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      Outcomes of Delayed Sternal Closure in Pediatric Heart Surgery: Single-Center Experience

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          Abstract

          Background

          Delayed sternal closure (DSC) after cardiac surgery is a therapeutic option in the treatment of the severely impaired heart in pediatric cardiac surgery.

          Methods

          A single-center retrospective review of all bypass surgeries performed over a 10-year period (2003–2012).

          Results

          Of a total of 2325 patients registered in our database, the DSC group included 259 cases (11%), and the remaining 2066 cases (89%) constituted the control group (PSC). RACHS-1 risk was higher for the DSC group (74% had a score of 3 or 4) than for the PSC group (82% had a score of 2 or 3). The most frequent diagnosis for the DSC group was transposition of the great arteries (28%). We found out that hemodynamic instability was the main indication observed in patients aged ≤ 8 years (63%), while bleeding was the principal indication for patients aged ≥ 8 years (94%) ( p ≤ 0.001). The average time between surgery and sternal closure was 2.3 ± 1.4 days. Overall mortality rates were higher for patients of the DSC group (22%) than for the PSC group (8.7%) (OR: 0.4 (95% CI: 0.4 to 0.5), p < 0.05). There were six patients with DSC who developed mediastinitis (2.3%). The risk of mediastinitis was significantly higher when DSC was performed 4 days after the primary surgery.

          Conclusions

          DSC is an important management strategy for congenital cardiac surgery in infants and children. The prolonged sternal closure time is associated with an increased rate of postoperative mediastinitis.

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          Most cited references26

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          The value of the chloride: sodium ratio in differentiating the aetiology of metabolic acidosis.

          D. Taylor, A Durward, I Murdoch … (2001)
          Stewart's physicochemical approach to acid-base balance defines the aetiology of a metabolic acidosis by quantifying anions of tissue acids (TA), which consist of unmeasured anions (UMA) and/or lactate. We hypothesised that an increase in TA during metabolic acidosis would lead to a compensatory fall in the plasma chloride (Cl) relative to sodium (Cl:Na ratio) in order to preserve electro-neutrality. Thus, the Cl:Na ratio could be used as a simple alternative to the anion gap in identifying raised TA. Two hundred and eighty two consecutive patients who were admitted to our Paediatric Intensive Care were enrolled in the study. We obtained 540 samples (admission n = 282, 24 h n = 258) for analysis of blood chemistry, lactate and quantification of TA and UMA. Samples were subgrouped into those with metabolic acidosis (standard bicarbonate 3 mEq/l). Metabolic acidosis occurred in 46% of samples, of which 52.3% (120/230) had increased UMA. The dominant component of TA was UMA rather than lactate, and these two components did not always rise in tandem. Our hypothesis of relative hypochloraemia was supported by a lower Cl:Na ratio (P 0.79) excluded TA (PPV 81%, LR 4.5). Base deficit (BD) and lactate performed poorly. In metabolic acidosis due to TA, plasma Cl concentration decreases relative to sodium. The Cl:Na ratio is a simple alternative to the AG for detecting TA in this setting.
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            Bloodstream infections after median sternotomy at a children's hospital.

            Karen Bell, Warren Bilker, Sarah Tabbutt … (2007)
            Postoperative bloodstream infections are a major source of morbidity and increased health care costs. In adults, mediastinitis has been described as a risk factor for bloodstream infections. The objectives of this retrospective cohort study were to determine the incidence and to identify risk factors for postoperative bloodstream infections among children after median sternotomy in an urban tertiary care children's hospital. For this study, 192 patients were randomly selected from among all patients undergoing median sternotomy between January 1, 1995, and December 31, 2003. Ninety-eight (51%) of the 192 eligible patients were male. The median patient age was 5.4 months (interquartile range: 1 day-41.5 years). Bloodstream infections occurred in 12 (6.3%; 95% confidence interval [CI]: 3.3%-10.7%) patients within the first 30 days after median sternotomy. Bloodstream infections developed a median of 11 days (range: 3-29 days) after median sternotomy. Gram-negative bacilli caused 6 (50%) of the 12 bloodstream infections. Specific causes of bloodstream infections included Pseudomonas aeruginosa (n = 3), coagulase-negative staphylococci (n = 3), Pseudomonas fluorescens-putida (n = 2), Staphylococcus aureus (n = 2), Serratia marcescens (n = 1), and Candida albicans (n = 1). Multivariable analysis revealed that the development of mediastinitis (odds ratio [OR], 28.16; 95% CI, 3.37-235.22) and the requirement for postoperative extracorporeal membrane oxygenation (OR, 12.52; 95% CI, 2.99-52.41) were associated with bloodstream infections after median sternotomy. Postoperative bloodstream infections occurred in 6.3% of children undergoing median sternotomy. Postoperative mediastinitis and the requirement for extracorporeal membrane oxygenation were risk factors for bloodstream infections after median sternotomy. These findings warrant exploration in a larger, multicenter study.
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              Re-exploration for hemorrhage following open heart surgery differentiation on the causes of bleeding and the impact on patient outcomes.

              Andrew Gregory, Kathryn Hall, J Sines … (2001)
              To differentiate surgical bleeding requiring re-exploration from postoperative coagulopathy and determine the differences in patient outcomes. This was a retrospective chart review of 2,263 adult patients undergoing elective and emergency open heart procedures encompassing coronary artery bypass, valvular, and a combined procedure to determine the impact of source of bleeding leading to re-exploration. Eighty-two patients (3.6%) required re-exploration. Sixty-six percent had surgical bleeding; the remaining 34% were coagulopathic. Postoperative coagulopathy was associated with preoperative heparin use (37% vs. 19.9% for controls p<0.05). Re-operative procedures combined bypass/ valve (p<0.001) and prolonged cardiopulmonary bypass and aortic cross-clamp times (p<0.05) were more prevalent in the coagulopathy group. Postoperative inotrope use was increased in patients who were re-explored (p<0.001), as were cardiac, pulmonary, renal and abdominal complications (p<0.001), and in all cases those patients with medically related bleeding had worse acute outcomes than the group with surgical causes for re-exploration. The hospital stay was prolonged for both patients with surgical bleeding (23.5 days) and patients with coagulopathy (27.1 days) compared to patients not undergoing re-exploration for bleeding (12.0 days, p<0.001). Survival was 91.3% for patients with surgical bleeding, 87.5% for patients with coagulopathy, and 98.0% for all others (p<0.01). Severe postoperative hemorrhage is associated with significant morbidity and increased mortality. Postoperative hospital stay, morbidity, and mortality were significantly worse in patients suffering from coagulopathy when compared to those patients with hemorrhage from surgical causes.
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                Author and article information

                Contributors
                Juan Calderón-Colmenero:
                ORCID: http://orcid.org/0000-0003-1281-2615
                Journal
                Journal ID (nlm-ta): Biomed Res Int
                Journal ID (iso-abbrev): Biomed Res Int
                Journal ID (publisher-id): BMRI
                Title: BioMed Research International
                Publisher: Hindawi
                ISSN (Print): 2314-6133
                ISSN (Electronic): 2314-6141
                Publication date Collection: 2018
                Publication date (Electronic): 19 April 2018
                Volume: 2018
                Electronic Location Identifier: 3742362
                Affiliations
                1Department of Paediatric Cardiology, Instituto Nacional de Cardiología Ignacio Chávez, Mexico City, Mexico
                2Department of Pediatric Cardiac and Congenital Heart Disease Surgery, Instituto Nacional de Cardiología Ignacio Chávez, Mexico City, Mexico
                Author notes

                Academic Editor: Francesco Onorati

                Author information
                http://orcid.org/0000-0003-1281-2615
                http://orcid.org/0000-0002-9989-1899
                Article
                DOI: 10.1155/2018/3742362
                PMC ID: 5933025
                SO-VID: 7d530368-5594-4ae4-bb6f-160e4191695e
                Copyright © Copyright © 2018 Daniel Hurtado-Sierra et al.
                License:

                This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

                History
                Date received : 17 August 2017
                Date accepted : 14 March 2018
                Categories
                Subject: Clinical Study

                Data availability:

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