Management Of Deep Sternal Wound Infection Research Articles

Pay attention to the prevention and treatment of deep sternal wound infection after sternotomy

Deep sternal wound infection (DSWI) is one of the potential and catastrophic complications after cardiac surgery. Despite the use of smaller incisions, routine application of prophylactic antibiotic and optimized blood glucose management, the incidence rate of DSWI still fluctuates between 1% and 5%. The early symptoms and signs of DSWI are not often obvious, making it too late for the clinicians to intervene in the process. Once left untreated, DSWI carries a very high mortality rate. Therefore, early prevention, diagnosis, and appropriate management of DSWI are crucial in preventing its progression to life-threatening outcomes. Considering the clinical severity and treatment complexity of DSWI, this article focuses on preventive experiences in each stage of DSWI, and reconstructive strategies after DSWI happens, raising attention among the medical community regarding DSWI.

Deep Sternal Wound Infections after Coronary Artery Bypass Grafting: Analysis of 29 Cases from Iraq

Background: Deep sternal wound infection (DSWI), or mediastinitis, is a devastating complication of coronary artery bypass grafting (CABG). This prospective study aimed to assess our management of DSWI in view of the published literature. Methods: Over 2-years (ending in January 2016), 29 patients (20 males) developed DSWI amongst 520 patients who underwent standard CABG surgeries (5.6%). Pre-, intra- and postoperative variables were documented. Whenever possible, the infections were culture-verified. Besides antibiotics, patients received one or more of the following therapies: drainage, debridement, closed irrigation, sternal re-wiring, vacuum-assisted closure (VAC), and bone resection. Results: the male to female ratio was 2.2:1. Mean age was 58.1 ± 7.3 years. The mean body mass index (BMI) was 27.9 ± 3.4 kg/m2. There were 18, 16 and 11 patients with diabetes mellitus (DM), hypertension and chronic obstructive pulmonary disease (COPD) respectively. Cardiopulmonary bypass (CPB) was utilized in 26 (89.7%) patients with a mean time of 117.5 ± 23.3 minutes. Most surgeries (n = 21, 72.4%) lasted 5 - 6 hrs. According to Pairolero classification, there were 3 (10.3%) Type I, 22 (75.9%) Type II and 4 (13.8%) Type III infections. Four (13.8%) cases were culture-verified. Twenty-three (79.3%) DSWIs were surgically managed. Sternal re-wiring was performed in 14 (48.3%) cases while VAC was added to other therapies in 2 (6.9%) patients. DSWIs completely resolved in 18 (62.0%) patients within 3 - 24 weeks while two (6.9%) patients died within 30 days. Conclusion: We have identified six independent risk factors for DSWI (male gender, obesity, DM, hypertension, COPD and CPB), five of them are modifiable.

Management plan for deep sternal wound infection targeting to survival free of recurrence: A prospective evaluation study

ObjectiveTo evaluate outcome of modalities for management of deep sternal wound infection (DSWI) defined as peri-procedural mortality and to determine the predictors for this outcome. Patients & MethodsManagement plan was controlled by the findings after sternal wound debridement till the patient was bacteriologically negative. This plan ranged between simple rewiring of sternal remnants, if appropriate, rewiring and bilateral pectoralis major advancement flap (PMF) coverage, vascularized omental flap (VOF) or PMF coverage without rewiring if sternal remnants were inappropriate and combined VOF and PMF coverage in case of wide sternal defect and/or absence of any trustable sternal remnants. ResultsThroughout the study duration 121 out of 7850 patients underwent sternotomy for open cardiac surgery developed DSWI for a frequency of 1.54%. Nineteen patients died for a total mortality rate of 15.7%, 9 patients developed complications for a morbidity rate of 7.4% and 93 patients passed their postoperative (PO) course uneventfully for a total success rate of 76.9%. PMF and VOF showed success rates of 94.7% and 81.8%, respectively. Wiring only and wiring followed by PMF showed success rates of 78.6% and 75%, respectively. Combined VOF and PMF showed a success rate of 72.2% for selected cases with wide sternal wound. Number of risk factors/patient was significantly higher in non-survivors than in survivors. Obesity and multiplicity of risk factors were the most significant predictors for mortality. Individually obesity and diabetes mellitus were the significant predictors for mortality. ConclusionManagement of DSWI is tedious, has prolonged hospital stay and is associated with high morbidity and mortality rates. Management of DSWI must be personalized according to findings on exploration of the sternal wound and flap coverage must be initiated only when the patient is bacteriologically free. Both PMF and/or VOF provided high acceptable success rate defined as survival free of DSWI recurrence.

Changes in the management of deep sternal wound infections: a 12-year review.

Deep sternal wound infection (DSWI) is a rare but life-threatening complication following cardiac surgery associated with increased morbidity and mortality. Management of these patients has evolved over the years and can include sternal rewiring, mediastinal irrigation, negative-pressure wound therapy (NPWT) dressing or repair with flaps. We reviewed changes in our management of DSWI and outcomes. Using the Australian and New Zealand Society of Cardiac and Thoracic Surgeons database, 5472 underwent cardiac surgery at St Vincent's Hospital, Melbourne, and 42 were identified as developing DSWI requiring re-operation between June 2002 and September 2014. Data were collected pertaining to risk factors for DSWI, management strategies and outcomes. Patients were compared from a period prior to NPWT dressing use (June 2002-February 2006, n = 14) and since the NPWT has been used regularly in the management of DSWI (from March 2006, n = 28). Patients were also compared based on the requirement for flap closure of their sternal wound. Because of the widespread use of NPWT dressings, there is a trend towards fewer sternal infections requiring flap closure (25 versus 42.8%) and less post-operative complications after definitive closure (7.1 versus 28.6%). Before and after widespread NPWT use, patients require similar number of re-operations before closure and have no significant differences in time to definitive closure or length of hospital stay. The use of NPWT dressings as a bridge to definitive closure may reduce the need for more burdensome flap reconstruction, does not delay definitive reconstruction or prolong hospital stay and may reduce post-reconstruction complications requiring re-operation.

Deep sternal wound infection after cardiac surgery: Evidences and controversies.

Despite many advances in prevention and perioperative care, deep sternal wound infection (DSWI) remains a pressing concern in cardiac surgery, with a still relevant incidence and with a considerable impact on in-hospital mortality and also on mid- and long-term survival. The permanent high impact of this complication is partially related to the increasing proportion of patients at high-risk for infection, as well as to the many patient and surgical risk factors involved in the pathogenesis of DSWI. The prophylactic antibiotic therapy is one of the most important tools in the prevention of DSWI. However, the choice of antibiotic, the dose, the duration, the adequate levels in serum and tissue, and the timing of antimicrobial prophylaxis are still controversial. The treatment of DSWI ranges from surgical revision with primary closure to surgical revision with open dressings or closed irrigation, from reconstruction with soft tissue flaps to negative pressure wound therapy (NPWT). However, to date, there have been no accepted recommendations regarding the best management of DSWI. Emerging evidence in the literature has validated the efficacy and safety of NPWT either as a single-line therapy, or as a "bridge" prior to final surgical closure. In conclusion, the careful control of patient and surgical risk factors - when possible, the proper antimicrobial prophylaxis, and the choice of validated techniques of treatment could contribute to keep DSWIs at a minimal rate.

Omentoplasty as an effective surgical modality for managing a high risk patient with deep sternal wound infection

Poorly managed diabetes and hypertensives are risk factors for deep sternal wound infection (DSWI) following cardiac surgery; leading to increased morbidity and mortality. To reappraise the effectiveness of omental flap in the management of High risk patient with DSWI. A middle aged man with extensive mediastinitis following cardiac surgery (from outside referral). He was a known Diabetic and Hypertensive who was poorly compliant on medications. The history, physical examination, gycosylated Haemoglobin (HbA1c) and microbiological analyses showed high blood pressure, poor glycaemic control, septicaemia with staphylococcal DSWI. Resuscitation was achieved with the use of oral antihypertensives, Human insulin and antibiotics respectively. The DSWI was managed with serial debridement and subsequent wound cover with omental flap. The hospital stay was shorter and outcome was good. The management of DSWI with omental flap may be an effective surgical modality that reduces morbidity and mortality even in high risk patients.

Primary treatment of deep sternal wound infection after cardiac surgery: a survey of German heart surgery centers

There are various primary treatment modalities of managing deep sternal wound infection (DSWI) following cardiac surgery, namely surgical debridement with primary reclosure in conjunction with irrigation, Vacuum-assisted closure (V.A.C. therapy, and primary or delayed flap closure. The purpose of this study was to assess whether there is consensus of the primary management of DSWI using one method as a single line therapy or a combination of these procedures. Therefore, a questionnaire with regards to the primary treatment modalities of DSWI was distributed to all 79 German heart surgery centers. All replied to the questionnaire. V.A.C. is used in 28/79 (35%) heart centers as the 'first-line' treatment, 22/79 (28%) perform primary reclosure in conjunction with a double-tube irrigation/suction system, and in 29/79 (37%) clinics both treatment options were used according to intraoperative conditions. Mostly, as a primary management of DSWI two treatment modalities are mainly in use: primary reclosure coupled with a double-tube suction/irrigation system and V.A.C. therapy. The current understanding is based purely on retrospective studies, not evidence-based medicine. Since prospective randomized studies have not yet been performed, controlled clinical trials comparing these treatment modalities are pivotal to define evidence for patients presenting with DSWI.