Pediatric Cardiac ICU National Cardiovascular Center Harapan Kita (NCCHK) – Jakarta

SOLUTIONS…..PRE-OPERATIVE

PLANNING WITH TB AND GRAM

NEGATIVE SEPSIS

Eva Miranda Marwali, MD, PhD

INDONESI

A

Dec

No disclosures Parents permission has been obtained for

patient’s photographs shown

Objectives

Pre-operative infection

Incidence of Tuberculosis (TB) and bacterial

infection (gram negative sepsis) in CHD

Impact on surgical outcome

What is the solution and pre-operative

planning? especially in limited resources

country

National Cardiovascular Center Harapan Kita

(NCCHK) Jakarta (Indonesia)

• Founded in 1985,

assigned as National

Cardiovascular Center

• Performed all CHD surgery

(incl. Arterial switch &

Norwood) except heart

transplant

• Total: ± 1000 pump cases

a year

• 16 PCICU beds with

PCICU NCCHK Database

(Jan – September 2017)

Database

Jan-Sept

2017

Total

PCICU

Admissio

n,

N

Total

sepsis

patients,

N (%)

Overall

mortality

N (%)

Mortality

from

sepsis

N (%)

Medical

cases

81 20 (25.3) 26 (32.1) 12/20 (60)

Surgical

cases

684 40 (5.9)* 47 (6.9) 17/40

(42.5) Sepsis as the major cause of death post surgery

(36%)

* Most of them with history of pre-operative

infection

NCCHK PCICU Microbiology Report 2016

of PCICU Medical and Surgical patients

ORGANISM ETT

Isolate %

GRAM NEGATIVE

Acinetobacter

baumanii 27 17.8

Enterobacter

gergoviae 15 9.9

Escherichia coli 12 7.9

Klebsiella

pneumoniae 22 14.5

Psudomonas

aeruginosa 18 11.8

Serratia marcescens 18 11.8

GRAM POSITIVE

ORGANISM Blood

Isolate %

GRAM NEGATIVE

Acinetobacter

baumanii 4 16.0

Acinetobacter wolffii 3 12.0

Enterobacter

aerogenes 5 20.0

Klebsiella

pneumoniae 2 8.0

Serratia

marcescens 3 12.0

Most cases are late presenter

Hospital acquired infections

Antibiotic overused

Global burden of ESBL and

MDR

Incidence and impact of sepsis on mortality (*before surgery)

Author Area/

Country PICU/ NICU

Incidence of infection/sepsis

Mortality rate +/- infection

Highest Mortality Overall Gram

― Gram

+ Mohsin SS , 2014 (Report)

Pakistan 34 CHD infants

74% *59%

NCCHK Database 2017

Indonesia

81 CHD children

25.3% *32.1%

Ascher SB, 2012 (Report)

Pediatrix Medical Group-USA

11,638 CHD infants

6% (71/1000

)

26% (gram -)

9% (fungal)

64%

*11% OR (95%CI)=1.53 (1.09-

2.13)

Negative gram (13%) candidemia (21%)

Berezin NE, Latin PICU/

16 -37% 31-63% 30%

Negative gram inf

Impact of pre-operative infection on surgical outcome in developing countries

Author Country Pre-operative

Identifying factors

Post-operative outcome

p OR

Vaidyanathan B (2002) Report in 100 children with VSD

India Pneumonia

(25%)

Intubation time

46 vs. 24 hours

(p=0.001) N/A

LOS ICU 7 vs.4 days (p=0.001)

LOS Hospital

10 vs.7 days (p=0.001)

Bakhsi DK (2007) Report in 330 neonates

India Use of

antibiotic (4.2%)

Mortality 0.014 5.6 (1.3-25.1)

Reddy NS (2012) Report 1028 infants

India

Pre-operative

BSI (7.8%)

Mortality 0.008 2.86 (1.32-6.21)

Sepsis <0.001 16.5 (8.8-30.9)

Intubation time

0.003 2.34 (1.35-4.08)

Sen AC (2017)

16 developi Major medical Infection 19.6% vs 6.3% 2.1 (1.5-2.8)

Impact of pre-operative infection/hospitalization on surgical outcome in developed countries

Author Country Pre-operative

Identifying factors

Post-op outcome

p OR

Brown KL (2003) Report in 355 pediatrics post CHD surgery

England

2 medical problems, i.e. pneumonia

(4.7%)

LOS ICU p<0.001 2.61 (1.87-

3.65)

Sarviki E (2008) Report 511 pts

Finland Pre-operative

stay > 48 hours

Surgical Site

Infection

67% vs. 40%

p=0.01

2.99 (1.32-6.76)

Barker GM (2010)

USA

Pre-op length of stay > 1 day

Major infection

p<0.0001 1.8 (1.5-

2.2)

Pre-op ventilator support

P<0.0001 2.1(1.8-2.5)

Why is pre-operative infection in CHD children matter in developing world?

Incidence of pre-

operative infection

Late diagnosis of CHD late presentation, malnutrition

Lack of a structure system for referral

and transport of sick neonates with CHD to a tertiary care center

Overcrowded ICU, understaffing, nosocomial

infection, antibiotic overused

Densely population, bad sanitation and

low immunization coverage

Surgical Cost and

Outcome

Bacterial (gram negative)

sepsis

Solutions……pre-operative planning

Treat sepsis based on sepsis

bundle and antibiogram

Infection marker: Fever, Leucocyte and

differential count, Platelet, ITR, CRP and

Procalcitonin

Surgery???

Pre-operative planning for gram negative

sepsis

National Cardiovascular Center Harapan Kita (NCCHK)

Protocol

When is the best time for surgery after pre-operative infection?

SURGE

RY

With

CPB

OUTCOME

??

Reactivation or a new nosocomial

infection ?

Immunomodulatory

strategies

Gram negative sepsis

Depends on

- Institutional Protocol

- Diagnosis of CHD and types of surgery

How emergency is the case?

- Type and severity of infection, and

susceptibility to infection (syndrome?)

- Is there any other option beside

surgery

For Emergency cases (i.e TAPVD obstructed, BT shunt)

- No surgery will be performed during sepsis

- Interventional catheterization is

recommended; such as stenting of the PDA, RVOT (TOF cases), obstructed PV drainage and atrial stenting.

Pre-operative planning for sepsis Emergency/Semi-elective surgery

NCCHK

Protocol

Peters B, et al. Ann Pediatr Cardiol

2009;2:3-23

Depends on infection marker and clinical condition

If resolved (most cases within 2-3 weeks, but can be earlier):

1. Fever or Pneumonia cases Surgery 2. Sepsis especially gram negative: mortality

Problem: ventilator dependent

3 options : 1. Conservatives (sort out sepsis first)

2. Palliative / stages surgery

Pre-operative planning for sepsis Elective surgery

NCCHK Protocol

J. Thorac Cardiovasc Surg 2004;127:1466-73

Median time for surgery 6.5

days of MV (range 1-16 days)

Avoid CPB we prefer to do PA banding first after severe pulmonary infection or sepsis, i.e cases with pulmonary hypertension due to lung overflow such as CAVSD and Truncus and difficult to wean from ventilator.

Try to repair the extra cardiac anomaly first such as Coarct. of Ao or IAA.

It is encouraged to have unremarkable surgery (quick in and quick out) and without residuals, so it will prevent the occurrence of LCOS after surgery.

Pre-operative planning for gram negative sepsis- Elective surgery

NCCHK Protocol

Brown JW et al. Eur J Cardiothorac Surg 2006;29:666-73

Sakurai T et al.Eur J Cardiothorac Surg.

2016;50:626-31

2 Cases with Severe Pulmonary

Hypertension and Down Syndrome

5 month old, 5 kg, with CAVSD and Down syndrome, with history of pneumonia

CAVSD repair

Post op severe AV valve regurgitation

10 month old, 5 kg, with big VSD (8mm) and big ASD (9 mm), with moderate malnutrition

ASD and VSD Closure

No residuals

Case 1 Case 2

On HFO for ARDS

POD 33 Deceased ec. Sepsis, ARDS,

DIC, MOF

Cost 26,600 US$

Survive, on nasal CPAP, discharge

home

LOS Hospital 27 days

Cost 18,300 US$

“QUICK IN AND QUICK OUT

SURGERY”

NCPAP, non invasive

ventilation Prone position

Non invasive ventilation and nutritional

support

Early diagnosis of CHD, good referral and transport system, ICU bed for CHD, nutrition support center with limited resource

Prevention for nosocomial infection: hand hygiene, VAP and BSI bundle, antimicrobial stewardship, staffing support, surveillance program

Antibiotic prophylaxis guidelines

Immunization program for CHD children before surgery

Pre-operative planning for sepsis Preventive measurements

BENCHMARKING

IS IMPORTANT

What about Tuberculosis ??

• At least 1 million children become ill with tuberculosis (TB) each year. Children represent about 10-11% of all TB cases.

• In 2015, 170,000 children died of TB, and there were an additional 40,000 TB deaths among children who were HIV-positive.

Indicates continued transmission in setting w/ poor epidemic control

80% in 22 highest burden countries Increasing numbers developing world

HIV epidemic (> 34% co- infected) Poverty, overcrowding, malnutrition. Travel MDR-TB and XDR-TB /Incomplete treatments Breakdown of TB control programs

“Global Burden of Childhood

Tuberculosis”

TB is a preventable and treatable disease

from which no child should die.

Jenkins, Pneumonia,

2016;8:24

TB among children with medical comorbidities

Cruz AT. Ped Inf Dis. 2014;33:885-8.

- An approximately 2.5 fold

increase in pulmonary TB in

children with CHD

- Cardiac surgery had to be

delayed in 60% of cases with

TB and CHD.

Pre-operative planning for TB

Pre-operative planning for TB

Screening for TB is mandatory if there is a suspicious of TB contact, infection or diseases

For TB endemic countries, it is suggested to do TB screening for CHD infants and children and HIV infection It is hard to diagnose TB in immunocompromise patients; CHD with malnourishment, infection/sepsis

Interferon gamma release assay and Gen Xpert

A. TB prophylaxis: 1. TB Exposure

2. Infected TB (LTBI): 5-10% of LTBI will develop into active TB disease

High risk group: Children < 5 years old, immunocompromise (HIV), severe malnourishment, live in dormitory, orphanage, CHD(??)

B. TB Treatment: Active TB Disease

TB prophylaxis and treatment should be given at least for 3 months before surgery OR until the sputum has been negative for TB. Beware of the drug side effects!

Pre-operative planning for TB

Indonesian TB Task Force

Indonesian Child Health Organization

Post op ventilatory challenges due to Pulmonary TB

Past Tuberculosis

Late presenting TOF

with Spinal deformity

Courtesy from dr P. Iyer

Presented in 12th PCICS Conference

• Rastelli in a 6 year old severely polycythemic dTGA.VSD.PS with pulmonary tuberculosis and bronchiectasis

Severe polycythemia ( Hb 26 gm/dl), severe malnutrition, right sided lung disease ( tuberculosis, bilateral bronchiectasis)

Ventilatory challenge - Did unexpectedly well, extubated after 70 hours.

Courtesy from dr P. Iyer Presented in 12th PCICS Conference

Conclusions

Pre-operative infection; TB and gram negative sepsis will

complicate post operative course of congenital heart disease

surgery

Solutions for pre-operative planning is mandatory with each

infant/child needs individualization regarding decision

and timing for surgery

Surgery is performed after sepsis resolved or do palliative/

stages surgery and minimized pump used.

If there is LTBI or TB disease: prophylaxis or treatment

should be given for at least 3 months before surgery.

Need further research for pre-operative infection problems

eva.marwali@pjnhk.go.id

THANK YOU….