The median duration of PSCICU of the NI patients was 10 days (7–13) vs. 5 days (4–7) (P<0.000) among non-NI patients. The mortality rate that was observed during the study period was 30.8% (54 patients) of the study population. NI patients had significant mortality (44/175) (25%, P<0.01). No statistically significant difference was observed in terms of sex and mortality (29 males vs. 25 females, P=0.5) and no statistically significant difference was observed in terms of mortality among the 3 months of IC observations (P=0.4). Patients who died were significantly younger (P<0.003), had a higher APACHI II score, with a median of 13 (3–20) (P<0.007), a higher complexity score for congenital cardiac lesions (P<0.002), longer cardiopulmonary bypass time and ischemic time (P<0.006 and P<0.002, respectively), longer duration of mechanical ventilation (P<0.000), longer duration of central venous line (P<0.000), use of TPN, and longer duration of PSCICU (P<0.02), Table 3 shows significant mortality patients data.
On carrying out multivariate analysis, age (OR 0.3, 95% CI 0.2–0.4), APACHE II score (OR 1.13, 95% CI 1–1.2), and prolonged mechanical ventilation (OR 2.8, 95% CI 1.1–7.2) were identified as the risk factors of mortality following congenital cardiac surgery Table 4 shows the OR for multivariate analysis of different risk factors for mortality.
In recent years, the attitude toward quality of healthcare and the cost of congenital heart surgery has received considerable attention from the public and has been the subject of government coverage scrutiny 18. In this study, of the 175 patients enrolled, 119 (68%) patients were found to have NI, which is a high rate when compared with other published data from both developed and developing countries (11–52%) 19–22. Many contributing factors may be responsible for this high figure: first, the delay in the application of strict IC practices and policies in our center as we started to consider IC policies by the beginning of 2009, when we joined the International Nosocomial Infection Control Consortium project, which is a prospective multicenter surveillance study for NI and DAI for developing countries worldwide. The second factor is that during the year 2009, we had a nurse-to-bed ratio of 1 : 3–1 : 4, whereas it was 1 : 2– 1 : 3 in other publications with relatively similar settings 20. Some studies have shown that overcrowding, understaffing, and imbalance between workload and resources are important determinants of NI 23. However, improvement of the NI rate is not impossible as with the 3-month observation for the IC practices, there was an improvement in the laboratory-confirmed blood stream infection rates from 37 to 12% with strict IC. In the study carried out by Costello et al. (2008), compliance with the use of the central venous line maintenance bundle in the ICU improved from 8% (n=323 observations) during the partial intervention period to 99% (n=60 observations) during the full intervention period (P=0.004) 17. Many authors have reported on the improved surveillance process outcome for the central venous lines bundle of care policy adopted by each PSCICU separately 10,12,17. In terms of the observation of IC practices, the overall rate of hand washing in between patients by practicing nurses was 47.1% (33–70%), which was comparable with other publications, ranging from 20 to 70% 16,17,24. In our study, young infants were more prone to NI, a finding that is similar to many other publications 15,22,25,26.
In our study, the mortality rate was about 31%, which is considered high when compared with the other rates reported by many authors (3–23%) 12,20,21. Our explanation for this high mortality rate is that most of the patients had delayed presentation for diagnosis with relatively high complexity score and subsequent serious complication occurred as pulmonary hypertension following large ventricular septal defects. Long waiting list adds to failure to thrive in most of the patients being prone to more NI, factors that are mentioned as contributing to mortality in publications before 18–28. Although in our series no significant difference in mortality was observed between males and females (P=0.9), other publications have reported unexplained female sex as a risk factor for mortality after congenital cardiac surgery 29,30. In our series, significant mortality was observed with younger age and prolonged duration of the use of invasive devices such as mechanical ventilators and central venous lines. Many series have studied the risk factors and associations with mortality in relation to congenital heart surgery, reporting the same factors as ours, especially the prolonged use of invasive devices 18,31–34. In our series, the use of TPN showed a statistically significant association with mortality (P<0.000), probably linked to complicated cases and prolonged use of the central line. Thomson et al. 35 have reported a role for TPN as a risk factor of mortality following congenital cardiac surgery. In this study, younger age, high APACHE II scores, and prolonged mechanical ventilation were found to be risk factors for mortality. A higher APACHI II score determined on the first postoperative day was found to be associated with increased mortality, especially if the score exceeded 28 36.
NI and mortality rates after congenital cardiac surgery were high in the children’s hospital in Egypt that was studied here. Several factors may have contributed to the high mortality rate such as age, hospital-acquired infection, bypass time, ischemic time, total ICU duration, central line duration, and APACHE II score. Implementation of policies that allow early screening and diagnosis of congenital heart disease, followed by the proper selection of patients before congenital heart surgery, together with the strict application of IC policies in pediatric postoperative intensive care units, are the key for solving this problem.
There are no conflicts of interest.
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