title: Cumulative corticosteroid exposure and infection risk after complex pediatric cardiac surgery.
abstract: BACKGROUND
  Children undergoing cardiac surgery may receive corticosteroids preoperatively to temper cardiopulmonary bypass-related inflammation, postoperatively for hemodynamic instability, and periextubation to reduce airway edema. Recent data have associated preoperative corticosteroids with infection. We aimed to determine if there is a relationship between cumulative corticosteroid exposure and infection.
  
  
  METHODS
  A retrospective review of children who underwent cardiac surgery at our institution from January 2009 to July 2010 was performed. To limit study heterogeneity, patients who were 5 years or younger with basic Aristotle score of 7 or higher and intensive care unit stay of 7 days or more were included. Infections during the first 30 postoperative days were recorded, defined as clinically relevant positive blood, urine, respiratory, or wound cultures, or culture-negative sepsis treated with 7 or more days of antimicrobial therapy. Multivariate logistic regression analysis was performed to determine independent risk factors for infection.
  
  
  RESULTS
  Seventy-six patients were reviewed. All patients received intraoperative methylprednisolone, 48% received postoperative hydrocortisone, and 86% received periextubation dexamethasone. Twenty-six patients (36%) had 58 infections. On univariate analysis, patients with infection had greater median comprehensive Aristotle score (14.5 [intraquartile range (IQR): 12.5 to 16] versus 11.5 [IQR: 10 to 13.1], p = 0.001), maximum vasoactive inotrope score (29 [IQR: 24 to 40] versus 24 [IQR: 17 to 31], p = 0.031, days endotracheally intubated (12 [IQR: 7 to 30] versus 5 [IQR: 4 to 6.5], p < 0.001), and days of corticosteroid exposure (7 [IQR: 5 to 12] versus 4 [IQR: 2 to 5), p < 0.001). Also, patients with infections more often underwent delayed sternal closure (p = 0.008). On multivariate analysis, days endotracheally intubated (p = 0.023) and days of corticosteroid exposure (p = 0.015) remained significant.
  
  
  CONCLUSIONS
  For children undergoing complex cardiac surgery, greater cumulative duration of corticosteroid exposure is independently associated with postoperative infection.
authors.affiliation: Department of Pediatrics, Division of Critical Care, Wayne State University, Children's Hospital of Michigan, Detroit, Michigan, USA. cmastrop@med.wayne.edu
authors.forename: Christopher W
authors.initials: CW
authors.lastname: Mastropietro
authors.forename: Renee
authors.initials: R
authors.lastname: Barrett
authors.forename: Maria Caridad
authors.initials: MC
authors.lastname: Davalos
authors.forename: Marwan
authors.initials: M
authors.lastname: Zidan
authors.forename: Kevin M
authors.initials: KM
authors.lastname: Valentine
authors.forename: Ralph E
authors.initials: RE
authors.lastname: Delius
authors.forename: Henry L
authors.initials: HL
authors.lastname: Walters
mesh_terms: D000046:Academic Medical Centers; D000305:Adrenal Cortex Hormones / Q000008:administration & dosage / Q000009:adverse effects*; D001424:Bacterial Infections / Q000453:epidemiology* / Q000209:etiology; D006348:Cardiac Surgical Procedures / Q000009:adverse effects / Q000379:methods* / Q000401:mortality; D002315:Cardiopulmonary Bypass / Q000379:methods; D002675:Child, Preschool; D015331:Cohort Studies; D016001:Confidence Intervals; D004305:Dose-Response Relationship, Drug; D004334:Drug Administration Schedule; D005260:Female; D006330:Heart Defects, Congenital / Q000175:diagnosis / Q000401:mortality* / Q000601:surgery*; D017052:Hospital Mortality / Q000639:trends; D006801:Humans; D015994:Incidence; D007223:Infant; D007231:Infant, Newborn; D007262:Infusions, Intravenous; D007430:Intraoperative Care / Q000379:methods; D007902:Length of Stay; D016015:Logistic Models; D008297:Male; D015999:Multivariate Analysis; D016017:Odds Ratio; D011183:Postoperative Complications / Q000453:epidemiology / Q000209:etiology; D011300:Preoperative Care / Q000379:methods; D012189:Retrospective Studies; D018570:Risk Assessment; D015996:Survival Rate
chemical_list: D000305:Adrenal Cortex Hormones