Risk Of Mediastinitis Research Articles

Topical vancomycin for sternal wound infection prophylaxis. A systematic review and updated meta-analysis of over 40,000 cardiac surgery patients

BackgroundDespite guideline recommendations, routine application of topical antibiotic agents to sternal edges after cardiac surgery is seldom done. Recent randomized controlled trials have also questioned the effectiveness of topical vancomycin in sternal wound infection prophylaxis. MethodsWe screened multiple databases for observational studies and randomized controlled trials assessing the effectiveness of topical vancomycin. Random effects meta-analysis and risk-profile regression were performed, and randomized controlled trials and observational studies were analyzed separately. The primary endpoint was sternal wound infection; other wound complications were also analyzed. Risk ratios served as primary statistics. ResultsTwenty studies (N = 40,871) were included, of which 7 were randomized controlled trials (N = 2,187). The risk of sternal wound infection was significantly reduced by almost 70% in the topical vancomycin group (risk ratios [95% confidence intervals]: 0.31 (0.23–0.43); P < .00001) and was comparable between randomized controlled trials (0.37 [0.21–0.64]; P < .0001) and observational studies (0.30 [0.20–0.45]; P < .00001; Psubgroup = .57). Topical vancomycin significantly reduced the risk of superficial sternal wound infections (0.29 [0.15–0.53]; P < .00001) and deep sternal wound infections (0.29 [0.19–0.44]; P < .00001). A reduction in the risk of mediastinitis and sternal dehiscence risks was also demonstrated. Risk profile meta-regression showed a significant relationship between a higher risk of sternal wound infection and a higher benefit accrued with topical vancomycin (ß-coeff. = −0.00837; P < .0001). The number needed to treat was 58.2. A significant benefit was observed in patients with diabetes mellitus (risk ratios 0.21 [0.11–0.39]; P < .00001). There was no evidence of vancomycin or methicillin resistance; on the contrary, the risk of gram-negative cultures was reduced by over 60% (risk ratios 0.38 [0.22–0.66]; P = .0006). ConclusionTopical vancomycin effectively reduces the risk of sternal wound infection in cardiac surgery patients.

Risk of mediastinitis in the postoperative period of myocardial revascularization surgery /

Objetivo: classificar os pacientes segundo o risco de desenvolvimento de mediastinite no pós-operatório de cirurgia de revascularização do miocárdio. Método: estudo observacional, transversal, realizado na Unidade de Terapia Intensiva Pós-Operatória de um hospital universitário no interior paulista. Amostra consecutiva e não probabilística foi constituída por pacientes adultos, submetidos à revascularização do miocárdio. A coleta de dados foi realizada na alta da Terapia Intensiva, utilizando o Escore de Risco Multivariável para Mediastinite. Para a obtenção do escore foram realizadas análises estatística descritivas. Resultados: Participaram do estudo 50 pacientes, 68% do sexo masculino, com média de idade de 62,7 anos. Nenhum paciente foi reoperado ou apresentava doença pulmonar obstrutiva crônica; 26,0% eram obesos; 12,0% apresentaram angina instável e 4,0% foram politransfundidos no pós-operatório. Segundo o escore, 58,0% apresentaram baixo e 42,0% médio risco de desenvolvimento de mediastinite. Conclusão: A maior parte dos pacientes apresentava baixo risco de desenvolvimento de mediastinite.

ESOPHAGEAL INTRAMURAL DISSECTION WITH PNEUMOMEDIASTINUM SECONDARY TO FOREIGN BODY INGESTION

SESSION TITLE: Wednesday Medical Student/Resident Case Report Posters SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: 10/23/2019 09:45 AM - 10:45 AM INTRODUCTION: Esophageal injuries are associated with significant morbidity and mortality. Intramural esophageal dissection (IED) is a rare entity involving separation of the mucosal and muscular layers of the esophagus creating a true and false lumen (1). We present a patient with esophageal dissection secondary to foreign body ingestion. CASE PRESENTATION: A 38-year-old freedom impaired man with schizophrenia presented with severe odynophagia after a suicide attempt by ingestion of plastic bags and a spoon. He vomited multiple times afterwards and was intubated due to respiratory distress. He was afebrile and hemodynamically stable. Physical exam was significant for crepitus around the neck and shoulders with severe pain to palpation. Abnormal labs included mild leukocytosis and elevated BUN, Cr, and CK. The esophagram revealed subcutaneous and mediastinal emphysema with no extravasation of contrast. Cervical and thoracic computed tomography (CT) with barium revealed neck and upper chest soft tissue emphysema involving the retropharyngeal space along with pneumomediastinum and pneumopericardium (Figure 1 & 2). ENT performed a microdirect laryngoscopy and rigid bronchoscopy removing a foreign body from the left hypopharynx. Given the risk for mediastinitis, intravenous antibiotics were started. Two days later, ENT repeated direct laryngoscopy and found an esophageal dissection extending from the level of C2 to T2 with separation of the posterior pharyngeal wall from the deep vertebral space (Figure 3). The patient was kept intubated to allow time for healing along with moderate sedation to prevent coughing from disrupting the epithelialization. Repeat CT of the head and neck showed minimal emphysema, esophageal and prevertebral soft tissue thickening, pleural effusions, and pneumonia. The patient was successfully extubated. Repeat esophagram noted contrast in the right and left mainstem bronchi. Given aspiration risk, an open gastrostomy tube was placed for enteral nutrition. DISCUSSION: IED is commonly due to iatrogenic interventions, but can occur rarely secondary to foreign body ingestion. Other causes include a sudden increase in intra-esophageal pressure or submucosal bleeding (1). Diagnosis is confirmed by esophagram, CT scan or standard endoscopy. IED may present with pneumomediastinum, which is hypothesized to be secondary to gas diffusion across the esophageal muscular layers (2). Management is typically conservative. CONCLUSIONS: Foreign bodies are a rare cause of IED. Early investigation and maintaining a strong suspicion for esophageal perforation are key to ensuring a favorable outcome. Reference #1: Soulellis CA, Hilzenrat N, Levental M. Intramucosal esophageal dissection leading to esophageal perforation: case report and review of the literature. Gastroenterol Hepatol (NY). 2008;4(5):362-365. http://www.ncbi.nlm.nih.gov/pubmed/21904510. Reference #2: Lee CH, Chen WP, Feng YM, Huang PY. Iatrogenic Full-Length Intramural Esophageal Dissection Associated with Pneumomediastinum after Attempted Diagnostic Gastroscopy. Journal of Clinical Case Reports. 2014; 4:443. DISCLOSURES: No relevant relationships by naseem helo, source=Web Response My spouse/partner as a Speaker/Speaker's relationship with Salix Please note: $1001 - $5000 Added 03/13/2019 by Ebtesam Islam, source=Web Response, value=Speaker fee No relevant relationships by Sarah Jaroudi, source=Web Response No relevant relationships by Barbara Mantilla, source=Web Response No relevant relationships by Kenneth Nugent, source=Web Response

Derivation and validation of an early diagnostic score for mediastinitis after cardiothoracic surgery

ObjectivesThe aim of this study was to elaborate on and validate a score for the early diagnosis of mediastinitis after cardiothoracic surgery. MethodsBetween 2007 and 2017, patients who experienced thoracic surgical-site infection after cardiothoracic surgery were enrolled. Laboratory, clinical, and chest CT findings were retrospectively analyzed. Patients were followed up until hospital discharge or intra-hospital death. Univariate and multivariate regression analyses were performed. Results950 surgical-site infections were found and analyzed (131 mediastinitis, 819 superficial/deep infections). Of the 131 mediastinitis episodes, 88% required surgical thoracic debridement,Staphylococcus aureus was identified in 43%, and overall mortality was 42%. The following variables were related to mediastinitis diagnosis: sternal diastasis (OR=2.5; 95% confidence interval [95%CI]: 1.2–5.3; P=0.012), bilateral pleural effusion (OR=1.9; 95%CI: 1.0–3.6; P=0.04), leukocyte count ≥14,000cells/mm3 (OR=2.5; 95%CI: 1.3–4.7; P=0.006), male sex (OR=2; 95%CI: 1.11–4; P=0.022), and positive blood culture (OR=3.0; 95%CI: 1.6–5.6; P=0.001). The score predicted with reasonable accuracy mediastinitis in the derivation cohort (AUC-ROC, 0.7476) and the validation cohort (AUC-ROC, 0.7149). Groups with high (31%) and low (5%) risk of mediastinitis were identified. ConclusionsAn early diagnostic score in patients with surgical-site infection after cardiothoracic surgery identified groups with a low and high risk for mediastinitis.

The risk of mediastinitis and deep sternal wound infections with single and bilateral, pedicled and skeletonized internal thoracic arteries

Bilateral internal thoracic artery (BITA) grafting may prolong survival in coronary artery bypass graft (CABG) patients, but its use has been curtailed due to concerns of deep sternal wound infections (DSWI) resulting in mediastinitis. This article examines the association of single internal thoracic artery (SITA) and BITA grafting and the role of harvesting techniques with the development of DSWI in CABG patients. The development of DSWI following BITA grafting is multifactorial and is independent of the harvesting technique.

Médiastinite au décours d’une échoendoscopie bronchique (EEB) avec cyto-aspiration ganglionnaire

Endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) is a minimally invasive procedure designed to explore mediastinal lymphadenopathy. Its use and indications have increased recently and severe, though rare, complications have been reported. EBUS-TBNA was performed in a 64-year-old patient presenting with mediastinal lymphadenopathy, probably due to sarcoidosis, but without histological proof. Within hours of the aspiration of subcarinal lymph nodes (station 7), the patient developed fever and dry cough associated with progressive dysphagia and dysphonia that persisted for four weeks. Mediastinitis was diagnosed after a CT-scan revealed a collection in the subcarinal space previously tapped using CT guidance. Intravenous antibiotics were started and both symptoms and the mediastinal collection resolved without need of a surgical procedure. The patient recovered fully. EBUS-TBNA is associated with a risk of mediastinitis that may manifest as an isolated fever arising within hours of the procedure. The pathogens responsible are usually contaminants from the oropharynx such as Streptococcus sp, probably inoculated directly into the mediastinum during transbronchial needle aspiration. Rapid diagnosis and treatment are necessary in order to reduce morbidity and mortality associated with mediastinitis.

Outcomes of Delayed Sternal Closure in Pediatric Heart Surgery: Single-Center Experience.

Background Delayed sternal closure (DSC) after cardiac surgery is a therapeutic option in the treatment of the severely impaired heart in pediatric cardiac surgery. Methods A single-center retrospective review of all bypass surgeries performed over a 10-year period (2003–2012). Results Of a total of 2325 patients registered in our database, the DSC group included 259 cases (11%), and the remaining 2066 cases (89%) constituted the control group (PSC). RACHS-1 risk was higher for the DSC group (74% had a score of 3 or 4) than for the PSC group (82% had a score of 2 or 3). The most frequent diagnosis for the DSC group was transposition of the great arteries (28%). We found out that hemodynamic instability was the main indication observed in patients aged ≤ 8 years (63%), while bleeding was the principal indication for patients aged ≥ 8 years (94%) (p ≤ 0.001). The average time between surgery and sternal closure was 2.3 ± 1.4 days. Overall mortality rates were higher for patients of the DSC group (22%) than for the PSC group (8.7%) (OR: 0.4 (95% CI: 0.4 to 0.5), p < 0.05). There were six patients with DSC who developed mediastinitis (2.3%). The risk of mediastinitis was significantly higher when DSC was performed 4 days after the primary surgery. Conclusions DSC is an important management strategy for congenital cardiac surgery in infants and children. The prolonged sternal closure time is associated with an increased rate of postoperative mediastinitis.

Cervical esophagotomy for removing a retained foreign esophageal body

The current paper presents the case of a patient with a retained foreign esophageal body, removed through open surgery (lateral cervical esophagotomy). The foreign body was a partial dental prosthesis with a metal hook that anchored it to the patient’s remaining natural teeth. The foreign body was lodged in the esophageal wall and the previous endoscopical extraction attempt had failed. The patient was transferred to our department from a regional hospital where an endoscopic attempt at removing the foreign body had failed. The patient complained of descending odynophagia and dysphagia for solids. After the previous esophageal endoscopy, the patient complained of retrosternal pain and pressure. A CT-scan with contrast of the neck and chest regions was performed. A secondary endoscopical exploration of the esophagus was performed, thus the foreign body’s location was precisely identified. We discovered that its metal grappling device was anchored in the lateral esophageal wall thus preventing endoscopic removal without tearing the esophageal wall open. As the patient’s current state was degrading (descending pains and risk of mediastinitis), we considered another transfer to be an unfortunate choice, so we chose an open surgery approach. We opted for a lateral cervical esophagotomy. The surgery was performed under general anesthesia, and the retained foreign body was removed. The lateral wall of the esophagus was perforated and torn open vertically at the spot where the metal hook of the prosthesis lodged itself into the muscle wall. A 4‑centimeter incision circumscribed both parietal lesions and allowed the removal of the foreign body without any further damage. Postoperatively, a nasogastric feeding tube was maintained for 14 days. Ten days after the surgery a follow‑up CT-scan was performed. The imaging exam did not show any mediastinal or retromediastinal fluids. After the nasogastric feeding tube was removed the patient was gradually allowed back on solids without any complaints.

Association Between Surgical Antimicrobial Prophylaxis Regimen and Risk of Mediastinitis Following Coronary Artery Bypass Grafting

Association Between Surgical Antimicrobial Prophylaxis Regimen and Risk of Mediastinitis Following Coronary Artery Bypass Grafting

The protective effect of topical rifamycin treatment against sternal wound infection in diabetic patients undergoing on-pump coronary artery bypass graft surgery : cardiovascular topic

SummaryObjectivesThe aim of this study was to investigate the protective effect of topical rifamycin SV treatment against sternal wound infection (SWI) in diabetic patients undergoing on-pump coronary artery bypass graft (CABG) surgery.MethodsOne hundred and fifty-nine diabetic patients who were scheduled to undergo isolated on-pump CABG surgery were included. Eight were excluded for various reasons. Of the 151 patients, 51 were on insulin therapy and 100 were on oral anti-diabetics. The risk of mediastinitis was assessed using the American College of Cardiology/American Heart Association 2004 guideline update for CABG surgery. According to the risk scores, patients were divided into two comparable groups: the rifamycin group (n = 78) received topical rifamycin treatment after on-pump CABG surgery, and the control group (n = 73) received no topical treatment.ResultsDeep sternal wound infection (mediastinitis) was not observed in either group (0/78 vs 0/73, p = 1.0). No superficial sternal wound infection was observed in the rifamycin group, however, it did occur in one patient in the control group (0/78 vs 1/73, p = 0.303). Wound culture was performed and coagulase-negative staphylococci were observed. The infection regressed on initiation of antibiotic therapy against isolated bacteria and the patient was discharged after a full recovery.ConclusionAlthough the difference in rate of superficial sternal wound infection (SSWI) in the rifamycin and control groups was not statistically significant, locally applied rifamycin SV during closure of the sternum in the CABG operation may have had a protective affect against SWI.

Mitral valve replacement via right thoracotomy approach for prevention of mediastinitis in a female patient with long-term uncontrolled diabetes mellitus: a case report

A 76-year-old woman with a history of percutaneous transvenous mitral commissurotomy and repeated hospital admissions due to heart failure was referred for an operation for severe mitral valve stenosis. She presented with hypertension, hyperlipidemia and cerebral infarction with stenosis of right internal carotid artery, retinopathy, neuropathy and nephropathy caused by long-term uncontrolled diabetes mellitus, hemoglobin A1c of 9.4%, and New York Heart Association (NYHA) functional classification of 3/4. Echocardiography revealed severe mitral valve stenosis with mitral valve area of 0.6 cm2, moderate tricuspid valve regurgitation, and dilatation of the left atrium. Taking into consideration the NYHA functional classification and severe mitral valve stenosis, an immediate surgical intervention designed to prevent mediastinitis was performed. The approach was via the right 4th thoracotomy, as conventional sternotomy would raise the risk of mediastinitis. Postoperative antibiotics were administered intravenously for 2 days, and signs of infection were not recognized.In patients with long-term uncontrolled diabetes mellitus, mid-line sternotomy can easily cause mediastinitis. The choice of operative approach plays an important role in preventing this complication. In this report, the importance of the conventional right thoracotomy for prevention for mediastinitis is reviewed.

QS245. Hyaluronate-Iodine Complex: New Method in Complicated Cardiac Surgical Wound Treatment

Background: Wound infection after sternotomy is a dangerous complication of cardio-surgical procedures. Treatment is often difficult due to the presence of necrotic and infected tissue, a risk of mediastinitis or cardiac perforation. A new wound healing system is based on combination of hyaluronan with iodine. The aim of our study was to assess the effect of hyaluronate-iodine on the treatment of sternal dehiscences. Methods: We treated eight patients with wound infections after sternotomy complicated by sternal dehiscence.

Topical Application of Bacitracin Ointment Is Associated with Decreased Risk of Mediastinitis after Median Sternotomy

The diagnosis of mediastinitis after open-heart surgery is infrequent but dreaded as it carries a high morbidity and mortality. The purpose of this study was to investigate the impact that topical antibacterials would have on the postoperative mediastinitis rate. Data were collected from 2455 consecutive patients who underwent sternotomy and cardiopulmonary bypass for both valvar and ischemic heart disease. Prior to 1999, patients (n = 1036) underwent surgery with standard perioperative intravenous antibiotics but no application of bacitracin. After 1999, patients (n = 1419) underwent surgery with intravenous antibiotics and application of bacitracin ointment to the sternotomy incision after closure. Cases of mediastinitis occurred in 12 patients (1.2%) not treated with bacitracin, which required re-exploration, sternectomy, and soft tissue closure of the mediastinum. Alternatively, 3 patients (0.2%) in the group treated with bacitracin developed mediastinitis (P < .01). Therefore, the use of topical antibacterials was associated with a 6-fold reduction in the risk of mediastinitis after cardiac surgery. This significant difference in the infection rate was observed even though the percentage of patients with risk factors for mediastinitis was equal to greater than the group not treated with bacitracin. Non-bacitracin versus bacitracin: diabetics, 298 versus 484; emergency operations, 24 versus 50; bilateral internal thoracic grafts, 28 versus 29; and obesity (body mass index >30), 294 versus 396. The use of topical antibacterials is associated with a decrease in the risk of mediastinitis after cardiac surgery.

Elevated preoperative fasting serum glucose levels increase the risk of postoperative mediastinitis in patients undergoing open heart surgery.

We conducted a case-control study to investigate the relationship between preoperative fasting serum glucose and postoperative mediastinitis in patients undergoing open heart surgery. Multivariate analysis revealed that a glucose level of 126 mg/dL or greater was associated with a significantly increased risk of mediastinitis (OR, 5.25; P = .002).