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12 children treated for serious infection after heart surgery at Children's Hospital
Meg Farris, WWLTV 10:40 PM. CDT September 11, 2017
NEW ORLEANS - Twelve children are being treated in Children's Hospital for an infection they acquired from a machine used during their open heart surgery. The Stockert 3T Heater-Cooler is used to cool the patients when the heart is stopped and being repaired. Later it warms the patients when the heart begins to beat again.
Doctors at Children's Hospital first noticed four patients whose chest incision was infected. That prompted immediate and vigilant surveillance to find any other patients who the machine was used on in June and July.
Children's Hospital sent out 55 letters to patients who potentially could have been infected. While filtered water was used on all these patients, some time ago, tap water was used. The theory is that even with the enhanced cleaning of the machine recommended by the FDA, the germ, from the tap water earlier, was not killed, and was spread from the machine as a fine mist in the O.R. contaminating the surgical site.
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"It's a bug that's a normal contaminant of soil, water and dust. It's often found in municipal water systems particularly in the costal U.S. It's a contaminant, but it's not harmful if you drink it in low quantities," he explained.
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Monday, September 11, 2017 - Mycobacterial Infection Being Treated at Children's Hospital
In mid-August 2017, a small group of patients who underwent cardiac surgery at Children?s Hospital between late May and July, 2017, developed a surgical site infection suspected to be Mycobacterium abscessus. This is the first time Children?s Hospital has experienced surgical site infections caused by mycobacterium, an environmental contaminant that is commonly found in water, soil, and dust. The infection is treatable and all patients are currently undergoing successful treatment in this hospital.
Children?s Hospital?s medical team is ensuring that each family is fully informed and that questions are answered, and the multidisciplinary team of cardiac surgeons, cardiac intensivists, cardiologists, and nurses are managing their clinical care.
Upon discovery, hospital leadership took immediate action to address the issue, to investigate, and to identify the cause. Children?s Hospital has complied with all Louisiana Office of Public Health mandatory reporting requirements. The hospital has enlisted the assistance and expertise of the Louisiana Office of Public Health, the Centers for Disease Control, and outside infection control consultants. Our response team has also consulted other hospitals that have dealt with the same issue in the past for guidance and information regarding lessons learned and best practices for treatment.
Because a common element in the affected children was open-heart surgery requiring the use of cardiopulmonary bypass, our investigation focused on the environment and equipment used in the cardiac operating room. We believe a piece of equipment used to regulate the temperature of patients while on bypass is the most likely source of this infection, and all suspected equipment has been removed from service and replaced.
Our investigation indicates that the risk appears to be limited to patients cared for in one operating room when a specific piece of equipment was used. This room has been terminally disinfected, and our ongoing environmental surveillance of the operating rooms has not shown any contamination with the organism beyond the involved device.
The overwhelming majority of surgical patients treated at Children?s Hospital have not been affected by this rare mycobacterial infection. We regret that any of our patients could possibly be affected. No patient affected by this situation will incur additional clinical cost for resulting treatment or evaluation. Our thoughts are with those involved, and our ongoing priority is the continued safe and effective care for the patients who allow us the privilege of caring for them.
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Meg Farris, WWLTV 10:40 PM. CDT September 11, 2017
NEW ORLEANS - Twelve children are being treated in Children's Hospital for an infection they acquired from a machine used during their open heart surgery. The Stockert 3T Heater-Cooler is used to cool the patients when the heart is stopped and being repaired. Later it warms the patients when the heart begins to beat again.
Doctors at Children's Hospital first noticed four patients whose chest incision was infected. That prompted immediate and vigilant surveillance to find any other patients who the machine was used on in June and July.
Children's Hospital sent out 55 letters to patients who potentially could have been infected. While filtered water was used on all these patients, some time ago, tap water was used. The theory is that even with the enhanced cleaning of the machine recommended by the FDA, the germ, from the tap water earlier, was not killed, and was spread from the machine as a fine mist in the O.R. contaminating the surgical site.
...
"It's a bug that's a normal contaminant of soil, water and dust. It's often found in municipal water systems particularly in the costal U.S. It's a contaminant, but it's not harmful if you drink it in low quantities," he explained.
...
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Monday, September 11, 2017 - Mycobacterial Infection Being Treated at Children's Hospital
In mid-August 2017, a small group of patients who underwent cardiac surgery at Children?s Hospital between late May and July, 2017, developed a surgical site infection suspected to be Mycobacterium abscessus. This is the first time Children?s Hospital has experienced surgical site infections caused by mycobacterium, an environmental contaminant that is commonly found in water, soil, and dust. The infection is treatable and all patients are currently undergoing successful treatment in this hospital.
Children?s Hospital?s medical team is ensuring that each family is fully informed and that questions are answered, and the multidisciplinary team of cardiac surgeons, cardiac intensivists, cardiologists, and nurses are managing their clinical care.
Upon discovery, hospital leadership took immediate action to address the issue, to investigate, and to identify the cause. Children?s Hospital has complied with all Louisiana Office of Public Health mandatory reporting requirements. The hospital has enlisted the assistance and expertise of the Louisiana Office of Public Health, the Centers for Disease Control, and outside infection control consultants. Our response team has also consulted other hospitals that have dealt with the same issue in the past for guidance and information regarding lessons learned and best practices for treatment.
Because a common element in the affected children was open-heart surgery requiring the use of cardiopulmonary bypass, our investigation focused on the environment and equipment used in the cardiac operating room. We believe a piece of equipment used to regulate the temperature of patients while on bypass is the most likely source of this infection, and all suspected equipment has been removed from service and replaced.
Our investigation indicates that the risk appears to be limited to patients cared for in one operating room when a specific piece of equipment was used. This room has been terminally disinfected, and our ongoing environmental surveillance of the operating rooms has not shown any contamination with the organism beyond the involved device.
The overwhelming majority of surgical patients treated at Children?s Hospital have not been affected by this rare mycobacterial infection. We regret that any of our patients could possibly be affected. No patient affected by this situation will incur additional clinical cost for resulting treatment or evaluation. Our thoughts are with those involved, and our ongoing priority is the continued safe and effective care for the patients who allow us the privilege of caring for them.