A comprehensive qualitative investigation of the factors that affect surgical site infection prevention in cardiac surgery in England using observations and interviews.

BACKGROUND: Interview and questionnaire studies have identified barriers and challenges to preventing surgical site infections (SSIs) by focusing on compliance with recommendations and care bundles using interviews, questionnaires and expert panels. This study proposes a more comprehensive investigation by using observations of clinical practice plus interviews which will enable a wider focus. AIM: To comprehensively identify the factors which affect SSI prevention using cardiac surgery as an exemplar. METHODS: The study consisted of 130 h of observed clinical practice followed by individual semi-structured interviews with 16 surgeons, anaesthetists, theatre staff, and nurses at four cardiac centres in England. Data were analysed thematically. FINDINGS: The factors were complex and existed at the level of the intervention, the individual, the team, the organization, and even the wider society. Factors included: the attributes of the intervention; the relationship between evidence, personal beliefs, and perceived risk; power and hierarchy; leadership and culture; resources; infrastructure; supplies; organization and planning; patient engagement and power; hospital administration; workforce shortages; COVID-19 pandemic; 'Brexit'; and the war in Ukraine. CONCLUSION: This is one of the first studies to provide a comprehensive overview of the factors affecting SSI prevention. The factors are complex and need to be fully understood when trying to reduce SSIs. A strong evidence base was insufficient to ensure implementation of an intervention.

Cardioplegic strategies to protect the hypertrophic heart during cardiac surgery.

Cardioplegic arrest and cardiopulmonary bypass are key triggers of myocardial injury during aortic valve surgery. Cardioplegic ischaemic arrest is associated with disruption to metabolic and ionic homeostasis in cardiomyocytes. These changes predispose the heart to reperfusion injury caused by elevated intracellular reactive oxygen species and calcium. Cardiopulmonary bypass is associated with an inflammatory response that can generate systemic oxidative stress which, in turn, provokes further damage to the heart. Techniques of myocardial protection are routinely applied to all hearts, irrespective of their pathology, although different cardiomypathies respond differently to ischaemia and reperfusion injury. In particular, the efficacy of cardioprotective interventions used to protect the hypertrophic heart in patients with aortic valve disease remains controversial. This review will describe key cellular changes in hypertrophy, response to ischaemia and reperfusion and cardioplegic arrest and highlight the importance of optimising cardioprotective strategies to suit hypertrophic hearts.

Inadequate blood glucose control is associated with in-hospital mortality and morbidity in diabetic and nondiabetic patients undergoing cardiac surgery.

BACKGROUND: Derangement of glucose metabolism after surgery is not specific to patients with diabetes mellitus. We investigated the effect of different degrees of blood glucose control (BGC) on clinical outcomes after cardiac surgery. METHODS AND RESULTS: We analyzed 8727 adults operated on between April 1996 and March 2004. The highest blood glucose level recorded over the first 60 hours postoperatively was used to classify patients as having good (<200 mg/dL), moderate (200 to 250 mg/dL), or poor (>250 mg/dL) BGC; 7547 patients (85%) had good, 905 (10%) had moderate, and 365 (4%) had poor BGC. Patients with inadequate BGC were more likely to present with advanced New York Heart Association class, congestive heart failure, hypertension, renal dysfunction, and ejection fraction <50% (P0

Risk factors for and economic implications of prolonged ventilation after cardiac surgery.

OBJECTIVE: The study's objective was to identify predictors of prolonged ventilation and assess clinical and cost implications in patients undergoing cardiac surgery. METHODS: Patients undergoing cardiac surgery were classified as (1) ventilated less than 96 hours or (2) ventilated 96 hours or more. Multivariate modeling was used to identify predictors of prolonged ventilation and to ascertain the impact of prolonged ventilation on in-hospital mortality and bed occupancy costs and 5-year survival. RESULTS: A total of 7553 patients were studied; 197 (2.6%) had prolonged ventilation. Median ventilation times were 8 and 192 hours, and in-hospital mortality was 1.0% and 22.2% in the control and prolonged ventilation groups, respectively (P < .001). In-hospital mortality remained higher in the prolonged ventilation group after adjustment and when comparing propensity-matched patients (odds ratio 8.06; 95% confidence interval [CI] 4.27-15.2; P < .001 for propensity-matched groups). Independent predictors of prolonged ventilation were as follows: older age, New York Heart Association class, ejection fraction less than 50%, creatinine greater than 200 micromol/L, multiple valve replacements, aortic procedures, operative priority, reoperation for bleeding, inotropes, and preoperative intra-aortic balloon pump. Five-year survival was lower in the prolonged ventilation group (56.1% [95% CI 46.6%-64.6%] vs 88.8% [95% CI 87.9%-89.6%]) also after adjustment for imbalances and when comparing propensity-matched patients (hazard ratio 2.39; 95% CI 1.75-3.27; P < .001 for propensity-matched groups). Mean bed occupancy costs were 14,286 dollars (95% CI 12,731 dollars-15,690 dollars) and 2761 dollars (95% CI 2705 dollars-2814 dollars) in the prolonged ventilation and control groups, respectively (P < .001). CONCLUSION: Prolonged ventilation is associated with high in-hospital mortality and costs, and poor 5-year survival. Identified predictors of prolonged ventilation might help to optimize the clinical management of these patients.