Early Versus Late Sternal Closure in Infants—Perioperative Associations and Outcomes

2021 ◽  
Vol 12 (5) ◽  
pp. 589-596
Author(s):  
Ahmed Asfari ◽  
Matthew G. Clark ◽  
Kristal M. Hock ◽  
Jordan L. Huskey ◽  
A. K. M. F. Rahman ◽  
...  
Keyword(s):  
Median Time ◽  
Heart Surgery ◽  
Univariate Analysis ◽  
Multivariable Analysis ◽  
Retrospective Chart Review ◽  
Future Research ◽  
Sternal Closure ◽  
Delayed Sternal Closure ◽  
Laboratory Variables ◽  
Neonates And Infants

Background: Delayed sternal closure (DSC) has been used for patients who develop bleeding, chest wall edema, and malignant arrhythmia following cardiopulmonary bypass. Multiple factors can influence the timing of when to perform DSC. We aimed to describe our DSC experience in neonates and infants by comparing outcomes between patients undergoing early (<48 hours) versus late DSC (> 48 hours). We explored the associations between specific clinical and laboratory variables and the timing of DSC. Methods: Retrospective chart review of neonates and infants (<one-year-old) with DSC after heart surgery from December 2012 to December 2018. Patients requiring extracorporeal membrane oxygenation were excluded. Results: A total of 121 patients were included in the analysis, 34% (n = 41) met late DSC criteria. The overall cohort had a 75% survival rate and a median time for open sternum of 42.5 hours (Q1:23-Q3:65). The median time for open sternum in the early and late DSC groups was 24 hours (Q1:21-Q3:43) and 93 hours (Q1:65-Q3:141), respectively ( P < .01). There was no statistical difference in mortality rate between groups. Patients with late DSC endured longer intensive care unit stays (median 24.3 days [Q1:13-Q3:35.3] vs 36.8 [Q1:23.9, 73.6]; P< .01) and a two-fold longer hospital stay compared to the early DSC group (multivariable analysis: relative risk = 2, 95% CI: 1.5-2.7; P < .01). Univariate analysis revealed patients with late DSC had higher median lactates both intraoperatively (7.6 [Q1:5.9-Q3:10.7] vs 9.3 [Q1:7.5-Q3:12.1]; P < .01) and 24 hours postoperatively (6.5 [Q1:4.3-Q3:10.3] vs 8.7 [Q1:5.7-Q3:14.70]; P = .03). A higher vasoactive inotrope score at 36 hours was associated with late DSC (odds ratio = 1.1, 95% CI: 1.01-1.2; P = .02). Conclusions: Future research that explores additional clinical and laboratory variables that can help guide DSC decision-making and timing is needed.

scholarly journals Clinical Evaluation of Delayed Sternal Closure following Open Heart Surgery in Neonates and Infants.

1992 ◽  
Vol 21 (2) ◽  
pp. 149-154
Author(s):  
Masanao IMAI ◽  
Masahiro YAMAGUCHI ◽  
Hidetaka OHASHI ◽  
Yoshihiro OSHIMA ◽  
Naoki YOSHIMURA ◽  
...  
Keyword(s):  
Clinical Evaluation ◽  
Heart Surgery ◽  
Open Heart Surgery ◽  
Open Heart ◽  
Sternal Closure ◽  
Delayed Sternal Closure ◽  
Neonates And Infants

Indications and Risks of Delayed Sternal Closure After Open Heart Surgery in Neonates and Early Infants

2012 ◽  
Vol 3 (2) ◽  
pp. 229-235 ◽  
Author(s):  
Ersin Erek ◽  
Yusuf Kenan Yalcinbas ◽  
Yasemin Turkekul ◽  
Arda Saygili ◽  
Ayse Ulukol ◽  
...  
Keyword(s):  
Heart Surgery ◽  
Univariate Analysis ◽  
Open Heart Surgery ◽  
Morbidity Rate ◽  
Wound Complications ◽  
Skin Closure ◽  
Sternal Closure ◽  
Delayed Sternal Closure ◽  
Patch Closure ◽  
Mechanical Ventilation Time

Background: Delayed sternal closure (DSC) has been an essential part of neonatal and infant heart surgery. Here, we report our single institution experience of DSC for eight years. Methods: The successive 188 patients were analyzed retrospectively. Sternum was closed at the end of the operation in 97 (51.6%) patients (primary sternal closure [PSC] group). Sternum was left open in 91 (48.4%) patients. Among them, 45 (23.9%) had only skin closure (DSCs group) and 46 (24.4%) had membrane patch closure (DSC membrane [DSCm] group). Median age was higher in PSC group (90 days) than DSCs (11 days) and DSCm groups (9.5 days). Results: Mortality was 1%, 11.1%, and 28.2% in PSC, DSCs, and DSCm groups, respectively ( P < .05). Univariate analysis recognized the neonatal age (odds ratio [OR] = 4.2), preoperative critical condition (OR = 5.3), cardiopulmonary bypass time >180 minutes (OR = 4), and cross clamp time >99 minutes (OR = 3.9) as risk factors for mortality. Total morbidity rate was higher in DSCm group (73.9%) than DSCs group (51.1%) and PSC group (23.7%; P < .001). Mechanical ventilation time, intensive care unit stay, and hospital stay were longer in DSCs and DSCm groups than PSC group ( P < .001). The incidence of hospital infection was also higher in DSCs (43.5%) and DSCm (33.3%) groups than PSC group (20.6%; P < .05). But there was no difference in the incidence of sternal wound complications, including both deep and superficial (4.1%, 8.8%, and 4.4%, respectively). Conclusion: Although the risk of sternal wound complications is not different, patients who necessitate DSC (using both skin and membrane closure techniques) have more complicated postoperative course than patients with PSC.

Delayed sternal closure: an effective procedure for life-saving in open-heart surgery

2010 ◽  
Vol 10 (2) ◽  
pp. 163-167 ◽  
Author(s):  
Haydar Yasa ◽  
Banu Bahriye Lafci ◽  
Levent Yilik ◽  
Mehmet Bademci ◽  
Aykut Sahin ◽  
...  
Keyword(s):  
Heart Surgery ◽  
Open Heart Surgery ◽  
Effective Procedure ◽  
Open Heart ◽  
Sternal Closure ◽  
Life Saving ◽  
Delayed Sternal Closure

Factors Associated With Patient Nonattendance in Rhinology Clinics

2019 ◽  
Vol 33 (3) ◽  
pp. 317-322
Author(s):  
Benjamin N. Hunter ◽  
Brandon Cardon ◽  
Gretchen M. Oakley ◽  
Arun Sharma ◽  
Dana L. Crosby
Keyword(s):  
Chart Review ◽  
Univariate Analysis ◽  
Multivariable Analysis ◽  
Retrospective Chart Review ◽  
The United States ◽  
Patient Demographics ◽  
Medical Centers ◽  
Insurance Type ◽  
Academic Medical ◽  
Included Patient

Background Nonattendance to clinical appointments is a global problem appreciated by clinicians with an ambulatory presence. There are few reports of nonattendance in otolaryngology clinics, and no reports on nonattendance for a single otolaryngology subspecialty. Objective To describe the no-show population in rhinology clinics. Methods A retrospective chart review was performed involving rhinology clinics from 2 academic medical centers in the United States. All patients who either attended their clinic appointment(s) or did not attend without previously cancelling from June 2016 to May 2017 were included. Data collected included patient demographics, appointment status, season and time of visit, insurance status, type of visit (new vs established), and provider seen. Results There were 2791 clinical appointments evaluated over a 12-month period at 2 rhinology clinics involving 4 fellowship-trained rhinologists. Ninety-two percent of patients kept their appointments, while 8% did not. Sex, season of visit, time of visit (am vs pm), type of visit, provider sex, provider location, or provider’s experience (<10 years vs ≥10 years) were not associated with patient’s attendance status. Univariate analysis showed that patient’s age ≤50 ( P = .001) and primary insurance type ( P < .001) were associated with nonattendance. Medicaid as the primary insurance type was associated with clinic nonattendance. Multivariable analysis showed that age ≤ 50 years, odds ratio (OR) 1.62 (95% confidence interval [CI] 1.14–2.30), P = .007, and primary insurance type (Medicaid: OR 3.75 [95% CI 2.58–5.45], P < .001) remained significant predictors of nonattendance. Conclusion Patients younger than 50 years and patients with Medicaid as the primary insurance types are associated with risk of missing rhinology clinic appointments. As a subspecialty, delivery of timely care and clinical efficiency could be improved by interventions directed toward improving attendance among this population.

Abstract TP244: Age-Related Disparities in Door-to-Needle Times: It’s Not What You Think

Stroke ◽  
2017 ◽  
Vol 48 (suppl_1) ◽  
Author(s):  
Christian J Burrell ◽  
Kristin P Guilliams ◽  
Jennifer A Williams ◽  
Laura Heitsch ◽  
Peter Panagos ◽  
...  
Keyword(s):  
Older Adults ◽  
Young Adults ◽  
Adult Population ◽  
Univariate Analysis ◽  
Multivariable Analysis ◽  
Age Groups ◽  
Retrospective Chart Review ◽  
Stroke Mimics ◽  
Age Related ◽  
Forward Stepwise

Introduction: Delays in door-to-needle time (DNT) for tPA administration are associated with worse outcomes after acute ischemic stroke (AIS). Studies suggest tPA is safe and effective in young adults, though the effect of age on timeliness of tPA decision making is unknown. In the young adult population, lower frequency of stroke and higher frequency of stroke mimics may lead to DNT delays. We tested the hypothesis that DNT are longer in young adults with AIS. Methods: From 1/2009 to 3/2016, patient demographics and tPA metrics were prospectively collected on all tPA-treated patients at a large, urban academic hospital. Discharge diagnosis (including stroke mimics) and symptomatic intracranial hemorrhage (sICH) rates were collected by retrospective chart review. DNT was compared between young (age ≤ 45) and older adults (age > 45) and across four age groups: ≤45, 46-65, 66-85, and ≥86. Univariate analysis evaluated associations between DNT and baseline characteristics (age, race, sex, admission year, onset-to-arrival time, and admission NIHSS), followed by forward stepwise linear regression including variables with P<0.2 on univariate analysis. Results: Of 560 patients treated with tPA, 63 (11%) were age ≤45 and 497 (89%) were age > 45. Mean DNT was 63 minutes in young adults compared to 50 minutes in older adults (P=0.002). Across four age groups, DNTs were longer in young adults (P=0.027, Figure). In multivariable analysis, age ≤45 (P=0.012), lower NIHSS (P=0.006), and more remote admission year (P=0.001) independently predicted longer DNT. Stroke mimics were more frequent in young adults: 32% vs 7% (P<0.001), though mean DNT remained longer in young adults after excluding mimics: 63 vs 49 min (P=0.008). sICH rate was similar in both groups: 0% vs 4.2% (p=0.10). Conclusions: Despite established safety and efficacy of tPA in young adults, we found DNT delays in this population. Further studies are needed to confirm this finding and address age-related disparities in DNT.

Multiple Myeloma and Plasmactyoma-Like Post-Transplant Lymphoproliferative Disorders (PTLD): Examination Of Outcomes and Prognostication In The Modern Era

Blood ◽  
2013 ◽  
Vol 122 (21) ◽  
pp. 1899-1899
Author(s):  
Aaron S. Rosenberg ◽  
Robin Ruthazer ◽  
Jessica K Paulus ◽  
Andrew M Evens ◽  
Andreas K. Klein
Keyword(s):  
Multiple Myeloma ◽  
Median Time ◽  
Univariate Analysis ◽  
Multivariable Analysis ◽  
Solid Organ Transplantation ◽  
The United States ◽  
Solid Organ ◽  
Multivariable Model ◽  
Risk Of Death ◽  
Baseline Characteristics

Abstract Introduction Although PTLD is a well described complication of solid organ transplantation (SOT), relatively little is known about multiple myeloma and plasmacytoma-like PTLD (PTLD-MM). We examined a large cohort of PTLD-MM patients (pts) in the Scientific Registry of Transplant Recipients (SRTR) investigating overall survival (OS) and the associated predictors of outcome. Methods The SRTR is a pt-level prospective database of all SOT recipients in the United States. Pts diagnosed with PTLD-MM in 1999-2011 were identified in text and standardized diagnosis fields. Baseline pt characteristics were obtained at the time of SOT and diagnosis. OS estimates were calculated using the Kaplan-Meier method, with follow up times censored at 4.5 years. Effects of baseline characteristics on survival were estimated in univariate analysis using Cox proportional hazards models; those with a p-value ≤ 0.10 were included in a multivariable model. January 1, 2006 was used to divide the data into two equal cohorts to ascertain the effect of diagnosis date on survival. Results We identified 217 pts with PTLD-MM. Disease characteristics are outlined in Table 1. Median time from SOT to PTLD-MM diagnosis was 4.8 years (range 0-21); 18% of pts were diagnosed within 1 year of SOT, while 23% were diagnosed 10 years or more from SOT. In the cohort diagnosed 1999-2005, median time to PTLD-MM was significantly shorter than in the cohort diagnosed 2006-2011 (3.8 vs 5.2 years respectively, p = 0.048). Of those with complete data on performance status (PS), pts in the earlier cohort were more likely to have PS of 80-100 when compared to the later cohort (68% vs 52%, p=0.04). Therapy was detailed in 181 pts: 118 had immunosuppression reduced; 26 received corticosteroids; 62 received cytotoxic therapy; 3 received immunomodulatory agents; 44 received one of the novel agents thalidomide, lenalidomide or bortezomib; 56 underwent radiation therapy and 24 underwent debulking surgery. Median OS for the entire cohort, excluding 2 pts with unknown survival time, was 2.2 years (95% CI 1.7 - 3.0). Male gender, increased age, worse PS, hepatitis C infection at time of SOT, and diagnosis in the earlier cohort were all associated with worse OS in univariate analysis (Table 1). Therapy was not associated with OS in this study. Median OS was longer in those pts diagnosed 2006 – 2011 compared with those diagnosed 1999-2005 (2.9 vs 1.7 years, p=0.04 Figure 1). In multivariable analysis increased age (adjusted HR (aHR) 1.2 per decade, 95% CI 1.1 - 1.5, p=0.009), PS < 80 (aHR 2.1, 95% CI 1.4 - 3.2, p<0.001) and diagnosis 1999-2005 compared with 2006-2011 (aHR 1.8, 95% CI 1.2 - 2.7, p=0.006) remained significantly associated with decreased OS. Excluding date of diagnosis from the multivariable model did not change effect estimates of other baseline characteristics. Conclusions To the best of our knowledge, this is the largest series of PTLD-MM reported to date. In contrast to prior reports (Blood 2013; 121: 1377-83, Haematologica, 2011; 96: 1067-71), outcomes of PTLD-MM were modest, with a median OS of only 2.2 years. Notably, OS has improved over time; those diagnosed in the latter half of our cohort had a 43% decrease in the risk of death compared to the earlier half. Trends in treatment and supportive care are likely to explain this improvement. Several prognostic factors identified pts with markedly divergent outcomes. Time from SOT to PTLD-MM was not associated with OS. Age and PS at diagnosis strongly predicted OS; risk of death increased by 20% for each decade of increased age, and doubled in pts with poor PS compared to those with preserved PS. Further examination of PTLD-MM is warranted to better understand these effects. Disclosures: No relevant conflicts of interest to declare.

Multicenter Quality Improvement Project to Prevent Sternal Wound Infections in Pediatric Cardiac Surgery Patients

2017 ◽  
Vol 8 (4) ◽  
pp. 453-459 ◽  
Author(s):  
Cathy Woodward ◽  
Richard Taylor ◽  
Minnette Son ◽  
Roozbeh Taeed ◽  
Marshall L. Jacobs ◽  
...  
Keyword(s):  
Cardiac Surgery ◽  
Quality Improvement ◽  
Heart Surgery ◽  
Congenital Heart Surgery ◽  
Wound Infections ◽  
Improvement Project ◽  
Sternal Closure ◽  
Increased Risk ◽  
Delayed Sternal Closure ◽  
Sternal Wound Infections

Background: Children undergoing cardiac surgery are at risk for sternal wound infections (SWIs) leading to increased morbidity and mortality. Single-center quality improvement (QI) initiatives have demonstrated decreased infection rates utilizing a bundled approach. This multicenter project was designed to assess the efficacy of a protocolized approach to decrease SWI. Methods: Pediatric cardiac programs joined a collaborative effort to prevent SWI. Programs implemented the protocol, collected compliance data, and provided data points from local clinical registries using Society of Thoracic Surgery Congenital Heart Surgery Database harvest-compliant software or from other registries. Results: Nine programs prospectively collected compliance data on 4,198 children. Days between infections were extended from 68.2 days (range: 25-82) to 130 days (range: 43-412). Protocol compliance increased from 76.7% (first quarter) to 91.3% (final quarter). Ninety (1.9%) children developed an SWI preprotocol and 64 (1.5%) postprotocol, P = .18. The 657 (15%) delayed sternal closure patients had a 5% infection rate with 18 (5.7%) in year 1 and 14 (4.3%) in year 2 P = .43. Delayed sternal closure patients demonstrated a trend toward increased risk for SWI of 1.046 for each day the sternum remained open, P = .067. Children who received appropriately timed preop antibiotics developed less infections than those who did not, 1.9% versus 4.1%, P = .007. Conclusion: A multicenter QI project to reduce pediatric SWIs demonstrated an extension of days between infections and a decrease in SWIs. Patients who received preop antibiotics on time had lower SWI rates than those who did not.

Minimization of Surgical Site Infections in Patients With Delayed Sternal Closure After Pediatric Cardiac Surgery

2019 ◽  
Vol 10 (4) ◽  
pp. 400-406 ◽  
Author(s):  
Mouhammad Yabrodi ◽  
Jeremy L. Hermann ◽  
John W. Brown ◽  
Mark D. Rodefeld ◽  
Mark W. Turrentine ◽  
...  
Keyword(s):  
Cardiac Surgery ◽  
Heart Surgery ◽  
Recent Literature ◽  
Surgical Site Infections ◽  
Congenital Heart Surgery ◽  
Infectious Complications ◽  
Pediatric Cardiac Surgery ◽  
Clinical Sepsis ◽  
Sternal Closure ◽  
Delayed Sternal Closure

Background: Delayed sternal closure (DSC) following pediatric cardiac surgery is commonly implemented at many centers. Infectious complications occur in 18.7% of these patients based on recent multicenter data. We aimed to describe our experience with DSC, hypothesizing that our practices surrounding the implementation and maintenance of the open sternum during DSC minimize the risk of infectious complications. Methods: We reviewed patients less than 365 days who underwent DSC between 2012 and 2016 at our institution. Infectious complications as defined by the Society of Thoracic Surgeons Congenital Heart Surgery Database were recorded. Patients with and without infectious complications were compared using Wilcoxon rank sum tests or Fisher exact tests as appropriate. Results: We identified 165 patients less than 365 days old who underwent DSC, 135 (82%) of whom had their skin closed over their open sternum. Median duration of open sternum was 3 days (range: 1-32 days). Infectious complications occurred in 15 (9.1%) patients—13 developed clinical sepsis with positive blood cultures, one patient developed ventilator-associated pneumonia, and one patient developed wound infection (0.6%). No cases of mediastinitis occurred. No statistical differences in characteristics between patients with and without infectious complications could be identified. Conclusion: Infectious complications after DSC at our institution were notably less than reported in recent literature, primarily due to minimization of surgical site infections. Practices described in the article, including closing skin over the open sternum whenever possible, could potentially aid other institutions aiming to reduce infectious complications associated with DSC.

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