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Identifier 000373032
Title Λοιμώξεις τραύματος στερνοτομής μετά από επεμβάσεις αορτοστεφανιαίας παράκαμψης με αμφοτερόπλευρη χρήση αποσκελετωμένων έσω μαστικών αρτηριών συχνότητα, αιτιολογία, παράγοντες κινδύνου και έκβαση
Alternative Title Sternal wound infections after coronary artery bypass grafting using bilateral skeletonized internal mammary arteries:frequency, etiology, risk factors and outcome
Author Ροσμαράκης, Ευάγγελος
Thesis advisor Σαμώνης, Γεώργιος
Reviewer Βάρδας, Παναγιώτης
Κατσαμούρης, Αστέριος
Abstract Coronary artery bypass on a beating heart (off-pump coronary artery bypass grafting or OPCABG) has become common in the last ten years in an attempt to decrease the complications associated with the use of extracorporeal circulation. There is also evidence that a new technique of OPCABG, which is performed with the use of bilateral skeletonized internal mammary arteries avoiding any procedure on the ascending aorta and a sternal closure technique based on alternative placement of figure of eight and single sternal wires, can further decrease sternal wound infections. In the retrospective part of the study, we examined the frequency, characteristics, and predisposing factors of postoperative infections, in a large cohort of patients undergoing OPCABG surgery over a period of 39 months (January 2001 - March 2004) at “Henry Dunant” Hospital, Athens, Greece. Cases were patients who developed microbiologically documented nosocomial infection. Patients who underwent valve surgery combined with coronary artery bypass surgery were excluded from the study. Twenty-one of 782 (2.7%) studied patients developed microbiologically documented nosocomial infection after OPCABG. Six of 782 studied patients (0,77%) developed sternal wound infection [4 (0.51%) developed superficial wound infection and 2 (0.26%) mediastinitis], 8 patients (1.02%) developed pneumonia, 7 (0.90%) bacteremia, 4 (0.51%) urinary tract infection (UTI), and 1 (0.13%) developed pressure sore infection. Four patients had 120 infections at two or more different sites. Specifically, 1 patient had UTI and mediastinitis, 1 UTI and pressure sore infection, 1 pneumonia and bacteremia, and 1 pneumonia, urinary tract infection, and bacteremia. Thus, there were 26 episodes of microbiologically documented infections in 21 patients. The backward stepwise multivariable logistic regression model revealed that independent risk factors associated with development of microbiologically documented nosocomial infection were arterial hypertension, previous vascular surgery, urgent operation, postoperative atrial fibrillation, number of inotrops used during operation and after operation, transfusions of fresh frozen plasma during ICU stay and ICU stay until development of infection. The nosocomial mortality of the studied patients was 14/782 (1.79%). There was statistically significant difference in mortality between patients with microbiologically documented nosocomial infection (5/21, 23.8%) and the rest of the patients who did not develop nosocomial infection (9/773, 1.2%), (p<0.001). However, the statistical analysis showed that independent risk factors for death were: urgent operation, anaemia (Ht<34%), and low left ventricular ejection fraction on admission (p<0.001). In the prospective part of the study, we also evaluated the frequency, risk factors, characteristics, and mortality of infections in 360 adult patients after off-pump coronary artery bypass grafting (OPCABG). The prospective cohort study was performed during the 121 period 06/2004-10/2005 at “Henry Dunant” Hospital, Athens, Greece. Cases were patients who developed nosocomial infections after OPCABG. Samples of serum for assay of C-reactive protein (CRP) and procalcitonin were obtained from a subgroup of patients preoperatively, 24, 48, and 72 hours following cardiac surgery. At least one sternal wound culture was received from each patient when he was transferred from ICU to the ward. Additional sternal wound cultures were received from patients with suspected sternal wound infection. Various variables were examined as possible risk factors of nosocomial infections and death after OPCABG. Out of 360 adult cases undergoing OPCABG surgery, 18 patients (5%) developed postoperative nosocomial infections. Seven of them (1.9%) developed sternotomy wound infection [one patient (0.3%) developed mediastinitis, and 6 patients (1.7%) developed superficial wound infection]. Five patients (1.4%) developed pneumonia, 4 (1.1%) developed bacteremia, 1 (0.3%) developed intra-aortic balloon pump (IABP) related infection, and afterwards (17 days after OPCABG) candidemia (0.3%). One patient (0.3%) developed pressure sore infection. Three patients had infections from two different sites. Specifically, except from 1 patient with IABP-related infection and candidemia, 1 patient had pneumonia and bacteremia, and 1 had superficial wound infection and bacteremia. Thus, there were 21 episodes of infections in 18 patients. 122 Ninety-five microorganisms were isolated from 80 out of 377 (21.2%) sternal wound cultures (received from 359 patients), while no microbes were isolated from the rest 297 (78.8%). The isolated organisms were gram-positive cocci, gram-negative microbes, and fungi. The most common isolates from sternal wound cultures were gram-positive cocci [74 of 95 isolates (77.9%)]. Gram-negative microbes were less common isolated in sternal wound cultures but had greater positive predictive value in sternal wound infections (5/18, 27.8%) compared with gram-positive cocci (7/74, 9.5%), although this difference was not significant (p=0,054, Fischer exact test). The mean increase of CRP and procalcitonin levels in the first two or three days respectively after surgery was significantly higher (p<0.05) in the group of patients who developed infection compared to patients without infection. Independent risk factors (p<0.05) associated with development of infection were history of major nervous system disorder, history of heart failure preoperatively, a very urgent operation, transfusions of red blood cells during ICU stay, and duration of central venous catheter placement. The mortality of the studied patients was 4/360 (1.1%). Specifically, the mortality was 2/18 (11.1%) for patients who developed infection, and 2/242 (0.6%) for the patients who did not develop nosocomial infection (p< 0.05). Although infection was 123 statistically associated with the studied outcome (mortality) in the bivariable analysis, the backward stepwise multivariable logistic regression model revealed that independent risk factors for death were: history of major nervous system disorder, and perioperative use of inotrops. In conclusion, the frequency of superficial wound infection, pneumonia, bacteremia, and urinary tract infection in this study is similar to the results of previous studies. However, the rate of mediastinitis of the studied population was lower than the rates that were observed in previous studies. Thus, there is evidence that this new technique of OPCABG that combines the use of bilateral skeletonized internal mammary arteries with a sternal closure technique based on alternative placement of figure of eight and single sternal wires not only did not increase deep sternal wound infections but could further decrease them. In addition, the identification of risk factors for infection after OPCABG surgery in combination with the appropriate use and evaluation of the results of diagnostic tests will help clinicians to identify cases with high probability for infection and afterwards to put the diagnosis early, especially in cases in which diagnosis is difficult. Regarding the role of CRP and procalcitonin levels, previous studies have shown that CRP and procalcitonin are not specific markers for infection. For example, high concentrations of procalcitonin were found in patients with three or more criteria for 124 the diagnosis of systemic inflammatory response syndrome, postoperative pulmonary dysfunction, myocardial infarction and cardiogenic shock. Our study adds to the literature the finding that CRP and procalcitonin also increased in patients with postoperative complications after off-pump coronary artery bypass surgery and that increase was higher for patients with infection compared to patients without infection during the first three postoperative days.
Language Greek
Subject Cardiovascular system
Coronary artery bypass grafting
Off-pump
Opcabg
Skeletonized internal mammary arteries
Sternal wound infections
Έσω μαστικές αρτηρίες
Αορτοστεφανιαία παράκαμψη
Λοιμώξεις στερνοτομής
Issue date 2011-07-15
Collection   Faculty/Department--School of Medicine--Department of Medicine--Doctoral theses
  Type of Work--Doctoral theses
Permanent Link https://elocus.lib.uoc.gr//dlib/3/6/3/metadata-dlib-1331884533-160534-10939.tkl Bookmark and Share
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