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J Thorac Cardiovasc Surg. 2017 Jun;153(6):1384-1391.e3. doi: 10.1016/j.jtcvs.2016.12.055. Epub 2017 Feb 9.

Pneumonia after cardiac surgery: Experience of the National Institutes of Health/Canadian Institutes of Health Research Cardiothoracic Surgical Trials Network.

Author information

1
Cardiothoracic Surgery, University of Virginia, Charlottesville, Va.
2
Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York, NY.
3
Cardiovascular Medicine, Brigham and Women's Hospital, Boston, Mass.
4
Department of Cardiothoracic Surgery, Stanford University, Stanford, Calif.
5
Cardiovascular and Thoracic Surgery, Montefiore-Einstein Heart Center, Bronx, NY.
6
Cardiothoracic Surgery, Emory University Hospital Midtown, Atlanta, Ga.
7
Montreal Heart Institute, Montreal, Canada.
8
Thoracic and Cardiovascular Surgery, Cleveland Clinic, Cleveland, Ohio.
9
Division of Cardiovascular Sciences, National Heart, Lung, and Blood Institute, Bethesda, Md.
10
Cardiac Surgery, The Heart Hospital Baylor Plano, Plano, Tex.
11
Division of Cardiothoracic Surgery, Columbia University Medical Center, New York, NY.
12
NIH Heart Center at Suburban Hospital, Bethesda, Md.
13
Cardiothoracic Research, Cleveland Clinic, Cleveland, Ohio.
14
Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York, NY. Electronic address: Annetine.gelijns@mssm.edu.
15
Division of Cardiology and Duke Clinical Research Institute, Duke Medicine, Durham, NC.
16
Cardiac Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, NH.

Abstract

RATIONALE:

Pneumonia remains the most common major infection after cardiac surgery despite numerous preventive measures.

OBJECTIVES:

To prospectively examine the timing, pathogens, and risk factors, including modifiable management practices, for postoperative pneumonia and estimate its impact on clinical outcomes.

METHODS:

A total of 5158 adult cardiac surgery patients were enrolled prospectively in a cohort study across 10 centers. All infections were adjudicated by an independent committee. Competing risk models were used to assess the association of patient characteristics and management practices with pneumonia within 65 days of surgery. Mortality was assessed by Cox proportional hazards model and length of stay by a multistate model.

MEASUREMENTS AND MAIN RESULTS:

The cumulative incidence of pneumonia was 2.4%, 33% of which occurred after discharge. Older age, lower hemoglobin level, chronic obstructive pulmonary disease, steroid use, operative time, and left ventricular assist device/heart transplant were risk factors. Ventilation time (24-48 vs ≤24 hours; hazard ratio [HR], 2.83; 95% confidence interval [95% CI], 1.72-4.66; >48 hours HR, 4.67; 95% CI, 2.70-8.08), nasogastric tubes (HR, 1.80; 95% CI, 1.10-2.94), and each unit of blood cells transfused (HR, 1.16; 95% CI, 1.08-1.26) increased the risk of pneumonia. Prophylactic use of second-generation cephalosporins (HR, 0.66; 95% CI, 0.45-0.97) and platelet transfusions (HR, 0.49, 95% CI, 0.30-0.79) were protective. Pneumonia was associated with a marked increase in mortality (HR, 8.89; 95% CI, 5.02-15.75) and longer length of stay of 13.55 ± 1.95 days (bootstrap 95% CI, 10.31-16.58).

CONCLUSIONS:

Pneumonia continues to impose a major impact on the health of patients after cardiac surgery. After we adjusted for baseline risk, several specific management practices were associated with pneumonia, which offer targets for quality improvement and further research.

KEYWORDS:

cardiac surgery; infections; outcomes; pneumonia; quality improvement

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