title: Surgical site infection related to use of elastomeric pumps in pectus excavatum repair. Lessons learned from root cause analysis.
abstract: BACKGROUND
  Pectus excavatum repair (PEX) is among the most painful thoracic procedures performed. Continuous peripheral nerve blockade (CPNB) is known to be efficacious in optimizing pain control while limiting narcotic use in adult thoracic procedures. It was introduced in May 2015 as a bridge to oral pain control in children undergoing PEX. Consequently, the surgical site infection (SSI) rate increased from 2.7% to 27.7%.
  
  
  METHODS
  SSI surveillance followed national guidelines. The abrupt increase prompted root cause analysis and cessation of CPNB use. A dynamic systems model of SSI in PEX was developed. Statistical analysis compared SSI outcomes with and without CPNB.
  
  
  RESULTS
  From May 2015 to June 2015, 21 PEX were performed; 11 with CPNB. 6 SSIs were observed. Use of CPNB significantly (p=0.008) increased SSI incidence. Haller index, number of bars, usage of Fiberwire®, methicillin resistant S. aureus colonization and length of stay did not differ. Root cause analysis revealed the proximity of CPNB catheters to the wound, the use of CPNB with implanted hardware and a delayed utilization of CPNB catheters to be of concern.
  
  
  CONCLUSIONS
  Introduction of CPNB coincided with a significant increase in SSI. Further study is needed to assess the safety of CPNB in pediatric PEX.
  
  
  METHODS
  Level III treatment study.
authors.affiliation: Department of Pediatric General and Thoracic Surgery, Cincinnati Children's Medical Center, 3333 Burnet Ave, Cincinnati, 45229, OH, USA. Electronic address: Nadja.apelt@cchmc.org.
authors.forename: Nadja
authors.initials: N
authors.lastname: Apelt
authors.affiliation: Department of Infectious Diseases, Cincinnati Children's Medical Center, 3333 Burnet Ave, Cincinnati, 45229, OH, USA.
authors.forename: Joshua
authors.initials: J
authors.lastname: Schaffzin
authors.affiliation: Department of Pediatric General and Thoracic Surgery, Cincinnati Children's Medical Center, 3333 Burnet Ave, Cincinnati, 45229, OH, USA.
authors.forename: Christina
authors.initials: C
authors.lastname: Bates
authors.affiliation: Department of Pediatric General and Thoracic Surgery, Cincinnati Children's Medical Center, 3333 Burnet Ave, Cincinnati, 45229, OH, USA.
authors.forename: Rebeccah L
authors.initials: RL
authors.lastname: Brown
authors.affiliation: Department of Anesthesia, Cincinnati Children's Medical Center, 3333 Burnet Ave, Cincinnati, 45229, OH, USA.
authors.forename: Marc
authors.initials: M
authors.lastname: Mecoli
authors.affiliation: Department of Anesthesia, Cincinnati Children's Medical Center, 3333 Burnet Ave, Cincinnati, 45229, OH, USA.
authors.forename: Senthilkumar
authors.initials: S
authors.lastname: Sadhasivam
authors.affiliation: Department of Pediatric General and Thoracic Surgery, Cincinnati Children's Medical Center, 3333 Burnet Ave, Cincinnati, 45229, OH, USA.
authors.forename: Victor
authors.initials: V
authors.lastname: Garcia
mesh_terms: D000293:Adolescent; D002648:Child; D020724:Elastomers; D005260:Female; D005660:Funnel Chest / Q000601:surgery*; D006801:Humans; D015994:Incidence; D008297:Male; D055624:Methicillin-Resistant Staphylococcus aureus / Q000302:isolation & purification; D011108:Polymers / Q000494:pharmacology*; D012189:Retrospective Studies; D060891:Root Cause Analysis / Q000379:methods*; D013203:Staphylococcal Infections / Q000453:epidemiology* / Q000382:microbiology; D013530:Surgical Wound Infection / Q000453:epidemiology* / Q000382:microbiology; D013905:Thoracoplasty / Q000009:adverse effects* / Q000379:methods; D014481:United States / Q000453:epidemiology
chemical_list: D020724:Elastomers; D011108:Polymers; C036925:elastomeric polymer
keywords: CPNB; Continuous peripheral nerve blockade; Elastomeric pump; Pectus excavatum repair; SSI; Surgical site infection