-associated neumonia in children. Pediatrics (4):1108 1115
20. Tablan OC, Anderson LJ, Besser R, Bridges C, Hajjeh R, CDC, Healthcare Infection Control Practices Advisory Committee (2004) Guidelines for reventing health-care associated neumonia, 2003: recommendations of CDC and the Healthcare Infection Control Practices Advisory Committee. MMWR Recomm Re 53(RR-3):1 36 21. Ziemer G, Karck M, Müller H, Luhmer I (1992) Staged chest closure in ediatric cardiac surgery reventing tyical and atyical cardiac tamonade. Eur J Cardiothorac Surg 6(2):91 95