Association between preoperative anemia and postoperative infection and death in children with acyanotic congenital heart disease undergoing elective cardiac surgery: A retrospective cohort study_Chinese Journal of Clinical Thoracic and Cardiovascular Surgery

Authors：

ZHOU Dan ¹ , FENG Mei ¹ , LI Li ¹ ,  SONG Jinping ² ,  TANG Menglin ¹

1. West China School of Nursing, Sichuan University/Department of Critical Care Medicine, West China Hospital, Sichuan University, Chengdu, 610041, P. R. China;
2. West China School of Nursing, Sichuan University, Chengdu, 610041, P. R. China;

Corresponding author：

SONG Jinping, Email: jinpings210@163.com; TANG Menglin, Email: menglin_tang@163.com

Keywords：

Congenital heart disease; children; elective surgery; anemia; infection; death

DOI：

10.7507/1007-4848.202110019

Video：

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Objective To analyze the relationship between preoperative anemia and postoperative infection and death in children with acyanotic congenital heart disease (CHD) after elective cardiac surgery. Methods Medical records and follow-up data of 3 859 children with acyanotic CHD who underwent elective cardiac surgery in our hospital from 2011 to 2018 were retrospectively collected, including 2 081 males and 1 778 females with a median age of 32.2 (13.7, 61.5) months. The relationship between preoperative anemia and postoperative infection and death within 90 days was analyzed by univariate and multivariate regression analyses. Results Preoperative anemia was found in 325 (8.4%) patients. There were 716 (18.6%) patients of postoperative infection, including 281 (7.3%) patients of confirmed infection and 435 (11.3%) patients of suspected infection. Forty-six (1.2%) patients died within 90 days after the operation. Univariate analysis showed that age, infection history within 3 months before admission, degree of pulmonary hypertension, the risk adjustment in congenital heart surgery-1 (RACHS-1) score, cardiopulmonary bypass (CPB), disease diagnosis, chromosome abnormality, preoperative left ventricular ejection fraction (LVEF)<55% and preoperative anemia were associated with postoperative infection. Age, degree of pulmonary hypertension, RACHS-1 score, CPB, disease diagnosis and preoperative LVEF<55% were associated with postoperative death within 90 days. Logistic regression analysis showed that preoperative anemia was significantly associated with confirmed postoperative infection [OR=1.82, 95%CI (1.18, 2.82), P=0.007], suspected infection [OR=1.60, 95%CI (1.11, 2.30), P=0.012] and total infection [OR=1.64, 95%CI (1.20, 2.24), P=0.002]. The results of modified Poisson regression analysis showed that there was no significant association between preoperative anemia and death within 90 days after the surgery [RR=1.59, 95%CI (0.69, 3.69), P=0.276]. Conclusion Preoperative anemia may be a risk factor for infection after elective cardiac surgery in children with acyanotic congenital heart disease.

Citation： ZHOU Dan, FENG Mei, LI Li, SONG Jinping, TANG Menglin. Association between preoperative anemia and postoperative infection and death in children with acyanotic congenital heart disease undergoing elective cardiac surgery: A retrospective cohort study. Chinese Journal of Clinical Thoracic and Cardiovascular Surgery, 2022, 29(10): 1354-1361. doi: 10.7507/1007-4848.202110019 Copy

1.	牛建钢. 2012~2015年郑州市二七区出生缺陷发生状况及影响因素. 郑州大学, 2017.
2.	杨学勇. 先天性心脏病的预防. 中国协和医科大学, 2009.
3.	Lytzen R, Vejlstrup N, Bjerre J, et al. Live-born major congenital heart disease in Denmark: Incidence, detection rate, and termination of pregnancy rate from 1996 to 2013. JAMA Cardiol, 2018, 3(9): 829-837.
4.	Wu W, He J, Shao X. Incidence and mortality trend of congenital heart disease at the global, regional, and national level, 1990-2017. Medicine (Baltimore), 2020, 99(23): e20593.
5.	Sen AC, Morrow DF, Balachandran R, et al. Postoperative infection in developing world congenital heart surgery programs: Data from the International Quality Improvement Collaborative. Circ Cardiovasc Qual Outcomes, 2017, 10(4): e002935.
6.	刘训. 体外循环下手术治疗儿童先天性心脏病术后并发肺部感染的相关危险因素分析. 重庆医科大学, 2019.
7.	Turcotte RF, Brozovich A, Corda R, et al. Health care-associated infections in children after cardiac surgery. Pediatr Cardiol, 2014, 35(8): 1448-1455.
8.	Meng L, Li J, He Y, et al. The risk factors analysis and establishment of an early warning model for healthcare-associated infections after pediatric cardiac surgery: A STROBE-compliant observational study. Medicine (Baltimore), 2020, 99(49): e23324.
9.	Hatachi T, Tachibana K, Inata Y, et al. Risk factors for healthcare-associated infections after pediatric cardiac surgery. Pediatr Crit Care Med, 2018, 19(3): 237-244.
10.	Sarvikivi E, Lyytikäinen O, Nieminen H, et al. Nosocomial infections after pediatric cardiac surgery. Am J Infect Control, 2008, 36(8): 564-569.
11.	Tweddell S, Loomba RS, Cooper DS, et al. Health care-associated infections are associated with increased length of stay and cost but not mortality in children undergoing cardiac surgery. Congenit Heart Dis, 2019, 14(5): 785-790.
12.	Bateman ST, Lacroix J, Boven K, et al. Anemia, blood loss, and blood transfusions in North American children in the intensive care unit. Am J Respir Crit Care Med, 2008, 178(1): 26-33.
13.	Goobie SM, Faraoni D, Zurakowski D, et al. Association of preoperative anemia with postoperative mortality in neonates. JAMA Pediatr, 2016, 170(9): 855-862.
14.	Faraoni D, DiNardo JA, Goobie SM. Relationship between preoperative anemia and in-hospital mortality in children undergoing noncardiac surgery. Anesth Analg, 2016, 123(6): 1582-1587.
15.	Khan Z, Natarajan G, Sallaam S, et al. Association between anemia and packed cell transfusion and outcomes of ventricular septal defect and atrioventricular canal repair in children. Pediatr Cardiol, 2014, 35(3): 471-478.
16.	Okoromah CA, Ekure EN, Lesi FE, et al. Prevalence, profile and predictors of malnutrition in children with congenital heart defects: A case-control observational study. Arch Dis Child, 2011, 96(4): 354-360.
17.	Goldberg JF, Shah MD, Kantor PF, et al. Prevalence and severity of anemia in children hospitalized with acute heart failure. Congenit Heart Dis, 2016, 11(6): 622-629.
18.	Karkouti K, Wijeysundera DN, Beattie WS, et al. Risk associated with preoperative anemia in cardiac surgery: A multicenter cohort study. Circulation, 2008, 117(4): 478-484.
19.	Ranucci M, Di Dedda U, Castelvecchio S, et al. Impact of preoperative anemia on outcome in adult cardiac surgery: A propensity-matched analysis. Ann Thorac Surg, 2012, 94(4): 1134-1141.
20.	Cholette JM, Faraoni D, Goobie SM, et al. Patient blood management in pediatric cardiac surgery: A review. Anesth Analg, 2018, 127(4): 1002-1016.
21.	Mazine A, Rached-D'Astous S, Ducruet T, et al. Blood transfusions after pediatric cardiac operations: A North American multicenter prospective study. Ann Thorac Surg, 2015, 100(2): 671-677.
22.	Goldstein B, Giroir B, Randolph A, et al. International pediatric sepsis consensus conference: Definitions for sepsis and organ dysfunction in pediatrics. Pediatr Crit Care Med, 2005, 6(1): 2-8.
23.	Xiang L, Su Z, Liu Y, et al. Effect of family socioeconomic status on the prognosis of complex congenital heart disease in children: An observational cohort study from China. Lancet Child Adolesc Health, 2018, 2(6): 430-439.
24.	Meyer HM, Torborg A, Cronje L, et al. The association between preoperative anemia and postoperative morbidity in pediatric surgical patients: A secondary analysis of a prospective observational cohort study. Paediatr Anaesth, 2020, 30(7): 759-765.
25.	Kedir H, Miller R, Syed F, et al. Association between anemia and postoperative complications in infants undergoing pyloromyotomy. J Pediatr Surg, 2019, 54(10): 2075-2079.
26.	Rodríguez-Hernández JL, Rodríguez-González F, Martínez-Quintana E. Anemia in adolescents and young adult patients with congenital heart disease. J Pediatr Hematol Oncol, 2018, 40(8): 620-624.
27.	Dimopoulos K, Diller GP, Giannakoulas G, et al. Anemia in adults with congenital heart disease relates to adverse outcome. J Am Coll Cardiol, 2009, 54(22): 2093-2100.
28.	Seicean A, Seicean S, Alan N, et al. Preoperative anemia and perioperative outcomes in patients who undergo elective spine surgery. Spine (Phila Pa 1976), 2013, 38(15): 1331-1341.
29.	Musallam KM, Tamim HM, Richards T, et al. Preoperative anaemia and postoperative outcomes in non-cardiac surgery: A retrospective cohort study. Lancet, 2011, 378(9800): 1396-1407.
30.	van Straten AH, Hamad MA, van Zundert AJ, et al. Preoperative hemoglobin level as a predictor of survival after coronary artery bypass grafting: A comparison with the matched general population. Circulation, 2009, 120(2): 118-125.
31.	Hopf HW, Hunt TK, West JM, et al. Wound tissue oxygen tension predicts the risk of wound infection in surgical patients. Arch Surg, 1997, 132(9): 997-1004.
32.	Schietroma M, Cecilia EM, De Santis G, et al. Supplemental peri-operative oxygen and incision site infection after surgery for perforated peptic ulcer: A randomized, double-blind monocentric trial. Surg Infect (Larchmt), 2016, 17(1): 106-113.
33.	Spahn DR, Schoenrath F, Spahn GH, et al. Effect of ultra-short-term treatment of patients with iron deficiency or anaemia undergoing cardiac surgery: A prospective randomised trial. Lancet, 2019, 393(10187): 2201-2212.
34.	Hassan N, Boville B, Reischmann D, et al. Intravenous ferumoxytol in pediatric patients with iron deficiency anemia. Ann Pharmacother, 2017, 51(7): 548-554.
35.	Shimpo H, Mizumoto T, Onoda K, et al. Erythropoietin in pediatric cardiac surgery: Clinical efficacy and effective dose. Chest, 1997, 111(6): 1565-1570.
36.	Cuenca J, García-Erce JA, Martínez F, et al. Perioperative intravenous iron, with or without erythropoietin, plus restrictive transfusion protocol reduce the need for allogeneic blood after knee replacement surgery. Transfusion, 2006, 46(7): 1112-1119.
37.	Cladellas M, Farré N, Comín-Colet J, et al. Effects of preoperative intravenous erythropoietin plus iron on outcome in anemic patients after cardiac valve replacement. Am J Cardiol, 2012, 110(7): 1021-1026.
38.	Faraoni D, Meier J, New HV, et al. Patient blood management for neonates and children undergoing cardiac surgery: 2019 NATA guidelines. J Cardiothorac Vasc Anesth, 2019, 33(12): 3249-3263.
39.	李奋. 先天性心脏病治疗时机及治疗方法的选择. 中国小儿急救医学, 2009, 16(5): 426-429.
40.	韩月英, 王厚照, 张雪梅, 等. 先天性心脏病患儿术后并发医院感染的危险因素及其病原菌分布和药敏实验分析. 现代生物医学进展, 2021, 21(4): 683-687, 682.
41.	Lau PE, Cruz SM, Ocampo EC, et al. Necrotizing enterocolitis in patients with congenital heart disease: A single center experience. J Pediatr Surg, 2018, 53(5): 914-917.
42.	Ren C, Wu C, Pan Z, et al. Pulmonary infection after cardiopulmonary bypass surgery in children: A risk estimation model in China. J Cardiothorac Surg, 2021, 16(1): 71.
43.	何勇, 李中杰, 刘光强, 等. 体外循环和非体外循环冠状动脉旁路移植术对肾功能不全患者肾脏功能的损伤比较. 中国临床研究, 2019, 32(9): 1185-1188.
44.	黄晨露, 周丽, 瞿尔力, 等. 下呼吸道感染婴幼儿发生重症肺炎的危险因素分析. 中国医院统计, 2017, 24(5): 360-362.

1. 牛建钢. 2012~2015年郑州市二七区出生缺陷发生状况及影响因素. 郑州大学, 2017.
2. 杨学勇. 先天性心脏病的预防. 中国协和医科大学, 2009.
3. Lytzen R, Vejlstrup N, Bjerre J, et al. Live-born major congenital heart disease in Denmark: Incidence, detection rate, and termination of pregnancy rate from 1996 to 2013. JAMA Cardiol, 2018, 3(9): 829-837.
4. Wu W, He J, Shao X. Incidence and mortality trend of congenital heart disease at the global, regional, and national level, 1990-2017. Medicine (Baltimore), 2020, 99(23): e20593.
5. Sen AC, Morrow DF, Balachandran R, et al. Postoperative infection in developing world congenital heart surgery programs: Data from the International Quality Improvement Collaborative. Circ Cardiovasc Qual Outcomes, 2017, 10(4): e002935.
6. 刘训. 体外循环下手术治疗儿童先天性心脏病术后并发肺部感染的相关危险因素分析. 重庆医科大学, 2019.
7. Turcotte RF, Brozovich A, Corda R, et al. Health care-associated infections in children after cardiac surgery. Pediatr Cardiol, 2014, 35(8): 1448-1455.
8. Meng L, Li J, He Y, et al. The risk factors analysis and establishment of an early warning model for healthcare-associated infections after pediatric cardiac surgery: A STROBE-compliant observational study. Medicine (Baltimore), 2020, 99(49): e23324.
9. Hatachi T, Tachibana K, Inata Y, et al. Risk factors for healthcare-associated infections after pediatric cardiac surgery. Pediatr Crit Care Med, 2018, 19(3): 237-244.
10. Sarvikivi E, Lyytikäinen O, Nieminen H, et al. Nosocomial infections after pediatric cardiac surgery. Am J Infect Control, 2008, 36(8): 564-569.
11. Tweddell S, Loomba RS, Cooper DS, et al. Health care-associated infections are associated with increased length of stay and cost but not mortality in children undergoing cardiac surgery. Congenit Heart Dis, 2019, 14(5): 785-790.
12. Bateman ST, Lacroix J, Boven K, et al. Anemia, blood loss, and blood transfusions in North American children in the intensive care unit. Am J Respir Crit Care Med, 2008, 178(1): 26-33.
13. Goobie SM, Faraoni D, Zurakowski D, et al. Association of preoperative anemia with postoperative mortality in neonates. JAMA Pediatr, 2016, 170(9): 855-862.
14. Faraoni D, DiNardo JA, Goobie SM. Relationship between preoperative anemia and in-hospital mortality in children undergoing noncardiac surgery. Anesth Analg, 2016, 123(6): 1582-1587.
15. Khan Z, Natarajan G, Sallaam S, et al. Association between anemia and packed cell transfusion and outcomes of ventricular septal defect and atrioventricular canal repair in children. Pediatr Cardiol, 2014, 35(3): 471-478.
16. Okoromah CA, Ekure EN, Lesi FE, et al. Prevalence, profile and predictors of malnutrition in children with congenital heart defects: A case-control observational study. Arch Dis Child, 2011, 96(4): 354-360.
17. Goldberg JF, Shah MD, Kantor PF, et al. Prevalence and severity of anemia in children hospitalized with acute heart failure. Congenit Heart Dis, 2016, 11(6): 622-629.
18. Karkouti K, Wijeysundera DN, Beattie WS, et al. Risk associated with preoperative anemia in cardiac surgery: A multicenter cohort study. Circulation, 2008, 117(4): 478-484.
19. Ranucci M, Di Dedda U, Castelvecchio S, et al. Impact of preoperative anemia on outcome in adult cardiac surgery: A propensity-matched analysis. Ann Thorac Surg, 2012, 94(4): 1134-1141.
20. Cholette JM, Faraoni D, Goobie SM, et al. Patient blood management in pediatric cardiac surgery: A review. Anesth Analg, 2018, 127(4): 1002-1016.
21. Mazine A, Rached-D'Astous S, Ducruet T, et al. Blood transfusions after pediatric cardiac operations: A North American multicenter prospective study. Ann Thorac Surg, 2015, 100(2): 671-677.
22. Goldstein B, Giroir B, Randolph A, et al. International pediatric sepsis consensus conference: Definitions for sepsis and organ dysfunction in pediatrics. Pediatr Crit Care Med, 2005, 6(1): 2-8.
23. Xiang L, Su Z, Liu Y, et al. Effect of family socioeconomic status on the prognosis of complex congenital heart disease in children: An observational cohort study from China. Lancet Child Adolesc Health, 2018, 2(6): 430-439.
24. Meyer HM, Torborg A, Cronje L, et al. The association between preoperative anemia and postoperative morbidity in pediatric surgical patients: A secondary analysis of a prospective observational cohort study. Paediatr Anaesth, 2020, 30(7): 759-765.
25. Kedir H, Miller R, Syed F, et al. Association between anemia and postoperative complications in infants undergoing pyloromyotomy. J Pediatr Surg, 2019, 54(10): 2075-2079.
26. Rodríguez-Hernández JL, Rodríguez-González F, Martínez-Quintana E. Anemia in adolescents and young adult patients with congenital heart disease. J Pediatr Hematol Oncol, 2018, 40(8): 620-624.
27. Dimopoulos K, Diller GP, Giannakoulas G, et al. Anemia in adults with congenital heart disease relates to adverse outcome. J Am Coll Cardiol, 2009, 54(22): 2093-2100.
28. Seicean A, Seicean S, Alan N, et al. Preoperative anemia and perioperative outcomes in patients who undergo elective spine surgery. Spine (Phila Pa 1976), 2013, 38(15): 1331-1341.
29. Musallam KM, Tamim HM, Richards T, et al. Preoperative anaemia and postoperative outcomes in non-cardiac surgery: A retrospective cohort study. Lancet, 2011, 378(9800): 1396-1407.
30. van Straten AH, Hamad MA, van Zundert AJ, et al. Preoperative hemoglobin level as a predictor of survival after coronary artery bypass grafting: A comparison with the matched general population. Circulation, 2009, 120(2): 118-125.
31. Hopf HW, Hunt TK, West JM, et al. Wound tissue oxygen tension predicts the risk of wound infection in surgical patients. Arch Surg, 1997, 132(9): 997-1004.
32. Schietroma M, Cecilia EM, De Santis G, et al. Supplemental peri-operative oxygen and incision site infection after surgery for perforated peptic ulcer: A randomized, double-blind monocentric trial. Surg Infect (Larchmt), 2016, 17(1): 106-113.
33. Spahn DR, Schoenrath F, Spahn GH, et al. Effect of ultra-short-term treatment of patients with iron deficiency or anaemia undergoing cardiac surgery: A prospective randomised trial. Lancet, 2019, 393(10187): 2201-2212.
34. Hassan N, Boville B, Reischmann D, et al. Intravenous ferumoxytol in pediatric patients with iron deficiency anemia. Ann Pharmacother, 2017, 51(7): 548-554.
35. Shimpo H, Mizumoto T, Onoda K, et al. Erythropoietin in pediatric cardiac surgery: Clinical efficacy and effective dose. Chest, 1997, 111(6): 1565-1570.
36. Cuenca J, García-Erce JA, Martínez F, et al. Perioperative intravenous iron, with or without erythropoietin, plus restrictive transfusion protocol reduce the need for allogeneic blood after knee replacement surgery. Transfusion, 2006, 46(7): 1112-1119.
37. Cladellas M, Farré N, Comín-Colet J, et al. Effects of preoperative intravenous erythropoietin plus iron on outcome in anemic patients after cardiac valve replacement. Am J Cardiol, 2012, 110(7): 1021-1026.
38. Faraoni D, Meier J, New HV, et al. Patient blood management for neonates and children undergoing cardiac surgery: 2019 NATA guidelines. J Cardiothorac Vasc Anesth, 2019, 33(12): 3249-3263.
39. 李奋. 先天性心脏病治疗时机及治疗方法的选择. 中国小儿急救医学, 2009, 16(5): 426-429.
40. 韩月英, 王厚照, 张雪梅, 等. 先天性心脏病患儿术后并发医院感染的危险因素及其病原菌分布和药敏实验分析. 现代生物医学进展, 2021, 21(4): 683-687, 682.
41. Lau PE, Cruz SM, Ocampo EC, et al. Necrotizing enterocolitis in patients with congenital heart disease: A single center experience. J Pediatr Surg, 2018, 53(5): 914-917.
42. Ren C, Wu C, Pan Z, et al. Pulmonary infection after cardiopulmonary bypass surgery in children: A risk estimation model in China. J Cardiothorac Surg, 2021, 16(1): 71.
43. 何勇, 李中杰, 刘光强, 等. 体外循环和非体外循环冠状动脉旁路移植术对肾功能不全患者肾脏功能的损伤比较. 中国临床研究, 2019, 32(9): 1185-1188.
44. 黄晨露, 周丽, 瞿尔力, 等. 下呼吸道感染婴幼儿发生重症肺炎的危险因素分析. 中国医院统计, 2017, 24(5): 360-362.

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Association between preoperative anemia and postoperative infection and death in children with acyanotic congenital heart disease undergoing elective cardiac surgery: A retrospective cohort study

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