Urinary tract infection in children after cardiac surgery: Incidence, causes, risk factors and outcomes in a single-center study

Nosocomial urinary tract infection [UTI] increases hospitalization, cost and morbidity. In this cohort study, we aimed to determine the incidence, risk factors, etiology and outcomes of UTIs in post-operative cardiac children. To this end, we studied all post-operative patients admitted to the Pediatric Cardiac Intensive Care Unit [PCICU] in 2012, and we divided the patients into two groups: the UTI [UTI group] and the non-UTI [control group]. We compared both groups for multiple peri-operative risk factors. We included 413 children in this study. Of these, 29 [7%] had UTIs after cardiac surgery [UTI group], and 384 [93%] were free from UTIs [control group]. All UTI cases were catheter-associated UTIs [CAUTIs]. A total of 1578 urinary catheter days were assessed in this study, with a CAUTI density rate of 18 per 1000 catheter days. Multivariate logistic regression analysis demonstrated the following risk factors for CAUTI development: duration of urinary catheter placement [p < 0.001], presence of congenital abnormalities of kidney and urinary tract [CAKUT] [p < 0.0041] and the presence of certain syndromes [Down, William, and Noonan] [p < 0.02]. Gram-negative bacteria accounted for 63% of the CAUTI. The main causes of CAUTI were Klebsiella [27%], Candida [24%] and Escherichia coli [21%]. Resistant organisms caused 34% of CAUTI. Two patients [7%] died in the UTI group compared with the one patient [0.3%] who died in the control group [p < 0.05]. Based on these findings, we concluded that an increased duration of the urinary catheter, the presence of CAKUT, and the presence of syndromes comprised the main risk factors for CAUTI. Gram-negative organisms were the main causes for CAUTI, and one-third of them found to be resistant in this single-center study

Predictors for the outcome of aortic regurgitation after cardiac surgery in patients with ventricular septal defect and aortic cusp prolapse in Saudi patients

Background and Aim: Aortic valve [AV] prolapse and subsequent aortic regurgitation [AR] are two complications of ventricular septal defects [VSD] that are located close to or in direct contact with the AV. This finding is one of the indications for surgical VSD closure even in the absence of symptoms to protect the AV integrity. The goal of our study was to assess the outcome and to identify the predictors for improvement or progression of AR after surgical repair

Materials and Methods: A retrospective study of all children with VSD and AV prolapse who underwent cardiac surgery at King Abdulaziz Cardiac Centre in Riyadh between July 1999 and August 2013

Results: A total of 41 consecutive patients, operated for VSD with prolapsed AV, with or without AR, were reviewed. The incidence of AV prolapse in the study population was 6.8% out of 655 patients with VSD. Thirty six [88%] patients had a perimembranous VSD, and four had doubly committed VSD. Only one patient had an outlet muscular VSD. Right coronary cusp prolapse was found in 38 [92.7%] patients. Preoperative AR was absent in five patients, mild or less in 25 patients, moderate in seven, and severe in four patients. Twenty six patients showed improvement in the degree of AR after surgery [Group A], 14 patients showed no change in the degree of AR [Group B] while only one patient showed the progression of his AR after surgery. Those with absent AR before surgery remained with no AR after surgery. Improvement was found more in those with mild degree of AR preoperatively compared to those with moderate and severe AR. Female gender also showed a tendency to improve more as compared to male

Conclusion: Early surgical closure is advisable for patients with VSD and associated AV prolapse to achieve a better outcome after repair and to prevent progression of AR in future

Impact of chylothorax on the early post operative outcome after pediatric cardiovascular surgery

Chylothorax is the accumulation of chyle in the pleural cavity, which usually develops after disruption of the thoracic duct along its intra-thoracic route. In the majority of cases, this rupture is secondary to trauma [including cardio thoracic surgeries]. Chylothorax is a potentially serious complication after cardiovascular surgeries that require early diagnosis and adequate management. This study aims to determine the risk factors and the impact of chylothorax on the early postoperative course after pediatric cardiac surgery. A retrospective study of all cases complicated with chylothorax after pediatric cardiac surgery was conducted at King Abdulaziz Cardiac Center between January 2007 and December 2009. There were 1135 cases operated on during the study period. Of these, 57 cases [5%] were complicated by chylothorax in the postoperative period. Thirty patients [54%] were males, while 27 [47%] were females. Ages ranged from 4 to 2759 days. The most common surgeries complicated by chylothorax were the single ventricle repair surgeries [15 cases, 27%]; arch repairs [10 cases, 18%]; ventricular septal defect repairs [10 cases, 18%]; atrioventricular septal defect repairs [7 cases, 12%]; arterial switch repair [6 cases, 11%], and others [8 cases, 14%]. The intensive care unit [ICU] and the length of hospital stays were significantly longer in the chylothorax group. Additionally, some early postoperative parameters such as incidence of sepsis, ventilation time, and inotropes duration and number were higher in the chylothorax group. Chylothorax after pediatric cardiac surgery is not a rare complication. It occurs more commonly with single ventricle repair and aortic arch repair surgeries, and has a significant impact on the postoperative course and post operative morbidity

Ultrasound guided vascular access in pediatric cardiac critical care

Safely obtaining vascular access in the pediatric population is challenging. This report highlights our real-world experience in developing a safer approach to obtaining vascular access using ultrasound guidance in children and infants with congenital heart disease. As part of a quality initiative, we prospectively monitored outcomes of all vascular access attempts guided by ultrasound from January 2010 to September 2010. Variables monitored included age, weight, the time from first needle puncture to wire insertion, site of insertion, number of attempts, type of line, and complications. There were 77 attempts [15 arterial and 62 venous] to obtain vascular access in 43 patients. The mean age was 15 months [6 days-11 years; median 2.5 months]. The mean weight was 7.2 kg [2-46 kg, median 3.8]. Success rates were 93% and 95% for arterial and venous cannulation, respectively. Mean time from first needle puncture to wire insertion was 3.9 min [0.5-15 min, median 2 min]. Fifty-five [75%] central line cannulations were successful from the first puncture; 17[23%] were successful from the second puncture; and one case [2%] required three punctures. Thirty patients [45%] weighed less than 3.5 kg. This lower body weight did not affect success rate, which was unexpectedly high [96.6%]. There were no associated complications. Ultrasound guided vascular cannulation in critically ill pediatric patients is safe, effective and efficient. This approach had a high success rate, and was associated with zero complications in our setting

Early outcome of tetralogy of fallot repair in the current era of management

Traditional use of trans-annular patch [TAP] to release right ventricular outflow tract [RVOT] obstruction during tetralogy of Fallot [TOF] repair may lead to a harmful pulmonary regurgitation. Different approaches have been used to release RVOT obstruction and spare the pulmonary valve [PV] function. In this study, we aim to evaluate the post-operative course of patients who had TOF repair in the current era that emphasizes on protective strategy of releasing RVOT obstruction and preserving PV function. A retrospective study of all TOF cases repaired in our institute between March 2002 and December 2007 was conducted. Cases were classified into two groups; group I included patients that had a TAP, while group II included cases that had simple TOF repair without TAP. Group I was subdivided into two groups, group [A] which include patients who had TAP without a valve. Group [B] includes those who had TAP with a monocuspid valve [Contegra]. We compared postoperative care and outcome of all groups. Eighty-three patients fulfilled the study criteria. There were 64 cases [77%] in group I, and 19 cases [23%] in group II. All children tolerated surgical repair and did well. We observed no statistically significant difference in the post-operative ICU care, complications rates and morbidity between all groups. There was no surgical mortality in all groups. Children undergoing TOP repair had excellent short-term outcome with the current protective strategy aiming to spare valvular function, and conserving myocardial function. Applying a monocuspid patch technique did not show clear short-term benefits. Long term follow up is needed to evaluate future difference in different techniques

Outcome of Norwood and Damus-Kaye-Stansel procedures for univentricular congenital heart anomalies

To review the experience with Norwood and Damus-Kaye-Stansel [DKS] staged repair in the management of hypoplastic left heart syndrome [HLHS], or functional single ventricle [FSV] with systemic outflow tract obstruction [SOTO]. A retrospective study was conducted from a single center from January 2001 to September 2007 at the Cardiac Sciences Department, King Abdulaziz Cardiac Center, National Guard Health Affairs, Riyadh, Kingdom of Saudi Arabia. The cardiac departmental database was reviewed, together with the echocardiographic findings. Demographic data representing age and weight at operation, gender, cardiac anatomy, non-cardiac abnormalities, and operative details were collected. Twenty-eight patients with a diagnosis of HLHS were included in the study. The mean +/- SD for weight was 3.4 +/- 0.85kg and 32 +/- 37 days for age. All infants at our institution who underwent a Norwood or DKS surgery for HLHS, or other forms of FSV with SOTO were included. All included patients underwent first stage palliation consisting of either a classical Norwood procedure in 6/23 [21%] patients, or a modified Norwood with right ventricle to pulmonary artery [RV-PA] conduit in 22/28 [79%] patients. After first stage palliation, 23 patients [82%] survived, and all but one underwent second stage palliation with bidirectional cavopulmonary anastomosis [BCPA]. The survival rate after second stage repair was 91%. Subsequently, 4 patients completed a third stage Fontan with 100% survival. All deceased patients had HLHS. The Norwood procedure is applied to a heterogeneous group of patients with variable outcomes in certain subgroups. Patients with HLHS palliated with the Norwood procedure are at a greater risk for morbidity and mortality compared to those with other forms of FSV with SOTO