Arterial grafting and the risk of sternal infection: How we can learn from our experience

Routine Mediastinal Drainage Fluid Culture for Early Diagnosis of Poststernotomy Mediastinitis

BACKGROUND

Early diagnosis of poststernotomy mediastinitis (PSM) is challenging. Since 2016, we have routinely performed mediastinal drainage fluid culture (MDFC) in patients undergoing sternotomy. This study aimed to determine the utility of MDFC for early diagnosis of PSM.

METHODS

Between November 2016 and April 2020, we conducted MDFC in 1,012 patients on the third postoperative day and prospectively observed for PSM occurrence for 3 months. If bacteria were identified, additional MDFC or blood culture was performed to reduce the possibility of false positives. Based on MDFC results, the decision for early treatment for PSM was at the attending physician's discretion.

RESULTS

Bacteria were identified in MDFC of 29 patients, eight of whom subsequently developed PSM. Among 983 patients with negative MDFC, only 15 developed PSM. In multivariate analysis, previous sternotomy history and positive MDFC were predictors of PSM. Positive MDFC was regarded as true positive if (1) PSM occurred subsequently, and/or (2) the same bacteria were identified in additional MDFC/blood culture. Non-occurrence of PSM in the absence of antibiotic treatment was regarded as false-positive MDFC. The sensitivity, specificity, and positive and negative predictive values of routine MDFC for diagnosis of mediastinal infection were 46.4, 99.0, 56.5, and 98.5%, respectively. When categorizing cases with positive MDFC based on the identified bacteria, the positive predictive value was highest (76.9%) when Staphylococci were identified.

CONCLUSION

Routine MDFC after sternotomy can facilitate early diagnosis of PSM. Early treatment for PSM may be indicated in patients in whom Staphylococci are identified in the MDFC.

Sternal Wound Reconstruction Made Simple

Sternal wounds and associated infections represent a complex reconstructive problem in a highly morbid patient population. Through strict adherence to excellent plastic surgical principles, this process can be simplified, allowing safe and effective wound closure. Emphasis is placed on thorough debridement, hardware removal, obtaining adequate tissue cultures, and finally, appropriate flap closure. In most cases, pectoralis major myocutaneous advancement flaps provide excellent coverage while eliminating dead space and providing sternal compression. Secondary flap options, such as the omental flap or rectus abdominis muscle, may occasionally be necessary. This article will provide an overview and simplified approach to sternal wound reconstruction.