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1.
Br J Oral Maxillofac Surg ; 59(6): 683-689, 2021 07.
Artigo em Inglês | MEDLINE | ID: mdl-34001379

RESUMO

We performed a systematic review of the literature about descending necrotising mediastinitis (DNM) of odontogenic origin. In parallel, a retrospective review of this pathology was carried out in an Oral and Maxillofacial Surgery Service of a reference hospital for a population of 1,100,000 inhabitants. The main objectives were to determine changes in mortality and prevalence of this serious complication. The systematic review included 51 articles with 89 patients and our study comprised seven patients. The period of time with the highest number of cases was between 2000-2009 (38 patients). The percentage of mortality observed was 20.2% in diffuse DNM and 4.9% in localised DNM. Thirty-one patients with DNM in our review were admitted for more than 41 days. Despite evidence of a decrease in DNM cases, publications have increased over the years, but it does not appear to be due to an increase in those of odontogenic origin. The survival of DNM has improved since 1998 and remained stable since then. Despite the low prevalence of this disease, multicentre control studies are needed to achieve better evidence about this entity.


Assuntos
Mediastinite , Drenagem , Humanos , Mediastinite/epidemiologia , Mediastinite/etiologia , Necrose , Estudos Retrospectivos
2.
Ann R Coll Surg Engl ; 103(3): 208-217, 2021 Mar.
Artigo em Inglês | MEDLINE | ID: mdl-33645267

RESUMO

INTRODUCTION: Tonsillectomy is a common surgical procedure performed chiefly for recurrent tonsillitis. The Scottish Intercollegiate Guidance Network (SIGN) introduced guidelines in 1998 to improve patient selection for tonsillectomy and reduce the potential harm to patients from surgical complications such as haemorrhage. Since the introduction of the guidance, the number of admissions for tonsillitis and its complications has increased. National Hospital Episode Statistics over a 20-year period were analysed to assess the trends in tonsillectomy, post-tonsillectomy haemorrhage, tonsillitis and its complications with reference to the guidance, procedures of limited clinical value and the associated costs and benefits. MATERIALS AND METHODS: A literature search was conducted via PubMed and the Cochrane Library to identify relevant research. Hospital Episode Statistics data were interrogated and relevant data compared over time to assess trends related to the implementation of national guidance. RESULTS: Over the period analysed, the incidence of deep neck space infections has increased almost five-fold, mediastinitis ten-fold and peritonsillar abscess by 1.7-fold compared with prior to SIGN guidance. Following procedures of limited clinical value implementation, the incidence of deep neck space infections has increased 2.4-fold, mediastinitis 4.1-fold and peritonsillar abscess 1.4-fold compared with immediately prior to clinical commissioning group rationing. The rate of tonsillectomy and associated haemorrhage (1-2%) has remained relatively constant at 46,299 (1999) compared with 49,447 (2009) and 49,141 (2016), despite an increase in the population of England by seven million over the 20-year period. DISCUSSION: The rise in admissions for tonsillitis and its complications appears to correspond closely to the date of SIGN guidance and clinical commissioning group rationing of tonsillectomy and is on the background of a rise in the population of the UK. The move towards daycase tonsillectomy has reduced bed occupancy after surgery but this has been counteracted by an increase in admissions for tonsillitis and deep neck space infections, sometimes requiring lengthy intensive care stays and a protracted course of rehabilitation. The total cost of treating the complications of tonsillitis in England in 2017 is estimated to be around £73 million. The cost of tonsillectomy and treating post-tonsillectomy haemorrhage is £56 million by comparison. The total cost per annum for tonsillectomy prior to the introduction of SIGN guidance was estimated at £71 million with tonsillitis and its complications accounting for a further £8 million.


Assuntos
Hospitalização/tendências , Mediastinite/epidemiologia , Abscesso Peritonsilar/epidemiologia , Hemorragia Pós-Operatória/epidemiologia , Abscesso Retrofaríngeo/epidemiologia , Tonsilectomia/tendências , Tonsilite/epidemiologia , Adenoidectomia/tendências , Adolescente , Adulto , Distribuição por Idade , Idoso , Idoso de 80 Anos ou mais , Criança , Pré-Escolar , Inglaterra/epidemiologia , Feminino , Custos de Cuidados de Saúde/tendências , Humanos , Incidência , Lactente , Recém-Nascido , Unidades de Terapia Intensiva , Tempo de Internação/tendências , Masculino , Pessoa de Meia-Idade , Guias de Prática Clínica como Assunto , Medicina Estatal , Tonsilite/cirurgia , Adulto Jovem
3.
J Thorac Cardiovasc Surg ; 162(4): 1125-1130.e1, 2021 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-32386766

RESUMO

OBJECTIVES: Perioperative bacterial decolonization and prophylactic antibiotic therapy at the Veterans Affairs Health Care System have changed over the past decade. Our objectives were to identify associated changes in the microbiology of mediastinitis and to perform a contemporary survival analysis in patients with mediastinitis after isolated coronary artery bypass grafting procedure. METHODS: From January 2006 to December 2015, 45,323 consecutive patients underwent coronary artery bypass grafting at 83 medical centers. The Veterans Affairs Health Care System nationwide administrative database was queried to identify patients with postoperative mediastinitis and obtain patient-level data. Simple descriptive statistics and multivariable logistic regression were used to analyze microbiologic data and identify risk factors for infection. Poisson regression was used to determine yearly incidence estimates. Cox proportional hazard model identified predictors of long-term survival from date of operation. RESULTS: During the study period, 348 patients (0.78%) developed postoperative mediastinitis-with a stable rate of incidence (Cochrane-Armitage test, P = .69). Of patients with microbiologic data, 75.5% of infections (n = 188) were caused by gram-positive and 24.5% (n = 61) gram-negative organisms. The incidence of methicillin-resistant Staphylococcus aureus mediastinitis decreased during the study period (Cochrane-Armitage test, P = .013). Gram-negative mediastinitis occurred earlier than gram-positive mediastinitis (median, 15.0 vs 25.0 days; P < .0001). Patients with mediastinitis did not have increased 30-day mortality (2.0% vs 1.9%; P = .9), but had worse long-term survival compared with uninfected patients (P < .0001). CONCLUSIONS: The incidence of methicillin-resistant S aureus mediastinitis has decreased over the past decade. Gram-negative bacteria are responsible for 1 in 4 cases of mediastinitis and infection is diagnosed earlier in the postoperative period than gram-positive mediastinitis. These findings highlight the need for efforts to prevent gram-negative and methicillin-susceptible S aureus mediastinitis.


Assuntos
Antibioticoprofilaxia/métodos , Ponte de Artéria Coronária/efeitos adversos , Mediastinite , Staphylococcus aureus Resistente à Meticilina/isolamento & purificação , Complicações Pós-Operatórias , Infecções Estafilocócicas , Infecção da Ferida Cirúrgica , Idoso , Ponte de Artéria Coronária/métodos , Feminino , Humanos , Incidência , Masculino , Mediastinite/epidemiologia , Mediastinite/etiologia , Mediastinite/microbiologia , Mediastinite/terapia , Pessoa de Meia-Idade , Avaliação de Resultados em Cuidados de Saúde , Complicações Pós-Operatórias/mortalidade , Complicações Pós-Operatórias/prevenção & controle , Modelos de Riscos Proporcionais , Infecções Estafilocócicas/epidemiologia , Infecções Estafilocócicas/etiologia , Infecções Estafilocócicas/prevenção & controle , Infecção da Ferida Cirúrgica/microbiologia , Infecção da Ferida Cirúrgica/prevenção & controle , Estados Unidos/epidemiologia , Saúde dos Veteranos/estatística & dados numéricos
4.
Am J Cardiol ; 134: 41-47, 2020 11 01.
Artigo em Inglês | MEDLINE | ID: mdl-32900469

RESUMO

The benefit of bilateral mammary artery (BIMA) use during coronary artery bypass grafting (CABG) continues to be debated. This study examined nationwide trends in BIMA use and factors influencing its utilization. Using the National Inpatient Sample, adults undergoing isolated multivessel CABG between 2005 and 2015 were identified and stratified based on the use of a single mammary artery or BIMA. Regression models were fit to identify patient and hospital level predictors of BIMA use and characterize the association of BIMA on outcomes including sternal infection, mortality, and resource utilization. An estimated 4.5% (n = 60,698) of patients underwent CABG with BIMA, with a steady increase from 3.8% to 5.0% over time (p<0.001). Younger age, male gender, and elective admission, were significant predictors of BIMA use. Moreover, private insurance was associated with higher odds of BIMA use (adjusted odds ratio 1.24) compared with Medicare. BIMA use was not a predictor of postoperative sternal infection, in-hospital mortality, or hospitalization costs. Overall, BIMA use remains uncommon in the United States despite no significant differences in acute postoperative outcomes. Several patient, hospital, and socioeconomic factors appear to be associated with BIMA utilization.


Assuntos
Ponte de Artéria Coronária/métodos , Doença da Artéria Coronariana/cirurgia , Mortalidade Hospitalar , Artéria Torácica Interna/transplante , Complicações Pós-Operatórias/epidemiologia , Distribuição por Idade , Idoso , Feminino , Custos Hospitalares/estatística & dados numéricos , Hospitais Rurais/estatística & dados numéricos , Hospitais de Ensino/estatística & dados numéricos , Hospitais Urbanos/estatística & dados numéricos , Humanos , Tempo de Internação/estatística & dados numéricos , Masculino , Mediastinite/epidemiologia , Pessoa de Meia-Idade , Respiração Artificial/estatística & dados numéricos , Distribuição por Sexo , Acidente Vascular Cerebral/epidemiologia , Infecção da Ferida Cirúrgica/epidemiologia , Estados Unidos/epidemiologia
5.
Rev. Pesqui. (Univ. Fed. Estado Rio J., Online) ; 12: 971-976, jan.-dez. 2020. graf, tab
Artigo em Inglês, Português | LILACS, BDENF - Enfermagem | ID: biblio-1119071

RESUMO

Objetivos: Identificar os fatores de risco pré e pós-operatórios relacionados ao desenvolvimento de mediastinite entre pacientes submetidos à cirurgia cardíaca em um hospital da cidade do Rio de Janeiro, caracterizar a população estudada e analisar a relação entre os fatores de risco e a incidência de mediastinite nos pacientes submetidos à cirurgia cardíaca. Método: Estudo descritivo, abordagem quantitativa, em que foram identificados os fatores de risco para mediastinite em pacientes que realizaram cirurgia cardíaca em um hospital do Rio de Janeiro. Resultados: Obteve-se um n de 192 pacientes, de maioria homens, na faixa etária de 50 a 69 anos e em sobrepeso. Diabetes mellitus e tabagismo foram as comorbidades mais frequentes, e CRVMC a cirurgia mais realizada, 4 pacientes apresentaram mediastinite. Conclusão: A identificação destes fatores contribui para elaboração de estratégias de prevenção para mediastinite, e na implementação de cuidados de enfermagem no pré e pós-operatório de cirurgias cardíacas


Objectives: To identify pre and postoperative risk factors related to the development of mediastinitis among patients submitted to cardiac surgery at a hospital in the city of Rio de Janeiro, to characterize the study population and to analyze the relationship between risk factors and the incidence of mediastinitis in patients undergoing cardiac surgery. Method: descriptive study, quantitative approach, in which the risk factors for mediastinitis were identified in patients who underwent cardiac surgery in a hospital in Rio de Janeiro. Results: a n of 192 patients, mostly males, aged 50 to 69 years and overweight were obtained. Diabetes mellitus and smoking were the most frequent comorbidities, and CRVMC the most performed surgery, 4 patients had mediastinitis. Conclusion: the identification of these factors contributes to the elaboration of prevention strategies for mediastinitis, and the implementation of nursing care in the pre and postoperative period of cardiac surgeries


Objetivos: Identificar los factores de riesgo pre y postoperatorios relacionados al desarrollo de mediastinitis entre pacientes sometidos a la cirugía cardiaca en un hospital de la ciudad de Río de Janeiro, caracterizar a la población estudiada y analizar la relación entre los factores de riesgo y la incidencia de mediastinitis en los pacientes sometidos a la cirugía cardiaca. Método: Estudio descriptivo, abordaje cuantitativo, en que se identificaron los factores de riesgo para la mediastinitis en pacientes que realizaron una intervención cardiaca en un hospital de Río de Janeiro. Resultados: Se obtuvo un n de 192 pacientes, de mayoría hombres, en el grupo de edad de 50 a 69 años y en sobrepeso. La diabetes mellitus y el tabaquismo fueron las comorbilidades más frecuentes, y CRVMC la cirugía más realizada, 4 pacientes presentaron mediastinitis. Conclusión: La identificación de estos factores contribuye a la elaboración de estrategias de prevención para la mediastinitis, y en la implementación de cuidados de enfermería en el pre y postoperatorio de cirugías cardíacas


Assuntos
Humanos , Masculino , Feminino , Criança , Adolescente , Adulto , Pessoa de Meia-Idade , Idoso , Complicações Pós-Operatórias/prevenção & controle , Cirurgia Torácica/estatística & dados numéricos , Mediastinite/epidemiologia , Complicações Pós-Operatórias/epidemiologia , Infecção da Ferida Cirúrgica/complicações , Estudos Retrospectivos , Fatores de Risco , Mediastinite/complicações
6.
Heart Surg Forum ; 22(5): E385-E389, 2019 Sep 16.
Artigo em Inglês | MEDLINE | ID: mdl-31596717

RESUMO

BACKGROUND: The aim of this study was to evaluate the frequency of postoperative complications in patients who underwent coronary artery bypass grafting (CABG) and simultaneous carotid endarterectomy (CEA) and find predictors of postoperative complications. METHODS: We retrospectively evaluated 86 patients after simultaneous CABG and CEA. Inclusion criteria were: patients with asymptomatic carotid stenosis with a reduction of the carotid lumen diameter of more than 70% detected with Doppler ultrasound and diagnosed with one, two, or three vessel coronary artery disease with coronary stenosis more than 75% and hemodynamic significant stenosis of the left main artery. Exclusion criteria were patients with urgent and previous cardiac surgery and patients with myocardial infarction and stroke in the past one month. We monitored preoperative (ejection fraction, coronarography status), operative (number of grafts, on-pump or off-pump technique) and postoperative (extubation, unit care and hospital stay, bleeding and reoperation) details and complications (myocardial infarction, neurological events, inotropic agents and transfusion requiry, infection, arrhythmic complication, renal failure, mortality). RESULTS: Postoperative complications were observed in 18 (29.9%) patients. Two patients (2.3%) had postoperative stroke and one patient (1.2%) had transient ischemic attack (TIA). Previous stroke was a predictor for increased postoperative neurological events (P < .05). Intrahospital mortality was 8.1%. CONCLUSION: Simultaneous CEA and CABG were performed with low rates of stroke and TIA. Previous stroke was identified as a predictor for increased postoperative neurological complications.


Assuntos
Estenose das Carótidas/cirurgia , Ponte de Artéria Coronária/efeitos adversos , Estenose Coronária/cirurgia , Endarterectomia das Carótidas/efeitos adversos , Complicações Pós-Operatórias/etiologia , Idoso , Arritmias Cardíacas/epidemiologia , Arritmias Cardíacas/etiologia , Doenças Assintomáticas , Estenose das Carótidas/complicações , Causas de Morte , Comorbidade , Estenose Coronária/complicações , Feminino , Humanos , Ataque Isquêmico Transitório/epidemiologia , Ataque Isquêmico Transitório/etiologia , Masculino , Mediastinite/epidemiologia , Mediastinite/etiologia , Complicações Pós-Operatórias/epidemiologia , Hemorragia Pós-Operatória/epidemiologia , Hemorragia Pós-Operatória/etiologia , Insuficiência Renal/epidemiologia , Insuficiência Renal/etiologia , Estudos Retrospectivos , Acidente Vascular Cerebral/epidemiologia , Acidente Vascular Cerebral/etiologia
7.
Scand Cardiovasc J ; 53(5): 226-234, 2019 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-31290699

RESUMO

Objective. We aimed to summarize the evidence from observational studies examining the risk factors of the incidence of mediastinitis in open heart surgery. Design. The study was a systematic review and meta-analysis of cohorts and case-control studies. Material and methods. We searched the literature and 74 studies with at least one risk factor were identified. Both fixed and random effects models were used. Heterogeneity between studies was examined by subgroup and meta-regression analysis. Publication bias or small study effects were evaluated and corrected by limit meta-analysis. Results. When correcting for small study effect, presence of obesity as estimated from 43 studies had Odds Ratio OR = 2.26. (95% CI: 2.17-2.36). This risk was increasing with decreasing latitude of study place. Presence of diabetes mellitus from 63 studies carried an OR = 1.90 (95% CI: 1.59-2.27). Presence of Chronic Obstructive Pulmonary Disease (COPD) from 30 studies had an OR = 2.59 (95% CI: 2.22-2.85). Presence of bilateral intramammary graft (BIMA) from 23 studies carried an OR = 2.54 (95% CI: 2.07-3.13). This risk was increasing with increasing frequency of female patients in the study population. Conclusion. Evidence from this study showed the robustness of the risk factors in the pathogenesis of mediastinitis. Preventive measures can be implemented for reducing obesity, especially in lower latitude countries. Furthermore, it is mandatory to monitor perioperative hyperglycemias with continuous insulin infusion. Use of skeletonized BIMA carries higher risk of mediastinitis especially in female patients without evidence of beneficial effect on survival for the time being.


Assuntos
Ponte de Artéria Coronária/efeitos adversos , Mediastinite/epidemiologia , Comorbidade , Humanos , Incidência , Mediastinite/diagnóstico , Estudos Observacionais como Assunto , Medição de Risco , Fatores de Risco , Fatores Sexuais , Resultado do Tratamento
8.
Innovations (Phila) ; 14(4): 291-298, 2019 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-31185776

RESUMO

OBJECTIVE: The management of concomitant mild-to-moderate aortic stenosis (AS) at the time of coronary artery bypass graft (CABG) is controversial. Here we perform a systematic review and meta-analysis of CABG and aortic valve replacement (AVR) versus CABG alone in patients with mild-moderate AS. METHODS: We searched MEDLINE and EMBASE databases until July 2018 for studies comparing CABG & AVR versus CABG in patients with mild-moderate AS undergoing coronary bypass. Data were extracted by 2 independent investigators. The main outcomes were operative mortality, long-term survival, and reintervention for AS. RESULTS: There were 6 unmatched retrospective observational studies with 1,172 patients (median follow-up 4.7 [interquartile range: 4.3 to 5.3] years). Patients undergoing CABG & AVR had less severe coronary artery disease. There were no differences in operative mortality (relative risk [RR]: 1.07; 95% CI, 0.59 to 1.94; P = 0.8). CABG & AVR was associated with greater incidence of stroke, bleeding, renal failure, and mediastinitis. At median follow-up of 5 years, there was no difference in long-term mortality (incidence rate ratio [IRR]:1.44; 95% CI, 0.83 to 2.51; P = 0.19), but CABG & AVR was associated with 73% lower risk of reoperation for AS (n = 13/485 versus n = 71/702; IRR: 0.27; 95% CI, 0.14 to 0.51; P < 0.001). CONCLUSIONS: In patients undergoing CABG with mild-moderate AS, combining AVR with CABG was associated with no difference in operative mortality but with increased risk of stroke, bleeding, renal failure, and mediastinitis. Long-term mortality was not different, but a risk of reoperation for AS at 5 years was 73% lower. Given the increasingly wide availability and safety of transcatheter aortic valve replacement (TAVR), one may consider a conservative approach toward concomitant mild-moderate AS.


Assuntos
Estenose da Valva Aórtica/cirurgia , Ponte de Artéria Coronária/métodos , Doença da Artéria Coronariana/cirurgia , Implante de Prótese de Valva Cardíaca/métodos , Estenose da Valva Aórtica/complicações , Doença da Artéria Coronariana/complicações , Humanos , Mediastinite/epidemiologia , Complicações Pós-Operatórias/epidemiologia , Hemorragia Pós-Operatória/epidemiologia , Insuficiência Renal/epidemiologia , Índice de Gravidade de Doença , Acidente Vascular Cerebral/epidemiologia
9.
Rev Gaucha Enferm ; 40: e20180200, 2019 Jun 19.
Artigo em Português, Inglês | MEDLINE | ID: mdl-31241655

RESUMO

OBJECTIVE: Verifying the clinical-surgical profile and the results of patients monitored in an surgical wound ambulatory after a cardiac surgeries. METHODS: This is a historical cohort research with patients submitted to cardiac surgery and monitored for a year in an outpatient surgical wound clinic from a hospital specialized in cardiology. The study analyzed the prevalent microorganisms in infections, the products used in the dressings, the time of follow-up, and the type of therapy established in the dressings. RESULTS: Among the 150 patients, most were sexagenarians (61.7 ± 11.4 years), hypertensive patients (75%), and diabetic (44.7%). There were 12 patients with mediastinitis (8%) and 44 with surgical site infection (29.3%). Fatty acids (80%) and calcium alginate (19%) were used for wound healing. The mean follow-up time was 35 ± 71 days. CONCLUSION: Sexagenary, hypertensive, diabetic and revascularized patients constituted the population monitored in the wounds outpatient clinic. The SSI and mediastinitis rates found were acceptable and similar to those in literature.


Assuntos
Bandagens , Procedimentos Cirúrgicos Cardíacos/efeitos adversos , Infecção da Ferida Cirúrgica/microbiologia , Infecção da Ferida Cirúrgica/terapia , Idoso , Alginatos/uso terapêutico , Instituições de Assistência Ambulatorial , Estudos de Coortes , Diabetes Mellitus/epidemiologia , Ácidos Graxos Essenciais/uso terapêutico , Feminino , Seguimentos , Humanos , Hipertensão/epidemiologia , Masculino , Mediastinite/epidemiologia , Pessoa de Meia-Idade , Veia Safena/cirurgia , Esternotomia/efeitos adversos , Infecção da Ferida Cirúrgica/epidemiologia , Cicatrização
10.
J Card Surg ; 34(5): 274-278, 2019 May.
Artigo em Inglês | MEDLINE | ID: mdl-30924558

RESUMO

BACKGROUND: Surgical site infections after cardiac surgery are associated with severe outcomes, including reoperation and death. We aimed to describe the effect of a standardized clinical-care protocol for preventing mediastinitis in patients who underwent coronary artery bypass graft surgery (CABG). METHODS: In a hospital certified by Joint Commission International, all patients who underwent CABG from January 2011 to December 2016 were compared in two periods according to the moment of implementation of a standardized clinical-care protocol for prevention of mediastinitis (CCPPM): pre-protocol (January 2011-December 2012) and post-protocol (January 2013-December 2016). The CCPPM consisted of the patient using a kit containing chlorhexidine 2% for bathing, mupirocin 20 mg/g for nasal topical use and chlorhexidine 0.12% for oral hygiene for 5 days before surgery, in addition to prophylaxis with a glycopeptide antimicrobial and strict glucose control (110-140 mg/dL) during surgery and immediate postoperative. RESULTS: We evaluated 1760 patients who underwent CABG in both periods. The occurrence of mediastinitis before protocol implementation was 1.44% (10 of 692 CABG). After the implementation of the protocol, there was an important reduction in the incidence of mediastinitis to 0.09% (1 of 1068 CABG) (P = 0.002). Although we did not observe a significant difference in mortality between the groups (2.3% vs 1%, P = 0.77), there was fewer in-hospital mortality due to mediastinitis after the CCPPM (0.2% vs 0%, P < 0.001). CONCLUSION: Implementation of a standardized CCPPM was associated with a significant reduction in the incidence of mediastinitis after CABG and reduction of mortality in the group of patients with mediastinitis.


Assuntos
Clorexidina/administração & dosagem , Ponte de Artéria Coronária , Hospitais Privados , Mediastinite/prevenção & controle , Assistência ao Paciente/métodos , Assistência ao Paciente/normas , Complicações Pós-Operatórias/prevenção & controle , Qualidade da Assistência à Saúde , Administração Tópica , Idoso , Antibioticoprofilaxia , Banhos , Feminino , Mortalidade Hospitalar , Humanos , Incidência , Masculino , Mediastinite/epidemiologia , Mediastinite/mortalidade , Pessoa de Meia-Idade , Mupirocina/administração & dosagem , Higiene Bucal , Complicações Pós-Operatórias/epidemiologia , Complicações Pós-Operatórias/mortalidade , Fatores de Tempo
11.
Surg Infect (Larchmt) ; 20(5): 378-381, 2019 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-30785856

RESUMO

Background: We describe the management and control of an outbreak of mediastinitis in a cardiac surgery department. Method: We performed a retrospective cohort study of 87 patients who underwent coronary artery bypass grafting (CABG), valve replacement, or both during a five-month period with a higher than normal number of cases of post-operative mediastinitis. In addition to medical records review, a survey was conducted among surgeons to estimate the frequency of cellulose-derived absorbable hemostatic (CDAH) use. Results: Eleven patients (12.5%) developed mediastinitis during the period. None of them died, and the course of the infections was benign. No differences were found between the infected and non-infected patients regarding clinical or demographic characteristics. The rate of infection by surgeon ranged from 0 to 21.4%. (p = 0.38). We found a significant linear relation between the frequency of CDAH use and the risk of infection, from 3.3% to 22.6% (p = 0.024). Cultures of unused CDAHs were negative. Cessation of product use led to no new cases for the following year and to a mediastinitis rate <1% for the following 24 months. Conclusion: We identified a cluster of undesired clinical outcomes compatible with mediastinitis that added morbidity and associated cost, but not deaths, related to the use of CDAH as a hemostatic. These data suggest keeping the use of CDAH in cardiothoracic surgery to a minimum.


Assuntos
Procedimentos Cirúrgicos Cardíacos/efeitos adversos , Celulose/efeitos adversos , Surtos de Doenças , Hemostasia Cirúrgica/efeitos adversos , Hemostáticos/efeitos adversos , Mediastinite/epidemiologia , Adulto , Idoso , Idoso de 80 Anos ou mais , Procedimentos Cirúrgicos Cardíacos/métodos , Celulose/administração & dosagem , Feminino , Hemostasia Cirúrgica/métodos , Hemostáticos/administração & dosagem , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Fatores de Risco
13.
Gastrointest Endosc ; 89(4): 769-778, 2019 04.
Artigo em Inglês | MEDLINE | ID: mdl-30218646

RESUMO

BACKGROUND AND AIMS: Mucosal injury (MI) is one of the most common perioperative adverse events of per-oral endoscopic myotomy (POEM). Severe undertreated MI may lead to contamination of the tunnel and even mediastinitis. This study explored the characteristics, predictors, and management approaches of intraoperative MI. METHODS: A retrospective review of the prospectively collected database at a large tertiary referral endoscopy unit was conducted for all patients undergoing POEM between August 2010 and March 2016. MI was graded according to the difficulty of repair (I, easy to repair; II, difficult to repair). The primary outcomes were the incidence and predictors of intraoperative MI. Secondary outcomes were MI details and the corresponding treatment. RESULTS: POEM was successfully performed in 1912 patients. A total of 338 patients experienced 387 MIs, for an overall frequency of 17.7% (338/1912). Type II MI was rare, with a frequency of 1.7% (39/1912). Major adverse events were more common in patients with MI than in those without MI (6.2% vs 2.5%, P < .001). On multivariable analysis, MI was independently associated with previous Heller myotomy (odds ratio [OR], 2.094; P = .026), previous POEM (OR, 2.441; P = .033), submucosal fibrosis (OR, 4.530; P < .001), mucosal edema (OR, 1.834; P = .001), and tunnel length ≥13 cm (OR, 2.699; P < .001). Previous POEM (OR, 5.005; P = .030) and submucosal fibrosis (OR, 12.074; P < .001) were significant predictors of type II MI. POEM experience >1 year was a protective factor for MI (OR, .614; P = .042) and type II MI (OR, .297; P = .042). CONCLUSIONS: MI during POEM is common, but type II injury is rare. Previous POEM and submucosal fibrosis were significant predictors of type II mucosal injury. POEM experience after the learning curve reduces the risk of MI.


Assuntos
Acalasia Esofágica/cirurgia , Mucosa Esofágica/lesões , Mucosa Gástrica/lesões , Complicações Intraoperatórias/epidemiologia , Piloromiotomia/efeitos adversos , Gastropatias/epidemiologia , Adulto , Cárdia/lesões , Edema/epidemiologia , Endoscopia do Sistema Digestório , Doenças do Esôfago/epidemiologia , Doenças do Esôfago/etiologia , Perfuração Esofágica/epidemiologia , Perfuração Esofágica/etiologia , Perfuração Esofágica/cirurgia , Feminino , Fibrose/epidemiologia , Fundo Gástrico/lesões , Miotomia de Heller/estatística & dados numéricos , Humanos , Complicações Intraoperatórias/etiologia , Complicações Intraoperatórias/cirurgia , Modelos Logísticos , Masculino , Mediastinite/epidemiologia , Mediastinite/etiologia , Pessoa de Meia-Idade , Análise Multivariada , Razão de Chances , Duração da Cirurgia , Complicações Pós-Operatórias/epidemiologia , Complicações Pós-Operatórias/etiologia , Estudos Retrospectivos , Fatores de Risco , Gastropatias/etiologia , Adulto Jovem
14.
Rev. gaúch. enferm ; 40: e20180200, 2019. tab, graf
Artigo em Português | LILACS, BDENF - Enfermagem | ID: biblio-1014143

RESUMO

Resumo OBJETIVO Verificar o perfil clínico-cirúrgico e os resultados de pacientes acompanhados em um ambulatório de ferida operatória após cirurgia cardíaca. MÉTODOS Coorte histórica com pacientes submetidos à cirurgia cardíaca e acompanhados por um ano em um ambulatório de feridas de um hospital especializado em cardiologia. Foram analisados os micro-organismos predominantes nas infecções, os produtos utilizados nos curativos, tempo de acompanhamento e o tipo de terapêutica instituída nos curativos. RESULTADOS Entre os 150 pacientes, predominaram sexagenários (61,7 ± 11,4 anos), hipertensos (75%), diabéticos (44,7%). Evidenciou-se 12 pacientes com mediastinite (8%) e 44 com infecção de sítio cirúrgico (29,3%). Utilizou-se para realização dos curativos os ácidos graxos (80%) e alginato de cálcio (19%). O tempo de acompanhamento foi de 35 ±71 dias. CONCLUSÃO Pacientes sexagenários, hipertensos, diabéticos e revascularizados constituíram a população acompanhada no ambulatório de feridas. As taxas de ISC e mediastinite encontradas foram aceitáveis e semelhantes às da literatura.


Resumen OBJETIVO Verificar el perfil clínico-quirúrgico y los resultados de pacientes acompañados en un ambulatorio de heridas operatorias después de cirugía cardiaca. MÉTODO Cohorte histórica con pacientes sometidos a la cirugía cardiaca y acompañados por un año en el ambulatorio de heridas de un hospital especializado en cardiología. Fueron analizados los microorganismos predominantes en las infecciones, los productos utilizados en las curaciones, el tiempo de seguimiento, o el tipo de tratamiento utilizado en las curaciones. RESULTADOS Entre los 150 pacientes predominaron el sexo masculino (58%), sexagenarios (61,7 ± 11,4 años), hipertensos (75%), diabéticos (44.7%). Se evidenciaron 12 pacientes con mediastinitis (8%) y 44 con infección en el sitio quirúrgico (29.3%). Se utilizó en las curaciones fueron los ácidos grasos (80%) y el alginato de calcio (19%). El tiempo medio de seguimiento fue de 35 ± 71 días. CONCLUSIÓN Los pacientes sexagenarios, hipertensos, diabéticos y revascularizados constituyeron la población acompañada en el ambulatorio de heridas. Las tasas de ISC y mediastinitis encontradas fueron aceptables y similares a las de la literatura.


Abstract OBJECTIVE Verifying the clinical-surgical profile and the results of patients monitored in an surgical wound ambulatory after a cardiac surgeries. METHODS This is a historical cohort research with patients submitted to cardiac surgery and monitored for a year in an outpatient surgical wound clinic from a hospital specialized in cardiology. The study analyzed the prevalent microorganisms in infections, the products used in the dressings, the time of follow-up, and the type of therapy established in the dressings. RESULTS Among the 150 patients, most were sexagenarians (61.7 ± 11.4 years), hypertensive patients (75%), and diabetic (44.7%). There were 12 patients with mediastinitis (8%) and 44 with surgical site infection (29.3%). Fatty acids (80%) and calcium alginate (19%) were used for wound healing. The mean follow-up time was 35 ± 71 days. CONCLUSION Sexagenary, hypertensive, diabetic and revascularized patients constituted the population monitored in the wounds outpatient clinic. The SSI and mediastinitis rates found were acceptable and similar to those in literature.


Assuntos
Humanos , Masculino , Feminino , Idoso , Infecção da Ferida Cirúrgica/microbiologia , Infecção da Ferida Cirúrgica/terapia , Bandagens , Procedimentos Cirúrgicos Cardíacos/efeitos adversos , Veia Safena/cirurgia , Infecção da Ferida Cirúrgica/epidemiologia , Cicatrização , Ácidos Graxos Essenciais/uso terapêutico , Estudos de Coortes , Seguimentos , Diabetes Mellitus/epidemiologia , Alginatos/uso terapêutico , Esternotomia/efeitos adversos , Instituições de Assistência Ambulatorial , Hipertensão/epidemiologia , Mediastinite/epidemiologia , Pessoa de Meia-Idade
15.
Med Sante Trop ; 28(3): 297-301, 2018 Aug 01.
Artigo em Inglês | MEDLINE | ID: mdl-30270835

RESUMO

Acute mediastinitis, also called descending necrotizing mediastinitis and cervicomediastinal necrotizing fasciitis, is a disease due to the spread of severe cervical or oropharyngeal infection. Our retrospective study examined clinical records of patients admitted to the surgical intensive care unit for the management of acute mediastinitis during the four-year period 2009-2012. The records showed 14 cases admitted during these four years. The patients' mean age was 30 years and 8 months, and the M/F sex-ratio was 1.33. The main predisposing factors found were the presence of a severe cervical infection, such as fasciitis, of odontogenic origin or the administration of anti-inflammatory drugs. The diagnosis is based on clinical data findings of thoracic pain with dyspnea or orthopnea, fever, or even septic shock and is confirmed by radiologic findings. The patient's multidisciplinary management combines medical management (supportive medical care in an intensive care unit and broad-spectrum antibiotic therapy) and surgical treatment by bilateral cervicotomy with mediastinal drainage. The mortality rate was high at 71.42%. In Madagascar, neglect of dental health can cause odontogenic fasciitis, which plays an important role in descending mediastinitis, a disease that still has a catastrophic prognosis today.


Assuntos
Mediastinite , Doença Aguda , Adolescente , Adulto , Criança , Pré-Escolar , Feminino , Hospitais , Humanos , Madagáscar , Masculino , Mediastinite/diagnóstico , Mediastinite/epidemiologia , Mediastinite/terapia , Mediastino/patologia , Pessoa de Meia-Idade , Necrose , Estudos Retrospectivos , Fatores de Tempo , Adulto Jovem
17.
Infect Control Hosp Epidemiol ; 39(6): 694-700, 2018 06.
Artigo em Inglês | MEDLINE | ID: mdl-29669607

RESUMO

OBJECTIVEIn 2012, the Centers for Medicare and Medicaid Services expanded a 2008 program that eliminated additional Medicare payment for mediastinitis following coronary artery bypass graft (CABG) to include Medicaid. We aimed to evaluate the impact of this Medicaid program on mediastinitis rates reported by the National Healthcare Safety Network (NHSN) compared with the rates of a condition not targeted by the program, deep-space surgical site infection (SSI) after knee replacement.DESIGNInterrupted time series with comparison group.METHODSWe included surveillance data from nonfederal acute-care hospitals participating in the NHSN and reporting CABG or knee replacement outcomes from January 2009 through June 2017. We examined the Medicaid program's impact on NHSN-reported infection rates, adjusting for secular trends. The data analysis used generalized estimating equations with robust sandwich variance estimators.RESULTSDuring the study period, 196 study hospitals reported 273,984 CABGs to the NHSN, resulting in 970 mediastinitis cases (0.35%), and 294 hospitals reported 555,395 knee replacements, with 1,751 resultant deep-space SSIs (0.32%). There was no significant change in incidence of either condition during the study. Mediastinitis models showed no effect of the 2012 Medicaid program on either secular trend during the postprogram versus preprogram periods (P=.70) or an immediate program effect (P=.83). Results were similar in sensitivity analyses when adjusting for hospital characteristics, restricting to hospitals with consistent NHSN reporting or incorporating a program implementation roll-in period. Knee replacement models also showed no program effect.CONCLUSIONSThe 2012 Medicaid program to eliminate additional payments for mediastinitis following CABG had no impact on reported mediastinitis rates.Infect Control Hosp Epidemiol 2018;39:694-700.


Assuntos
Infecção Hospitalar , Mediastinite/epidemiologia , Infecção da Ferida Cirúrgica/epidemiologia , Artroplastia do Joelho , Centers for Medicare and Medicaid Services, U.S. , Ponte de Artéria Coronária , Infecção Hospitalar/economia , Infecção Hospitalar/epidemiologia , Bases de Dados Factuais , Economia Hospitalar , Política de Saúde , Hospitais , Humanos , Análise de Séries Temporais Interrompida , Mediastinite/economia , Medicaid , Estados Unidos/epidemiologia
18.
Thorac Cardiovasc Surg ; 66(6): 508-516, 2018 09.
Artigo em Inglês | MEDLINE | ID: mdl-29536456

RESUMO

BACKGROUND: Median sternotomy in patients with risk factors for wound healing is associated with high rates of postoperative wound infections and sternum instability. METHODS: A total of 338 patients with elective first median sternotomy and at least four predefined risk factors were randomized between Sternal Talon (Gebrüder Martin GmbH & Co. KG-KLS Martin Group, Tuttlingen, Germany) and wire cerclage. The primary end point was mediastinitis and/or sternal instability within 30 ± 5 days, and the secondary end points were mediastinitis and/or sternal instability within 60 ± 5 days; incidence of pneumonia during hospitalization within the first 30 (±5) days and chest pain intensity. RESULTS: The primary end point was reached in 10 Sternal Talon and 7 wire cerclage patients (6.2 vs. 4.7%, odds ratio [OR]: 1.3, 95% confidence interval [CI]: 0.5-3.6, p = 0.57) from 338 randomized patients. Sternal Talon group, n = 170 patients versus wire cerclage group, n = 168 patients. The differences between treatment groups with regard to the incidence of mediastinitis/sternum instability within the first 60 (±5) days after the primary sternum closure and the incidence of pneumonia during the hospitalization within the first 30 (±5) days were not statistically significant, either. We observed comparable rates of superficial surgical site infection (SSI) in Sternal Talon and wire cerclage patients (16.1 vs. 12.1%, OR: 1.4, 95% CI: 0.7-2.7, p = 0.31). CONCLUSION: According to these data, there is no statistically significant difference between Sternal Talon closure and wire cerclage in reducing the incidence of mediastinitis and superficial SSI after primary closure of median sternotomy in high-risk patients.


Assuntos
Placas Ósseas , Fios Ortopédicos , Esternotomia , Técnicas de Fechamento de Ferimentos/instrumentação , Cicatrização , Idoso , Idoso de 80 Anos ou mais , Áustria/epidemiologia , Placas Ósseas/efeitos adversos , Fios Ortopédicos/efeitos adversos , Dor no Peito/epidemiologia , Feminino , Alemanha/epidemiologia , Humanos , Incidência , Modelos Logísticos , Masculino , Mediastinite/epidemiologia , Pessoa de Meia-Idade , Razão de Chances , Pneumonia/epidemiologia , Estudos Prospectivos , Fatores de Risco , Esternotomia/efeitos adversos , Infecção da Ferida Cirúrgica/epidemiologia , Fatores de Tempo , Resultado do Tratamento , Técnicas de Fechamento de Ferimentos/efeitos adversos
19.
J Hosp Infect ; 100(4): 421-427, 2018 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-29409978

RESUMO

BACKGROUND: Reducing post-sternotomy mediastinitis (PSM) requires incorporating multiple methods. However, the independent effects of these measures are not well studied. AIM: To evaluate the independent effect of preoperative disinfection using isopropyl alcohol (IPA)-chlorhexidine gluconate (CHG) and the topical application of a retrosternal gentamicin collagen sponge at wound closure on reducing PSM. METHODS: From October 2012 to August 2014, 2340 patients were included in this prospective, controlled registry. Patients were divided into four groups. In groups 1 and 2, the skin was disinfected with IPA, and in groups 3 and 4, the skin was disinfected with IPA-CHG. A retrosternal gentamicin collagen sponge was used in groups 2 and 4. Freedom from PSM up to the 30th postoperative day was the primary endpoint. The secondary endpoint was freedom from any surgical site dehiscence. A stepwise regression model was made to reveal the independent factors associated with lower incidence of PSM. FINDINGS: There were significant differences in outcome among the groups (P < 0.0001). Primary healing was highest in group 4 (91.4%), which showed the lowest rate for mediastinitis (0.9%). Multivariate analysis showed that the use of CHG and a gentamicin sponge was statistically significant (P = 0.026 and 0.013, respectively). The other significant independent factors were valve operation (P = 0.001), body mass index >30 kg/m2 (P = 0.001), preoperative stroke (P = 0.005), and blood transfusion (P = 0.022). CONCLUSION: Preoperative skin disinfection with IPA-CHG is superior to only IPA, and it should be recommended. The addition of a retrosternal gentamicin-releasing sponge further reduces the rate of mediastinitis.


Assuntos
Antibacterianos/administração & dosagem , Quimioprevenção/métodos , Clorexidina/administração & dosagem , Gentamicinas/administração & dosagem , Mediastinite/epidemiologia , Mediastinite/prevenção & controle , Esternotomia/efeitos adversos , Adulto , Idoso , Idoso de 80 Anos ou mais , Animais , Feminino , Humanos , Incidência , Masculino , Pessoa de Meia-Idade , Estudos Prospectivos , Resultado do Tratamento , Adulto Jovem
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