Cardiothoracic Surgical Patients Research Articles

A single-centre retrospective study of the utility of routine chest X-ray post intrathoracic drain removal in cardiothoracic surgical patients.

Routine chest X-ray (CXR) post intrathoracic drain removal in cardiac surgical patients is common practice to identify the presence of a pneumothorax following drain removal. Such pneumothoraces occur infrequently and rarely require intervention. We investigated the utility of routine CXR post drain removal and hypothesised that the practice is unnecessary and a possible area for significant cost saving. We conducted a single-centre, retrospective study of 390 patients who underwent cardiac surgery over a one-year period. Routine CXR post drain removal was reviewed for the presence of a pneumothorax. Rates of intervention post routine CXR were analysed to assess for clinical benefit obtained from this practice. Potential cost savings were calculated by the cost of a mobile CXR and by considering the radiographer's time. There were 15 pneumothoraces detected on routine CXR post drain removal. All pneumothoraces detected on routine post drain removal CXR were defined as small. No patients had a clinically significant pneumothorax requiring re-insertion of a chest drain. The potential cost saved by omitting routine CXR post drain removal was estimated to be approximately A$7750 per year. This study did not detect any clinically significant pneumothoraces requiring intervention. It also suggests that routine CXR post drain removal does not provide any clinical benefit and indicates that current practice should be reviewed.

Year in Review 2023: Noteworthy Literature in Cardiothoracic Critical Care.

This article reviews noteworthy investigations and society recommendations published in 2023 relevant to the care of critically ill cardiothoracic surgical patients. We reviewed 3,214 articles to identify 18 publications that add to the existing literature across a variety of topics including resuscitation, nutrition, antibiotic management, extracorporeal membrane oxygenation (ECMO), neurologic care following cardiac arrest, coagulopathy and transfusion, steroids in pulmonary infections, and updated guidelines in the management of acute respiratory distress syndrome (ARDS).

The Use of Virtual Care to Optimise Health Resources in Cardiothoracic Surgical Patients: A Quality Improvement Project

Telehealth and virtual care (VC) can be integrated into the healthcare system as an approach to maximise its efficiency and delivery of care of remote cardiothoracic surgery patients. This has enabled the Cardiothoracic Surgical Care Team (CSCT) at Liverpool Hospital and participating area hospitals to assess and strategically plan the management of the patient early in the consultation process.

Chest X-ray Overuse in Cardiothoracic Intensive Care Unit per American College of Radiology Criteria

BackgroundA routine chest radiograph (CXR) is frequently incorporated into postoperative clinical pathways. Whereas prior studies evaluated CXR use for specific indications, overall CXR "stewardship" within cardiothoracic surgery remains undescribed. We characterized CXR use within a cardiothoracic intensive care unit (ICU) and quantified X-ray–driven changes in patient management. MethodsAll CXRs performed during 3 months in the cardiothoracic ICU of an academic 900-bed tertiary care hospital were retrospectively reviewed. Attending radiologist CXR reports and clinical history from ordering providers were manually reviewed to classify CXRs as indicated or not indicated by American College of Radiology (ACR) Appropriateness Criteria. Multiple resident-level providers further reviewed CXRs to determine whether the image demonstrated any actionable or unexpected findings. ResultsBetween October 1, 2021, and January 3, 2022, 1273 CXRs were performed on adult cardiac and general thoracic surgery patients; the most common indication was routine daily (55.9%), followed by support device monitoring (12.4%) and new ICU transfer (10.4%). Only 34.3% of performed CXRs met ACR Appropriateness Criteria; 65.7% did not (P = .002). Only 3.8% of not indicated CXRs had actionable or significant findings vs 13.0% of indicated CXRs (P = .02). Of the 32 not indicated CXRs with actionable findings, 37.5% recommended endotracheal tube repositioning and 28.1% recommended other line or tube repositioning. ConclusionsCXRs are overused in the cardiothoracic ICU according to ACR Appropriateness Criteria. CXRs performed outside these guidelines have significantly fewer actionable or meaningful findings. Optimizing CXR use can improve resource utilization and efficiency in care of cardiothoracic surgical patients.

Determinants of long-term opioid use in hospitalized patients.

Long-term opioid use is an increasingly important problem related to the ongoing opioid epidemic. The purpose of this study was to identify patient, hospitalization and system-level determinants of long term opioid therapy (LTOT) among patients recently discharged from hospital. To be eligible for this study, patient needed to have filled at least one opioid prescription three-months post-discharge. We retrieved data from the provincial health insurance agency to measure medical service and prescription drug use in the year prior to and after hospitalization. A multivariable Cox Proportional Hazards model was utilized to determine factors associated with time to the first LTOT occurrence, defined as time-varying cumulative opioid duration of ≥ 60 days. Overall, 22.4% of the 1,551 study patients were classified as LTOT, who had a mean age of 66.3 years (SD = 14.3). Having no drug copay status (adjusted hazard ratio (aHR) 1.91, 95% CI: 1.40-2.60), being a LTOT user before the index hospitalization (aHR 6.05, 95% CI: 4.22-8.68) or having history of benzodiazepine use (aHR 1.43, 95% CI: 1.12-1.83) were all associated with an increased likelihood of LTOT. Cardiothoracic surgical patients had a 40% lower LTOT risk (aHR 0.55, 95% CI: 0.31-0.96) as compared to medical patients. Initial opioid dispensation of > 90 milligram morphine equivalents (MME) was also associated with higher likelihood of LTOT (aHR 2.08, 95% CI: 1.17-3.69). Several patient-level characteristics associated with an increased risk of ≥ 60 days of cumulative opioid use. The results could be used to help identify patients who are at high-risk of continuing opioids beyond guideline recommendations and inform policies to curb excessive opioid prescribing.

2156. Impact of Asymptomatic Upper Respiratory Viral Shedding in Pediatric Cardiothoracic Surgical Patients

Abstract Background Intraoperative and postoperative complications associated with symptomatic upper respiratory infections in young children are well-documented; however, asymptomatic upper respiratory viral shedding is frequent and may be prolonged. Necessary pediatric cardiac surgical procedures could be delayed with recognition of asymptomatic viral shedding. This study aimed to assess if a positive preoperative respiratory viral panel PCR (+ RVP) impacted postoperative length of stay in the pediatric intensive care unit (PICU) or hospital and assessed for an association among + RVP and adverse clinical events. Methods Patients < 3 years old presenting to a freestanding children’s hospital for cardiothoracic surgery from March 2018-March 2020 were enrolled. Within 24 hours before surgery, an RVP via nasopharyngeal swab for PCR was collected from subjects. Chart review was completed after hospital discharge. Mean difference between RVP status and length of stay for PICU and hospital was assessed with an independent, two group, sample t-test. Logistic regression was used to test association between RVP status and adverse clinical events (VAP, SSI, prolonged fever, ventilator use, or antibiotics), adjusted by complexity of surgical procedure using the Risk Adjustment in Congenital Heart Surgery-1 (RACHS-1) score. Results There were 95 subjects included, approximately 50% female, 75% Caucasian; 39% had + RVP (Table 1). There was no statistical association between RVP status and length of PICU (p=0.35) or hospital stay (p=0.28) (Table 2). Odds ratio for extubation in the operating room was significantly associated with +RVP, though small sample size and wide confidence intervals limit generalizability of this observation (Table 3). There were no clinically significant associations between RVP status and adverse events. Table 1.Subject DemographicsTable 2.Mean Difference in Length of Stay by RVP StatusTable 3.Odds Ratios of Clinical Adverse Events by RVP status Conclusion This limited, single-center study suggests that preoperative RVPs in pediatric cardiac surgery candidates identified asymptomatic viral shedding in 39%, though provided no detectable clinical benefit. Larger studies are needed to fully explore specific adverse clinical events and individual viral pathogen impacts. Institutional policies requiring preoperative RVP screening for pediatric cardiac surgery should be discouraged. Disclosures Kari Simonsen, MD, MBA, MedImmune: Grant/Research Support|Melinta Therapeutics: Grant/Research Support|Pfizer: Grant/Research Support.

Abstract 12319: Open-Heart Surgeries Leading to Unexpected Latent Disease - A Rare Case of Disseminated Mycobacterium Chimaera

Global reports describe several cases of disseminated Mycobacterium chimaera related to surgical field contamination by specific 3T heater-cooler units utilized in open cardiothoracic procedures. Eventual diagnosis leads to aggressive multidrug regimens and possible surgery, resulting in a high, yet potentially avoidable overall mortality rate. A years-long latency period between a patient’s initial exposure and clinical presentation can make this infection extremely challenging to diagnose. A 68-year-old-male with coronary artery disease (CAD) and a bicuspid aortic valve (BAV) suffered from shortness of breath and palpitations for eight years. An extensive cardiac work-up, including a cardiac MRI, revealed aortic root dilatation and significant CAD involving the left anterior descending coronary artery. The patient underwent an elective BAV repair, aortic root replacement, and single vessel coronary artery bypass surgery without any acute post-operative complications. Approximately four years later, he began experiencing fevers, night sweats, and vision changes. Eventually, he was ultimately diagnosed with disseminated M. chimaera confirmed by tissue biopsy. His treatment course of linezolid, moxifloxacin, ethambutol, and rifabutin, was complicated by adverse effects and complex resistance patterns. The complications he experienced secondary to this disease would eventually include long-standing bacteremia, encephalitis, splenic lesions, and aortic root abscess, which ultimately required open sternotomy for AV replacement and aortic root exchange. This patient remains the sole survivor from his home hospital among several other patients who also underwent cardiac surgeries and subsequently developed disseminated M. chimaera. He has since developed additional spinal involvement described as destructive osteomyelitis/discitis and confirmed via biopsy. As he continues to combat this clinically devastating bacterial pathogen, his multi-system complications with such an insidious presentation serve as a reminder to maintain a high clinical suspicion for the possibility of disseminated mycobacterial and other similar infectious processes in the differential diagnoses of all cardiothoracic surgical patients.

A pilot study of agreement between noninvasive thermometers and the core temperature of postoperative cardiothoracic surgical patients

ObjectiveReliable and accurate temperature assessment is fundamental for clinical monitoring; noninvasive thermometers of various designs are widely used in intensive care units, sometimes without a specific assessment of their suitability and interchangeability. This study evaluated agreement of four noninvasive thermometers with a pulmonary artery catheter temperature. MethodsThis prospective method comparison study was conducted in an Australian adult intensive care unit. One hundred postoperative adult cardiothoracic surgery patients who had a pulmonary artery catheter (Edwards Lifescience) in situ were identified. The temperature reading from the pulmonary artery catheter was compared to contemporaneous measurements returned by four different thermometers—temporal Artery (TA, Technimed), Per Axilla (Axilla, Welch Allyn), Tympanic (Tymp, Covidien), and the NexTemp® (NEXT, Medical Indicators [used per axilla]). The time required to obtain each noninvasive temperature measurement was recorded. ResultsAgreements between each noninvasive temperature and the pulmonary artery catheter standard were assessed using summary statistics and the Bland–Altman method comparison approach. A clinically acceptable maximum difference from the standard was defined as ±0.5 °C. Temperature agreement with the pulmonary artery standard (mean difference °C [95% limits of agreement °C]) was greatest for Tymp (−0.20 [−0.92 to 0.52]), intermediate for AXILLA (−0.37 [−1.3 to 0.59]) and NEXT (−0.71 [−1.7 to 0.27]), and least for TA (−0.60 [−2.0 to 0.81]). The proportion of measurements within ±0.5 °C of the standard were TYMP (81%), AXILLA (63%), TA (45%), and NEXT (30%). The time to obtain measurements varied, with the Tymp and TA estimates immediate, the AXILLA a mean of 40 s (standard deviation = 11 s), while NEXT results were at the manufacturer-recommended 3-min point. ConclusionsTympanic thermometers showed closest agreement with the pulmonary artery standard. Deviations by more than 0.5 °C from that standard were relatively common with all noninvasive devices.

The effect of tracheostomy on extracorporeal membrane oxygenation outcomes.

The optimal timing for pursuing tracheostomy in patients with prolonged mechanical ventilation with either veno-arterial (VA) or veno-venous (VV) extracorporeal membrane oxygenation (ECMO) is a discussion of risk versus benefit. Depending on the etiology, cardiothoracic surgical patients carry some of the highest risk for respiratory failure postprocedure.Given that patients with end-stage cardiopulmonary status may be fraught with substantial comorbidities, it is critically important to manage the risk-benefit profile of performing a tracheostomy procedure on a patient requiring ECMO support.These cohorts have risk factors that may depend on each patient's inflammatory state, lung de-recruitment peri-procedure and postprocedure and bleeding requiring transfusions to name a few.We provide a descriptive analysis of ECMO patients on both VA and VV configurations who survived to hospital discharge receiving tracheostomy either during or after their ECMO course. A retrospective single-institutional study collected all consecutive patients age 18 and above who received any form of ECMO between 2016 and 2020. Five hundred forty-fivepatients were screened based on having received ECMO. Patients with mixed EMCO modality were excluded due to heterogeneity of disease process. A total of 521 patients received either VV or VA ECMO. A total of 54 patients received tracheostomy and had sufficiently clean data for analysis. Tracheostomy patients were compared based on survival to discharge, tracheostomy surgical complications, ECMO duration, ECMO configuration, inotrope and vasopressor use, transfusion rates, total ventilator days, total days on intravenoussedation, and history of cardiotomy or heart transplant were assessed. Baseline characteristics of race, age, gender, and body mass index (BMI) were also collected. A total of 54 patients received tracheostomy. Twenty-nineof those patients received tracheostomy during the course of their ECMO, of whom 13 were on VV ECMO, 16 on VA ECMO. Another 25 patients underwent tracheostomy after successful ECMO explant; 8 of those were VV ECMO with the remaining 17 were on VA ECMO before explantation, with mean delay to tracheostomy, 10 and 19 days after explant between both modalities, respectively. A statistically significantly greater proportion of VV ECMO patients received a tracheostomy at any point versusVA ECMO patients (25.93% vs. 8.35%, p ≤ .0001). No statistically significant difference was noted in timing of tracheostomy when stratified by EMCO modality (VA 51.51% after explant vs. VV 38.10% after explant, p = .33).There was a greater frequency of minor tracheostomy complications in patients who were on ECMO at the time of their tracheostomy (p = .014) than in those who received their tracheostomy after being explanted. However, these minor complications did not contribute to a change in survival to hospital discharge (p = .58). Similarly, the small number of major complications (n = 13) did not impair survival to hospital discharge (p = .84).Finally, mean duration of ECMO was longer in those who received tracheostomy during ECMO versus after ECMO. (488.45 vs. 259.72 h, p < .01). Tracheostomy is known to increase patient mobility, clinical participation, and overall decrease in sedation use. Pursuing tracheostomy during ECMO is feasible, does not result in major bleeding, and is associated with only minor complications that overall do not decrease survival. While there is an increased duration of ECMO support in the tracheostomy cohort, this may be due to existing patient conditions, and may not be causal. Research is needed to further determine the external patient factors and specific timing to optimize both VV and VA ECMO courses. We hope that our analysis will pave the initial pathway for an evidence-based guideline on optimal timing of tracheostomy in ECMO patients, whether initiated during or after ECMO and taking into consideration ECMO configuration, its expected duration, and patient comorbidities.

Nurse and Provider Pain Management Education Priorities and Barriers

BackgroundThe purpose of this research was to describe health care nurse and providers’ pain management education priorities and barriers for pediatric cardio-thoracic surgical (CTS) patients and their caregivers. DesignThis was a qualitative-descriptive study design using survey methodology. MethodsA convenience sample of 206 (CTS) health care professionals including 172 nurses, 11 advanced practice providers, and 23 physicians were invited to participate in this study. The survey was distributed through a work e-mail within a 145-bed tertiary pediatric hospital and focused on collaborative pain management educational priorities and barriers. ResultsOf the 206 cardio-thoracic service health care nurses/providers surveyed, 45.6 % (N = 94) responded to the survey. The top pain management education priority for these nurses/providers included immediate postoperative pain management knowledge for the caregiver and pediatric CTS patient. The lowest priority 13.8% (N = 13) included education related to pain management needs after discharge. Of the 94 nurses/providers who responded, 31.9% (n = 30) identified the presence of timing and communication barriers in providing pain management education with caregivers and pediatric CTS patients. AimsThe aim of this research was to describe health care providers pain management education priorities and barriers for cardio-thoracic surgical (CTS) pediatric patients and their caregivers. Setting145-bed tertiary pediatric hospital. Participants/SubjectsNurses, advanced practice providers [APP's], and physicians. ConclusionsNurses and providers prioritize immediate postoperative pain management education; however, there remains a need to focus more on the outcomes of pain management education for caregivers and pediatric CTS patients after discharge.

9. The impact of nasal screening for methicillin-resistant staphylococcus aureus on surgical site infection after primary lumbar fusion

<h3>BACKGROUND CONTEXT</h3> Surgical site infections (SSI) constitute significant morbidity in spine surgery. Efforts at SSI prevention include preoperative methicillin-resistant Staphylococcus aureus (MRSA) screening and decolonization, with demonstrated success for arthroplasty patients along with vascular and cardiothoracic surgical patients. The variety of surgical approaches and anatomic regions within spine surgery can limit the impact of analyses at the subspecialty level. Despite the success of MRSA nasal screening and decolonization in reducing SSI rates in other disciplines, the impact on spine surgery is less understood. <h3>PURPOSE</h3> To determine the relationship between nasal MRSA testing and operative debridement rates for surgical site infection after primary lumbar fusion. <h3>STUDY DESIGN/SETTING</h3> Retrospective cohort study at two academic tertiary referral centers. <h3>PATIENT SAMPLE</h3> Adult patients (>18 years) were identified from January 2015 to March 2020 based on CPT codes for spinal instrumentation and fusion. Inclusion criteria were primary instrumented posterior lumbar fusion between 1-3 levels and exclusion criteria were revision surgery, tumor, infection, lateral-only surgery or operative surgeon with fewer than 20 cases. <h3>OUTCOME MEASURES</h3> Operative incision and drainage (I&D) of the index lumbar spine wound within 90-days after surgery was the primary outcome. <h3>METHODS</h3> Chart text, operative reports and laboratory reports were reviewed for data abstraction. Multivariable logistic regression modeling assessed for demographic differences between MRSA testing groups as well as factors contributing to I&D risk. <h3>RESULTS</h3> There were 2,148 patients included with a mean age 62.5 (SD 12.9), 56.9% female, and mean BMI 29.4 (SD 6.2). MRSA testing 90 days prior to surgery was completed in 884 (41.1%) of patients, and 19 (2.2%) of tested patients were colonized with MRSA preoperatively. Thirty-six (1.7%) patients underwent surgical I&D within 90 days of their index procedure for a surgical site infection. I&D risk was not associated with presence or result of MRSA testing, preoperative mupirocin prescriptions, or type of intraoperative antibiotic after controlling for surgeon. I&D risk was associated with higher BMI (5.7% increased risk for every 1 unit increase in BMI or a coefficient of 0.057, 95% confidence interval 0.017 to 0.097, p = 0.005) after controlling for age, diabetes and smoking status. <h3>CONCLUSIONS</h3> The present study demonstrates no difference in surgical I&D rates between patients who underwent MRSA testing, who had positive MRSA colonization or who underwent other interventions aimed at decreasing SSI rates such as preoperative mupirocin decolonization or addition of intraoperative vancomycin. Increased BMI was associated with risk of undergoing an operative I&D for surgical site infection, suggesting that patient factors dominate over clinical interventions in the prevention of surgical site infection after primary lumbar spine fusion. <h3>FDA DEVICE/DRUG STATUS</h3> This abstract does not discuss or include any applicable devices or drugs.

Hospital-Acquired Blood Stream Infection in an Adult Intensive Care Unit.

Background Hospital-acquired blood stream infections are a common and serious complication in critically ill patients. Methods A retrospective case series was undertaken investigating the incidence and causes of bacteraemia in an adult intensive care unit with a high proportion of postoperative cardiothoracic surgical and oncology patients. Results 405 eligible patients were admitted to the intensive care unit over the course of nine months. 12 of these patients developed a unit-acquired blood stream infection. The average Acute Physiology And Chronic Health Evaluation II (APACHE II) score of patients who developed bacteraemia was greater than that of those who did not (19.8 versus 16.8, respectively). The risk of developing bacteraemia was associated with intubation and higher rates of invasive procedures. The mortality rate amongst the group of patients that developed bacteraemia was 33%; this is in contrast to the mortality rate in our unit as 27.2%. There was a higher proportion of Gram-negative bacteria isolated on blood cultures (9 out of 13 isolates) than in intensive care units reported in other studies. Conclusion Critical-care patients are at risk of secondary bloodstream infection. This study highlights the importance of measures to reduce the risk of infection in the intensive-care setting, particularly in patients who have undergone invasive procedures.

Goal-directed haemodynamic therapy (GDHT) in surgical patients: systematic review and meta-analysis of the impact of GDHT on post-operative pulmonary complications

BackgroundPerioperative goal-directed haemodynamic therapy (GDHT), defined as the administration of fluids with or without inotropes or vasoactive agents against explicit measured goals to augment blood flow, has been evaluated in many randomised controlled trials (RCTs) over the past four decades. Reported post-operative pulmonary complications commonly include chest infection or pneumonia, atelectasis, acute respiratory distress syndrome or acute lung injury, aspiration pneumonitis, pulmonary embolism, and pulmonary oedema. Despite the substantial clinical literature in this area, it remains unclear whether their incidence is reduced by GDHT. This systematic review aims to determine the effect of GDHT on the respiratory outcomes listed above, in surgical patients.MethodsWe searched the Cochrane Central Register for Controlled Trials (CENTRAL), MEDLINE, EMBASE, and clinical trial registries up until January 2020. We included all RCTs reporting pulmonary outcomes. The primary outcome was post-operative pulmonary complications and secondary outcomes were specific pulmonary complications and intra-operative fluid input. Data synthesis was performed on Review Manager and heterogeneity was assessed using I2 statistics.ResultsWe identified 66 studies with 9548 participants reporting pulmonary complications. GDHT resulted in a significant reduction in total pulmonary complications (OR 0.74, 95% CI 0.59 to 0.92). The incidence of pulmonary infections, reported in 45 studies with 6969 participants, was significantly lower in the GDHT group (OR 0.72, CI 0.60 to 0.86). Pulmonary oedema was recorded in 23 studies with 3205 participants and was less common in the GDHT group (OR 0.47, CI 0.30 to 0.73). There were no differences in the incidences of pulmonary embolism or acute respiratory distress syndrome. Sub-group analyses demonstrated: (i) benefit from GDHT in general/abdominal/mixed and cardiothoracic surgery but not in orthopaedic or vascular surgery; and (ii) benefit from fluids with inotropes and/or vasopressors in combination but not from fluids alone. Overall, the GDHT group received more colloid (+280 ml) and less crystalloid (−375 ml) solutions than the control group. Due to clinical and statistical heterogeneity, we downgraded this evidence to moderate.ConclusionsThis systematic review and meta-analysis suggests that the use of GDHT using fluids with inotropes and/or vasopressors, but not fluids alone, reduces the development of post-operative pulmonary infections and pulmonary oedema in general, abdominal and cardiothoracic surgical patients. This evidence was graded as moderate.PROSPERO registry reference: CRD42020170361

PHAEOHYPHOMYCOTIC OSTEOMYELITIS AFTER BILATERAL LUNG TRANSPLANTATION

SESSION TITLE: Fellows Transplantation Posters SESSION TYPE: Fellow Case Report Posters PRESENTED ON: October 18-21, 2020 INTRODUCTION: Phaeohyphomycoses are a heterogenous group of infections caused dematiaceous fungi, which are characterized by melanin pigmentation in the cell wall. While rare, these infections are being increasingly seen in both immunocompromised and immunocompetent individuals.1 Transplant patients are at a higher risk due to prolonged immunosuppression. We present a case of Bipolaris spp. osteomyelitis in a lung transplant recipient. CASE PRESENTATION: A 43 year-old female status post bilateral lung transplant for interstitial lung disease secondary to dermatomyositis on tacrolimus and prednisone, with a history of multiple surgical debridements of a chronic polymicrobial open chest wall wound infected with Vancomycin-resistant Enterococcus (VRE) and Enterobacter spp., presented with poor wound healing of the chest wound. She was taken to the operating room, and areas of devitalized tissue and purulence were debrided to create a single wound. Her empiric antibiotics were adjusted to daptomycin, and liposomal amphoptericin B upon identification of VRE and a mold. Final fungal cultures demonstrated Bipolaris, so voriconazole was substituted for amphotericin. After a fourteen day course of daptomycin, the patient was discharged with voriconazole and wound dressings with Iodasorb. Three weeks later, the patient was readmitted and started on broad spectrum antibiotics and continued on voriconazole after a CT Chest concerning for osteomyelitis was performed. She underwent surgical debridement by thoracic and plastic surgery of the chest wound and sternum. Bone specimens were noted to have invasive fungal elements in the bone consistent with osteomyelitis. Fontana-Masson staining was positive for melanin. Bacterial wound cultures grew VRE, Methicillin-sensitive Staphylococcus aureus, and Beta-Hemolytic Streptococci. She was discharged on oral linezolid and voriconazole for at least 6 weeks. DISCUSSION: Phaeohyphomycosis accounts for approximately for 2.6% of all fungal infections seen and are evenly distributed between stem cell and solid organ transplant patients.2 Bipolaris is an environmental mold associated with allergic fungal sinusitis with a higher prevalence in Southwest United States. Other less common presentations include cutaneous, subcutaneous skin infections, osteomyelitis and keratitis.1 Bipolaris in wound infections is rare, with cases reported only in cardiothoracic surgical patients, typically associated with delayed sternal closures. CONCLUSIONS: Bipolaris infection has not been reported in any other surgery except cardiac in literature. No standardized therapy exists, but in vitro sensitivity study show that itraconazole and voriconazole have excellent activity against Bipolaris.1 This case highlights the importance of considering phaeohyphomycotic infections in lung transplant recipients. Reference #1: Revankar S. G. (2015). Phaeohyphomycosis in Transplant Patients. Journal of fungi (Basel, Switzerland), 2(1), 2. https://doi.org/10.3390/jof2010002. Reference #2: McCarty, T. P., Baddley, J. W., Walsh, T. J., Alexander, B. D., Kontoyiannis, D. P., Perl, T. M., Walker, R., Patterson, T. F., Schuster, M. G., Lyon, G. M., Wingard, J. R., Andes, D. R., Park, B. J., Brandt, M. E., Pappas, P. G., & TRANSNET Investigators (2015). Phaeohyphomycosis in transplant recipients: Results from the Transplant Associated Infection Surveillance Network (TRANSNET). Medical mycology, 53(5), 440–446. https://doi.org/10.1093/mmy/myv018. DISCLOSURES: No relevant relationships by Sravya Brahmandam, source=Web Response No relevant relationships by Sruti Brahmandam, source=Web Response No relevant relationships by Dibson Gondim, source=Web Response No relevant relationships by ALLAN RAMIREZ, source=Web Response

Implementing Cardiac Surgical Unit-Advanced Life Support Through Simulation-Based Learning: A Quality Improvement Project.

The European Association for Cardio Thoracic Surgery and the Society of Thoracic Surgeons endorse Cardiac Surgical Unit-Advanced Life Support, a protocol designed specifically for cardiothoracic surgical patients who suffer postoperative cardiac arrests. To enhance patient outcomes and to reduce death rates, cardiothoracic intensive care unit nurses must be able to perform the protocol with confidence, proficiency, and without delays. To this end, simulation-based learning (SBL) is a pedagogical method ideal for optimized learning. This quality improvement project was designed to implement a post-cardiac surgery resuscitation protocol in a nonacademic, community medical center to enhance nurse knowledge, confidence, and proficiency for optimal patient outcomes. The Cardiac Surgical Unit-Advanced Life Support is an evidence-based resuscitation protocol that was implemented using didactic, hands-on training, and SBL. It was evaluated using knowledge surveys, comparisons in nurse confidence and performance measures, and patient outcomes data. Nurses' knowledge gains (ie, mean test scores) on our test were statistically significant between 3 time points (F2,60 = 81.204, P < .001). Knowledge significantly increased from pre-education to immediate post-education (P < .001), but declined from immediate post-education to 3-month post-education assessments (P < .001); however, the 3-month post knowledge mean was still higher than the pre-education knowledge mean (P < .001). Nurses were confident in their ability to apply the protocol, although results failed to show a correlation between confidence and performance ability. Statistical significance for delay in cardiopulmonary resuscitation was found between pre- and post-nursing education patient cardiac arrest events (P = .05). Didactic and hands-on learning supported knowledge retention over time for cardiothoracic surgical intensive care unit nurses. Improving self-confidence and the application of an unfamiliar resuscitation protocol through SBL and any impact a training program has on patient outcomes will require ongoing practice and more evaluation.

Targeted Multidrug Resistant Organism Antimicrobial Prophylaxis and Postoperative Infections in Pediatric Cardiothoracic Surgical Patients.

To determine if receiving targeted antimicrobial (AM) prophylaxis has an effect on the rate of postoperative infections in patient's colonized with a multidrug resistant organism (MDRO) undergoing cardiothoracic surgery (CTS). Single-center, retrospective medical record review of pediatric patients from birth to 18 years of age undergoing CTS from January 2013 to September 2018. Demographic data collected included age, specific MDRO, site of MDRO colonization, type of surgery, perioperative AM agent and type of infection. Patients were stratified into 2 groups, MDRO+ and MDRO-. Demographic and clinical characteristics were compared between groups with a Student's t test for continuous variables and a χ2, Fisher exact test or Mann-Whitney U test for noncontinuous variables. A 2-sided significance level of α = 0.05 was used to determine statistical significance. All analyses were performed using IBM SPSS Version 24 (SPSS Inc., Chicago, IL). Fifty patients (26 males/24 females) were included in the MDRO (+) group and 295 patients (168 males/127 females) in the MDRO (-) group. The median age was 0.48 years (interquartile range 0.24-1 year) and 0.9 years (interquartile range 0.19-8 years) in the MDRO (+) and MDRO (-) groups, P = 0.003. 2 of 50 (4%) MDRO (+) patients and 15 of 295 (5.1 %) MDRO (-) patients developed an infection, P = 1. 10 of 50 (20%) MDRO (+) patients received targeted AM toward the MDRO and none developed an infection. Of the 2 MDRO (+) patients with infection, 1 was infected with the MDRO. For MDRO (+) patients, there was no difference in the rate of infection whether targeted AM therapy was received, P = 1. There was no difference in the rate of postoperative infection between MDRO (+) and MDRO (-) patients. Additionally, these preliminary pediatric data suggest targeting AM agents to a specific MDRO does not impact the rate of postoperative infection in children undergoing CTS. Larger studies are warranted to confirm these findings.

Mortality in Australian Cardiothoracic Surgery: Findings From a National Audit

Independent peer review of mortality cases has potential to identify issues in cardiothoracic surgical patients. The Australian and New Zealand Audit of Surgical Mortality aims to improve surgical care through peer-reviewed assessment of all surgical mortality. The aim of this study was to describe common clinical management issues that contribute to patient mortality in a cohort of Australian cardiothoracic surgical patients. This approach may subsequently provide a basis for quality improvement. Cardiothoracic mortality reports to the Australian and New Zealand Audit of Surgical Mortality from February 2009 through December 2015 were reviewed. The surgeon report and assessor comments were coded to identify clinical management issues. These were divided into perioperative stages (preoperative, intraoperative, and postoperative), and at each stage a thematic analysis was performed. Of the 908 cases analyzed, 1371 clinical management issues were identified. Postoperative issues were the most common (n= 552), followed by preoperative (n= 378) and intraoperative issues (n= 370). Communication issues were present at all 3 stages (n= 71). Overall the most common theme was intraoperative technical issues (n= 287). Many of these issues revolved around unintentional injury to anatomic structures during surgery and inadequate myocardial protection. Communication issues commonly related to surgical handover to the intensive care unit and lack of shared decision-making. Also common were consultant surgeons being unaware of patient deterioration or significant changes in management. The Australian and New Zealand Audit of Surgical Mortality provides valuable insights into issues affecting mortality in cardiothoracic patients. Potentially avoidable management issues play a large role in determining the outcome of these patients. Quality improvement initiatives targeting these areas may be valuable.

Impact of a family caregiver training program in Kolkata, India on post-operative health perceptions and outcomes of cardiothoracic surgical patients

# Background Patient and family caregiver education is essential for adequate home care after a cardiothoracic surgical intervention. In resource-poor settings where access to medical care is limited and health literacy is low, pre-discharge caregiver education is frequently overlooked. This study evaluates the effect of the Care Companion Program (CCP), an in-hospital patient family engagement and education program that targets family caregivers to support post-surgical patient recovery. # Methods This study was based on a quasi-experimental design at a tertiary care facility in Kolkata, India, in which 188 patient-caregiver dyads providing support to patients undergoing surgical intervention for cardiovascular disease were selected to participate. One hundred dyads received standard of care (SoC), and 88 dyads received the CCP. Patient-caregiver dyads were evaluated on patient post-discharge complications and physical functional status; Caregiver Activation Measure and health knowledge. Assessments were conducted at baseline, discharge, and post-discharge at 30 days. # Results Post-discharge 30-day complication rates were significantly lower for the CCP group compared to SoC (34.4% vs. 14.5%, respectively, *P*0.003). The CCP group showed a significantly greater increase in their Caregiver Activation Measure scores between baseline and discharge (4.2 ± 9.1 vs. 1.3 ± 7.4, respectively, *P*\<0.001) that were sustained at 30 days post-discharge (7.2 ± 17.4 vs. 1.4 ± 10.4, respectively, *P*\<0.001). Knowledge scores for the CCP group showed significant improvement (*P*\<0.001) between baseline and discharge and were sustained at 30 days post-discharge (*P*0.003). Compared to the SoC group, patients in the CCP group reported a significantly greater increase in their physical functional status (World Health Organization Quality of Life short form assessment (WHOQOL-BREF) physical health domain) between baseline and 30 days post-discharge (*P*=0.018). # Conclusions The results of the study suggest significant associations between participation in the CCP and reduced 30-day complications, increased caregiver activation, and increases in health knowledge. Programs such as the CCP may play an important role in engaging family caregivers to improve health outcomes in settings with limited healthcare resources.

Impact of a family caregiver training program in Kolkata, India on post-operative health perceptions and outcomes of cardiothoracic surgical patients

Impact of a family caregiver training program in Kolkata, India on post-operative health perceptions and outcomes of cardiothoracic surgical patients

A randomized, controlled pilot clinical trial of cryopreserved platelets for perioperative surgical bleeding: the CLIP-I trial (Editorial, p. 2759).

Cryopreservation extends platelet (PLT) shelf life from 5 to 7 days to 2 to 4 years. However, only 73 patients have been transfused cryopreserved PLTs in published randomized controlled trials (RCTs), making safety data insufficient for regulatory approval. The Cryopreserved vs. Liquid Platelet (CLIP) study was a double-blind, pilot, multicenter RCT involving high-risk cardiothoracic surgical patients in four Australian hospitals. The objective was to test, as the primary outcome, the feasibility and safety of the protocol. Patients were allocated to study group by permuted block randomization, with patients and clinicians blinded by use of an opaque shroud placed over each study PLT unit. Up to 3 units of cryopreserved or liquid-stored PLTs were administered per patient. No other aspect of patient care was affected. Adverse events were actively sought. A total of 121 patients were randomized, of whom 23 received cryopreserved PLTs and 18 received liquid-stored PLTs. There were no differences in blood loss (median, 715 mL vs. 805 mL at 24 hr; difference between groups 90 mL [95% CI, -343.8 to 163.8 mL], p = 0.41), but the Bleeding Academic Research Consortium criterion for significant postoperative hemorrhage in cardiac surgery composite bleeding endpoint occurred in nearly twice as many patients in the liquid-stored group (55.6% vs. 30.4%, p = 0.10). Red blood cell transfusion requirements were a median of 3 units in the cryopreserved group versus 4 units with liquid-stored PLTs (difference between groups, 1 unit [95% CI, -3.1 to 1.1 units]; p = 0.23). Patients in the cryopreserved group were more likely to be transfused fresh-frozen plasma (78.3% vs. 27.8%, p = 0.002) and received more study PLT units (median, 2 units vs. 1 unit; difference between groups, 1 unit [95% CI, -0.03 to 2.0 units]; p = 0.012). There were no between-group differences in potential harms including deep venous thrombosis, myocardial infarction, respiratory function, infection, and renal function. No patient had died at 28 days, and postoperative length of stay was similar in each group. In this pilot RCT, compared to liquid-stored PLTs, cryopreserved PLTs were associated with no evidence of harm. A definitive study testing safety and hemostatic effectiveness is warranted.