Hospital-Acquired Infection in Pediatric Subjects With Congenital Heart Disease Postcardiotomy Supported on Extracorporeal Membrane Oxygenation*

Abstract

Objective: To determine prevalence of and risk factors for infection in pediatric subjects with congenital heart disease status postcardiotomy supported on extracorporeal membrane oxygenation, as well as outcomes of these subjects. Design: Retrospective cohort from the Extracorporeal Life Support Organization. Setting: U.S. and international medical centers providing care to children with congenital heart disease status postcardiotomy. Patients: Critically ill pediatric subjects less than 8 years old admitted to medical centers between January 1, 2013, and December 31, 2015, who underwent cardiac surgery for congenital heart disease and required extracorporeal membrane oxygenation support within the first 14 postoperative days. Subjects were excluded if they underwent orthotopic heart transplantation, required preoperative extracorporeal membrane oxygenation, and had more than one postoperative extracorporeal membrane oxygenation run. Interventions: None. Measurements and Main Results: A total of 1,314 extracorporeal membrane oxygenation subject encounters in the Extracorporeal Life Support Organization registry met inclusion criteria. Neonates comprised 53% (n = 696) of the cohort, whereas infants made up 33% (n = 435). Of the 994 subjects with Society of Thoracic Surgeons-European Association for Cardio-Thoracic Surgery categorizable surgery, 33% (n = 325) were in Society of Thoracic Surgeons-European Association for Cardio-Thoracic Surgery category 4 and 23% (n = 231) in Society of Thoracic Surgeons-European Association for Cardio-Thoracic Surgery category 5. While on extracorporeal membrane oxygenation, 229 subjects (17%) acquired one or more extracorporeal membrane oxygenation–related infections, which represents an occurrence rate of 67 infections per 1,000 extracorporeal membrane oxygenation days. Gram-negative (62%) and Gram-positive (42%) infections occurred most commonly. Forty percent had positive blood cultures. Infants and children were at higher infection risk compared with neonatal subjects; subjects undergoing less complex surgery had higher infection rates. Unadjusted survival to hospital discharge was lower in infected subjects compared with noninfected subjects (43% vs 51%; p = 0.01). After adjusting for confounders via propensity matching, we identified no significant mortality difference between infected and noninfected subjects. Conclusions: Neonatal and pediatric subjects in this study have a high rate of acquired infection. Infants and children were at higher infection risk compared with neonatal subjects. There was not, however, a significant association between extracorporeal membrane oxygenation–related infection and survival to hospital discharge after propensity matching.

Neurological Outcome According to the Site of Cannulation in Septic Children Supported by Venoarterial Extracorporeal Membrane Oxygenation

“…The proportion of patients with congenital heart disease reported here is also high (16%), and these patients requiring ECMO within the first 14 postoperative days are at higher risk of infection. 28 Although a sensitivity analysis led to similar conclusions for the main outcome after exclusion of these patients, this limitation needs to be addressed since almost half of the patients with central cannulation have congenital heart disease. Third, we acknowledge that by limiting to the first run only, we excluded the occurrence of situations where cannulation was changed, as can sometimes occur.…”

Mortality prediction in pediatric postcardiotomy veno-arterial extracorporeal membrane oxygenation: A comparison of scoring systems

“…VA-ECMO can be used as a rescue therapy for failure to wean from CPB, LCOS, cardiac arrest (CA), and acute respiratory distress syndrome (ARDS) after CHD surgery, providing time for cardiopulmonary recovery. However, it is accompanied by high morbidity and mortality; coagulopathies, renal injury, and infection are common complications of pediatric postcardiotomy VA-ECMO ( 17 , 22 , 23 ). Many single risk factors before and during ECMO can predict mortality after VA-ECMO, such as renal failure, lactate level, and clearance ( 24 , 25 ).…”

Cell Saver Blood Reinfusion Up to 24 Hours Post Collection in Pediatric Cardiac Surgical Patients Does Not Increase Incidence of Hospital-Acquired Infections or Mortality

“…The composite outcome of HAI or death was evaluated as an additional measure given the low mortality rate within the studied population, allowing for better overall comparison between the two study groups. Given the known increase in infections and blood product transfusions, morbidity and mortality in patients requiring ECMO (28)(29)(30)(31), we chose to exclude patients who required ECMO within the first 48 hours postoperatively. We collected data on other known risk factors for HAI including duration of mechanical ventilation, inotropes, nitric oxide, delayed chest closure, central venous catheters, indwelling urinary catheters, ECMO (post initial 48 hours), and hospital length of stay (4,6,7,28,(31)(32)(33)(34)(35).…”