Treatment Of Poststernotomy Mediastinitis Research Articles

The role of negative pressure wound therapy in the treatment of poststernotomy mediastinitis in Asians: A single-center, retrospective cohort study.

Poststernotomy mediastinitis (PSM) is a critical and life-threatening complication that can arise after cardiac surgery. The aim of this study was to evaluate and compare the outcomes of negative pressure wound therapy (NPWT) and conventional methods in the management of mediastinitis following heart surgery with a focus on Asian populations. For this retrospective study, we included and evaluated a total of 34 patients who had undergone cardiac operations between January 2011 and September 2021 and developed PSM. The patients were divided into two groups, the NPWT group (n = 16, 47.1%) and the conventional treatment group (n = 18, 52.9%), and compared. The two groups showed no significant differences in terms of patient characteristics, PSM wound classification based on the El Oakley classification, and wound closure methods, but there was a higher incidence of diabetes mellitus in the NPWT group. With regard to mediastinal cultures, a higher prevalence of Staphylococcus epidermidis was observed in the NPWT group. However, we found no significant differences between the two groups regarding the time interval from diagnosis to wound closure, hospitalization duration, and re-exploration rate. Notably, the NPWT group exhibited a significantly higher in-hospital mortality rate than the conventional treatment group (p = 0.024). Our findings suggest that the use of NPWT might not lead to improved medical outcomes for patients with PSM when compared to conventional treatment methods. As a result, it becomes imperative to exercise great care when choosing patients for NPWT. To obtain more definitive and conclusive results and identify the most appropriate cases for NPWT, conducting larger randomized clinical trials is necessary.

ВЕРТИКАЛЬНЫЙ ЛОСКУТ ПРЯМОЙ МЫШЦЫ ЖИВОТА В РЕКОНСТРУКЦИИ ДЕФЕКТА ПЕРЕДНЕЙ ГРУДНОЙ СТЕНКИ

The case report of a patient with post-sternotomy mediastinitis is presented. A successful case of treatment of such a formidable complication after cardiac surgery was demonstrated. Success in the treatment of such patients depends on the complete cupping inflammatory process in the site of operation, as well as chest wall reconstruction. The positive clinical effect of vacuum-assisted dressings in the treatment of post-sternotomy mediastinitis is shown. The vertical rectus abdominis myocutaneous flap was used as a plastic material to cover a defect in the chest wall. The course of surgery and the result of treatment are described in details. To date, the surgical society has not developed a generally accepted tactic in the treatment of poststernotomy mediastinitis, both at the stage of arresting the infectious process, and in the process of reconstructive and restorative intervention. In practice, along with alloplastic materials, synthetic and metal implants are used. The autologous tissues include muscle flaps and the greater omentum. In thoracic surgery, the rectus abdominis can serve as an alternative to omentoplasty for extended chest wall defects.

Vacuum Assisted Closure Versus Conventional Surgical Techniques in Treatment of Post-Sternotomy Mediastinitis

Background: In cardiac surgery patients, post-sternotomy mediastinitis, also known as deep sternal wound infection (DSWI), is a major cause of postoperative morbidity and mortality. Negative pressure wound therapy (NPWT), also known as vacuum assisted closure (VAC) dressing, is one therapeutic alternative that offers the following advantages: regulation of fluid drainage, reduction of local edema, and bacterial load reduction, and early development of granulation tissue by angiogenic stimulation. By acting topically with a low complication rate, offering greater comfort to the medical team and patient, and reducing hospitalization time, antibiotic usage, and dressing changes, this therapy has become an important and efficient method for fighting infection in complex wounds. Objective: To evaluate the effectiveness and clinical outcome of vacuum‑assisted closure (VAC) therapy in the treatment of post-sternotomy mediastinitis in comparison with conventional treatment. Patients and methods: This study was conducted in National Heart Institute (NHI), Egypt. Patients were hospitalized from March 2019 to March 2020. It included patients with post-sternotomy mediastinitis treated with conventional therapy and VAC divided in two groups each group contained 30 patients. Results: The duration of VAC therapy was 7.42±2.23 days. Mean hospital stay after VAC therapy was 12.18±1.92 days. Twenty-two (92%) patients were treated successfully. At the end of VAC therapy, the mean reduction in wound size was 31.7%. The mean granulation tissue formation was 59%. Conclusion: VAC is a safe, reliable, and relatively new option for the treatment of DSWI after cardiac surgery. VAC is an alternative to conventional treatment in wound healing strategy in post-sternotomy mediastinitis.

Incisional negative pressure wound therapy in reconstructive surgery of poststernotomy mediastinitis.

The efficacy of negative pressure wound therapy in the treatment of poststernotomy mediastinitis has been revealed in many reports. The present retrospective observational study examined the efficacy of incisional negative pressure wound therapy in the reconstructive surgery of poststernotomy mediastinitis. We retrospectively examined 1034 consecutive patients, who underwent median sternotomy in the period between October 2013 and September 2015. Mediastinitis developed in 21 patients (2%), who subsequently underwent surgical reconstruction. We applied incisional negative pressure wound therapy (iNPWT) after primary closure of the wound over redon drains in ten patients (iNPWT + redon group). In 11 patients, only redons were used (redons only group). We observed the time between the introduction and removal of redon drains, hospital stay until final wound closure and the rate of failure of treatment. Failure of treatment is defined as the need for further surgical reconstruction. In the iNPWT + redon group, the duration of redon drainage therapy was 6·9 ± 5·2 days versus 13·36 ± 11·58 in the redons only group. Hospital stay was 11·4 ± 8·6 versus 101·64 ± 89·2, and failure of treatment was 10% versus 45·5%, respectively. The primary results of this study appear to support the beneficial effect of iNPWT after radical wound reconstruction.

Major Bleeding Events in Patients with Vacuum-Assisted Therapy of Post-Sternotomy Mediastinits

Objective: In the last decade vacuum assisted therapy for surgical treatment of post-sternotomy mediastinitis became standard therapy. Severe complications like acute major bleeding are rare, but can be lethal. Methods: Between January 2011 and July 2014 68 (1.4%) of 4865 patients (pts.) with sternotomy received a vacuum assisted closure (VAC) due to post-sternotomy mediastinitis in our department. We analyzed patient characteristics and clinical outcome retrospectively. Results: The mean age of patients with mediastinitis was 67.6 ± 11.7 years. 38% (26 pts.) were female. 53% (36 pts.) underwent coronary artery bypass grafting with use of bilateral internal mammary arteries in 38% (26 pts.). 15% (10 pts.) had isolated aortic valve replacement, 29% (20 pts.) other combined procedures and 2% (2 pt.) ventricular assist devices. Body-mass-index was 28.5 ± 5.1 kg/m2. Diagnosis of deep sternal infection occurred 21.8 ± 18.3 days after primary operation. Infection related mean hospital stay was 22 ± 11.7 days with 8 ± 4.2 VAC-operations and mean weight loss of 4.8 ± 5.3 kg. Total in-hospital mortality was 17.6% (12 pts.). 10 pts. died due to sepsis and multiple organ failure (7 pts.), heart failure (2 pats.) or endocarditis. Major bleeding complication occurred in 4 pts. (6.9%) due to injury of right ventricle in 3 pts. and massive erosion of the right lung in one patient. Emergency extracorporal circulation (ECC) via femoral vessels was established in all cases, nevertheless one patient died within the operation. Sternum restabilization was performed in three patients during emergency operation. One patient died subsequently at day 18 due to sepsis. Two of these patients are still alive. One patient was re-admitted with recurrent sternum instability after 15 days. Conclusion: Major bleeding events due to injury of the right ventricle are a rare, but potentially lethal complication of post-sternotomy mediastinitis. However, VAC therapy is an effective method, but surgical debridement and refixation of the sternum should performed as early as possible.

Harvesting the Omentum for Poststernotomy Mediastinitis

Sir: The eloquently written and beautifully illustrated article by Vyas and colleagues1 presents some strong arguments for limiting the abdominal access to harvest the omentum in the management of poststernotomy mediastinitis. We concur with this principle. It is with a similar intent that some advocate harvesting the omentum laparoscopically.2,3 Indeed, it is true that more equipment is required for the latter—not more personnel (one surgeon, one assistant, and one scrub nurse). The other points advanced in the penultimate paragraph in their article1 against laparoscopic harvest of an omental flap also warrant closer scrutiny. First, yes, laparoscopy does require additional stab wounds (all <10 mm); however, bear in mind that in at least 15 percent of their cases1 additional abdominal incisions were necessary to release the adhered omentum. Second, the percentage of ventral hernias was more than doubled by converting the transdiaphragmatic approach to a laparotomy. The incisional hernia rate is distinctively higher when compared with the 1.5 to 1.8 percent rate reported following laparoscopy.4 Third, the mean blood loss (Table 3) following laparotomy was significantly higher compared with not only the transdiaphragmatic approach but also with laparoscopy. The latter offers a clear and complete view during dissection, avoids blunt adhesiolysis, and reduces bleeding to an absolute minimum. Finally, during laparoscopic harvest of an omental flap, the loss of any amount of pneumoperitoneum only occurs once the flap has been safely dissected, prepared, and at the end of the abdominal surgical procedure. Obviously, creating a wrist/lower arm–sized transdiaphragmatic opening at the beginning of the procedure limits the possibility of laparoscopic harvest of an omental flap. This opens the door to a pertinent question. In the study by Vyas et al.,1 a steady increase in the number of laparotomies since 2002 can be observed (Fig. 3). Was this because of the failure of intention-to-treat by technique (transdiaphragmatic harvesting) or were the laparotomies planned preoperatively? If planned, it would be of interest to know which selection criteria the authors developed for either of the procedures. It may be fair to seek an alternative to the transdiaphragmatic approach to the omentum in patients who have undergone previous, perhaps extensive, abdominal surgery. This does not have to be a laparotomy. Laparoscopic harvest of an omental flap has been shown to be feasible and not a contraindication in these cases. Most of the patients in the four largest case series of laparoscopic harvest of an omental flap for reconstruction in poststernotomy mediastinitis had a history of previous, major abdominal surgery.2,3 In each, the outcome following laparoscopic harvest of an omental flap was good. A recently published meta-analysis for a systematic review comparing patient-based outcome with muscle flaps or an omental flap indicated a slight survival advantage for reconstruction with an omental flap (overall relative risk, 1.29; 95 percent CI, 0.58 to 2.88).5 In addition, the results of our systematic review5 suggest that muscle flaps are associated with more, and more frequent, complications compared with omental flaps. Vyas et al.1 do not compare their results with a similar cohort of patients in whom muscle flaps were harvested. However, their good results lend further support to lowering the threshold in preferentially choosing the omentum in the treatment of poststernotomy mediastinitis when a flap is indicated. DISCLOSURE The authors have no financial interest to declare in relation to the content of this communciation. No outside funding was received. Jan J. van Wingerden, F.C.S.(S.A.)., M.Med.(Plast.Chir.) Oren Lapid, M.D. Department of Plastic, Reconstructive, and Hand Surgery Academic Medical Center University of Amsterdam Amsterdam, The Netherlands Erik R. Totté, M.D., Ph.D. Leeuwarden Institute for Minimal Invasive Surgery Medical Center Leeuwarden Leeuwarden, The Netherlands

Primary closure using Redon drains for the treatment of post-sternotomy mediastinitis

Post-sternotomy mediastinitis is a severe complication of open heart surgery resulting in prolonged hospital stay and increased mortality. Vacuum-assisted closure is commonly used as treatment for post-sternotomy mediastinitis, but has some disadvantages. Primary closure over high vacuum suction Redon drains previously has shown to be an alternative approach with promising results. We report our short- and long-term results of Redon therapy-treated mediastinitis. We performed a retrospective analysis of 124 patients who underwent primary closure of the sternum over Redon drains as treatment for post-sternotomy mediastinitis in Amphia Hospital (Breda, Netherlands) and St. Antonius Hospital (Nieuwegein, Netherlands). Patient characteristics, preoperative risk factors and procedure-related variables were analysed. Duration of therapy, hospital stay, treatment failure and mortality as well as C-reactive protein and blood leucocyte counts on admission and at various time intervals during hospital stay were determined. Mean age of patients was 68.7 ± 11.0 years. In 77.4%, the primary surgery was coronary artery bypass grafting. Presentation of mediastinitis was 15.2 ± 9.8 days after surgery. Duration of Redon therapy was 25.9 ± 18.4 days. Hospital stay was 32.8 ± 20.7 days. Treatment failure occurred in 8.1% of patients. In-hospital mortality was 8.9%. No risk factors were found for mortality or treatment failure. The median follow-up time was 6.6 years. One- and 5-year survivals were 86 and 70%, respectively. Primary closure using Redon drains is a feasible, simple and efficient treatment modality for post-sternotomy mediastinitis.

In patients with post-sternotomy mediastinitis is vacuum-assisted closure superior to conventional therapy?: Table 1:

A best evidence topic in cardiac surgery was written according to a structured protocol. The question addressed was whether vacuum-assisted closure therapy (VAC) is superior to conventional therapy for treating post-sternotomy mediastinitis. Altogether >261 papers were found using the reported search, of which 9 represented the best evidence to answer the clinical question. The authors, journal, date and country of publication, patient group studied, study type, relevant outcomes and results of these papers are tabulated. Several studies indicate that VAC therapy is associated with shorter lengths of intensive care and in-hospital stay as well as faster rates of wound healing and fewer dressing changes. It has also been shown that VAC therapy is correlated with a statistically significant reduction in reinfection rates, particularly those that occur in the early postoperative period (at the 1-week follow-up). Patients can be discharged with the dressing in situ and managed in the community with a view to delayed closure or reconstruction. However, the studies comparing VAC with conventional therapy are all retrospective in nature and reinforce the need for randomized controlled trials in order to more accurately establish differences in outcomes between VAC and conventional therapy. Additionally, owing tło the variability of treatment protocols within the non-VAC arm, it is more challenging to draw definitive conclusions regarding the superiority of VAC therapy to every modality that is considered conventional treatment. We conclude that VAC therapy is a portable and an increasingly economical option for the treatment of post sternotomy mediastinitis. Although reductions in mortality rates were not reproduced in all studies, evidence suggests that VAC should still be considered as a first-line therapy for post-sternotomy mediastinitis and as a bridge therapy to musculocutaneous reconstruction or primary closure.

Primary closure using Redon drains vs vacuum-assisted closure in post-sternotomy mediastinitis

Vacuum-assisted closure (VAC) is a commonly used therapy for the treatment of post-sternotomy mediastinitis. Primary closure of the sternum with high vacuum suction using Redon drains is an alternative that may reduce hospital stay. The aim of this study was to describe for the first time, the results of VAC compared with Redon drainage. We performed a retrospective analysis of 132 patients undergoing VAC (n = 89) or primary closure of the sternum with Redon drains (n = 43) as treatment for post-sternotomy mediastinitis between January 2000 and January 2011. Patient characteristics, risk factors and procedure-related variables were analysed. Duration of therapy, treatment failure, hospital stay and mortality as well as C-reactive protein and blood leucocyte counts on admission and at various time intervals during hospital stay were determined. In-hospital mortality was 12.5% in the VAC group compared with 14% in the Redon group (P = 0.96). Treatment failure in the VAC and Redon groups occurred in 28 and 23% of the patients, respectively (P = 0.68). Intensive-care stay in the VAC group was 6.8 ± 14.4 days, and 4.8 ± 10.1 days in the Redon group (P = 0.99). Hospitalization in the VAC group was 74 ± 61 days and in the Redon group, 45 ± 38 days (P = 0.0001). Primary closure using high vacuum suction drains is a safe and feasible treatment modality for post-sternotomy mediastinitis. It reduces hospital stay when compared with VAC therapy, without compromising mortality.

EComment. Vacuum-assisted closure therapy in cardiac surgery

The retrospective study by Vos et al. has reported on the superiority of VAC-therapy compared to open packing in patients with post-sternotomy mediastinitis (PM) [1]. We have reviewed our experience regarding the management of deep sternal wound infections (also commonly called PM) in 85 patients over a period of 11 years (2000–2010) where the in-hospital mortality rate for this specific group was 7% vs. 3% . The higher logistic EuroSCORE for these patients (10.2% vs. 7.9%) indicates the higher rate of preoperative co-morbidities [2]. Our therapeutic approach is consistent with immediate application of VAC-therapy plus systemic antibiotics even when there is no clear distinction of whether there is an infective deep sternal wound or not [2]. This approach may improve the wound healing process through the early removal of the infective tissues and reduction of dead space. In case of sternal dehiscence, further surgical revision is required. Upon resolution of acute infection and confirmation of wound cultures as negative, a primary sternal closure technique is applied followed by insertion of closed irrigation - suction drains [2]. Bilateral myocutaneous pectoral flap reconstruction can be performed when necessary with particular emphasis on the preservation of its vascular supply. Six percent of these patients required a further plastic intervention [2]. In 2003, Luckraz et al. found that VAC-therapy combined with primary closure or myocutaneous flap is superior to VAC-therapy alone in patients with PM (VAC duration 13.5 days vs. 8 days, healed scar 77% vs. 64%, mortality rate 7.7% vs. 28.6%) [3]. The overall cost of the VAC-therapy per patient was regarded as nearly $4000 cheaper per patient than the single use of a closed irrigation system [3]. Pectoralis flaps can frequently be used for the definitive treatment of PM and the final sternal reconstruction. These flaps, as described by Jurkiewicz et al., allow early closure and healing of sternal wounds and are currently the conventional treatment for PM [4]. Alternatively, omental flaps can also be used for the treatment of PM specifically in the case of replacement of the ascending aorta with a prosthetic graft [4]. In 2007, Raja and Berg published their meta-analysis regarding the routine use of VAC-therapy in all patients with deep sternal wound infections post cardiac surgery. The authors identified 13 papers (out of 198) representing the best evidence in the use of VAC-therapy [5]. All the studies were retrospective or small cohort and the largest one was by Agarwal et al. with 103 patients (64% had the definitive diagnosis of PM) [5]. According to Agarwal et al., all the patients were treated with VAC-therapy (average period 11 days/patient) of whom 68% had definitive chest closure. The overall mortality rate was 28%, however, no deaths were related to VAC-therapy. Four deaths were due to PM sepsis [5]. This meta-analysis illustrates that VAC-therapy is a safe and effective additional method for the surgical management of PM. However, a prospective double-blinded randomized controlled trial is essential in order to validate the effectiveness, cost effectiveness and improvement of quality of life of patients undergoing VAC-therapy [5]. Conflict of interest: none declared.

Vacuum-assisted closure with a portable system for treatment of poststernotomy mediastinitis

The patient was a 50-year-old man with diabetes who was on insulin. Complications of mediastinitis developed after coronary bypass surgery, which had been performed for unstable angina. Upon hospital admission, the patient was treated with antibiotics, and the wound was cleaned on a daily basis. However, because the patient's fever persisted, the wound was completely opened surgically and found to be deep and large. Because the patient's condition was relatively stable, minimally invasive vacuum-assisted closure was selected. We fabricated a portable vacuum-assisted closure system that imposed few limitations on individual movement. Vacuum-assisted closure treatment resulted in both rapid abatement of fever and improved granulation. Dressings were changed once a week; the wound was closed 4 weeks after vacuum-assisted closure and healed completely. Vacuum-assisted closure may be an effective therapy for postoperative mediastinitis, and our portable vacuum-assisted closure system may significantly reduce patient distress as well as direct medical care.

Improved results of the vacuum assisted closure and Nitinol clips sternal closure after postoperative deep sternal wound infection

Postoperative deep sternal wound infection is a severe complication of cardiac surgery, with a high mortality rate and a high morbidity rate. The objective of this prospective study is to report our experience with the vacuum assisted closure (VAC) system for the management of deep wound infection. We also devised an innovative closure technique post VAC therapy using thermo reactive clips. The advantage of this technique is that the posterior face of the sternum does not have to be separated from the mediastinal structures thus minimising the risk of damage. From October 2006 to October 2008, we prospectively evaluated 21 patients affected by mediastinitis after sternotomy. Nineteen patients had sternotomy for coronary artery bypass grafting (CABG), one patient for aortic valve replacement (AVR) and another one for ascending aortic replacement (AAR). All patients were treated with the VAC system at the time of infection diagnosis. When the wound tissue appeared viable and the microbiological cultures were negative, the chest was closed using the most suitable procedure for the patient in question; nine patients were closed using pectoralis flaps, nine patients using Nitinol clips, one patient with a combined technique (use of Nitinol clips and muscle flap), one patient with a direct wound closure and another patient, who needed AAR with a homograft performed in another institution, was closed using sternal wires. We had no mortality; wound healing was successfully achieved in all patients. In more than 50% of the patients, the VAC therapy allowed direct sternal resynthesis. The average duration of the vacuum therapy was 26 days (range 14-37 days). VAC is a safe and effective option in the treatment of post-sternotomy mediastinitis, with excellent survival and immediate improvement of local wound conditions; furthermore, the use of Nitinol clips after VAC therapy demonstrated to be a safe and non-invasive option for sternal resynthesis. After VAC therapy, a reduction in number of muscular flaps used and an increase of direct sternal resynthesis were observed.

Sympathetic and sensory nerve activation during negative pressure therapy of sternotomy wounds

Negative pressure wound therapy (NPWT) has been adopted as the first-line treatment for poststernotomy mediastinitis as a result of the excellent clinical outcome. The knowledge concerning the effects of NPWT on the cardiovascular system and homeostasis is still limited. The aim of the present study was to investigate whether the plasma levels of neurohormones change during NPWT. Six pigs underwent median sternotomy followed by NPWT at -125 mmHg. The plasma levels of noradrenaline, adrenaline, neuropeptide Y, substance P, vasoactive intestinal peptide (VIP), and calcitonin gene-related peptide (CGRP) were determined before (0 min) and 5, 20, 60 and 180 min after the application of NPWT. The results show a transient increase in the plasma levels of noradrenaline and adrenaline when NPWT was applied. The plasma level of the adrenergic co-transmitter neuropeptide Y was higher in NPWT--than in sham-treated pigs, after 180 min of negative pressure. After 180 min of NPWT there was an increase in the plasma levels of the sensory nerve transmitter substance P, while no such effect was observed for CGRP or VIP. In conclusion, the results suggest sympathetic nerve activation during NPWT. This may be the result of an increase in workload on the heart during the initial phase of NPWT.

Management of Poststernotomy Mediastinitis: Experience and Results of Different Therapy Modalities

Different primary treatment modalities have been utilized to treat poststernotomy mediastinitis (PM) following cardiac surgery. A literature survey using the key phrases "treatment of deep sternal wound infection" and "poststernotomy-mediastinitis" was performed. Furthermore, a questionnaire regarding the primary treatment of PM was distributed to all 79 German heart surgery centers. The review of the literature shows that the current understanding is based purely on retrospective studies, not on evidence-based medicine. All 79 German heart centers replied to the questionnaire. Vacuum-assisted closure therapy (V. A. C.(R)) 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 %) German heart centers both treatment options were used according to the intraoperative conditions. As a primary treatment for PM two treatment modalities are currently in use: primary reclosure coupled with a double-tube suction/irrigation system versus V. A. C.(R) therapy. Since prospective randomized studies have not yet been performed, controlled clinical trials comparing both treatment modalities are pivotal to define the evidence for patients presenting with PM.

Management of poststernotomy mediastinitis with vacuum therapy following pectoralis plastic

Aims: In cardiac surgery poststernotomy mediastinitis continues to be a serious cause of morbidity and mortality. We report our experience with vacuum-assisted closure (VAC) therapy followed by reconstruction with soft tissue flaps as treatment for deep sternal wound infections. Method: We performed a retrospective analysis of 4200 consecutive cardiac surgical patients (pts) using median sternotomy from 11/2004 to 8/2007. After removing of sternal wires, necrotic debris and potentially infective material restabilization of the sternum were performed and VAC-therapy was employed. Wound closure and subsequent reconstruction were performed using a bilateral pectoralis muscle plasty. Results: Of the analyzed patients 15 female and 28 male patients suffered from deep sternal wound infections and were treated with VAC. The most common risk factors were diabetes mellitus (OR 3.5), COPD (OR 2.9), use of bilateral mammarian artery (OR1.6) and obesity (1.3). Median age of patients with deewp sternal infections was 69y and 68y in control-pts. Staphylococcus epidermis was the most common pathogen (37.8%) followed by enterococcus faecilis (18.9%) and staphylococcus aureus (13.5). In 13.5% no pathogen could be detected. The 30d mortality was 0%, the in hospital mortality was 13.9%. Due to bleeding complications 6 pts underwent re-surgery. In one patient a partial necrosis of the muscle was observed. Conclusion: The results of our studies demonstrate that vacuum therapy is an important tool for treating poststernotomy mediastinitis. We consider pectoralis major flap reconstruction as a safe technique and regarded it as an important adjunct to the treatment of poststernotomy mediastinitis.

Vacuum-assisted closure in the treatment of poststernotomy mediastinitis in the paediatric patient

Delayed sternal closure after paediatric open heart procedure is often necessary. The risk of delayed sternal closure is infection: superficial wound or sternal and mediastinal infection. The incidence of sternal wound infection reported in the literature varies from 0.5 to 10%. The mortality for poststernotomy deep sternal infection continues to be high--from 14 to 47%. Established treatment includes surgical debridement, drainage and irrigation, antibiotics, frequent change of wound dressing and direct or secondary closure with omentum or pectoral muscle flap. Between October 2003 and August 2005, three children, aged from 9 days to 2 years and who had developed severe mediastinitis after cardiac surgery were treated with the vacuum-assisted closure (VAC) system. The duration of VAC treatment ranged from 12 to 21 days. The response to VAC was rapid with local purulence and C-reactive protein (CRP) both decreasing within 72 h in all cases. After good granulation was obtained, two patients required a thin skin graft. All three children had peritoneal dialysis which did not permit omental use. The use of pectoralis major is a difficult technique in neonates and the haemodynamic conditions were poor in our cases. The VAC technique is a good indication in post-cardiotomy mediastinitis in children: it plays a role in the reduction of infection and provides good healing.

Combined Therapy of Teicoplanin and Caffeic Acid Phenethyl Ester (CAPE) in the Treatment of Experimental Mediastinitis in the Rat

Post-sternotomy mediastinitis affects 1-3% of patients undergoing cardiac surgery and is lethal in 10-47% of these patients.We investigated the effect of an antioxidant/anti-inflammatory agent, caffeic acid phenethyl ester (CAPE), in the attenuation of inflammatory response induced by methicillin-resistant Staphylococcus aureus (MRSA) infection in a rat experimental mediastinitis model. Rats, divided into six equal groups, received MRSA precolonized stainless steel wire pieces implanted into their mediastinal spaces. Control group and CAPE control group received saline and CAPE 10 μmol/kg.day−1 respectively, where Group A received a single dose of teicoplanin 24 mg/kg i.m. for the first day and then 12 mg/kg.day−1. Group B received teicoplanin as in Group A plus CAPE 10 μmol/kg. day−1 intra-peritoneally. Group C received teicoplanin 60 mg/kg i.m. for the first day and then 30 mg/kg.day−1 and Group D received teicoplanin as in Group C plus CAPE 10 μmol/kg.day−1. By the end of 14 days rats were sacrificed and serum malondialdehyde (MDA), myeloperoxidase (MPO), nitric oxide (NO), urea and creatinine levels were evaluated. Mediastinal organ tissues were collected for histopathological analysis.Infection rates in all the drug-treated groups were lower than the control groups (P = 0.002) but statistical significance was attained only between the groups A and D (P = 0.018). In connective tissues and the peribronchial area polymorphonuclear leukocytic (PNL) infiltration in the treatment groups, although becoming very close, did not reach statistical significance (P = 0.053, P = 0.075, respectively). PNL infiltration especially in the peribronchial tissues of the Group B animals was found to be significantly less than the Control and CAPE Control groups with P values of 0.013 and 0.010, respectively. MDA and MPO levels were significantly lower in the treatment groups (P < 0.001 and P < 0.001 respectively). Levels of the degradation products of NO were lower in treatment groups compared to two control groups (P = 0.003, P = 0.005). NO levels in Group D were lowest among all treatment groups (P = 0.001).It has been demonstrated that although bacterial colonization can be controlled in mediastinitis, the inflammatory response persists. The combination of an antioxidant / anti-inflammatory agent, CAPE, added to standard antibiotic therapy might be effective in the treatment of post-sternotomy mediastinitis due to MRSA.

Acute poststernotomy mediastinitis managed with debridement and closed-drainage aspiration: Factors associated with death in the intensive care unit

The purpose of the study is to describe an intensive care unit's experience in the treatment of poststernotomy mediastinitis and to identify factors associated with intensive care unit death. Over a 10-year period, 316 consecutive patients with mediastinitis occurring less than 30 days after sternotomy were treated in a single unit. First-line therapy was closed-drainage aspiration with Redon catheters. Variables recorded, including patient demographics, underlying disease classification, clinical and biologic data available at intensive care unit admission and day 3, and their association with intensive care unit mortality, were subjected to multivariate analyses. Intensive care unit mortality (20.3%) was significantly associated with 5 variables available at admission: age greater than 70 years (odds ratio, 2.70), operation other than coronary artery bypass grafting alone (odds ratio, 2.59), McCabe class 2/3 (odds ratio, 2.47), APACHE II score (odds ratio, 1.12 per point), and organ failure (odds ratio, 2.07). After introducing day 3 variables into the logistic regression model, independent risk factors for intensive care unit death were as follows: age greater than 70 years, operations other than coronary artery bypass grafting alone, McCabe class 2/3, APACHE II score, mechanical ventilation still required on day 3, and persistently positive bacteremia. For patients receiving mechanical ventilation for less than 3 days, mortality was very low (2.4%). In contrast, for patients receiving mechanical ventilation for 3 days or longer, mortality reached 52.8% and was associated with non-coronary artery bypass grafting cardiac surgery, persistently positive bacteremia, and underlying disease. In patients requiring intensive care for acute poststernotomy mediastinitis, age, type of cardiac surgery, underlying disease, and severity of illness at the time of intensive care unit admission were associated with intensive care unit death. Two additional factors (mechanical ventilation dependence and persistently positive bacteremia) were identified when the analyses were repeated with inclusion of day 3 patient characteristics.

High-vacuum drains rival conventional underwater-seal drains after pediatric heart surgery

The collection of fluid in the mediastinum after cardiac surgery is traditionally prevented using underwater seal drains that may be connected to low-pressure suction. High-vacuum drains (redivac drains) are a potential alternative to this arrangement and have previously been utilized in areas of general surgery, as well as in the treatment of post-sternotomy mediastinitis. There has been no study to date addressing the safety and efficacy of these drains following pediatric cardiac surgery. Five hundred and forty-six patients were prospectively randomised to receive either the redivac drains or the conventional underwater-seal drains attached to low-pressure wall suction. We sought to test the null hypothesis that there was no difference in the incidence of residual pericardial or pleural collections requiring drainage between the 2 drainage systems. Secondary endpoints included time to drain removal, volume of drainage and drain size. Analysis was performed on an intention to treat basis. Two hundred and thirty-seven patients were allocated to the redivac group, while 241 were allocated to the conventional drain group. Age and gender distribution, the use of cardiopulmonary bypass, numbers of patients with univentricular morphology and number of drains utilized were similar in the 2 groups. The use of redivac drains resulted in a significantly lower incidence of residual pleural effusions requiring drainage (4 vs. 18, P=0.003). There was no difference in the incidence of pericardial effusion requiring drainage. Redivac drains drained an equivalent volume through smaller calibre tubes (12 Ch vs. 16 Ch, P<0.0001) over a shorter period of time (42h (IQR 22-45) vs. 43h (IQR 27-52), P<0.01) than the conventional drainage system. Redivac drains are as safe and effective as conventional drains in the pediatric setting, and resulted in a lower incidence of residual pleural effusions requiring drainage. Together with their ease of care, earlier mobilisation of patients and greater cost-effectiveness, the routine use of high-vacuum drains can be recommended following pediatric heart surgery.

Evaluation of vacuum-assisted closure in the treatment of poststernotomy mediastinitis

Objective Poststernotomy mediastinitis, although infrequent, is a potentially life-threatening complication of cardiac surgery that continues to have a significant morbidity and mortality despite aggressive therapy. Vacuum-assisted closure uses controlled suction to provide evacuation of wound fluid, decrease bacterial colonization, stimulate granulation tissue, and reduce the need for dressing changes. Methods One hundred two patients from Duke University Hospital, The Durham Veterans Administration Hospital, and referring institutions underwent vacuum-assisted closure treatment. There were 63 men and 39 women, with a mean age of 67. The infection was noticed between postoperative days 8 and 34, at which time the wounds were opened and debrided. Results Ninety-six of the 102 patients received vacuum-assisted therapy while the remaining 6 underwent daily multiple dressing changes without vacuum-assisted therapy. Fifty-three of the 96 patients required only sternal debridement, followed by wound vacuum therapy and closure by secondary intention, while the remaining 43 had an additional procedure. Of these, 33 patients underwent omental transposition and 10 patients had a pectoralis flap. The length of stay for all patients was 27 ± 12 days. This was related in part to intravenous antibiotics. Hospital mortality for all patients was 3.7% (4 patients). Two of these patients underwent vascular flap and succumbed to multisystemic organ failure, while the other 2 received only wound vacuum therapy following debridement and succumbed to overwhelming sepsis. Conclusion Vacuum-assisted drainage is an effective therapy for mediastinitis following debribement or before placement of a vascularized tissue flap.