Factors associated with emergency department length of stay of foreign patients visiting a regional core hospital in Japan.

Aim: This study aims to elucidate the foreign patient-specific factors associated with emergency department length of stay (EDLOS) in a regional core hospital emergency department (ED) in Japan. Methods: This retrospective observational study included non-Japanese patients who visited the ED in a Japanese regional core hospital between April 1, 2018, and March 31, 2020. The effects on EDLOS were assessed using multivariate linear regression analysis, which included factors such as age, sex, consultation language, interpreter usage, arrival time, day of visit, mode of arrival, underlying disease, triage level, diagnosis of injury/noninjury, diagnostic investigations, consultation with specialists, and treatments or procedures. Results: Of 65,297 ED patients, there were 777 study patients, with a median age of 37 years (interquartile range [IQR], 24.0-50.0). The median EDLOS was 101 min (IQR, 63.0-153.0). Multivariate linear regression analysis indicated that an extended EDLOS was associated with: language apart from Japanese, Chinese, or English (51.7 min; 95% confidence interval [CI], 17.8-85.6), helicopter arrival (115.6 min; 95% CI, 48.8-182.5), blood testing (60.5 min; 95% CI, 34.6-86.4), computed tomography (23.8 min; 95% CI, 3.7-43.9), consultation with specialists (36.2 min; 95% CI, 11.8-60.6), intravenous fluid/medication (29.7 min; 95% CI, 3.3-56.1), and surgical procedure/reduction/fixation in the ED (38.8 min; 95% CI, 14.2-63.4). Conclusions: Consultation in a language other than Japanese, English, or Chinese was associated with a longer EDLOS in a regional core hospital in Japan. Devising ways to accommodate patients who speak various languages could be important.

Antibiotic Prophylaxis for Open Chest Management After Pediatric Cardiac Surgery.

OBJECTIVES: Although open chest management optimizes hemodynamics after cardiac surgery, it increases postoperative infections and leads to increased mortality. Despite the importance of antibiotic prophylaxis during open chest management, no specific recommendations exist. We aimed to compare the occurrence rates of bloodstream infection and surgical site infection between the different prophylactic antibiotic regimens for open chest management after pediatric cardiac surgery. DESIGN: Retrospective, single-center, observational study. SETTING: PICU at a tertiary children's hospital. PATIENTS: Consecutive patients younger than or equal to 18 years old with open chest management after cardiac surgery followed by delayed sternal closure, between January 2012 and June 2018. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: We compared the composite occurrence rate of postoperative bloodstream infection and surgical site infection within 30 days after cardiac surgery between three prophylactic antibiotic regimens: 1) cefazolin, 2) cefazolin + vancomycin, and 3) vancomycin + meropenem. In 63 pediatric cardiac surgeries with open chest management, 17 bloodstream infections, and 12 surgical site infections were identified postoperatively. The composite occurrence rates of bloodstream infection and surgical site infection were 10 of 15 (67%), 10 of 19 (53%), and nine of 29 (31%) in the cefazolin, cefazolin + vancomycin, and vancomycin + meropenem regimens, respectively (p = 0.07). After adjusting for age, open chest management duration, extracorporeal membrane oxygenation use, and nasal methicillin-resistant Staphylococcus aureus colonization in multivariable analysis, there was no significant difference between the cefazolin and the cefazolin + vancomycin regimens (p = 0.19), while the vancomycin + meropenem regimen had a lower occurrence rate of bloodstream infection and surgical site infection than the cefazolin regimen (odds ratio, 0.0885; 95% CI, 0.0176-0.446; p = 0.003). CONCLUSIONS: In this study, a lower occurrence rate of postoperative bloodstream infection and surgical site infection was observed among patients with broad-spectrum antibiotic regimen after pediatric cardiac surgery with open chest management. Further studies, ideally randomized controlled studies investigating the efficacy of broad-spectrum antibiotics and their complications, are warranted before routine implementation of broad-spectrum prophylactic antibiotic regimen.

Risk Factors for Healthcare-Associated Infections After Pediatric Cardiac Surgery.

OBJECTIVES: Healthcare-associated infections after pediatric cardiac surgery are significant causes of morbidity and mortality. We aimed to identify the risk factors for the occurrence of healthcare-associated infections after pediatric cardiac surgery. DESIGN: Retrospective, single-center observational study. SETTING: PICU at a tertiary children's hospital. PATIENTS: Consecutive pediatric patients less than or equal to 18 years old admitted to the PICU after cardiac surgery, between January 2013 and December 2015. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: All the data were retrospectively collected from the medical records of patients. We assessed the first surgery during a single PICU stay and identified four common healthcare-associated infections, including bloodstream infection, surgical site infection, pneumonia, and urinary tract infection, according to the definitions of the Centers for Disease Control and Prevention and National Healthcare Safety Network. We assessed the pre-, intra-, and early postoperative potential risk factors for these healthcare-associated infections via multivariable analysis. In total, 526 cardiac surgeries (394 patients) were included. We identified 81 cases of healthcare-associated infections, including, bloodstream infections (n = 30), surgical site infections (n = 30), urinary tract infections (n = 13), and pneumonia (n = 8). In the case of 71 of the surgeries (13.5%), at least one healthcare-associated infection was reported. Multivariable analysis indicated the following risk factors for postoperative healthcare-associated infections: mechanical ventilation greater than or equal to 3 days (odds ratio, 4.81; 95% CI, 1.89-12.8), dopamine use (odds ratio, 3.87; 95% CI, 1.53-10.3), genetic abnormality (odds ratio, 2.53; 95% CI, 1.17-5.45), and delayed sternal closure (odds ratio, 3.78; 95% CI, 1.16-12.8). CONCLUSIONS: Mechanical ventilation greater than or equal to 3 days, dopamine use, genetic abnormality, and delayed sternal closure were associated with healthcare-associated infections after pediatric cardiac surgery. Since the use of dopamine is an easily modifiable risk factor, and may serve as a potential target to reduce healthcare-associated infections, further studies are needed to establish whether dopamine negatively impacts the development of healthcare-associated infections.

Predicting extubation readiness by monitoring the electrical activity of the diaphragm after prolonged mechanical ventilation: a pediatric case report.

BACKGROUND: The intensity of the electrical activity of the diaphragm (Edi) correlates with inspiratory effort. The ratio of tidal volume to the Edi is known as neuroventilatory efficiency (NVE) and is used as an index for ventilation efficiency. Here, we present a case showing that Edi and NVE may be effective parameters to predict successful extubation. CASE PRESENTATION: A 6-month-old female infant required prolonged mechanical ventilation after cardiac surgery. Fifty-two days after surgery, her trachea was extubated but required reintubation. Edi monitoring was initiated to assess diaphragm function. The Edi was > 70 mcV just after the reintubation, and her NVE was 1.0 mL/mcV, but gradually decreased. On day 59, her Edi values during the spontaneous breathing trials were 13 mcV with the improvement of NVE (2.5 mL/mcV) and her trachea was extubated without complications. CONCLUSIONS: The Edi and NVE were valuable for deciding the extubation readiness in a long-term mechanically ventilated patient.

Elevated Central Venous to Arterial CO2 Difference Is Not Associated With Poor Clinical Outcomes After Cardiac Surgery With Cardiopulmonary Bypass in Children.

OBJECTIVE: To investigate whether elevated central venous to arterial CO2 difference is associated with delayed extubation and prolonged ICU stay in children after cardiac surgery with cardiopulmonary bypass. DESIGN: Retrospective review of medical records. SETTING: PICU in a tertiary children's hospital. PATIENTS: Pediatric patients younger than 18 years old who underwent cardiac surgery with cardiopulmonary bypass between January 2014 and December 2014. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: In total, 114 patients were included in this study. On ICU admission, blood samples were obtained simultaneously from an arterial line and a central venous line. There were no strong correlations between central venous to arterial CO2 difference (median, 11.1 [8.4-13] mm Hg) and other commonly used variables for the assessment of oxygen delivery including arteriovenous oxyhemoglobin saturation difference (R = 0.16) and blood lactate concentration (R = 0.02). When the patients were divided into two groups, based on the CO2 difference, the high group (difference ≥ 6 mm Hg; n = 103 [90%]) and the low group (difference < 6 mm Hg; n = 11 [10%]) showed no difference in the time to extubation (6 vs 5 hr, respectively; p = 0.80) or in the time to discharge from ICU (4 vs 5 d, respectively; p = 0.49). There was no mortality within 30 days of surgery. CONCLUSIONS: Elevation of central venous to arterial CO2 difference on ICU admission in children after cardiac surgery with cardiopulmonary bypass does not appear to be associated with delayed extubation or prolonged ICU stay.