李霞
中国医学科学院阜外医院 小儿恢复室
OBJECTIVES:1) To describe the postoperative course and outcomes of cardiac surgery in children with perioperative viral respiratory infection, 2) to evaluate optimal surgical timing for preoperative viral respiratory infection patients, and 3) to define risk stratification.DESIGN:Retrospective study of children undergoing cardiac surgery. Children were tested using a multiplex polymerase chain reaction (respiratory virus polymerase chain reaction) panel capturing seven respiratory viruses. Respiratory virus polymerase chain reaction testing was routinely performed in patients under 2 years old. Those with negative results yet highly suspected of viral respiratory infection after surgeries would be tested again.SETTING:A pediatric cardiac surgical ICU of pediatric cardiac surgery department at Fuwai Hospital.PATIENTS:Children admitted between January 1, 2014, and December 31, 2016, to perform respiratory virus polymerase chain reaction testing and cardiac surgery were included.INTERVENTIONS:None.MEASUREMENTS AND MAIN RESULTS:A total of 2,831 patients had respiratory virus polymerase chain reaction testing, and viruses were detected in 91 patients (3.2%), including 35 preoperative and 56 postoperative. Of the 35 preoperative viral respiratory infection patients, there were 29 viral respiratory infection-resolved (patients for whom surgery was postponed until resolution of viral respiratory infection symptoms and negative respiratory virus polymerase chain reaction) and six viral respiratory infection-unresolved (who underwent cardiac surgery before resolution of symptoms and clearance of carriage) patients. Furthermore, there were seven deaths, including one in the preoperative viral respiratory infection-unresolved group and six in the postoperative viral respiratory infection group. A propensity score matching was performed to correct the selection bias and identify the comparable patient groups. Compared to their matched nonviral respiratory infection patients, viral respiratory infection-resolved patients had similar duration of mechanical ventilation and length of stay, while viral respiratory infection-unresolved patients had longer durations of postoperative mechanical ventilation (p = 0.033), PICU (p = 0.028) and hospital length of stay (p = 0.010), and postoperative viral respiratory infection patients had significantly greater duration of postoperative recovery (p < 0.001) and higher mortality (p < 0.001). Earlier diagnosis of postoperative viral respiratory infection was associated with longer mechanical ventilation duration (r = 0.422; p < 0.001). Palliative cardiac surgery was the only variable significantly associated with mortality in multivariate analysis (odds ratio, 12.0; 95% CI, 1.6-87.5; p = 0.014).CONCLUSIONS:The preoperative-unresolved and postoperative viral respiratory infection were associated with prolonged postoperative recovery, increased severity, and mortality in children with cardiac surgeries. Our results suggested the optimal surgical timing may be after the resolution of viral respiratory infection symptoms and carriage unless the perceived benefits of early surgery outweigh the risk of death, prolonged ventilation, and PICU length of stay. Palliative surgeries were associated with increasing mortality.
Pediatric critical care medicine : a journal of the Society of Critical Care Medicine and the World Federation of Pediatric Intensive and Critical Care Societies 2020
OBJECTIVES:Assess the diagnostic value of serial monitoring of procalcitonin levels on early postoperative infection after pediatric cardiac surgery with cardiopulmonary bypass.DESIGN:Prospective, observational study.SETTING:A pediatric cardiac surgical ICU (PICU) and pediatric cardiac surgery department at Fuwai Hospital, Chinese Academy of Medical Sciences, Peking Union Medical College.PATIENTS:Patients were 3 years old and below, underwent cardiac surgery involving cardiopulmonary bypass, the Aristotle Comprehensive Complexity score was 8 or higher and free from active preoperative infection or inflammatory disease.INTERVENTIONS:Blood samples for measurement of procalcitonin, C-reactive protein, and WBC were taken before surgery and daily for 7 days in postoperative period. Clinical, laboratory, and imaging data were collected on enrollment. Procalcitonin, C-reactive protein, WBC levels, and procalcitonin variation were calculated and compared between those with and without infection.MEASUREMENTS AND MAIN RESULTS:Two hundred and thirty-eight children were enrolled. Presence of infection within 7 days of surgery, length of intubation, and ICU stay were documented. Two independent experts in regard to the complete medical chart determined the final diagnosis of postoperative infection. Infection was diagnosed in 45 patients. Procalcitonin peaked on the first postoperative day. No differences were found on procalcitonin within 3 days after operation between the infected and the noninfected patients, and significant correlation was found between procalcitonin on postoperative days 1-3 and cardiopulmonary bypass duration. Serum procalcitonin concentration was always higher than 1.0 ng/mL within 7 days after surgery and/or procalcitonin variation between postoperative days 4 and 7 was positive in the infected patients. Best receiver operating characteristics curves area under the curve were obtained for procalcitonin and procalcitonin variation from postoperative days 5 to 7. WBC- and C-reactive protein-related receiver operating characteristics curves area under the curve revealed a very poor ability to predict infection. Logistic regression found that only procalcitonin on postoperative day 7 and PICU stay was independently correlated to the infection status. There was no significant correlation between the absolute value of procalcitonin and timing of infection.CONCLUSIONS:Procalcitonin was more accurate than C-reactive protein and WBC to predict early postoperative infection, but the diagnostic properties of procalcitonin could not be observed during the first 3 postoperative days due to the inflammatory process related to cardiopulmonary bypass. The dynamic change of procalcitonin is more important than the absolute value to predict postoperative infection. The maintenance of a high level (procalcitonin > 1.0 ng/mL) within 7 days after surgery and/or a second increase in procalcitonin between the fourth and the seventh postoperative day could be used as an indicator of postoperative infection. Continuous procalcitonin monitoring might help to discover infection earlier.
Pediatric critical care medicine : a journal of the Society of Critical Care Medicine and the World Federation of Pediatric Intensive and Critical Care Societies 2017
