Wound management across Australian and New Zealand pediatric cardiac services: a cross-sectional survey.

BACKGROUND: CHD is associated with considerable burden of care. Up to one-third of babies born with CHD require surgery or intervention during the first year of life with an associated increased risk of surgical site infection. Pediatric wound care is informed largely by adult data, with no national or international guidelines available. AIM: To examine pediatric cardiac surgical wound care practices reported by healthcare professionals Australia and New Zealand-wide. METHODS: A bi-national cross-sectional survey exploring pre-, intra- and post-operative wound practices was distributed using Exponential Non-Discriminative Snowball Sampling. Data were subject to descriptive analysis using SPSS Statistics 22.0. FINDINGS: Sixty-eight surveys representing all Australian and New Zealand pediatric cardiac surgical services were analyzed. Most respondents were experienced nurses. Pre-operative care varied greatly in practice and pharmaceutical agents used. Little consistency was reported for intra- and post-operative wound care. Nursing and medical staff shared responsibility for wound care. Wound photography was widely used, but only uploaded to electronic medical records by some. DISCUSSION: These results highlight that wound care management is largely informed at an institutional level. The many practices reported are likely to reflect a range of factors including cardiac condition complexity, surgery, prematurity, and the presence of scar tissue. The importance of a research and training program, which is multimodal, available, and reflective, is highlighted. CONCLUSION: These findings call for the establishment of a nurse-led program of research and education. The resultant suite of cardiac wound strategies could offer an effective and consistent pathway forward.

A Multicenter, Randomized, Controlled Phase IIb Trial of Avoidance of Hyperoxemia during Cardiopulmonary Bypass.

BACKGROUND: Cardiac surgery utilizing cardiopulmonary bypass (CPB) is one of the most common forms of major surgery. Cardiac surgery-associated multiorgan dysfunction (CSA-MOD) is well recognized and includes acute kidney injury (AKI), hepatic impairment, myocardial damage, and postoperative neurologic deficit. Pathophysiology of CSA-MOD involves numerous injurious pathways linked to the use of CPB including oxidative stress and formation of reactive iron species. During cardiac surgery with CPB, arterial return blood is oxygenated to supranormal levels. This study aimed to determine whether the avoidance of arterial hyperoxemia decreased oxidative stress and reduced the severity of the multiorgan dysfunction in patients undergoing cardiac surgery utilizing CPB. METHODS: The study was a multicenter, open-label, parallel-group, randomized controlled study of the avoidance of arterial hyperoxemia versus usual care in patients undergoing cardiac surgery involving CPB. Primary outcome was the incidence and severity of AKI. Secondary outcomes included serum biomarkers for CSA-MOD, duration of mechanical ventilation, and length of intensive care and hospital stay. RESULTS: A total of 298 patients were randomized and analyzed at two hospitals in New Zealand and Australia. Mean PaO2 was significantly different between groups during CPB. There was no difference in the development of AKI (intervention arm 72.0% vs. usual care 66.2%; difference, -5.8% [95% CI, -16.1 to 4.7%]; P = 0.28), other markers of organ damage, or intensive care unit and hospital length of stay. CONCLUSIONS: Avoiding modest hyperoxemia during CPB failed to demonstrate any difference in AKI, markers of organ damage, or length of stay.

Targeted therapeutic mild hypercapnia after cardiac arrest: A phase II multi-centre randomised controlled trial (the CCC trial).

BACKGROUND: In intensive care observational studies, hypercapnia after cardiac arrest (CA) is independently associated with improved neurological outcome. However, the safety and feasibility of delivering targeted therapeutic mild hypercapnia (TTMH) for such patients is untested. METHODS: In a phase II safety and feasibility multi-centre, randomised controlled trial, we allocated ICU patients after CA to 24h of targeted normocapnia (TN) (PaCO2 35-45mmHg) or TTMH (PaCO2 50-55mmHg). The primary outcome was serum neuron specific enolase (NSE) and S100b protein concentrations over the first 72h assessed in the first 50 patients surviving to day three. Secondary end-points included global measure of function assessment at six months and mortality for all patients. RESULTS: We enrolled 86 patients. Their median age was 61 years (58, 64 years) and 66 (79%) were male. Of these, 50 patients (58%) survived to day three for full biomarker assessment. NSE concentrations increased in the TTMH group (p=0.02) and TN group (p=0.005) over time, with the increase being significantly more pronounced in the TN group (p(interaction)=0.04). S100b concentrations decreased over time in the TTMH group (p<0.001) but not in the TN group (p=0.68). However, the S100b change over time did not differ between the groups (p(interaction)=0.23). At six months, 23 (59%) TTMH patients had good functional recovery compared with 18 (46%) TN patients. Hospital mortality occurred in 11 (26%) TTMH patients and 15 (37%) TN patients (p=0.31). CONCLUSIONS: In CA patients admitted to the ICU, TTMH was feasible, appeared safe and attenuated the release of NSE compared with TN. These findings justify further investigation of this novel treatment.

Intravenous fluid use after cardiac surgery: a multicentre, prospective, observational study.

BACKGROUND: The optimal strategy for fluid replacement after major surgery remains unclear and there is considerable interest in the investigation of more restrictive fluid regimens. OBJECTIVE: We aimed to establish current practice of fluid administration to patients after cardiac surgery. DESIGN, SETTING AND PARTICIPANTS: A multicentre, prospective observational study, over an 8-week period, of consecutive patients admitted to five intensive care units in New Zealand and Australia. MAIN OUTCOME MEASURES: We collected patient demographic data and details of fluid boluses and all other intravenous (IV) fluids administered in the first 24 hours after ICU admission. RESULTS: We included 235 patients, and 1226 fluid boluses with an average volume of 504 mL/bolus were administered. The median total fluid given for volume expansion in the first 24 hours was 2250mL (interquartile range [IQR], 1250-3500mL) from a median total IV fluid intake of 4493mL/patient (IQR, 2842-5498 mL). The decision to administer a fluid bolus was made 40% of the time by nursing staff, 45% by an ICU resident and 12% by an ICU specialist. The most common reason for fluid administration was hypotension (65%), and crystalloid fluid was used for 65% of the boluses. CONCLUSIONS: We showed that fluid boluses are responsible for a large proportion of the positive fluid balance seen in patients after cardiac surgery. These data justify further study to evaluate whether modification of fluid bolus administration can improve patient outcomes.