1
|
Iguidbashian J, Feng Z, Colborn KL, Barrett CS, Newman SR, Harris M, Campbell DN, Mitchell MB, Jaggers J, Stone ML. Open Chest Duration Following Congenital Cardiac Surgery Increases Risk for Surgical Site Infection. Pediatr Cardiol 2024; 45:1284-1288. [PMID: 36583758 DOI: 10.1007/s00246-022-03088-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/16/2022] [Accepted: 12/21/2022] [Indexed: 12/31/2022]
Abstract
Surgical site infections (SSI) following congenital heart surgery (CHS) remain a significant source of morbidity. Delayed sternal closure (DSC) is often required to minimize the potential for hemodynamic instability. The purpose of this study was to determine the incidence of SSI among patients undergoing DSC versus primary chest closure (PCC) and to define a potential inflection point for increased risk of SSI as a function of open chest duration (OCD).A retrospective review of our institutional Society of Thoracic Surgeons dataset is to identify patients undergoing CHS at our institution between 2015 and 2020. Incidences of SSI were compared between DSC and PCC patients. DSC patients were evaluated to determine the association of OCD and the incidence of SSI.2582 operations were performed at our institution between 2015 and 2020, including 195 DSC and 2387 PCC cases. The incidence of SSI within the cohort was 1.8% (47/2,582). DSC patients had significantly higher incidences of SSI (17/195, 8.7%) than PCC patients (30/2387, 1.3%, p < 0.001). Further, patients with an OCD of four or more days had a significantly higher incidence of SSI (11/62, 17.7%, p = 0.006) than patients with an OCD less than 4 days (6/115, 5.3%).The incidence of SSI following CHS is higher in DSC patients compared to PCC patients. Prolonged OCD of 4 days or more significantly increases the risk of SSI and represents a potentially modifiable risk factor for SSI predisposition. These data support dedicated, daily post-operative assessment of candidacy for chest closure to minimize the risk of SSI.
Collapse
Affiliation(s)
- John Iguidbashian
- Department of Surgery, University of Colorado School of Medicine, 12605 E 16th Ave, Aurora, CO, 80045, USA.
| | - Zihan Feng
- Department of Surgery, University of Colorado School of Medicine, 12605 E 16th Ave, Aurora, CO, 80045, USA
| | - Kathryn L Colborn
- Department of Surgery, University of Colorado School of Medicine, 12605 E 16th Ave, Aurora, CO, 80045, USA
| | - Cindy S Barrett
- Department of Cardiology and Cardiothoracic Surgery, Children's Hospital of Colorado, Aurora, CO, USA
| | - Shanna R Newman
- Department of Cardiology and Cardiothoracic Surgery, Children's Hospital of Colorado, Aurora, CO, USA
| | - Marisa Harris
- Department of Cardiology and Cardiothoracic Surgery, Children's Hospital of Colorado, Aurora, CO, USA
| | - David N Campbell
- Department of Cardiology and Cardiothoracic Surgery, Children's Hospital of Colorado, Aurora, CO, USA
| | - Max B Mitchell
- Department of Cardiology and Cardiothoracic Surgery, Children's Hospital of Colorado, Aurora, CO, USA
| | - James Jaggers
- Department of Cardiology and Cardiothoracic Surgery, Children's Hospital of Colorado, Aurora, CO, USA
| | - Matthew L Stone
- Department of Cardiology and Cardiothoracic Surgery, Children's Hospital of Colorado, Aurora, CO, USA
| |
Collapse
|
2
|
Di Chiara C, Ponzoni M, Piché-Renaud PP, Mengato D, Giaquinto C, Morris SK, Donà D. Alternative Antimicrobial Irrigation Strategies for the Treatment of Infections in Children: A Review of the Existing Literature. Antibiotics (Basel) 2023; 12:1271. [PMID: 37627691 PMCID: PMC10451316 DOI: 10.3390/antibiotics12081271] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2023] [Revised: 07/26/2023] [Accepted: 07/28/2023] [Indexed: 08/27/2023] Open
Abstract
As a synergistic treatment approach with systemic antimicrobial therapy or a systemic antibiotic-sparing strategy, the local administration of antimicrobial agents has been proposed as an alternative route for complicated infections. With the rationale of concentrating the active principle in the desired target site, avoiding potentially toxic systemic levels and bypassing anatomical and physiological barriers, local irrigation or infusion of antibiotics may effectively shorten the antimicrobial therapy course and reduce both infection-related and systemic therapy-related complications. Although evidence from the adult population supports its use in selected patients with an acceptable safety profile, data specifically focused on the pediatric population are limited. To provide a rapid and easily accessible tool for clinical practice, we synthesized the most relevant evidence on the use of local antimicrobial agents in common severe infections in children: meningitis, mediastinitis, pleural infections, recurrent urinary infections, and peritonitis. A literature search was performed using predefined combined keywords through an electronic research database (PubMed). Described molecules, dosages, routes, treated age groups, and related efficacy have been summarized for prompt application to clinical practice. It should, however, be noted that the evidence for the pediatric population remains limited, and the local administration of several molecules remains off-label. A careful multidisciplinary and patient-tailored evaluation, as well as a rational use of available guidelines, should always be the basis of clinical decision making in settings where local administration of antibiotics may be considered.
Collapse
Affiliation(s)
- Costanza Di Chiara
- Department for Women’s and Children’s Health, University of Padua, 35128 Padua, Italy; (C.G.); (D.D.)
- Penta—Child Health Research, 35127 Padua, Italy
- Division of Pediatric Infectious Diseases, The Hospital for Sick Children, Toronto, ON M5G 1X8, Canada; (P.-P.P.-R.); (S.K.M.)
- Child Health Evaluative Sciences, The Hospital for Sick Children, Toronto, ON M5G 1X8, Canada
| | - Matteo Ponzoni
- Congenital Cardiac Surgery Unit, Labatt Family Heart Centre, The Hospital for Sick Children, Toronto, ON M5G 1X8, Canada;
| | - Pierre-Philippe Piché-Renaud
- Division of Pediatric Infectious Diseases, The Hospital for Sick Children, Toronto, ON M5G 1X8, Canada; (P.-P.P.-R.); (S.K.M.)
| | - Daniele Mengato
- Hospital Pharmacy Department, University Hospital of Padua, Via Giustiniani, 2, 35128 Padua, Italy;
| | - Carlo Giaquinto
- Department for Women’s and Children’s Health, University of Padua, 35128 Padua, Italy; (C.G.); (D.D.)
- Penta—Child Health Research, 35127 Padua, Italy
| | - Shaun K. Morris
- Division of Pediatric Infectious Diseases, The Hospital for Sick Children, Toronto, ON M5G 1X8, Canada; (P.-P.P.-R.); (S.K.M.)
- Child Health Evaluative Sciences, The Hospital for Sick Children, Toronto, ON M5G 1X8, Canada
- Department of Pediatrics, Faculty of Medicine, University of Toronto, Toronto, ON M5R 0A3, Canada
- Division of Clinical Public Health and Centre for Vaccine Preventable Diseases, Dalla Lana School of Public Health, Toronto, ON M5T 3M7, Canada
| | - Daniele Donà
- Department for Women’s and Children’s Health, University of Padua, 35128 Padua, Italy; (C.G.); (D.D.)
- Penta—Child Health Research, 35127 Padua, Italy
| |
Collapse
|
3
|
Kahan Y, Tope SG, Ovadia A, Shpring A, Shatzman-Steuerman R, Sherman G, Barkai G, Mandelberg A, Armoni-Domany K, Tasher D. Risk Factors and Characteristics of Candidemia After Cardiac Surgery in Pediatric Patients in Central Israel. Pediatr Infect Dis J 2023; 42:368-373. [PMID: 36854105 DOI: 10.1097/inf.0000000000003847] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/02/2023]
Abstract
BACKGROUND Candidemia is a serious complication in pediatric patients with congenital heart defects (CHD) after cardiac surgery. Information about the epidemiology, clinical characteristics and risk factors for candidemia in this vulnerable population remains limited. METHODS This retrospective case-control study was conducted in 2 pediatric intensive care units between 2004 and 2019. All patients <18 years old who developed candidemia following cardiac surgery were included. Each case was matched with 2 control patients based on age and date of surgery. Multivariable logistic regression analysis was conducted to determine the risk factors for postoperative candidemia. RESULTS Thirty-five candidemia cases were identified and matched to 70 control cases. The incidence of candidemia was 6.3 episodes per 1000 admissions. The median age for candidemia cases was 4 months. The attributable mortality was 28.5%. The predominant (54%) pathogens isolated were non- albicans Candida species, of which C. parapsilosis isolates demonstrated high resistance to fluconazole (70%). Independent risk factors associated with candidemia included cumulative antibiotic exposure for ≥4 days [OR: -4.3; 95% confidence interval (CI): 1.3-14.6; P = 0.02], the need for total parenteral nutrition or peritoneal dialysis (OR: -6.1; 95% CI: 2-18.8; P = 0.001), male sex (OR: 6.2; 95% CI: 1.9-20.3; P = 0.002) and delayed sternal closure≥2 days (OR: -3.2; 95% CI: 1-11.2; P = 0.05). CONCLUSIONS Postoperative candidemia in children with CHD is an uncommon but severe complication. Our study revealed an unexpectedly high frequency of fluconazole-resistant C. parapsilosis as the main cause of non- albicans candidemia. In addition to confirming previously recognized risk factors, our results reveal new potential risk factors such as delayed sternal closure and male sex.
Collapse
Affiliation(s)
- Yaara Kahan
- Pediatric Infectious Diseases Unit, Edith Wolfson Medical Center, Holon, Israel
- Pediatric Infectious Disease Unit, Edmond and Lily Safra Children's Hospital, Sheba Medical Center, Tel-Hashomer, Israel
| | - Samantha G Tope
- Pediatric Infectious Disease Unit, Edmond and Lily Safra Children's Hospital, Sheba Medical Center, Tel-Hashomer, Israel
| | - Adi Ovadia
- Pediatric Infectious Disease Unit, Edmond and Lily Safra Children's Hospital, Sheba Medical Center, Tel-Hashomer, Israel
- Department of Pediatrics, Edith Wolfson Medical Center, Holon, Israel
| | - Adi Shpring
- Pediatric Infectious Disease Unit, Edmond and Lily Safra Children's Hospital, Sheba Medical Center, Tel-Hashomer, Israel
- Department of Pediatrics, Edith Wolfson Medical Center, Holon, Israel
| | - Rachel Shatzman-Steuerman
- Pediatric Infectious Disease Unit, Edmond and Lily Safra Children's Hospital, Sheba Medical Center, Tel-Hashomer, Israel
| | - Gilad Sherman
- Pediatric Infectious Disease Unit, Edmond and Lily Safra Children's Hospital, Sheba Medical Center, Tel-Hashomer, Israel
| | - Galia Barkai
- Pediatric Infectious Disease Unit, Edmond and Lily Safra Children's Hospital, Sheba Medical Center, Tel-Hashomer, Israel
| | - Avigdor Mandelberg
- Pediatric Infectious Disease Unit, Edmond and Lily Safra Children's Hospital, Sheba Medical Center, Tel-Hashomer, Israel
- Department of Pediatrics, Edith Wolfson Medical Center, Holon, Israel
| | - Keren Armoni-Domany
- Pediatric Infectious Disease Unit, Edmond and Lily Safra Children's Hospital, Sheba Medical Center, Tel-Hashomer, Israel
- Department of Pediatrics, Edith Wolfson Medical Center, Holon, Israel
| | - Diana Tasher
- Pediatric Infectious Diseases Unit, Edith Wolfson Medical Center, Holon, Israel
- Pediatric Infectious Disease Unit, Edmond and Lily Safra Children's Hospital, Sheba Medical Center, Tel-Hashomer, Israel
| |
Collapse
|
4
|
Fadaly AS, Abdellatif GM, Saeed SE, Brik A, Elsharawy M, Deebis A, Elfwakhry RM, Shemais DS. Efficacy of Primary Closure Technique in Treatment of Post-Sternotomy Mediastinitis in Paediatric Group: A Randomized Controlled Trial. Int J Gen Med 2022; 15:7929-7939. [PMID: 36317099 PMCID: PMC9617555 DOI: 10.2147/ijgm.s388446] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2022] [Accepted: 10/14/2022] [Indexed: 11/05/2022] Open
Abstract
Purpose To assess the efficacy of primary sternal closure technique compared to vacuum-assisted closure technique in treatment of post-cardiac surgery mediastinitis in paediatric age group. Additionally, assessed postoperative need for IV drug use, hospital stay length, wound and sternal healing and survival. Hypotheses: primary sternal closure is a reliable technique for treatment of poststernotomy mediastinitis following cardiac surgery in paediatric age group. Materials and Methods A prospective randomized controlled trial included 217 pediatric patients developed post-cardiac surgery mediastinitis from 2016 to 2022. They were randomly divided into primary sternal closure group (A) and vacuum-assisted closure group (B) and operated by two cardiothoracic surgeons. Follow-up of the patients was done for 6-months duration following treatment of mediastinitis to assess postoperative need for hospitalization, IV drug use, wound complications, sternal stability and survival. Results The final analysis included 101 patients in each group. The chance of survival over 6 months after surgery was more for primary sternal closure group (175.2) days versus (157.6) days for the vacuum-assisted closure group, with significant difference Log Rank test p-value (0.005). Duration for IV antibiotics use in the primary closure group was 8.55±3.57 and it was 32.61±8.39 showing high statistically significant difference (p<0.001). Patients in the primary closure group had earlier discharge from hospital 15.77±4.18 than vacuum assisted group 42.61±8.39, with high statistically significant difference (p<0.001). Primary closure group showed better sternal stability and sternotomy wound healing on clinical follow-up. Conclusion Primary sternal closure technique is a favorable technique over vacuum-assisted closure technique for treatment of paediatric mediastinitis following cardiac surgery. The reinforced sternal closure technique is a reliable technique with promising results regarding IV drugs need, hospitalization duration, survival and sternotomy wound healing.
Collapse
Affiliation(s)
- Ahmed S Fadaly
- Department of Cardiothoracic Surgery, Faculty of Human Medicine, Zagazig University, Zagazig, Egypt
| | | | - Sameh E Saeed
- Department of Cardiothoracic Surgery, Faculty of Human Medicine, Zagazig University, Zagazig, Egypt
| | - Alaa Brik
- Department of Cardiothoracic Surgery, Faculty of Human Medicine, Zagazig University, Zagazig, Egypt
| | - Mamdouh Elsharawy
- Department of Cardiothoracic Surgery, Faculty of Human Medicine, Zagazig University, Zagazig, Egypt
| | - Ahmed Deebis
- Department of Cardiothoracic Surgery, Faculty of Human Medicine, Zagazig University, Zagazig, Egypt
| | | | - Dina Said Shemais
- Department of Cardiothoracic Surgery, Faculty of Human Medicine, Zagazig University, Zagazig, Egypt,Correspondence: Dina Said Shemais, Department of cardiothoracic surgery, Zagazig University, Zagazig, 44631, Egypt, Tel +201090726390, Email
| |
Collapse
|
5
|
Horriat NL, McCandless MG, Humphries LS, Ghanamah M, Kogon BE, Hoppe IC. Management of pediatric sternal wounds following congenital heart surgery: The role of the plastic surgeon in debridement and closure. J Card Surg 2022; 37:3695-3702. [PMID: 35979680 DOI: 10.1111/jocs.16841] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2022] [Revised: 07/23/2022] [Accepted: 07/25/2022] [Indexed: 11/30/2022]
Abstract
BACKGROUND Management of sternal wound infections (SWIs) in pediatric patients following congenital heart surgery can be extremely difficult. Patients with congenital cardiac conditions are at risk for complications such as sternal dehiscence, infection, and cardiopulmonary compromise. In this study, we report a single-institution experience with pediatric SWIs. METHODS Fourteen pediatric patients requiring plastic surgery consultation for complex sternal wound closure were included. A retrospective chart review was performed with the following variables of interest: demographic data, congenital cardiac condition, respective surgical palliations, development of mediastinitis, causative organism, number of debridements, presence of sternal wires, and choice of flap coverage. Primary endpoints included achieved chest wall closure and overall survival. RESULTS Of the 14 patients, 8 (57%) were diagnosed with culture-positive mediastinitis. The sternum remained wired at the time of final flap closure in eight (57%) patients. All patients were reconstructed with pectoralis major flaps, except one (7%) who also received an omental flap and two (14%) who received superior rectus abdominis flaps. One patient (7%) was treated definitively with negative pressure wound therapy, and one (7%) was too unstable for closure. Six patients developed complications, including one (7%) with persistent mediastinitis, two (14%) with hematoma formation, one (7%) with abscess, and one (7%) with skin necrosis requiring subsequent surgical debridement. There were three (21%) mortalities. CONCLUSIONS The management of SWI in congenital cardiac patients is challenging. The standard tenets for management of SWI in adults are loosely applicable, but additional considerations must be addressed in this unique subset population.
Collapse
Affiliation(s)
- Narges L Horriat
- Division of Plastic and Reconstructive Surgery, Department of Surgery, University of Mississippi Medical Center, Jackson, Mississippi, USA
| | - Martin G McCandless
- Division of Plastic and Reconstructive Surgery, Department of Surgery, University of Mississippi Medical Center, Jackson, Mississippi, USA
| | - Laura S Humphries
- Division of Plastic and Reconstructive Surgery, Department of Surgery, University of Mississippi Medical Center, Jackson, Mississippi, USA
| | - Mohammed Ghanamah
- Division of Cardiothoracic Surgery, Department of Surgery, University of Mississippi Medical Center, Jackson, Mississippi, USA
| | - Brian E Kogon
- Division of Cardiothoracic Surgery, Department of Surgery, University of Mississippi Medical Center, Jackson, Mississippi, USA
| | - Ian C Hoppe
- Division of Plastic and Reconstructive Surgery, Department of Surgery, University of Mississippi Medical Center, Jackson, Mississippi, USA
| |
Collapse
|
6
|
Kusne S, Irish W, Arabia F. Extended systemic antibiotic prophylaxis in ventricular assist device recipients, an infectious disease perspective. J Card Surg 2022; 37:1819-1823. [PMID: 35655403 DOI: 10.1111/jocs.16487] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2022] [Accepted: 03/28/2022] [Indexed: 11/26/2022]
Abstract
OBJECTIVES To evaluate whether mediastinitis/deep sternal wound infection (Med/DSWI) is more common in ventricular assist device (VAD) with delayed sternal closure (DSC) compared to VAD with primary sternal closure (PSC). METHODS A literature search was done over the last four decades for studies that addressed this comparison. RESULTS Two studies met our inclusion criteria, and their results are contradictory. The first study compared 184 VAD recipients with PSC to 180 VAD recipients with DSC. There was no difference in VAD-related infections between DSC and PSC (15% vs. 16%, respectively; odds ratio = 0.965, 95% confidence interval [CI] = 0.525-1.635). The second study compared 464 VAD recipients with PSC to 94 VAD recipients with DSC. The rate of surgical site infection was higher in the DSC patients (12.5% vs. 1.4%, respectively; odds ratio = 10.1; 95% CI = 3.8-27.0). DSC was identified as an independent risk factor for postoperative mortality, but no detailed infection information was given. CONCLUSIONS There is no clear evidence of the association between DSC, compared to PSC, and Med/DSWI. Therefore, DSC is not an absolute indication for extended systemic antibiotic prophylaxis. The decision to extend the duration of systemic antibiotic prophylaxis should be made on a case-by-case basis, in collaboration with an infectious disease specialist.
Collapse
Affiliation(s)
- Shimon Kusne
- Division of Infectious Diseases, Mayo Clinic, Scottsdale, Arizona, USA
| | - William Irish
- Department of Surgery, The Brody School of Medicine at East Carolina University, Greenville, North Carolina, USA
| | - Francisco Arabia
- Departments of Surgery and Medicine, Banner-University Medical Center Phoenix, Phoenix, Arizona, USA
| |
Collapse
|
7
|
Çeli K M, Aygün F, Özkan M. Sternotomy with electrocautery and sternal wound infection in congenital heart surgery in patients under 1 year of age. J Card Surg 2021; 36:2336-2341. [PMID: 33896040 DOI: 10.1111/jocs.15561] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2020] [Revised: 03/16/2021] [Accepted: 03/23/2021] [Indexed: 12/25/2022]
Abstract
OBJECTIVE The present study aimed to compare the rate of wound site infection in patients <1 year of age who underwent sternotomy using electrocautery, a routinely performed procedure in our clinic, with those reported in the literature. METHODS This double-center study included patients <1 year of age who underwent cardiac surgery via sternotomy performed with electrocautery for congenital heart disease between January 2017 and June 2019. Patient's data were retrospectively obtained from the hospital records. RESULTS In our study, seven patients developed SSI, which was superficial in six (1.3%) patients and in the form of mediastinitis in one (0.2%) patient. CONCLUSION Sternotomy with electrocautery, which we consider an easy and safe method, was also not found to be statistically different from the other methods in terms of SWI.
Collapse
Affiliation(s)
- Mehmet Çeli K
- Department of Cardiovascular Surgery, Konya Medical and Research Center, Başkent University, Konya, Turkey
| | - Fatih Aygün
- Department of Cardiovascular Surgery, Konya Medical and Research Center, Başkent University, Konya, Turkey
| | - Murat Özkan
- Department of Cardiovascular Surgery, Başkent University, Ankara, Turkey
| |
Collapse
|
8
|
von Stumm M, Sequeira-Gross T, Petersen J, Naito S, Müller L, Sinning C, Girdauskas E. Narrative review of the contemporary surgical treatment of unicuspid aortic valve disease. Cardiovasc Diagn Ther 2021; 11:503-517. [PMID: 33968629 DOI: 10.21037/cdt-20-814] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Unicuspid aortic valve disease (UAVD) is a frequent and long-lasting challenge for adult congenital heart disease centers. UAVD patients become usually symptomatic in their twenties or thirties and require a surgical treatment plan which should respect their complete lifespan combined with an adequate quality of life. Unfortunately, all current surgical strategies of congenital aortic valve disease bear some important limitations: (I) Aortic valve replacement using bioprosthetic valves is associated with early structural degeneration and leads frequently to re-operations. (II) Mechanical valves are commonly associated with lifelong risk of severe bleeding due to oral anticoagulation. (III) Using a pulmonary autograft (i.e., Ross procedure) for aortic valve replacement is associated with excellent long-term results in non-elderly patients. However, failure of pulmonary autograft or pulmonary homograft may require re-operations. (IV) Aortic valve repair or Ozaki procedure is only performed in a few heart centers worldwide and is associated with a limited reproducibility and early patch degeneration, suture dehiscence or increased risk of endocarditis. In contrast to degenerative tricuspid aortic valve disease, UAVD remains relatively understudied and reports on UAVD treatment are rare and usually limited to retrospective single-center observations. For this review, we searched PubMed for papers in the English language by using the search words unicuspid aortic valve, congenital aortic valve, Ross procedure, Ozaki procedure, aortic valve repair, mechanical/bioprosthetic aortic replacement, homograft. We read the abstracts of relevant titles to confirm their relevance, and the full papers were then extracted. References from extracted papers were checked for additional relevant reports. This review summarizes current surgical treatment strategies for UAVD including aortic valve replacement using bioprosthetic or mechanical valves, homografts, pulmonary autografts (i.e., Ross procedure) and aortic valve repair techniques for UAV. Furthermore, Ozaki procedure will be discussed.
Collapse
Affiliation(s)
- Maria von Stumm
- Department of Cardiovascular Surgery, University Heart & Vascular Center, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Tatjana Sequeira-Gross
- Department of Cardiovascular Surgery, University Heart & Vascular Center, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Johannes Petersen
- Department of Cardiovascular Surgery, University Heart & Vascular Center, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Shiho Naito
- Department of Cardiovascular Surgery, University Heart & Vascular Center, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Lisa Müller
- Department of Cardiovascular Surgery, University Heart & Vascular Center, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Christoph Sinning
- Department of Cardiology, University Heart & Vascular Center, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Evaldas Girdauskas
- Department of Cardiovascular Surgery, University Heart & Vascular Center, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| |
Collapse
|
9
|
Elsisy MF, Dearani JA, Crestanello JA, Ashikhmina EA, Van Dorn CS, Stephens EH. Outcomes of Primary vs Secondary Delayed Sternal Closure in Pediatric Cardiac Surgery. Ann Thorac Surg 2021; 113:1231-1237. [PMID: 33662305 DOI: 10.1016/j.athoracsur.2021.02.029] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/09/2020] [Revised: 02/11/2021] [Accepted: 02/16/2021] [Indexed: 11/01/2022]
Abstract
BACKGROUND Delayed sternal closure (DSC) is a management strategy for hemodynamic instability and severe coagulopathy after complex congenital heart surgery. We hypothesized that DSC results in better outcomes than perioperative sternal reopening. METHODS We reviewed patients aged <18 years old undergoing cardiac surgery 2007-2017 at our institution. A total of 179 patients (3.8%) had primary DSC (PDSC, sternum left open after initial operation) and 45 patients (0.9%) had secondary DSC (SDSC, sternum closed primarily and reopened perioperatively). Perioperative characteristics and outcomes among PDSC ≤2 days (98 patients), PDSC >2 days (81 patients), and SDSC (45 patients) were analyzed. RESULTS Median age was 120 days (range, 3-6553 days) and median DSC duration was 2 days (range, 1-60 days). The PDSC >2 days group was the youngest group, and the distribution of procedures was different between groups. Indications for DSC were hemodynamic instability in 152 patients (67.9%) and severe coagulopathy in 33 patients (14.7%), with no difference between groups (P = .141). Extracorporeal membrane oxygenation use was higher in the PDSC >2 days group than the other groups (47.5% vs 7.1%, P < .01 and 47.5% vs 28.9%, P = .02), respectively. Operative mortality was higher in SDSC compared to the other groups (17.8% vs 0% for PDSC ≤2 and 6.2% for PDSC >2 days, P < .01). Hospital stay was longer in SDSC (57 ± 7 days) than PDSC ≤2 days (22 ± 5 days) and PDSC >2 days (44 ± 6, P = .01). Survival was better in PDSC regardless of duration than SDSC. CONCLUSIONS PDSC demonstrated better outcomes than SDSC. Sternal reopening can be life-saving, but, when anticipated, PDSC can yield better outcomes.
Collapse
Affiliation(s)
- Mohamed F Elsisy
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, Minnesota
| | - Joseph A Dearani
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, Minnesota
| | | | - Elena A Ashikhmina
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, Minnesota
| | - Charlotte S Van Dorn
- Department of Pediatric and Adolescent Medicine, Division of Pediatric Critical Care Medicine, Mayo Clinic, Rochester, Minnesota; Department of Pediatric and Adolescent Medicine, Division of Pediatric Cardiology, Mayo Clinic, Rochester, Minnesota
| | | |
Collapse
|
10
|
Hosokawa T, Shibuki S, Tanami Y, Sato Y, Ko Y, Nomura K, Oguma E. Extracardiac Complications in Intensive Care Units after Surgical Repair for Congenital Heart Disease: Imaging Review with a Focus on Ultrasound and Radiography. J Pediatr Intensive Care 2020; 10:85-105. [PMID: 33884209 DOI: 10.1055/s-0040-1715483] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2020] [Accepted: 06/24/2020] [Indexed: 12/24/2022] Open
Abstract
Pediatric patients show various extracardiac complications after cardiovascular surgery, and radiography and ultrasound are routinely performed in the intensive care unit to detect and evaluate these complications. This review presents images of these complications, sonographic approach, and timing of occurrence that are categorized based on their extracardiac locations and include complications pertaining to the central nervous system, mediastinum, thorax and lung parenchyma, diaphragm, liver and biliary system, and kidney along with pleural effusion and iatrogenic complications. This pictorial review will make it easier for medical doctors in intensive care units to identify and manage various extracardiac complications in pediatric patients after cardiovascular surgery.
Collapse
Affiliation(s)
- Takahiro Hosokawa
- Department of Radiology, Saitama Children's Medical Center, Saitama, Japan
| | - Saki Shibuki
- Department of Radiology, Saitama Children's Medical Center, Saitama, Japan
| | - Yutaka Tanami
- Department of Radiology, Saitama Children's Medical Center, Saitama, Japan
| | - Yumiko Sato
- Department of Radiology, Saitama Children's Medical Center, Saitama, Japan
| | - Yoshihiro Ko
- Department of Cardiovascular Surgery, Saitama Children's Medical Center, Saitama, Japan
| | - Koji Nomura
- Department of Cardiovascular Surgery, Saitama Children's Medical Center, Saitama, Japan
| | - Eiji Oguma
- Department of Radiology, Saitama Children's Medical Center, Saitama, Japan
| |
Collapse
|
11
|
Kennedy JT, DiLeonardo O, Hurtado CG, Nelson JS. A Systematic Review of Antibiotic Prophylaxis for Delayed Sternal Closure in Children. World J Pediatr Congenit Heart Surg 2020; 12:93-102. [PMID: 32783516 DOI: 10.1177/2150135120947685] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Antibiotic prophylaxis following delayed sternal closure in pediatric cardiac surgery is not standardized. We systematically reviewed relevant literature published between 1990 and 2019 to aid future trial design. Patient characteristics, antimicrobial prophylaxis regimens, and postoperative incidence of infection were collected. Twenty-eight studies described 36 different regimens in over 3,000 patients. There were 11 single-drug regimens and 25 multidrug regimens. Cefazolin-only was the most common regimen (9/36, 25%). The overall incidence of surgical site infection was 7.5% (217/2,910 patients) and bloodstream infection was 7.4% (123/1,667 patients). In the 2010s, multidrug regimens were associated with a significantly lower incidence of both surgical site infections (4.6% vs. 20%, P < .001) and bloodstream infections (6.0% vs. 50%, P < .001) compared to single-drug regimens.
Collapse
Affiliation(s)
- John T Kennedy
- 124506University of Central Florida College of Medicine, Orlando, FL, USA
- Department of Surgery, 124506University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Olivia DiLeonardo
- Department of Medical Education, Nemours Children's Hospital, Orlando, FL, USA
- Nemours Children's Hospital Medical Library, Orlando, FL, USA
| | | | - Jennifer S Nelson
- 124506University of Central Florida College of Medicine, Orlando, FL, USA
- Department of Cardiovascular Services, Nemours Children's Hospital, Orlando, FL, USA
| |
Collapse
|
12
|
Hosokawa T, Yamada Y, Tanami Y, Sato Y, Ko Y, Nomura K, Oguma E. Computed tomography findings of mediastinitis after cardiovascular surgery. Pediatr Int 2020; 62:206-213. [PMID: 31845441 DOI: 10.1111/ped.14101] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/17/2019] [Revised: 10/11/2019] [Accepted: 12/05/2019] [Indexed: 12/20/2022]
Abstract
BACKGROUND To our knowledge, no systematic study has been conducted on computed tomography (CT) imaging of mediastinitis in children post-cardiovascular surgery. We aimed to assess the CT findings of pediatric patients diagnosed with mediastinitis after cardiovascular surgery. METHODS We included 28 pediatric patients with suspected mediastinitis after undergoing cardiovascular surgery and who underwent CT. Patients were divided into a group with mediastinitis requiring antibiotic therapy (n = 15) confirmed by positive bacterial culture from the mediastinum and a group without mediastinitis (n = 13). Fisher's exact test was used to compare the following CT findings between the two groups: (i) mediastinal fluid collection; (ii) free gas bubble within fluid collection; (iii) sternal destruction; and (iv) capsular ring enhancement. The enhancement extent was categorized into the following four grades: whole rim enhancement, >50% of the rim enhancement, <50% of the rim enhancement, and no rim enhancement. A receiver operating characteristic curve analysis was performed to establish a cut-off point for obtaining the maximum diagnostic accuracy. RESULTS A significant difference was observed between patients, with and without mediastinitis in sternal destruction (73.6% vs 0%, P = <0.0001) and capsular ring enhancement (100.0% vs 38.5%, P = 0.0004). By using a cut-off grade of the whole rim enhancement, the estimated sensitivity and specificity for mediastinitis diagnosis were 100% and 92.3%, respectively. CONCLUSION Computed tomography findings of sternal destruction and capsular ring enhancement were observed more in patients with mediastinitis than in those without mediastinitis, and should be assessed carefully to diagnose mediastinitis accurately in pediatric patients who have undergone cardiac surgery.
Collapse
Affiliation(s)
- Takahiro Hosokawa
- Department of Radiology, Saitama Children's Medical Center, Saitama, Japan
| | - Yoshitake Yamada
- Department of Radiology, Keio University School of Medicine, Tokyo, Japan
| | - Yutaka Tanami
- Department of Radiology, Saitama Children's Medical Center, Saitama, Japan
| | - Yumiko Sato
- Department of Radiology, Saitama Children's Medical Center, Saitama, Japan
| | - Yoshihiro Ko
- Department of Cardiovascular Surgery, Saitama Children's Medical Center, Saitama, Japan
| | - Koji Nomura
- Department of Cardiovascular Surgery, Saitama Children's Medical Center, Saitama, Japan
| | - Eiji Oguma
- Department of Radiology, Saitama Children's Medical Center, Saitama, Japan
| |
Collapse
|
13
|
Yabrodi M, Hermann JL, Brown JW, Rodefeld MD, Turrentine MW, Mastropietro CW. Minimization of Surgical Site Infections in Patients With Delayed Sternal Closure After Pediatric Cardiac Surgery. World J Pediatr Congenit Heart Surg 2019; 10:400-406. [PMID: 31307311 DOI: 10.1177/2150135119846040] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Delayed sternal closure (DSC) following pediatric cardiac surgery is commonly implemented at many centers. Infectious complications occur in 18.7% of these patients based on recent multicenter data. We aimed to describe our experience with DSC, hypothesizing that our practices surrounding the implementation and maintenance of the open sternum during DSC minimize the risk of infectious complications. METHODS We reviewed patients less than 365 days who underwent DSC between 2012 and 2016 at our institution. Infectious complications as defined by the Society of Thoracic Surgeons Congenital Heart Surgery Database were recorded. Patients with and without infectious complications were compared using Wilcoxon rank sum tests or Fisher exact tests as appropriate. RESULTS We identified 165 patients less than 365 days old who underwent DSC, 135 (82%) of whom had their skin closed over their open sternum. Median duration of open sternum was 3 days (range: 1-32 days). Infectious complications occurred in 15 (9.1%) patients-13 developed clinical sepsis with positive blood cultures, one patient developed ventilator-associated pneumonia, and one patient developed wound infection (0.6%). No cases of mediastinitis occurred. No statistical differences in characteristics between patients with and without infectious complications could be identified. CONCLUSION Infectious complications after DSC at our institution were notably less than reported in recent literature, primarily due to minimization of surgical site infections. Practices described in the article, including closing skin over the open sternum whenever possible, could potentially aid other institutions aiming to reduce infectious complications associated with DSC.
Collapse
Affiliation(s)
- Mouhammad Yabrodi
- 1 Division of Critical Care, Department of Pediatrics, Riley Hospital for Children at Indiana University Health, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Jeremy L Hermann
- 2 Division of Cardiothoracic Surgery, Department of Surgery, Riley Hospital for Children at Indiana University Health, Indiana University School of Medicine, Indianapolis, IN, USA
| | - John W Brown
- 2 Division of Cardiothoracic Surgery, Department of Surgery, Riley Hospital for Children at Indiana University Health, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Mark D Rodefeld
- 2 Division of Cardiothoracic Surgery, Department of Surgery, Riley Hospital for Children at Indiana University Health, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Mark W Turrentine
- 2 Division of Cardiothoracic Surgery, Department of Surgery, Riley Hospital for Children at Indiana University Health, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Christopher W Mastropietro
- 1 Division of Critical Care, Department of Pediatrics, Riley Hospital for Children at Indiana University Health, Indiana University School of Medicine, Indianapolis, IN, USA
| |
Collapse
|
14
|
Silvetti S, Landoni G, Castagnola E, Nuri H, Pomé G, Moscatelli A. Antibiotic Management for Delayed Sternal Closure Following Pediatric Cardiac Surgery: A Systematic Review of Recent Literature. J Cardiothorac Vasc Anesth 2019; 34:1333-1340. [PMID: 31420313 DOI: 10.1053/j.jvca.2019.07.134] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/13/2019] [Revised: 07/02/2019] [Accepted: 07/16/2019] [Indexed: 12/21/2022]
Abstract
Delayed sternal closure after pediatric cardiac surgery is a management option for the treatment of patients with severely impaired heart function. The optimal antimicrobial treatment strategy for this condition is unknown. The aim of this systematic review was to evaluate the current antibiotic administration attitudes in pediatric cardiac surgery patients needing an open chest in terms of infection with a focus on surgical site infection rate. The authors performed a systematic review and meta-analysis of all articles, which described the antibiotic administration strategy and surgical site infection rate in pediatric patients with an open chest after cardiac surgery. The authors performed a subgroup analysis on "standard" versus "non-standard" (defined as any antimicrobial drugs different from the adult guidelines recommendations) therapy for one-proportion meta-analysis with a random effect model. The authors identified 12 studies published from January 1, 2000 to July 1, 2019 including a total of 2,203 patients requiring an open chest after cardiac surgery, 350 of whom (15.9%) developed infections and 182 (8.3%) developed a surgical site infection. The surgical site infection rate in patients with "non-standard" strategy was higher than in patients with "standard" strategy: 8.8% (140 reported infections/1,582 patients) versus 6.8% (42 reported infections/621 patients), p = 0.001. The "standard" antibiotic management proposed by guidelines for adult cardiac surgery patients could be used an acceptable strategy to treat pediatric patients with an open chest after cardiac surgery.
Collapse
Affiliation(s)
- Simona Silvetti
- Neonatal and Pediatric Intensive Care Unit, Department of Surgery and Critical Care, IRCCS Istituto Giannina Gaslini, Genova, Italy
| | - Giovanni Landoni
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, University Vita-Salute San Raffaele, Milano, Italy.
| | - Elio Castagnola
- Infectious Disease Unit, Department of Pediatrics, IRCCS Istituto Giannina Gaslini, Genova, Italy
| | - Halkawt Nuri
- Cardiac Surgery Unit, Department of Surgery and Critical Care, IRCCS Istituto Giannina Gaslini, Genova, Italy
| | - Giuseppe Pomé
- Cardiac Surgery Unit, Department of Surgery and Critical Care, IRCCS Istituto Giannina Gaslini, Genova, Italy
| | - Andrea Moscatelli
- Neonatal and Pediatric Intensive Care Unit, Department of Surgery and Critical Care, IRCCS Istituto Giannina Gaslini, Genova, Italy
| |
Collapse
|
15
|
Brancaccio G, Filippelli S, Affinito V, Di Donato RM. Use of intermittent high negative pressure vacuum-assisted closure for pediatric poststernotomy mediastinitis. J Cardiovasc Med (Hagerstown) 2018; 18:694-695. [PMID: 21045715 DOI: 10.2459/jcm.0b013e32834037b8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Affiliation(s)
- Gianluca Brancaccio
- Department of Cardiac Surgery, Ospedale Pediatrico Bambino Gesù, Rome, Italy
| | | | | | | |
Collapse
|
16
|
Outcomes of Delayed Sternal Closure in Pediatric Heart Surgery: Single-Center Experience. BIOMED RESEARCH INTERNATIONAL 2018; 2018:3742362. [PMID: 29850507 PMCID: PMC5933025 DOI: 10.1155/2018/3742362] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/17/2017] [Accepted: 03/14/2018] [Indexed: 11/18/2022]
Abstract
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.
Collapse
|
17
|
Perioperative antibiotics in pediatric cardiac surgery: protocol for a systematic review. Syst Rev 2017; 6:107. [PMID: 28558846 PMCID: PMC5450342 DOI: 10.1186/s13643-017-0502-y] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/08/2017] [Accepted: 05/18/2017] [Indexed: 12/05/2022] Open
Abstract
BACKGROUND Post-operative infections in pediatric cardiac surgery are an ongoing clinical challenge, with rates between 1 and 20%. Perioperative antibiotics remain the standard for prevention of surgical-site infections, but the type of antibiotic and duration of administration remain poorly defined. Current levels of practice variation through informal surveys are very high. Rates of antibiotic-resistant organisms are increasing steadily around the world. METHODS/DESIGN We will identify all controlled observational studies and randomized controlled trials examining prophylactic antibiotic use in pediatric cardiac surgery. Data sources will include MEDLINE, EMBASE, CENTRAL, and proceedings from recent relevant scientific meetings. For each included study, we will conduct duplicate independent data extraction, risk of bias assessment, and evaluation of quality of evidence using the GRADE approach. DISCUSSION We will report the results of this review in agreement with the PRISMA statement and disseminate our findings at relevant critical care and cardiology conferences and through publication in peer-reviewed journals. We will use this systematic review to inform clinical guidelines, which will be disseminated in a separate stand-alone publication. STUDY REGISTRATION NUMBER PROSPERO CRD42016052978C.
Collapse
|
18
|
Nelson-McMillan K, Hornik CP, He X, Vricella LA, Jacobs JP, Hill KD, Pasquali SK, Alejo DE, Cameron DE, Jacobs ML. Delayed Sternal Closure in Infant Heart Surgery—The Importance of Where and When: An Analysis of the STS Congenital Heart Surgery Database. Ann Thorac Surg 2016; 102:1565-1572. [DOI: 10.1016/j.athoracsur.2016.08.081] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/15/2016] [Indexed: 11/26/2022]
|
19
|
Abstract
OBJECTIVES The objectives of this review are to discuss the prevalence and risk factors associated with the development of hospital-acquired infections in pediatric patients undergoing cardiac surgery and the published antimicrobial prophylaxis regimens and rational approaches to the diagnosis, prevention, and treatment of nosocomial infections in these patients. DATA SOURCE MEDLINE and PubMed. CONCLUSION Hospital-acquired infections remain a significant source of potentially preventable morbidity and mortality in pediatric cardiac surgical patients. Through improved understanding of these conditions and implementation of avoidance strategies, centers caring for these patients may improve outcomes in this vulnerable population.
Collapse
|
20
|
Roughton M, Agarwal S, Song DH, Gottlieb LJ. Rigid sternal fixation in the management of pediatric postmedian sternotomy mediastinitis: A 20-year study. J Plast Reconstr Aesthet Surg 2015; 68:1656-61. [PMID: 26386647 DOI: 10.1016/j.bjps.2015.08.014] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2014] [Revised: 07/03/2015] [Accepted: 08/07/2015] [Indexed: 11/30/2022]
Abstract
BACKGROUND AND AIM Pediatric patients are at a risk of mediastinitis, a life-threatening complication of median sternotomy, following cardiac surgery for congenital conditions. Our experience with rigid internal sternal fixation in pediatric patients with postmedian sternotomy mediastinitis is presented. METHODS AND MATERIALS A retrospective chart review was performed of patients <18 years of age diagnosed with postoperative mediastinitis between January 1, 1990 and December 31, 2009. Charts were reviewed for demographic data, cardiac history, causative microorganism, and infectious risk factors. The methods of surgical intervention including flap coverage and use and type of sternal plating (resorbable and/or titanium) were also recorded. The primary end point of interest was overall survival. RESULTS Twenty-five pediatric patients were diagnosed with postoperative mediastinitis. Rigid fixation of the sternum following debridement was performed in 20 patients (age range: 1 month-18 years), all of whom successfully tolerated the procedure. Resorbable plates were used in 13 patients. Five patients did not undergo rigid fixation due to either serious ill-health or lack of adequate sternal bone stock. No patient experienced recurrent sternal wound infection. A total of 20 patients (80%) survived to discharge. Three patients succumbed to their heart condition prior to rigid fixation, one died following sternal closure from unrelated causes, and one patient was lost to follow-up. CONCLUSIONS Post-sternotomy mediastinitis in pediatric patients may be addressed using wide debridement, rigid sternal fixation, and flap coverage. In our series of 25 patients with pediatric mediastinitis, none died from mediastinitis. Placement of hardware did not adversely affect patient survival. This study demonstrates the feasibility of rigid sternal fixation.
Collapse
Affiliation(s)
- Michelle Roughton
- Division of Plastic and Reconstructive Surgery, University of North Carolina Medical Center, Chapel Hill, NC, USA
| | - Shailesh Agarwal
- Section of Plastic Surgery, University of Michigan Medical School, Ann Arbor, MI, USA
| | - David H Song
- Section of Plastic and Reconstructive Surgery, University of Chicago Medical Center, Chicago, IL, USA
| | - Lawrence J Gottlieb
- Section of Plastic and Reconstructive Surgery, University of Chicago Medical Center, Chicago, IL, USA.
| |
Collapse
|
21
|
Costello J, Amling J, Emerson D, Peer S, Afflu D, Zurakowski D, Jonas R, Nath D. Negative pressure wound therapy for sternal wound infections following congenital heart surgery. J Wound Care 2014; 23:31-6. [DOI: 10.12968/jowc.2014.23.1.31] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
- J.P. Costello
- Division of Cardiovascular Surgery, Children's national Health System, Washington DC, US
- The Sheikh Zayed Institute for Pediatric Surgical Innovation, Children's national Health System, Washington DC, US
| | - J.K. Amling
- Wound and Surgical airway Program, Children's national Health System, Washington DC, US
| | - D.A. Emerson
- Division of Cardiovascular Surgery, Children's national Health System, Washington DC, US
| | - S.M. Peer
- Division of Cardiovascular Surgery, Children's national Health System, Washington DC, US
| | - D.K. Afflu
- Division of Cardiovascular Surgery, Children's national Health System, Washington DC, US
| | - D. Zurakowski
- Departments of anaesthesia and Surgery, Boston Children's Hospital, Harvard Medical School, Boston, Ma, US
| | - R.A. Jonas
- Division of Cardiovascular Surgery, Children's national Health System, Washington DC, US
| | - D.S. Nath
- Division of Cardiovascular Surgery, Children's national Health System, Washington DC, US
| |
Collapse
|
22
|
Mangukia CV, Agarwal S, Satyarthy S, Datt V, Satsangi D. Mediastinitis Following Pediatric Cardiac Surgery. J Card Surg 2013; 29:74-82. [DOI: 10.1111/jocs.12243] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Affiliation(s)
- Chirantan V. Mangukia
- Department of Cardiothoracic and Vascular Surgery; G.B. Pant Hospital; New Delhi India
| | - Saket Agarwal
- Department of Cardiothoracic and Vascular Surgery; G.B. Pant Hospital; New Delhi India
| | - Subodh Satyarthy
- Department of Cardiothoracic and Vascular Surgery; G.B. Pant Hospital; New Delhi India
| | - Vishnu Datt
- Department of Anesthesiology; G.B. Pant Hospital; New Delhi India
| | - Deepak Satsangi
- Department of Cardiothoracic and Vascular Surgery; G.B. Pant Hospital; New Delhi India
| |
Collapse
|
23
|
Woodward CS, Son M, Taylor R, Husain SA. Prevention of sternal wound infection in pediatric cardiac surgery: a protocolized approach. World J Pediatr Congenit Heart Surg 2013; 3:463-9. [PMID: 23804910 DOI: 10.1177/2150135112454145] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Sternal wound infections (SWIs) are a costly complication for children after cardiac surgery, increasing morbidity, mortality, and financial cost. There are no pediatric guidelines to reduce the incidence of SWI in this vulnerable population. METHODS A quality improvement, multidisciplinary team was formed, and a protocol to prevent SWI was developed. A prospective review of patients who underwent pediatric cardiac surgery was conducted over a two-year period to follow adherence to the protocol and incidence of SWI. The Centers for Disease Control definitions for surgical site infections were used to determine the depth and presence of infection. RESULTS Three hundred and eight children <18 years of age had sternotomies during the study period. There was a reduction in all SWI between the first and second years of the study (odds ratio [OR] = 0.35; confidence interval [CI] 95% 0.12-1.01; P = .059). Delayed sternal closure (DSC) was associated with increased risk of SWI (OR = 5.4; CI 95% 2.13-14.9; P ≤ .001). Institution of a protocol in patients with DSC was associated with decreased infections during the second year (first year: n = 7 (14%), second year: n = 2 (4%), P = .14). CONCLUSIONS Institution of a protocol was associated with a decreased number of infections in children. A multicenter study of a bundled protocol approach to SWI prevention is needed. Children with DSC had a significantly higher risk of developing a wound infection. Initiating strategies to reduce SWI with a focus on children with DSC may result in improved overall infection rates.
Collapse
Affiliation(s)
- Cathy S Woodward
- Division of Critical Care, Department of Pediatrics, University of Texas Health Science Center, San Antonio, TX, USA
| | | | | | | |
Collapse
|
24
|
Erek E, Yalcinbas YK, Turkekul Y, Saygili A, Ulukol A, Sarioglu A, Sarioglu CT. Indications and risks of delayed sternal closure after open heart surgery in neonates and early infants. World J Pediatr Congenit Heart Surg 2013; 3:229-35. [PMID: 23804779 DOI: 10.1177/2150135111432771] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND Delayed sternal closure (DSC) has been an essential part of neonatal and infant heart surgery. Here, we report our single institution experience of DSC for eight years. METHODS The successive 188 patients were analyzed retrospectively. Sternum was closed at the end of the operation in 97 (51.6%) patients (primary sternal closure [PSC] group). Sternum was left open in 91 (48.4%) patients. Among them, 45 (23.9%) had only skin closure (DSCs group) and 46 (24.4%) had membrane patch closure (DSC membrane [DSCm] group). Median age was higher in PSC group (90 days) than DSCs (11 days) and DSCm groups (9.5 days). RESULTS Mortality was 1%, 11.1%, and 28.2% in PSC, DSCs, and DSCm groups, respectively (P < .05). Univariate analysis recognized the neonatal age (odds ratio [OR] = 4.2), preoperative critical condition (OR = 5.3), cardiopulmonary bypass time >180 minutes (OR = 4), and cross clamp time >99 minutes (OR = 3.9) as risk factors for mortality. Total morbidity rate was higher in DSCm group (73.9%) than DSCs group (51.1%) and PSC group (23.7%; P < .001). Mechanical ventilation time, intensive care unit stay, and hospital stay were longer in DSCs and DSCm groups than PSC group (P < .001). The incidence of hospital infection was also higher in DSCs (43.5%) and DSCm (33.3%) groups than PSC group (20.6%; P < .05). But there was no difference in the incidence of sternal wound complications, including both deep and superficial (4.1%, 8.8%, and 4.4%, respectively). CONCLUSION Although the risk of sternal wound complications is not different, patients who necessitate DSC (using both skin and membrane closure techniques) have more complicated postoperative course than patients with PSC.
Collapse
Affiliation(s)
- Ersin Erek
- Istanbul Mehmet Akif Ersoy Thoracic and Cardiovascular Surgery Training and Research Hospital, Cardiovascular Surgery Department, Istanbul, Turkey
| | | | | | | | | | | | | |
Collapse
|
25
|
Bowman ME, Rebeyka IM, Ross DB, Quinonez LG, Forgie SE. Risk factors for surgical site infection after delayed sternal closure. Am J Infect Control 2013; 41:464-5. [PMID: 23102981 DOI: 10.1016/j.ajic.2012.05.022] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2012] [Revised: 05/27/2012] [Accepted: 05/29/2012] [Indexed: 10/27/2022]
Abstract
We examined the rates and risk factors for surgical site infections (SSIs) following delayed sternal closure after pediatric cardiac surgery by way of retrospective review of prospectively collected infection control data. Of 130 patients, 13.7% developed an SSI, and 6.9% developed mediastinitis following delayed sternal closure. There was a trend toward increased SSIs in patients undergoing delayed sternal closure in beds in the open bay of a pediatric intensive care unit.
Collapse
|
26
|
Volumetric Computed Tomography Angiography in the Evaluation of Mediastinal Fluid Collections following Congenital Cardiac Surgery. Case Rep Pediatr 2013; 2013:426923. [PMID: 23424699 PMCID: PMC3569889 DOI: 10.1155/2013/426923] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2012] [Accepted: 12/27/2012] [Indexed: 11/18/2022] Open
Abstract
We present 3 patients with 4 causes of mediastinal fluid collection after congenital cardiac surgery in this extended case report. Volumetric computed tomography played an essential role in diagnosing causes and extent, relevant to subsequent management. Recent advances in volumetric computed tomography allow fast and accurate imaging of cardiovascular and extravascular structures in children with acceptable radiation dose, providing a powerful imaging tool for the evaluation of complications after congenital cardiac surgery.
Collapse
|
27
|
Mo A, Lin H. Successful Therapy for a Patient With Aortic Graft Infection Without Graft Removal. Ann Vasc Surg 2011; 25:698.e1-4. [DOI: 10.1016/j.avsg.2010.11.016] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2010] [Revised: 10/08/2010] [Accepted: 11/22/2010] [Indexed: 11/15/2022]
|
28
|
Woodward CS, Son M, Calhoon J, Michalek J, Husain SA. Sternal Wound Infections in Pediatric Congenital Cardiac Surgery: A Survey of Incidence and Preventative Practice. Ann Thorac Surg 2011; 91:799-804. [DOI: 10.1016/j.athoracsur.2010.10.030] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/03/2010] [Revised: 10/11/2010] [Accepted: 10/12/2010] [Indexed: 10/18/2022]
|
29
|
Durandy Y. Mediastinitis in pediatric cardiac surgery: Prevention, diagnosis and treatment. World J Cardiol 2010; 2:391-8. [PMID: 21179306 PMCID: PMC3006475 DOI: 10.4330/wjc.v2.i11.391] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/06/2010] [Revised: 10/07/2010] [Accepted: 10/14/2010] [Indexed: 02/06/2023] Open
Abstract
In spite of advances in the management of mediastinitis following sternotomy, mediastinitis is still associated with significant morbidity. The prognosis is much better in pediatric surgery compared to adult surgery, but the prolonged hospital stays with intravenous therapy and frequent required dressing changes that occur with several therapeutic approaches are poorly tolerated. Prevention includes nasal decontamination, skin preparation, antibioprophylaxis and air filtration in the operating theater. The expertise of the surgical team is an additional factor that is difficult to assess precisely. Diagnosis is often very simple, being made on the basis of a septic state with wound modification, while retrosternal puncture and CT scan are rarely useful. Treatment of mediastinitis following sternotomy is always a combination of surgical debridement and antibiotic therapy. Continued use of numerous surgical techniques demonstrates that there is no consensus and the best treatment has yet to be determined. However, we suggest that a primary sternal closure is the best surgical option for pediatric patients. We propose a simple technique with high-vacuum Redon's catheter drainage that allows early mobilization and short term antibiotherapy, which thus decreases physiological and psychological trauma for patients and families. We have demonstrated the efficiency of this technique, which is also cost-effective by decreasing intensive care and hospital stay durations, in a large group of patients.
Collapse
Affiliation(s)
- Yves Durandy
- Yves Durandy, Perfusion and Intensive Care Unit in Pediatric Cardiac Surgery, Institut Hospitalier Jacques Cartier, Avenue du Noyer Lambert, 91300 Massy, France
| |
Collapse
|
30
|
Gazit AZ, Huddleston CB, Checchia PA, Fehr J, Pezzella AT. Care of the pediatric cardiac surgery patient--part 2. Curr Probl Surg 2010; 47:261-376. [PMID: 20207257 DOI: 10.1067/j.cpsurg.2009.12.003] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Affiliation(s)
- Avihu Z Gazit
- Pediatric Critical Care Medicine and Cardiology, St. Louis Children's Hospital, Washington University School of Medicine, St. Louis, Missouri, USA
| | | | | | | | | |
Collapse
|
31
|
Johnson JN, Jaggers J, Li S, O'Brien SM, Li JS, Jacobs JP, Jacobs ML, Welke KF, Peterson ED, Pasquali SK. Center variation and outcomes associated with delayed sternal closure after stage 1 palliation for hypoplastic left heart syndrome. J Thorac Cardiovasc Surg 2010; 139:1205-10. [PMID: 20167337 DOI: 10.1016/j.jtcvs.2009.11.029] [Citation(s) in RCA: 49] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/23/2009] [Revised: 10/14/2009] [Accepted: 11/14/2009] [Indexed: 11/24/2022]
Abstract
OBJECTIVE There is debate whether primary or delayed sternal closure is the best strategy after stage 1 palliation for hypoplastic left heart syndrome. We describe center variation in delayed sternal closure after stage 1 palliation and associated outcomes. METHODS Society of Thoracic Surgeons Congenital Database participants performing stage 1 palliation for hypoplastic left heart syndrome from 2000 to 2007 were included. We examined center variation in delayed sternal closure and compared in-hospital mortality, prolonged length of stay (length of stay > 6 weeks), and postoperative infection in centers with low (< or = 25% of cases), middle (26%-74% of cases), and high (> or = 75% of cases) delayed sternal closure use, adjusting for patient and center factors. RESULTS There were 1283 patients (45 centers) included. Median age at surgery was 6 days (interquartile range, 4-9 days), and median weight at surgery was 3.2 kg (interquartile range, 2.8-3.5 kg); 59% were male. Delayed sternal closure was used in 74% of cases (range, 3%-100% of cases/center). In centers with high (n = 23) and middle (n = 17) versus low (n = 5) delayed sternal closure use, there was a greater proportion of patients with prolonged length of stay and infection, and a trend toward increased in-hospital mortality in unadjusted analysis. In multivariable analysis, there was no difference in mortality. Centers with high and middle delayed sternal closure use had prolonged length of stay (odds ratio, 2.83; 95% confidence interval, 1.46-5.47; P = .002 and odds ratio, 2.23; confidence interval, 1.17-4.26; P = .02, respectively) and more infection (odds ratio, 2.34; confidence interval, 1.20-4.57; P = .01 and odds ratio, 2.37; confidence interval, 1.36-4.16; P = .003, respectively). CONCLUSION Use of delayed sternal closure after stage 1 palliation varies widely. These observational data suggest that more frequent use of delayed sternal closure is associated with longer length of stay and higher postoperative infection rates. Further evaluation of the risks and benefits of delayed sternal closure in the management of these complex infants is necessary.
Collapse
Affiliation(s)
- Jason N Johnson
- Division of Pediatric Cardiology, Department of Pediatrics, Duke University Medical Center, Durham, NC 27715, USA
| | | | | | | | | | | | | | | | | | | |
Collapse
|
32
|
Ridout A, Sadiq J, Lakhoo K. Pre-sternal mass with a congenital sternal defect: a rare presentation. Pediatr Surg Int 2009; 25:525-7. [PMID: 19415304 DOI: 10.1007/s00383-009-2360-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/30/2009] [Indexed: 11/28/2022]
Abstract
Anterior chest wall and anterior mediastinal infections are very rare in children with no predisposing thoracic surgery. Congenital sternal defects occur as a result of incomplete ossification of the sternal bone, and show a wide range of severity. We present the case of a 15-month-old boy who presented to the A&E department with an anterior chest-wall mass. After investigation, it was found to be an infective mass, with extension into the anterior mediastinum, through a previously undiagnosed 5 mm congenital sternal defect identified peri-operatively. After antibiotic therapy and surgical management the patient made complete recovery with no recurrence or complications within 6 months of review.
Collapse
Affiliation(s)
- Ashley Ridout
- Department of Paediatric Surgery, Oxford Children's Hospital & University of Oxford, Headington, Oxford, OX3 9DU, UK
| | | | | |
Collapse
|
33
|
Candida mediastinitis with aortic rupture after congenital heart surgery. Int J Cardiol 2009; 134:e76-8. [DOI: 10.1016/j.ijcard.2007.12.094] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/01/2007] [Revised: 12/28/2007] [Accepted: 12/29/2007] [Indexed: 11/18/2022]
|
34
|
Rapid extracorporeal life support rescue in patients undergoing the Norwood procedure. J Thorac Cardiovasc Surg 2009; 137:765-6. [PMID: 19258110 DOI: 10.1016/j.jtcvs.2007.12.071] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/21/2007] [Accepted: 12/24/2007] [Indexed: 11/20/2022]
|
35
|
Ghafoori AF, Twite MD, Friesen RH. Postoperative hyperglycemia is associated with mediastinitis following pediatric cardiac surgery. Paediatr Anaesth 2008; 18:1202-7. [PMID: 19076575 DOI: 10.1111/j.1460-9592.2008.02808.x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
INTRODUCTION Mediastinitis is an infrequent, but significant complication of median sternotomy. Perioperative hyperglycemia is associated with increased morbidity, including infection in pediatric and adult cardiac surgical patients. We hypothesized that perioperative blood glucose levels would be higher in patients who later developed mediastinitis. METHODS We examined the medical records of all infants and children diagnosed with poststernotomy mediastinitis (n = 24) from July 2001 to December 2005. Data recorded included postoperative blood glucose levels, age, diagnosis, operation, surgical complexity score, duration of operation and cardiopulmonary bypass, delayed sternal closure, perioperative use of steroids and total parenteral nutrition, and duration of postoperative inotropic and ventilatory support. Records of patients without mediastinitis matched for age, complexity score, and month of operation (control group, n = 32) were also reviewed. Data were analyzed with t-tests and chi-square tests. Variables with P < 0.21 on univariate tests were entered into a multivariate logistic regression model. RESULTS Initially, postoperative blood glucose levels were elevated, but similar in both mediastinitis and control groups. The number of subjects having peak blood glucose levels >7.2 mm (>130 mg.dl(-1)) during the first 24 h was greater in the mediastinitis group (P = 0.07). The significant multivariate predictor of mediastinitis was 24 h peak blood glucose >7.2 mM (>130 mg.dl(-1)) (P = 0.039). CONCLUSION Our data support the hypothesis that postoperative hyperglycemia is a risk factor for the development of mediastinitis in infants and children following cardiac surgery.
Collapse
Affiliation(s)
- A Fawad Ghafoori
- Department of Anesthesiology, The Children's Hospital, University of Colorado School of Medicine, Denver, CO 80045, USA
| | | | | |
Collapse
|
36
|
Kuroczynski W, Muench M, Kampmann C, Parker J, Peivandi AA, Heinemann M, Pruefer D, Vahl CF. Risikofaktoren bei Patienten mit zweizeitigem Thoraxverschluss nach Korrektur eines angeborenen Herzfehlers. ZEITSCHRIFT FUR HERZ THORAX UND GEFASSCHIRURGIE 2008. [DOI: 10.1007/s00398-008-0619-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
|
37
|
Gaca AM, Jaggers JJ, Dudley LT, Bisset GS. Repair of Congenital Heart Disease: A Primer–Part 1. Radiology 2008; 247:617-31. [DOI: 10.1148/radiol.2473061909] [Citation(s) in RCA: 78] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
|
38
|
Kadohama T, Akasaka N, Nagamine A, Nakanishi K, Kiyokawa K, Goh K, Sasajima T. Vacuum-assisted closure for pediatric post-sternotomy mediastinitis: are low negative pressures sufficient? Ann Thorac Surg 2008; 85:1094-6. [PMID: 18291211 DOI: 10.1016/j.athoracsur.2007.09.004] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/26/2007] [Revised: 08/27/2007] [Accepted: 09/04/2007] [Indexed: 10/22/2022]
Abstract
We present 3 cases of pediatric post-sternotomy mediastinitis treated by a vacuum-assisted closure (VAC). The patients 2 girls, aged 6 months and 10 months, and a 2-year-old boy. The onset of infection was at 9, 14, and 32 postoperative days. The culture examination detected coagulase-negative Staphylococci strains in 2 cases, and Staphylococcus aureus in 1 case. A VAC was performed at -50 mm Hg for 10, 12, and 7 days. The wounds were closed without vascularized soft tissue. A VAC under a low negative pressure is a useful and safe procedure for the management of pediatric post-sternotomy mediastinitis.
Collapse
Affiliation(s)
- Takayuki Kadohama
- Department of Surgery, Asahikawa Medical University, Asahikawa, Japan.
| | | | | | | | | | | | | |
Collapse
|
39
|
Anslot C, Hulin S, Durandy Y. Postoperative mediastinitis in children: improvement of simple primary closed drainage. Ann Thorac Surg 2007; 84:423-8. [PMID: 17643610 DOI: 10.1016/j.athoracsur.2007.03.064] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/08/2006] [Revised: 03/21/2007] [Accepted: 03/21/2007] [Indexed: 11/28/2022]
Abstract
BACKGROUND Mediastinitis is a significant cause of postoperative morbidity. In 1989, we proposed simple primary closed drainage as a new treatment. Our goal is to describe improvements made to the original technique. METHODS After wound debridement, infected areas were drained with Redon catheters connected to strong negative-pressure drainage bottles. Mediastinal effluents were cultured every day, and the catheters were withdrawn when the effluent culture was negative for microorganisms. Patients were classified into three groups: isolated mediastinitis (group 1), mediastinitis associated with endocarditis (group 2), and mediastinitis associated with other organ failure (group 3). RESULTS Sixty-four patients were treated during a 10-year period: 15 neonates, 33 infants, and 16 children. Group 1 consisted of 40 patients. The time to mediastinal sterilization was 4 days (range, 1 to 14 days), and the antibiotic course was 11 days (range, 7 to 28 days), with a hospital stay of 13 days (range, 10 to 30 days). No deaths occurred in this group. Group 2 consisted of 7 patients. The time to mediastinal sterilization was 8 days (range, 3 to 10 days), and the antibiotic course was 30 days (range, 26 to 37 days), with a hospital stay of 37 days (range, 20 to 54 days). One patient in group 2 did not survive. Group 3 consisted of 17 patients. The time to mediastinal sterilization was 6 days (range, 1 to 10 days), and the antibiotic course was 15 days (range, 10 to 31 days), with a hospital stay of 20 days (range, 18 to 36 days). Two patients in group 3 did not survive. None of the deaths was directly related to mediastinitis, as the mediastinum was sterile in all 3 patients before death. CONCLUSIONS This simple treatment was efficient and reliable in achieving mediastinal sterilization. In addition, short antibiotic courses decreased restraint, which is poorly tolerated in pediatric patients.
Collapse
Affiliation(s)
- Christine Anslot
- Intensive Care Unit of Pediatric Cardiac Surgery, Institut Jacques Cartier, Massy, France
| | | | | |
Collapse
|
40
|
Kagen J, Lautenbach E, Bilker WB, Matro J, Bell LM, Dominguez TE, Gaynor JW, Shah SS. Risk factors for mediastinitis following median sternotomy in children. Pediatr Infect Dis J 2007; 26:613-8. [PMID: 17596804 DOI: 10.1097/inf.0b013e31806166bb] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
BACKGROUND Mediastinitis is a devastating complication of pediatric cardiothoracic surgery. However, risk factors for the development of mediastinitis are poorly characterized. The objective of this study was to identify risk factors for mediastinitis in a cohort of children undergoing cardiothoracic surgery at a tertiary care children's hospital. METHODS This case-control study included patients who underwent median sternotomy between January 1, 1995 and December 31, 2003. Univariate analyses, logistic regression, and multinomial regression were performed to determine the association between potential risk factors and the development of mediastinitis. RESULTS Forty-three patients with mediastinitis and 184 patients without mediastinitis were included. One hundred and twelve (49%) patients were female. The median patient age was 128 days (interquartile range: 7 days-2.0 years). A known or possible genetic syndrome was present in 53 (24%) patients. The following factors were associated with the development of mediastinitis: presence of a known or possible genetic syndrome (adjusted odds ratio, OR: 4.5; 95% confidence interval, CI: 1.8-11.4); American Society of Anesthesiologists score >3 (adjusted OR: 3.4; 95% CI: 1.1-10.3); and presence of intracardiac pacing wires for >3 days (adjusted OR: 15.8; 95% CI: 2.0-127.2). CONCLUSIONS The presence of a known or possible genetic syndrome, American Society of Anesthesiologists score >3, and the presence of intracardiac pacing wires for >3 days were each associated with the development of mediastinitis in children after median sternotomy.
Collapse
Affiliation(s)
- Jessica Kagen
- Division of Infectious Diseases, The Children's Hospital of Philadelphia, Philadelphia, PA 19104, USA
| | | | | | | | | | | | | | | |
Collapse
|
41
|
Vida VL, Leon-Wyss J, Larrazabal A, Cruz S, Castaneda AR. Mediastinitis in pediatric cardiac surgery: treatment and cost-effectiveness in a low-income country. Pediatr Cardiol 2007; 28:163-6. [PMID: 17505863 DOI: 10.1007/s00246-006-0008-1] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/08/2006] [Accepted: 11/18/2006] [Indexed: 10/23/2022]
Abstract
Mediastinitis is a serious postoperative complication following pediatric cardiac surgery. The objective of this study is to evaluate the cost-effectiveness of surgical treatment for mediastinitis in Guatemala. All children who underwent a median sternotomy and developed postoperative mediastinitis between January 2004 and December 2005 were evaluated. Type of surgical treatment for mediastinitis, hospital outcome, and costs were analyzed. Eighteen (3.3%) of the 535 children who underwent a median sternotomy developed mediastinitis. Two patients underwent debridement of the infected tissues and delayed sternal closure, whereas 16 patients had debridement, primary chest closure, and continuous antibiotic irrigation of the mediastinum. All 11 patients who had the diagnosis of mediastinitis within 2 weeks after the operation survived. Three of the 7 patients (43%) who had delayed diagnosis died (p = 0.0003); all 3 had osteomyelitis (p = 0.0007). Primary closure with antibiotic irrigation was associated to a lower mortality rate and proved less expensive in comparison to delayed sternal closure (p = 0.003) mainly due to the shorter intensive care requirement. Debridement followed by primary closure of the chest and continuous antibiotic irrigation of the mediastinum seems to be a feasible and less expensive method to treat selected cases of postoperative mediastinitis in children.
Collapse
Affiliation(s)
- V L Vida
- Department of Pediatric Cardiac Surgery of Guatemala, UNICAR, 9a Avenida, 8-00 Zone 11, Guatemala City, CA, Guatemala.
| | | | | | | | | |
Collapse
|
42
|
Alphonso N, Anagnostopoulos PV, Scarpace S, Weintrub P, Azakie A, Raff G, Karl TR. Perioperative antibiotic prophylaxis in paediatric cardiac surgery. Cardiol Young 2007; 17:12-25. [PMID: 17244387 DOI: 10.1017/s1047951107000066] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/28/2006] [Indexed: 11/05/2022]
Affiliation(s)
- Nelson Alphonso
- Paediatric Heart Center, University of California San Francisco Children's Hospital, San Francisco, California 94143-0117, USA
| | | | | | | | | | | | | |
Collapse
|