İzole Koroner Arter Baypas Greft Cerrahisi Sonrası Gelişen Safen Ven Greft İnsizyon Alanı Enfeksiyonlarının Değerlendirilmesi: Tek Merkez Deneyimimiz

Yıl 2022, Cilt: 17 Sayı: 3, 179 - 187, 02.11.2022

Özay Akyıldız , Ömer Ulular

https://doi.org/10.17517/ksutfd.1037822

Öz

Özet

Amaç: Bu çalışmada, hastanemiz kardiyovasküler cerrahi kliniğinde son 12 yıl içinde yapılan izole koroner arter baypas greft cerrahisinden sonra gelişen safen ven greft insizyon alanı cerrahi alan enfeksiyonu olgularının, etken olan mikroorganizmaları, risk faktörlerini ve klinik özelliklerini ortaya koymak amacıyla değerlendirilmesi amaçlanmıştır.

Gereç ve Yöntemler: Mart 2009-Kasım 2020 tarihleri arasında hastanemiz kardiyovasküler cerrahi kliniğinde izole koroner arter baypas greft cerrahisi yapılan ve postoperatif dönemde safen ven greft insizyon alanı enfeksiyonu gelişen ve cerrahi alan enfeksiyonu olarak kabul edilen toplam 34 hasta (23 kadın, 11 erkek; ort. yaş 68.0±9.0 yıl; dağılım 51-86 yıl) çalışmaya alındı. Çalışmaya dahil edilen hastaların demografik verileri, altta yatan hastalıkları, preoperatif, intraoperatif ve postoperatif risk faktörleri retrospektif olarak incelendi.

Bulgular: Yaklaşık 12 yıllık bir periyotta yapılan izole koroner arter baypas greft cerrahisinde safen ven greft insizyon alanı cerrahi alan enfeksiyonu oranı %0.8 olarak belirlenmiştir. Bunların 23’ü (%67.6) yüzeyel insizyonel cerrahi alan enfeksiyonu, 11’i (%32.4) derin insizyonel cerrahi alan enfeksiyonu olarak değerlendirilmiştir. Cerrahi alan enfeksiyonu gelişen hastalarda yaş, kadın cinsiyet, obezite, diabetes mellitus, sigara, acil cerrahi, 1’den fazla safen ven greft kullanımı, operasyon, kardiyopulmoner baypas ve aortik klemp sürelerinin uzun oluşu, intraoperatif kan transfüzyonu, yoğun bakım ünitesi’nde kalma süresi uzunluğu, inotrop kullanımı ve toplam hastanede yatış süresi uzunluğu anlamlı bulundu. Pürülan akıntı kültürlerinde üreyen mikroorganizmaların 18’ini

(%53) Gram negatif bakteriler, 12’sini (%35.3) Gram pozitif bakteriler ve birini (%2.9) mantarlar oluşturmuştur. Beş (%14.7) hastada ise patojen mikroorganizma üretilemedi. Cerrahi alan enfeksiyonu tespit edilen hastalardan en sık izole edilen iki etken koagülaz negatif stafilokoklar (%17.6) ve Escherichia coli (%17.6) idi.

Sonuç: Kardiyovasküler cerrahi girişim geçiren hastalarda özellikle cerrahi alan enfeksiyonuna dikkat edilmelidir. Koroner arter baypas greft cerrahisi sonrası cerrahi alan enfeksiyonunun, risk faktörlerinin belirlenmesi, cerrahi tekniklerin modifikasyonu ve postoperatif dönemin sıkı tutulması ile azaltılabileceği akılda tutulmalıdır. Taburcu olduktan sonraki takip ve kişisel bakım önemlidir ve enfeksiyon ortaya çıktığında ampirik tedavi yaklaşımı hastanemizde önde gelen enfeksiyöz ajanların koagülaz negatif stafilokoklar ve E. coli olduğu dikkate alınarak belirlenmelidir.

Anahtar Kelimeler

Cardiovascular surgery, saphenous vein, graft, surgical site infection

Evaluation of Postoperative Development of Saphenous Vein Graft Incision Site Infections in Patients Undergoing Isolated Coronary Artery Bypass Graft Surgery: A Single Center Experience

Öz

Abstract

Objective: This study aimed to evaluate surgical site infection patients developing saphenous vein graft incision site infection after isolated coronary artery bypass graft surgery performed in the cardiovascular surgery clinic of our hospital in the last 12 years to reveal the causative microorganisms, risk factors, and clinical characteristics.

Material and Methods: A total of 34 surgical site infection patients (23 females, 11 males; mean age 68.0±9.0 years; range 51-86 years) who underwent isolated coronary artery bypass graft surgery in the cardiovascular surgery clinic of our hospital between March 2009 and November 2020 and who postoperatively developed saphenous vein graft incision site infection were included in the study. The patients’ demographic data, underlying diseases, and preoperative, intraoperative, and postoperative risk factors were analyzed retrospectively.

Results: In all isolated coronary artery bypass graft surgeries performed over a period of about 12 years, the rate of saphenous vein graft incision site surgical site infection was found to be 0.8%. Of these, 23 (67.6%) were evaluated as superficial incisional surgical site infection and 11 (32.4%) as deep incisional surgical site infection. In the patients who developed surgical site infection, the parameters of age, female sex, obesity, diabetes mellitus, smoking, emergency surgery, use of more than 1 saphenous vein graft, prolonged operation, cardiopulmonary bypass, and aortic clamp durations, intraoperative blood transfusion, length of stay in the intensive care unit, use of inotropes, and total length of hospital stay were all found to be significant. The microorganisms in purulent discharge cultures consisted of Gram-negative bacteria in 18 (53%), Gram-positive bacteria in 12 (35.3%), and fungi in 1 (2.9%). No pathogenic microorganism growth was observed in 5 (14.7%) patients. In the patients with surgical site infection, coagulase-negative staphylococci (17.6%) and Escherichia coli (17.6%) were the most frequently isolated agents.

Conclusion: Particular attention should be paid to surgical site infection in patients undergoing a cardiovascular surgery intervention. It should be noted that post coronary artery bypass graft surgery surgical site infection can be reduced by determining its risk factors, modifying surgical techniques, and postoperative close monitoring of patients. Follow-up and personal care are crucial after discharge and an empirical treatment approach should be determined when an infection occurs, taking into account that coagulase-negative staphylococci and E. coli were the two leading infectious agents in our hospital.

Anahtar Kelimeler

Cardiovascular surgery, saphenous vein, graft, surgical site infection, Cardiovascular surgery, saphenous vein, graft, surgical site infection

Kaynakça

• Spadaccio C, Benedetto U. Coronary artery bypass grafting (CABG) vs. percutaneous coronary intervention (PCI) in the treatment of multivessel coronary disease: quo vadis? A review of the evidences on coronary artery disease. Ann Cardiothorac Surg. 2018;7:506-515.
• Figuerola-Tejerina A, Rodriguez-Caravaca G, Bustamante-Munguira J, San Roman-Montero JM, Duran-Poveda M. Epidemiological surveillance and surgical site ınfection and its risk factors in cardiac surgery: A prospective cohort study. Rev Esp Cardiol. 2016;69:842-848.
• Lopes RD, Hafley GE, Allen KB, Ferguson TB, Peterson ED, Harrington RA et al. Endoscopic versus open vein-graft harvesting in coronary-artery bypass surgery. N Engl J Med. 2009;361:235-244.
• Cove ME, Spelman DW, MacLaren G. Infectious complications of cardiac surgery. A clinical review. J Cardiothorac Vasc Anesth. 2012;26:1094-1100.
• Lazar HL, Salm TV, Engelman R, Orgill D, Gordon S. Prevention and management of sternal wound infections. J Thorac Cardiovasc Surg. 2016;152:962-972.
• Sharma M, Fakih MG, Berriel-Cass D, Meisner S, Saravolatz L, Khatib R. Harvest surgical site infection following coronary artery bypass grafting: risk factors, microbiology, and outcomes. Am J Infect Control. 2009;37:653-657.
• Swenne CL, Lindholm C, Borowiec J, Carlsson M. Surgical-site infections within 60 days of coronary artery by-pass graft surgery. J Hosp Infect. 2004;57:14-24.
• Fowler VG, O’Brien SM, Muhlbaier LH, Corey GR, Ferguson TB, Peterson ED. Clinical predictors of major infections after cardiac surgery. Circulation. 2005;112:358-365.
• O’Hara LM, Thom KA, Preas MA. Update to the Centers for Disease Control and Prevention and the Healthcare Infection Control Practices Advisory Committee Guideline for the Prevention of Surgical Site Infection (2017): A summary, review, and strategies for implementation. Am J Infect Control. 2018;46:602-609.
• Bray GA, Heisel WE, Afshin A, Jensen MD, Dietz WH, Long M et al. The Science of Obesity Management: An Endocrine Society Scientific Statement. Endocr Rev. 2018;39:79-132.
• Horan TC, Andrus M, Dudeck MA. CDC/NHSN surveillance definition of health care-associated infection and criteria for specific types of infections in the acute care setting. Am J Infect Control. 2008;36(5):309-332.
• Refik Saydam Hıfzıssıhha Merkezi Başkanlığı Ulusal Hastane Enfeksiyonları Sürveyans ve Kontrol Birimi. Türkiye Hastane Enfeksiyonları Sürveyansı Cep Kitabı. Ankara: Sağlık Bakanlığı 2010.
• Berrios-Torres SI, Umscheid CA, Bratzler DW, Leas B, Stone EC, Kelz RR et al. Centers for Disease Control and Prevention Guideline for Prevention of Surgical Site Infection, 2017. JAMA Surg. 2017;152:784-791.
• Garner JS, Jarwis WR, Emori TG, Horan TC, Hughes JM. CDC definitions for nosocomial infections. Am J Infect Control. 1988;3:128-140.
• DeLaria GA, Hunter JA, Goldin MD, Serry C, Javid H, Najafi H. Leg wound complications associated with coronary revascularization. J Thorac Cardiovasc Surg. 1981;81:403-407.
• Uzunköy A. Cerrahi alan enfeksiyonları: Risk faktörleri ve önleme yöntemleri. Ulusal Travma ve Acil Cerrahi Dergisi. 2005;11(4):269-281.
• Chukwuemekai A, Lindsay J. Modified incision for long saphenous vein Harvest. Ann Thorac Surg. 1998;66:279.
• Paletta CE, Huang DB, Fiore AC, Swartz MT, Rilloraza FL, Gardner JE. Major leg wound complications after saphenous vein harvest for coronary revascularization. Ann Thorac Surg. 2000;70:492-497.
• Brush Jr JE, Siraj ES, Kemp CD, Liverman DP, McMichael BY, Lamichhane R et al. Effect of diabetes mellitus on complication rates of coronary artery bypass grafting. Am J Cardiol. 2019;124:1389-1396.
• L’Ecuyer PB, Murphy D, Little JR, Fraser VJ. The epidemiology of chest and leg wound infections following cardiothoracic surgery. Clin Infect Dis. 1996;22:424-429.
• Yazkan R. Göğüs cerrahisinde postoperatif komplikasyonlar. In Toraks Travmaları ve Tedavisi. (Ed Yücel O):149-59. Ankara, Derman Tıbbi Yayıncılık, 2013.
• Herwaldt LA. Staphylococcus aureus nasal carriage and surgical site infections. Surgery. 2003;134:2-9.
• Olsen MA, Lock-Buckley P, Hopkins D, Polish LB, Sundt TM, Fraser VJ. The risk factors for deep and superficial chest surgical-site infections after coronary artery bypass graft surgery are different. J Thorac Cardiovasc Surg. 2002;124(1):136-145.
• Trick W. Risk factors for radial artery harvest site infections following coronary bypass surgery. Clin Infect Dis. 2000;30:270-275.
• Muhammed Tamim, Aly Al-Sanei, Emad Bukhari, Charles Canver. Endoscopic saphenous vein harvesting: results of our initial experience. Turkish J Thorac Cardiovasc Surg. 2008;16:162-166.
• Cheng D, Allen K, Cohn W, Connolly M, Edgerton J, Falk V et al. Endoscopic vascular harvest in coronary artery bypass grafting surgery: A meta-analysis of randomized trials and controlled trials. Innovations (Phila). 2005;1:61-74.
• Lako A, Bilali S, Memishaj S, Daka A, Dedj T, Nurka T et al. The impact of blood use on patients undergoing coronary artery bypass surgery: a prospective study. G. Chir. 2014;35:20-26.
• Leal-Noval SR, Rincon-Ferrari MD, Garcia-Curiel A, Herruzo-Aviles A, Camacho-Lara-a P, Garnacho-Montero J et al. Transfusion of blood components and postoperative infection in patients undergoing cardiac surgery. Chest. 2001;119(5):1461-1468.
• Göl KM, Karahan M, Ulus T, Erdil N, Iscan Z, Karabiber N et al. Bloodstream, respiratory, and deep surgical wound infections after open heart surgery. J Card Surg. 1998;13:252-259.
• Friedman ND, Bull AL, Russo PL, Leder K, Reid C, Billah B et al. An alternative scoring system to predict risk for surgical site infection complicating coronary artery bypass graft surgery. Infect Control Hosp Epidemiol. 2007;28(10):1162-1168.
• Blakemore WS, McGarrity GJ, Thurer RJ, Wallace HW, MacVaugh H, Coriell LL. Infection by airborne bacteria with cardiopulmonary bypass. Surgery. 1971;70:830-838.
• Vos RJ, Van Putte BP, Kloppenburg GTL. Prevention of deep sternal wound infection in cardiac surgery: a literature review. J Hosp Infect. 2018;100:411-420.