Intraoperative Hyperglycemia and Postoperative Bacteremia in the Pediatric Cardiac Surgery Patient

doi:10.1016/j.athoracsur.2009.10.054

The Annals of Thoracic Surgery

Volume 89, Issue 2, February 2010, Pages 578-584

Presented at the Fifty-fifth Annual Meeting of the Southern Thoracic Surgical Association, Austin, TX, Nov 5–8, 2008.

https://doi.org/10.1016/j.athoracsur.2009.10.054 Get rights and content

Background

Intraoperative hyperglycemia has been found to be associated with a higher incidence of postoperative infections in the adult cardiac surgery population. The goal of this study was to determine the association of intraoperative hyperglycemia and postoperative bacteremia in the pediatric population.

Methods

A retrospective chart review of all cardiac surgical cases for patients 18 years of age or younger requiring cardiopulmonary bypass support between June 2002 and July 2007 yielded 1,132 total cases representing 992 unique patients. Patient demographic and clinical data of interest were collected. Descriptive statistics and regression analyses were performed to investigate the hypothesized relationship between glucose levels and infection rates.

Results

From the 992 patient records examined, 15 patients exhibited a bacteremia within 14 days of surgery (1.5%). The association between the highest glucose during cardiopulmonary bypass and bacteremia reached statistical significance when the glucose level reached 175 mg/dL (χ² = 4.59, 1 degree of freedom; p = 0.032). A patient was more than three times as likely to have a postoperative bacteremia when the glucose level reached this amount or exceeded it (odds ratio, 3.3, 95% confidence interval, 1.04 to 10.39). Ten of the 15 (66.7%) postoperative infections occurred in patients with peak bypass glucose levels of at least 175 mg/dL.

Conclusions

Intraoperative hyperglycemia was found to be associated with a higher risk of postoperative bacteremia in the pediatric cardiac surgery population.

Section snippets

Material and Methods

Appropriate and necessary approvals from the institutional review board were obtained before study-related activities. A retrospective chart review to collect data from the medical records of all patients 18 years of age or younger at the time of surgery who underwent repair of a congenital heart defect using CPB from June 2002 to July 2007 was performed. Demographic characteristics including age at time of surgery, weight at time of surgery, sex, and cardiac diagnosis were obtained (Table 1).

Results

One thousand one hundred thirty-two cardiovascular surgical procedures requiring CPB were evaluated for this study. Of those procedures, there were 992 unique patients. A summary of the study population's characteristics can be found in Table 1. The glucose values for the cohort ranged from 64 to 395 mg/dL. Of the 992 unique patients, 15 experienced a positive postoperative blood culture (bacteremia as defined above; 1.51%) within 14 days after surgery.

The incidence of positive respiratory

Comment

This study examines the association between intraoperative hyperglycemia and postoperative bacteremia in the pediatric cardiac surgical population. These data show that there is an association between an intraoperative glucose level of at least 175 mg/dL and the development of a postoperative bacteremia.

Although limited to the adult population, it is interesting to note that the American Association of Clinical Endocrinologists and the American Diabetes Association in a joint consensus

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Citation Excerpt :
Although pediatric perioperative guidelines for SSI prevention are unavailable, appropriate timing has been associated with a reduction in SSIs in adult patients and is a key component of the Surgical Care Improvement Project sponsored by the Centers for Medicare and Medicaid.19,20 Although intraoperative glucose levels have not been found to be a risk factor for SSIs in adult patients, higher postoperative glucose levels are a risk factor.21 Glucose control (defined as <200 mg/dL) the day after cardiac surgery is advocated as a measure to reduce SSIs.22
Few recent studies have assessed the epidemiology of and risk factors for surgical site infections (SSIs) and bloodstream infections (BSIs) in infants after cardiac surgery. We hypothesized that infants younger than 30 days old and those with higher Risk Adjustment in Congenital Heart Surgery-1 scores would have an increased risk of SSIs, but not an increased risk of BSIs after surgery.
We performed a retrospective cohort study of infants younger than 1 year of age undergoing cardiac surgery from January 2010 to December 2011 to determine the rates of SSIs and BSIs occurring within 3 months of surgery, risk factors associated with these infections, and causative pathogens. Multivariable associations using Cox proportional hazard modeling assessed potential risk factors for BSIs or SSIs.
Overall, 8.7% (48 of 552) of surgical procedures were complicated by SSIs (n = 19) or BSIs (n = 29). Thus, SSIs and BSIs occurred after 3.4% and 5.3% of procedures, respectively. Multivariate models found age younger than 30 days, incorrect timing of preoperative antibiotics, and excessive bleeding within 24 hours of surgery to be significant predictors for SSIs, and duration of use of arterial lines to be a significant predictor for BSIs. Gram-positive bacteria caused 75% of SSIs and BSIs and methicillin-susceptible Staphylococcus aureus caused 63% of SSIs.
We identified some potential strategies to reduce risk, including closer monitoring of timing of preoperative antimicrobial prophylaxis and enhanced efforts to achieve intraoperative hemostasis and earlier removal of arterial lines.
SSIs and BSIs remain important complications after cardiac surgery in infants.
Risk of postoperative hypoglycemia in cardiovascular surgical patients receiving computer-based versus paper-based insulin therapy
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Original articlePediatric cardiacIntraoperative Hyperglycemia and Postoperative Bacteremia in the Pediatric Cardiac Surgery Patient

Background

Methods

Results

Conclusions

Section snippets

Material and Methods

Results

Comment

Semin Thorac Cardiovasc Surg

Mayo Clin Proc

J Pediatr Surg

J Pediatr

J Thorac Cardiovasc Surg

J Thorac Cardiovasc Surg

Ann Thorac Surg

Infect Dis Clin North Am

J Thorac Cardiovasc Surg

Association of hyperglycemia with increased mortality after severe burn injury

J Trauma

Prognostic factors and outcome of children with severe head injury: an 8-year experience

Childs Nerv Syst

Hyperglycemia and outcomes from pediatric traumatic brain injury

J Trauma

Association of timing, duration, and intensity of hyperglycemia with intensive care unit mortality in critically ill children

Pediatr Crit Care Med

Hyperglycemia is a marker for poor outcome in the postoperative pediatric cardiac patient

Pediatr Crit Care Med

Diagnosis and classification of diabetes mellitus

Diabetes Care

Original article
Pediatric cardiac
Intraoperative Hyperglycemia and Postoperative Bacteremia in the Pediatric Cardiac Surgery Patient