Pulmonary support on day 30 as a predictor of morbidity and mortality in congenital diaphragmatic hernia.

PURPOSE: Congenital diaphragmatic hernia (CDH) is associated with significant in-hospital mortality, morbidity and length-of-stay (LOS). We hypothesized that the degree of pulmonary support on hospital day-30 may predict in-hospital mortality, LOS, and discharge oxygen needs and could be useful for risk prediction and counseling. METHODS: 862 patients in the CDH Study Group registry with a LOS ≥ 30 days were analyzed (2007-2010). Pulmonary support was defined as (1) room-air (n=320) (2) noninvasive supplementation (n=244) (3) mechanical ventilation (n=279) and (4) extracorporeal membrane oxygenation (ECMO, n=19). Cox Proportional hazards and logistic regression models were used to determine the case-mix adjusted association of oxygen requirements on day-30 with mortality and oxygen requirements at discharge. RESULTS: On multivariate analysis, use of ventilator (HR 5.1, p=.003) or ECMO (HR 19.6, p<.001) was a significant predictor of in-patient mortality. Need for non-invasive supplementation or ventilator on day-30 was associated with a respective 22-fold (p<.001) and 43-fold (p<.001) increased odds of oxygen use at discharge compared to those on room-air. CONCLUSIONS: Pulmonary support on Day-30 is a strong predictor of length of stay, oxygen requirements at discharge and in-patient mortality and may be used as a simple prognostic indicator for family counseling, discharge planning, and identification of high-risk infants.

Factors associated with survival in patients who undergo peritoneal dialysis catheter placement following cardiac surgery.

PURPOSE: Pediatric post-cardiac surgery patients are at risk for acute kidney injury and intraabdominal hypertension. The present study assesses indications and outcomes of postoperative peritoneal dialysis catheter (PDC) placement in this population. METHODS: We retrospectively reviewed single-institution patients who underwent PDC placement post-cardiac surgery between 1999 and 2011 (n=55). Baseline, clinical course, and outcome data were recorded pre- and post-PDC. We used multivariable logistic and Cox analyses to assess factors associated with mortality. RESULTS: In-hospital mortality of the study cohort was 67.3% (n=37). Peritoneal dialysis was performed in 21 patients (38.2%). Five patients (9.1%) experienced adverse events related to PDC placement. Greater post-PDC decreases in abdominal girth (adjusted odds ratio [OR]=2.43; P=0.02) and BUN (OR=1.06; P=0.04) were associated with survival. Additionally, preoperative ventilator independence (hazard ratio [HR]=1.18; P<0.01) and lower creatinine (HR=8.32; P<0.01), as well as greater post-PDC decrease in inotrope score (HR=1.33; P<0.02) were associated with survival. CONCLUSIONS: In-hospital mortality of the study cohort was 67%. Less severe pre-PDC renal impairment, increased pre-PDC abdominal girth, and greater post-PDC improvement of abdominal girth, renal function, and inotrope requirements were associated with survival. Prospective trials are needed to assess appropriate indications and timing of PDC placement, with consideration of more aggressive treatment for intraabdominal hypertension.

Characterizing peritoneal dialysis catheter use in pediatric patients after cardiac surgery.

OBJECTIVE: Children who undergo cardiac surgery are at high risk for renal insufficiency and abdominal compartment syndrome. Peritoneal dialysis catheter (PDC) implantation is used in this population for abdominal decompression and access for dialysis. However, there is no consensus regarding PDC use, and the practice varies widely. This study was undertaken to assess associated factors, outcomes, and variability in the use of PDC in patients who have undergone cardiac surgery. METHODS: The cohort was obtained from the Kids' Inpatient Database, years 2006 and 2009. Patients who underwent cardiac surgery were included and the subset that underwent PDC implantation during the same hospitalization was identified. Univariable and multivariable analyses assessed factors associated with PDC and survival. RESULTS: A cohort of 28,259 patients underwent cardiac surgery, of whom 558 (2%) had PDCs placed. In the PDC group, 39.1% (n = 218) had acute renal failure whereas 3.5% or patients (n = 974) in the non-PDC group had acute renal failure. Among patients receiving PDC, mortality was 20.3% (n = 113; vs 3.4% overall mortality, n = 955). Excluding patients with acute renal failure, mortality remained 12% (n = 41) for the PDC group. Factors associated significantly with PDC placement in the overall cohort were younger age, greater surgical complexity, nonelective admission, hospital region, use of cardiopulmonary bypass, and acute renal failure. CONCLUSIONS: Patients receiving PDC after cardiac surgery had 20% mortality, which remained 12% after excluding patients with acute renal failure. Given the variability in PDC use and poor outcomes, further research is needed to assess the possible benefit of earlier intervention for peritoneal access in this high-risk cohort.

Use of negative pressure wound therapy for abdominal wounds in neonates and infants.

BACKGROUND: Negative pressure wound therapy (NPWT) is an established and effective tool in the management of complicated abdominal wounds. This management approach has been used in infants, but few large series reports exist in the literature. METHODS: The outcomes of infants with abdominal wounds receiving NPWT over the last 10 years at our institution were evaluated. Overall survival, time between initiation of NPWT, and discharge/death were examined. RESULTS: We identified 18 infants who had abdominal wounds treated with NPWT. Diagnoses were varied, as was the duration of therapy. The median NPWT duration of treatment was 34.0 ± 92.1 days. Forty-four percent of the infants had a stoma before application of NPWT, and 22% of the infants had enterocutaneous fistulas before use of NPWT. There were only 2 cases in which a new fistula developed during the use of NPWT, and both of these omphalopagus conjoined twins had undergone the Bianchi procedure. No additional NPWT-related complications were identified. Of 18 infants, 6 died in this cohort. CONCLUSION: Negative pressure wound therapy is an important therapeutic tool for the management of abdominal wounds in infants.

Does the ex utero intrapartum treatment to extracorporeal membrane oxygenation procedure change outcomes for high-risk patients with congenital diaphragmatic hernia?

PURPOSE: In the most severe cases of congenital diaphragmatic hernia (CDH), significant barotrauma or death can occur before advanced therapies such as extracorporeal membrane oxygenation (ECMO) can be initiated. We have previously examined the use of the ex utero intrapartum treatment (EXIT) to ECMO procedure (EXIT with placement on ECMO) in high-risk infants and reported a survival advantage. We report our experience with EXIT to ECMO in a more recent cohort of our patients with most severe CDH. METHODS: Every patient with less than 15% predicted lung volume during January 2005 to December 2010 was included. We obtained data on prenatal imaging, size and location of the defect, and survival. RESULTS: Seventeen high-risk infants were identified. All 17 (100%) received ECMO and required a patch. Six children were delivered by EXIT to ECMO, and only 2 (33%) survived. An additional patient was delivered by EXIT to intubation with ECMO on standby and died. Of the 10 children who did not receive EXIT, 5 (50%) survived. CONCLUSIONS: No clear survival benefit with the use of the EXIT to ECMO procedure was demonstrated in this updated report of our high-risk CDH population. The general application of EXIT to ECMO for CDH is not supported by our results.

Twelve hundred abscesses operatively drained: an antibiotic conundrum?

BACKGROUND: The incidence of soft tissue infections from antimicrobial-resistant pathogens is increasing. This study evaluated the epidemiology of operatively drained soft tissue abscesses. METHODS: This retrospective study evaluated 1,200 consecutive patients from 2002 to 2008 who underwent incision and drainage (I&D) in the main operating room. Patients were excluded for perirectal or hidradenitis infections. RESULTS: Of 1,200 consecutive cases with an I&D, 1,005 patients had intraoperative cultures. The 1,817 positive isolates included gram-positive aerobes (1,180 [65%]), gram-negative aerobes (207 [11%]), anaerobes (416 [23%]), and fungi (14 [1%]). The most prevalent organism was Staphylococcus aureus, 30% (536), with 80% (431) being methicillin-resistant S aureus (MRSA). MRSA was the predominant organism in all except the breast abscesses. Anaerobes were identified primarily in the breast in diabetics, and in trunk and extremity abscesses in intravenous drug users. The most frequently prescribed empiric antibiotic was ampicillin/sulbactam (66%). The initial empiric antibiotic did not cover MRSA (82%; P < .001), resistant gram-negative aerobes (24%), and anaerobes (26%). CONCLUSION: Gram-positive aerobes plus anaerobes represented approximately 80% of the pathogens in our series, with the anaerobic rates being underestimated. Empiric antibiotics should cover MRSA and anaerobes in patients with superficial abscesses drained operatively.