Closed drainage using redon catheters for poststernotomy mediastinitis: results and risk factors for adverse outcome

Topical skin adhesive PRINEO as the ideal wound closure system in cardiac surgery to limit surgical site infection

OBJECTIVE

Surgical site infections (SSIs) are a major source of morbidity after cardiac surgery, involving prolonged hospitalisation. Among the numerous techniques of skin closure and dressings available, the optimal method remains undetermined. The DERMABOND-PRINEO (PRINEO) (PRINEO, Ethicon, J&J) is the only skin closure system which combines a topical skin adhesive with a mesh. Other surgical disciplines have highlighted remarkable results with PRINEO. The aim of this study was to evaluate the effects of PRINEO, used as the final layer in sternotomy closure, in the incidence of postoperative SSIs.

METHOD

This was a retrospective single-centre cohort study including adult patients who underwent cardiac surgery between January 2015 and December 2018. Patients who had undergone heart transplantation or ventricular assist surgery were excluded. Included patients were divided into two groups depending on the type of post-operative wound care technique used. Group 1 consisted of patients who had their sternotomy closed with a standard dressing and group 2 consisted of patients who were treated with PRINEO. The primary endpoint of our study was the occurrence of SSIs and secondary outcomes were the length of hospitalisation and mortality.

RESULTS

A total of 1603 patients were reviewed with the occurrence of 44 SSIs. Both groups were homogeneous in terms of risk factors. The incidence of SSIs was significantly lower in group 2 (PRINEO) than in group 1 (standard dressing) (n=29, 3.8% vs n=15, 1.8%, respectively; p=0.042). However, there was no significant difference in the duration of hospitalisation and mortality.

CONCLUSION

In our practice, PRINEO has proven to be a safe wound closure system after sternotomy, with a reduced SSI rate compared to conventional wound care techniques.

Successful method in the treatment of complicated sternal dehiscence and mediastinitis: Sternal reconstruction with osteosynthesis system supported by vacuum-assisted closure

BACKGROUND

This study aims to evaluate the results of the method we used to treat sternal dehiscence and mediastinitis due to median sternotomy following open heart surgery.

METHODS

Between July 2014 and March 2019, a total of 13 patients (8 males, 5 females; mean age: 60.3±2.9 years; range, 33 to 74 years) who underwent sternal reconstruction procedure and developed sternal dehiscence and mediastinitis after cardiac surgery were retrospectively analyzed. Data of the patients were retrieved from the hospital records.

RESULTS

Before the procedure, reconstruction was performed by using the Robiscek technique in three cases and a conventional rewiring technique was used in one case. Except for one case, all the other cases had sternal purulent discharge (n=12, 92%). Except for four cases, all cases had at least two fracture lines in the sternum (n=9, 69%). One to 10 sessions of (median=4) vacuum-assisted closure therapy were used in cases before the procedure. At least two bars were placed between the opposite ribs for sternal fixation. Except for three cases, all of the cases were placed transdiaphragmatic harvested omentum in the sternal cavity. Seroma and local infection recurrence occurred in two cases (n=2, 15.3%) and incisional hernia in one case (n=1, 7.6%). Thoracic stabilization was successfully achieved in all cases.

CONCLUSION

Thoracic stabilization can be successfully achieved in complicated sternal dehiscence cases with sternal reconstruction with STRATOS system supported by vacuum-assisted closure therapy, until the culture turns negative in the preoperative period and by the use of transdiaphragmatic omentum intraoperatively inside the sternal cavity.

Characteristics and outcomes of patients with postoperative Candida versus bacterial mediastinitis: a case-matched comparative study

OBJECTIVES

Postoperative mediastinitis, a feared complication after cardiac surgery, is associated with high mortality, especially of critically ill patients. Candida species infections are rare and severe, with poorly known outcomes. We conducted a case-control study to describe the characteristics, management and outcomes of patients with postoperative Candida mediastinitis.

METHODS

This French, monocentre, retrospective study included all patients with postoperative Candida mediastinitis (January 2003-February 2020) requiring intensive care unit admission. Candida mediastinitis patients (henceforth cases) were matched 1:1 with postoperative bacterial mediastinitis (henceforth control), based on 3 factors during mediastinitis management: age >40 years, cardiac transplantation and invasive circulatory device used. The primary end point was the probability of survival within 1 year after intensive care unit (ICU) admission.

RESULTS

Forty cases were matched to 40 controls. The global male/female ratio was 2.1, with mean age at admission 47.9 ± 13.8 years. Candida species were: 67.5% albicans, 17.5% glabrata, 15% parapsilosis, 5.0% tropicalis, 2.5% krusei and 2.5% lusitaniae. The median duration of mechanical ventilation was 23, 68.8% of patients received renal replacement therapy and 62.5% extracorporeal membrane oxygenation support. The probability of survival within the first year after ICU admission was 40 ± 5.5% and was significantly lower for cases than for controls (43 ± 8% vs 80 ± 6.3%, respectively; Log-rank test: P < 0.0001). The multivariable Cox proportional hazards model retained only renal replacement therapy [hazard ratio (HR) 3.7, 95% confidence interval (CI) 1.1-13.1; P = 0.04] and Candida mediastinitis (HR 2.4, 95% CI 1.1-5.6; P = 0.04) as independently associated with 1-year mortality.

CONCLUSIONS

Candida mediastinitis is a serious event after cardiac surgery and independently associated with 1-year mortality. Further studies are needed to determine whether deaths are directly attributable to Candida mediastinitis.

From open packing to negative wound pressure therapy: A critical overview of deep sternal wound infection treatment strategies after cardiac surgery

Deep sternal wound infection is a challenging aspect of modern cardiac surgery. The considerable mortality rate, devastating morbidity and, negative impact on long-term survival has driven cardiac and plastic surgeons to seek a more advantageous treatment solution. This review summarizes progress in the field of deep sternal wound infection treatment after cardiac surgery. Emphasis is placed on outcomes analysis of contemporary treatment strategy based on negative pressure wound therapy followed by sternotomy wound reconstruction, and its comparison with conventional treatment modalities used afore. Furthermore, complications and drawbacks of treatment strategies are critically evaluated to outline current options for successfully managing this life-threatening complication following cardiac surgery.

Effect of negative pressure wound therapy followed by tissue flaps for deep sternal wound infection after cardiovascular surgery: propensity score matching analysis

OBJECTIVES

Deep sternal wound infection (DSWI) after cardiovascular surgery via median sternotomy remains a severe complication associated with a drastic decrease in the quality of life. We assessed the risk factors for in-hospital death caused by DSWI and the available treatments for DSWI.

METHODS

Between January 1991 and August 2015, we retrospectively reviewed 73 patients (51 males and 22 females, mean age 67.5 ± 10.3 years) who developed DSWI after cardiovascular surgery via median sternotomy. Pathogenic bacteria mainly comprised methicillin-resistant Staphylococcus aureus (MRSA) (49.3%). Fifteen patients (20.5%) died in hospital with DSWI. Treatment of DSWI consisted of open daily irrigation (up to 2006) or negative pressure wound therapy (NPWT) (2007 onwards), followed by primary closure or reconstruction of tissue flaps. We assessed the risk factors for in-hospital mortality from DSWI by comparing data from the 15 patients who died and the 58 survivors using propensity score matching analysis of the treatments used for DSWI.

RESULTS

Univariate analysis identified age, use of intra-aortic balloon pumping, prolonged mechanical ventilation, tracheotomy, prolonged intensive care unit stay, postoperative low output syndrome, postoperative myocardial infarction, postoperative renal failure, postoperative use of haemodialysis, postoperative pneumonia, postoperative cerebral disorder, MRSA infection, NPWT and tissue flaps as being associated with in-hospital mortality (P < 0.05). Multivariate analysis identified NPWT (odds ratio, 0.062; 95% confidence interval, 0.004-0.897; P = 0.041) and tissue flaps (odds ratio, 0.022; 95% confidence interval, 0.000-0.960; P = 0.048) as independently associated with reduced in-hospital mortality after DSWI. On comparing 22 patients receiving NPWT with 22 not on NPWT using propensity score matching, patients on NPWT had significantly lower in-hospital mortality than those without NPWT (NPWT vs non-NPWT, 5 vs 36%, P = 0.021). In DSWI infected by MRSA, NPWT significantly reduced the in-hospital mortality caused by DSWI (NPWT vs non-NPWT, 0 vs 52%, P = 0.003).

CONCLUSIONS

NPWT and tissue flaps may be favourable factors associated with reduced in-hospital mortality attributable to DSWI. NPWT as a bridge therapy to tissue flaps may play a major role in treating DSWI and improve the prognosis for patients with MRSA-infected DSWI.

Sternal Wound Infection after Cardiac Surgery: Management and Outcome

Background

Sternal Wound Infection (SWI) is a severe complication after cardiac surgery. Debridement associated with primary closure using Redon drains (RD) is an effective treatment, but data on RD management and antibiotic treatment are scarce.

Methods

We performed a single-center analysis of consecutive patients who were re-operated for SWI between 01/2009 and 12/2012. All patients underwent a closed drainage with RD (CDRD). Patients with endocarditis or those who died within the first 45 days were excluded from management analysis. RD fluid was cultured twice weekly. Variables recorded were clinical and biological data at SWI diagnosis, severity of SWI based on criteria for mediastinitis as defined by the Centers for Disease Control (CDC), antibiotic therapy, RD management and patient’s outcome.

Results

160 patients developed SWI, 102 (64%) fulfilled CDC criteria (CDC+) and 58 (36%) did not (CDC- SWI). Initial antibiotic treatment and surgical management were similar in CDC+ and CDC- SWI. Patients with CDC+ SWI had a longer duration of antibiotic therapy and a mortality rate of 17% as compared to 3% in patients with CDC- SWI (p = 0.025). Rates of superinfection (10% and 9%) and need for second reoperation (12% and 17%) were similar. Failure (death or need for another reoperation) was associated with female gender, higher EuroScore for prediction of operative mortality, and stay in the ICU.

Conclusion

In patients with SWI, initial one-stage surgical debridement with CDRD is associated with favorable outcomes. CDC+ and CDC- SWI received essentially the same management, but CDC+ SWI has a more severe outcome.

Vancomycin pharmacokinetic and pharmacodynamic models for critically ill patients with post-sternotomy mediastinitis

BACKGROUND AND OBJECTIVE

Vancomycin is commonly used to treat serious methicillin-resistant staphylococcal infections, especially post-sternotomy mediastinitis (PSM). However, information on pharmacokinetics and pharmacodynamics in intensive care unit (ICU) patients remains scarce. We conducted vancomycin pharmacokinetic-pharmacodynamic modeling for ICU patients with PSM.

METHODS

This cohort study included 30 consecutive patients who received multiple vancomycin doses during primary closed drainage of PSM with Redon catheters, targeting serum drug trough concentrations of 25-35 mg/L, and generating 359 serum vancomycin concentration-time values for analysis. Population pharmacodynamics served to describe the withdrawal of Redon catheters, i.e., the probability of in-ICU cure.

RESULTS

Vancomycin pharmacokinetics corresponded to a two-compartment open model with first-order elimination kinetics. Mean [between-subject variability] population estimates were 1.91 (men)/1.25 (women) [0.28] L/h for vancomycin elimination, with intercompartmental clearance of 5.71 [1.01] L/h, and respective central and peripheral distribution volumes of 21.9 and 68 [0.53] L. Vancomycin clearance increased with body weight and declined with severity at ICU admission and serum creatinine (SCr), thereby allowing the prediction of the vancomycin plateau. Intercompartmental clearance decreased with diabetes mellitus (-70 %). The probability of withdrawing all Redon catheters (patient cured) was dependent only on the area under the concentration-time curve to minimum inhibitory concentration (AUC/MIC) exposures ratio in plasma. Neither preoperative factors, antistaphylococcal co-treatments, nor the initial number of Redon catheters significantly influenced this probability. The AUC/MIC exposures ratio had no significant effect on SCr levels.

CONCLUSION

These modeling analysis results identified five clinically relevant covariates that influenced vancomycin pharmacokinetics and might achieve better individualization of vancomycin dosing for methicillin-resistant staphylococcal PSM in ICU patients.

High-dose continuous oxacillin infusion results in achievement of pharmacokinetics targets in critically ill patients with deep sternal wound infections following cardiac surgery

Knowledge regarding antimicrobial therapy strategies in deep sternal wound infections (DSWI) following cardiac surgery is limited. Therefore, we aimed to determine the steady-state plasma and mediastinal concentrations of oxacillin administered by continuous infusion in critically ill patients with DSWI and to compare these concentrations with the susceptibility of staphylococci recovered. A continuous infusion of oxacillin (150 to 200 mg/kg of body weight/24 h) was administered after a loading dose (50 mg/kg). Plasma and mediastinal concentrations of total and unbound oxacillin were determined 4 h after the loading dose (H4) and then at day 1 (H24) and day 2 (H48). Twelve patients were included. Nine patients exhibited bacteremia, 5 were in septic shock, 8 were positive for Staphylococcus aureus, and 4 were positive for coagulase-negative staphylococci. The median MIC (first to third interquartile range) was 0.25 (0.24 to 0.41) mg/liter. Median plasma concentrations of total and unbound oxacillin at H4, H24, and H48 were, respectively, 64.4 (41.4 to 78.5) and 20.4 (12.4 to 30.4) mg/liter, 56.9 (31.4 to 80.6) and 21.7 (6.5 to 27.3) mg/liter, and 57.5 (32.2 to 85.1) and 20 (14.3 to 35.7) mg/liter. The median mediastinal concentrations of total and unbound oxacillin at H4, H24, and H48 were, respectively, 2.3 (0.7 to 25.9) and 0.9 (<0.5 to 15) mg/liter, 29.1 (19.7 to 38.2) and 12.6 (5.9 to 19.8) mg/liter, and 31.6 (14.9 to 42.9) and 17.1 (6.7 to 26.7) mg/liter. High-dose oxacillin delivered by continuous infusion is a valuable strategy to achieve our pharmacokinetic target (4× MIC) at the site of action at H24. But concerns remain in cases of higher MICs, emphasizing the need for clinicians to obtain the MICs for the bacteria and to monitor oxacillin concentrations, especially the unbound forms, at the target site.

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

OBJECTIVES

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.

METHODS

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.

RESULTS

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.

CONCLUSIONS

Primary closure using Redon drains is a feasible, simple and efficient treatment modality for post-sternotomy mediastinitis.

Overview and management of sternal wound infection

Sternal wound infection is a life-threatening complication after cardiac surgery associated with high morbidity and mortality. Past treatment options have included closed suction and continuous irrigation. Current paradigms in the management of sternal wound infection include surgical debridement, vacuum-assisted closure therapy, flap coverage, and sternal plating. We provide a general overview of sternal wound infection and treatment options for the plastic surgeon.

Our experience with pectoralis major flap for management of sternal dehiscence: A review of 25 cases

Objective:

To report our experience of the pectoralis major flap as the treatment modality for post coronary artery bypass sternal wound dehiscence.

Materials and Methods:

A retrospective study of 25 open heart surgery cases, performed between January 2006 and December 2010 at Deenanath Mangeshkar Hospital, Pune, was carried out. Unilateral or bilateral pectoralis major muscle flap by the double breasting technique using rectus extension was used in the management of these patients. The outcome was assessed on the basis of efficacy of flap surgery in achieving wound healing and post-surgery shoulder joint movements to evaluate donor site morbidity. The follow-up ranged from 5 months to 3.5 years.

Results:

Twenty-three (92%) patients were discharged with complete wound closure. One patient (4%) had wound dehiscence after flap surgery. One patient (4%) died in the hospital in the immediate postoperative period due to mediastinitis. No recurrent sternum infection has occurred till date in 24 patients (96%). For one patient (4%) who had wound dehiscence, daily dressing was done and wound healing was achieved with secondary intension. At follow-up, shoulder joint movements were normal in all the patients.

Conclusions:

The double breasting technique of the pectoralis major muscle flaps with rectus sheath extension is efficient in covering the entire length of the defect and can reduce the morbidity, without affecting the function of the shoulder joint.

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

OBJECTIVES

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.

METHODS

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.

RESULTS

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).

CONCLUSIONS

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.

Evaluation of risk factors for hospital mortality and current treatment for poststernotomy mediastinitis

PURPOSE

Poststernotomy mediastinitis (PSM) following cardiovascular surgery remains an intractable complication associated with considerable mortality. It is therefore necessary to assess the risk factors associated with hospital mortality and evaluate the surgical treatment options for PSM.

METHODS

We identified 59 (2.2%) patients who developed PSM after cardiovascular surgery between January 1991 and January 2010. PSM was defined as deep sternal wound infection requiring surgical treatment. In all, 31 patients were infected with methicillin-resistant Staphylococcus aureus (MRSA); and 14 patients died in hospital from PSM. A total of 51 patients were treated by simple closure or tissue flap reconstruction after débridement (traditional treatment), and 8 underwent closure or reconstruction after negative-pressure wound therapy (NPWT). The risk factors for in-hospital mortality due to PSM were analyzed by comparing the characteristics of survivors and nonsurvivors. The available surgical treatments for mediastinitis were also assessed.

RESULTS

Univariate analysis identified age, sex, pulmonary disease, MRSA infection, prolonged mechanical ventilation and prolonged intensive care unit stay as risk factors for in-hospital mortality (P < 0.05). Multiple logistic regression analysis identified MRSA infection (odds ratio 20.263, 95% confidence interval 1.580-259.814; P = 0.0208) as an independent risk factor for hospital mortality. NPWT was associated with significantly less surgical failure than traditional treatment (P = 0.0204). There were no deaths as a result of PSM in patients who underwent NPWT irrespective of the presence of MRSA infection.

CONCLUSION

MRSA infection was an independent risk factor for PSM-related in-hospital mortality. NPWT may improve the prognosis for patients with MRSA mediastinitis.

Mediastinitis in pediatric cardiac surgery: Prevention, diagnosis and treatment

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.

A rifampicin-containing antibiotic treatment improves outcome of staphylococcal deep sternal wound infections

BACKGROUND

Deep sternal wound infection (DSWI) is a severe complication after cardiac surgery, mostly caused by staphylococci. Little is known about the optimal antibiotic management.

METHODS

A 10 year retrospective analysis of 100 patients with staphylococcal DSWI after cardiac surgery in a tertiary hospital. Treatment failure was defined as sternal wound dehiscence or fistula at the end of the prescribed antibiotic therapy, 12 months later, or DSWI-related death.

RESULTS

Most patients were male (83%) and the median age was 72 years [interquartile range (IQR) 63-76]. Coronary artery bypass was the most frequent preceding procedure (93%). The median time to diagnosis of DSWI was 13 days (IQR 10-18) after surgery. Clinical presentation consisted of wound discharge in 77% of patients. Coagulase-negative staphylococci were isolated in 54 and Staphylococcus aureus in 46 patients. All patients received antibiotics and 95% underwent surgical debridement. The median duration of antibiotic treatment was 47 days (IQR 41-78). During follow-up, 21 out of 100 patients experienced treatment failure. Of these, 8/21 patients (38%) died from DSWI after a median of 12 days (IQR 8-30). In the multivariate analysis, a rifampicin-containing antibiotic regimen was the only factor associated with lower risk of treatment failure (hazard ratio 0.26, 95% confidence interval 0.10-0.64, P = 0.004). Prolonged treatment (12 weeks instead of 6 weeks) did not alter outcome (P = 0.716) in patients without prosthetic valve endocarditis.

CONCLUSIONS

Treatment of rifampicin-susceptible staphylococcal DSWI with a rifampicin-containing antibiotic regimen may improve the outcome. After surgical debridement an antibiotic treatment of 6 weeks may be adequate for staphylococcal DSWI.

Combination of continuous irrigation and vacuum-assisted closure is effective for mediastinitis after cardiac surgery in small children

There is still no consensus on the optimal management to treat pediatric mediastinitis. We assessed the efficacy of continuous irrigation and vacuum-assisted closure (VAC) for mediastinitis in children. This study retrospectively reviewed 20 patients aged <5 years with mediastinitis from December 2002 to December 2009. The median age at the onset was 12 months (0.6-60 months), and the median body weight was 6.9 kg (3.1-15.3 kg). Continuous irrigation was applied for extensive mediastinitis or unstable hemodynamic cases and VAC for localized or ineffective cases after continuous irrigation. A 2-4-week course of intravenous antibiotics was administered after sternal closure. Continuous irrigation was initially applied in 19 patients and VAC in one patient. VAC was employed in six patients because of recurrent or prolonged mediastinitis after continuous irrigation. All patients underwent direct sternal closure without any flap. The median duration of the hospital stay was 49.5 days (15-158 days). Although two patients died of low cardiac output, 18 children survived and had no recurrence after the discharge during a median follow-up of 14 months (1-81 months). The combination of continuous irrigation and VAC is, therefore, considered to be a safe and effective option to minimize the morbidity and mortality in pediatric mediastinitis.

Multidisciplinary therapy of a large esophago-pericardial fistula arising from Barrett's esophagus

Esophago-pericardial fistula is a rare complication of benign esophageal pathologies. We present the case report of a patient with Barrett's esophagus complicated by an esophago-pericardial fistula managed by a multi-therapeutic approach to close the fistula using an autologous pericardial patch; placement of a coated, expandable, metallic esophageal stent; and a feeding jejunostomy.

Managing deep sternal wound infections with vacuum-assisted closure

Deep sternal wound infection is an uncommon but serious complication of cardiac surgery. Currently, there is no consensus on the optimal management. Vacuum-assisted closure (VAC) has been increasingly used to facilitate wound healing. We aim to review the management of deep sternal wound infections using VAC dressing at our hospital. A retrospective review of consecutive cases of deep sternal wound infections was carried out. Median sternotomies were carried out in 2665 patients between July 2001 and June 2006. Thirty-one patients developed deep sternal wound infections (1.2%). In 26 of these patients, VAC dressing was used either as a stand-alone therapy or as an adjunct to late sternal reconstruction. Deep sternal wound infections were diagnosed on average 13 days from initial surgery. Of the patients treated with VAC dressing, 17 (65%) had stand-alone VAC therapy and 9 had VAC therapy followed by sternal reconstruction. The average duration of VAC dressing in the two groups were 21 and 13 days respectively. There were seven in-hospital deaths, six in the stand-alone VAC group and one death from a reconstructive patient who did not have VAC therapy. The length of hospital stay was similar in two VAC groups (37 vs 45 days). Median follow up was 17 months. No late relapse was found in the stand-alone group. In the intermediate therapy group, two patients had chronic wound sinuses and one patient had a wound collection. Vacuum-assisted closure dressing may be used both as a stand-alone and as an intermediate therapy for deep sternal wound infection. Reconstructive surgery may be avoided in a significant proportion of patients. No late relapse has been associated with VAC use.

Postoperative mediastinitis in children: improvement of simple primary closed drainage

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.

Poststernotomy mediastinitis: a review of conventional surgical treatments, vacuum-assisted closure therapy and presentation of the Lund University Hospital mediastinitis algorithm

Poststernotomy mediastinitis, also commonly called deep sternal wound infection, is one of the most feared complications in patients undergoing cardiac surgery. The overall incidence of poststernotomy mediastinitis is relatively low, between 1% and 3%, however, this complication is associated with a significant mortality, usually reported to vary between 10% and 25%. At the present time, there is no general consensus regarding the appropriate surgical approach to mediastinitis following open-heart surgery and a wide range of wound-healing strategies have been established for the treatment of poststernotomy mediastinitis during the era of modern cardiac surgery. Conventional forms of treatment usually involve surgical revision with open dressings or closed irrigation, or reconstruction with vascularized soft tissue flaps such as omentum or pectoral muscle. Unfortunately, procedure-related morbidity is relatively frequent when using conventional treatments and the long-term clinical outcome has been unsatisfying. Vacuum-assisted closure is a novel treatment with an ingenious mechanism. This wound-healing technique is based on the application of local negative pressure to a wound. During the application of negative pressure to a sternal wound several advantageous features from conventional surgical treatment are combined. Recent publications have demonstrated encouraging clinical results, however, observations are still rather limited and the underlying mechanisms are largely unknown. This review provides an overview of the etiology and common risk factors for deep sternal wound infections and presents the historical development of conventional therapies. We also discuss the current experiences with VAC therapy in poststernotomy mediastinitis and summarize the current knowledge on the mechanisms by which VAC therapy promotes wound healing. Finally, we suggest a structured algorithm for using VAC therapy for treatment of poststernotomy mediastinitis in clinical practice.

Poststernotomy mediastinitis: comparison of two treatment modalities

Poststernotomy mediastinitis (PM) is a serious and potentially lethal condition with an overall incidence varying from 0.4-5%. There is little consensus on the ideal management of PM. The aim of this retrospective study was to investigate the effectiveness of topical negative pressure (TNP) therapy vs. traditional closed drainage techniques (CDT) as a treatment modality for PM. We reviewed the data of 10,467 patients who underwent median sternotomy between 1 January 1992 and 31 December 2003. During this period 63 patients were treated for PM. Twenty-nine of these patients were treated with TNP and 34 with conventional CDT. Primary points of interest were: treatment modalities, mortality, surgical site infection recurrence and, duration of therapy and hospital stay. In this series, the total incidence of poststernotomy mediastinitis was 0.6% with high morbidity rates. In the TNP group, lower rates of recurring infection, therapeutic failure and fewer defects at discharge were seen (P<0.05). In conclusion, the results of our series add further data to the knowledge that PM is an important cause of morbidity and mortality. TNP is a safe and adequate treatment modality for treating PM.

Vacuum-Assisted Closure for Sternal Wounds: A First-Line Therapeutic Management Approach

BACKGROUND

Vacuum-assisted closure therapy has gained widespread use since its introduction in 1997. Previous studies have attributed significant benefit to its use for treatment of sternal wounds with or without mediastinitis. Management of sternal wounds with this therapy has been shown to decrease the number of dressing changes, reduce the time between débridement and definitive closure, and reduce costs associated with a protracted course of in-hospital dressing changes. The therapy has been used both as a bridge between débridement and definitive closure and as a catalyst to secondary sternal-wound healing.

METHODS

The authors performed a retrospective review of 103 patients who underwent vacuum-assisted closure therapy after median sternotomy between June of 1999 and March of 2004 at a single institution. The wounds were classified as sterile wounds, superficial sternal infections, and mediastinitis. The wound closure device, consisting of a polyurethane sponge and evacuation tube with in-line suction, was applied sterilely to all wounds over a layer of Acticoat.

RESULTS

Vacuum-assisted closure was utilized in the treatment of sternal wounds for 103 patients (67 male patients and 36 female patients) whose mean age was 52 years (range, 3 months to 91 years). Patient comorbidities included diabetes, chronic obstructive pulmonary disease, end-stage renal disease, immunosuppression, and others. Sixty-four percent of the patients had a diagnosis of mediastinitis; 36 percent had either superficial infections or a sterile wound. The therapy was utilized for an average period of 11 days per patient. Sixty-eight percent of the patients (70 of 103) had definitive chest closure with open reduction internal fixation and/or flap closure. The remaining 32 percent had no definitive closure method. The overall mortality rate was 28 percent (29 of 103 patients), although no deaths were directly related to use of the therapy, and only four deaths resulted from sepsis as a consequence of mediastinitis.

CONCLUSIONS

The authors report the largest series of patients treated with this therapy for post-sternotomy sternal wounds and believe it is safe and effective as a first-line therapy in the management of sternal wounds. The mortality rate from their study represents the patients' underlying disease process and comorbidities and is not a reflection of complications associated with the therapy. Vacuum-assisted closure therapy has been shown to decrease wound edema, decrease the time to definitive closure, and reduce wound bacterial colony counts. The authors have implemented the therapy for most patients with sternal wounds/mediastinitis at their institution, and believe it should be a standard protocol in the first-line management of these types of wounds.

BLOOD NEUTROPHIL BACTERICIDAL ACTIVITY AGAINST METHICILLIN-RESISTANT AND METHICILLIN-SENSITIVE STAPHYLOCOCCUS AUREUS DURING CARDIAC SURGERY

Whether methicillin-resistant Staphylococcus aureus (MRSA) constitutes per se an independent risk factor for morbidity and mortality after surgery as compared with methicillin-sensitive Staphylococcus aureus (MSSA) remains a subject of debate. The aim of this study was to assess whether innate defenses against MRSA and MSSA strains are similarly impaired after cardiac surgery. Both intracellular (isolated neutrophil functions) and extracellular (plasma) defenses of 12 patients undergoing scheduled cardiac surgery were evaluated preoperatively (day 0) and postoperatively (day 3) against two MSSA strains with a low level of catalase secretion and two MRSA strains with a high level of catalase secretion, inasmuch as SA killing by neutrophils relies on oxygen-dependent mechanisms. After surgery, an increase in plasma concentration of IL-10, an anti-inflammatory cytokine able to inhibit reactive oxygen species secretion and bactericidal activity of neutrophils, was evidenced. Despite the fact that univariate analysis suggested a specific impairment of neutrophil functions against MRSA strains, two-way repeated-measures ANOVA failed to demonstrate that the effect of S. aureus phenotype was significant. On the other hand, an increase in type-II secretory phospholipase A2 activity, a circulating enzyme involved in SA lysis, was evidenced and was associated with an enhancement of extracellular defenses (bactericidal activity of plasma) against MRSA. Overall, cardiac surgery and S. aureus phenotype had a significant effect on plasma bactericidal activity. Cardiac surgery was characterized by enhanced antibacterial defenses of plasma, whereas neutrophil killing properties were reduced. The overall effect of S. aureus phenotype on neutrophil functions did not seem significant.

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

OBJECTIVE

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.

METHODS

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.

RESULTS

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.

CONCLUSIONS

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.

Usefulness of routine epicardial pacing wire culture for early prediction of poststernotomy mediastinitis

Poststernotomy mediastinitis (PSM) is one of the most serious complications of cardiac surgery, and its associated morbidity and mortality demand early recognition for emergency therapy. In this study, we investigated the usefulness of epicardial pacing wire (EPW) cultures for the prediction of PSM. Among 2,200 patients who underwent a cardiac surgical procedure at our hospital between 1 January 1999 and 31 December 2001, 82 (3.7%) had PSM; Staphylococcus aureus was the organism (45.1%) most frequently isolated at the time of surgical debridement. EPWs from 1,607 (73.0%) patients, 73 (4.5%) of whom developed PSM, were cultured. EPW cultures from 466 (29.0%) were positive, most often (74.9%) for coagulase-negative Staphylococci. EPW cultures were truly positive in 26 cases, truly negative in 1,106 cases, falsely positive in 428 cases, and falsely negative in 47 cases (with sterile cultures in 35 cases and a culture positive for an organism different from that isolated at the time of debridement in 12 cases). EPW culture had a positive predictive value of only 5.7% and a high negative predictive value (95.9%) for the diagnosis of PSM, with an accuracy of 70.4%. However, the likelihood ratio of positive (1.27) and negative (0.89) tests indicated only small changes in pretest-to-posttest probability. Therefore, a strategy of routine culture of EPWs to predict PSM seems questionable.

Primary closure for postoperative mediastinitis in children

OBJECTIVES

Mediastinitis affects approximately 1% of children undergoing median sternotomy. Conventional therapy involves debridement followed by open wound care with delayed closure, days to weeks of closed suction or antimicrobial irrigation, and vacuum-assisted closure or muscle flap closure. We hypothesized that primary closure without prolonged suction or irrigation is an effective, less traumatic treatment for mediastinitis in children.

METHODS

From January 1986 to July 2002, 6705 procedures involving median sternotomy were performed at the C. S. Mott Children's Hospital, resulting in 57 cases of mediastinitis (0.85%). Cases were divided into 2 groups, with 42 cases treated with primary closure and 15 cases treated with delayed or muscle flap closure. The 42 cases of primary closure comprised the primary study group of this institutional review board-approved, retrospective analysis. Patient demographics, surgical variables, mediastinitis-related parameters, and outcomes were evaluated.

RESULTS

One patient had recurrent mediastinitis for an overall infection eradication rate of 97% (40/41). Three patients (7%) required re-exploration for suspected ongoing infection. Of these re-explorations, 1 patient had evidence of continued mediastinitis. The remaining 2 patients with sepsis of unclear cause had no clinical or culture evidence of recurrent infection. One of these patients ultimately died of sepsis without active mediastinitis for a hospital survival of 97% (41/42). No significant differences could be detected between the treatment successes and failures in this small cohort of patients.

CONCLUSIONS

Simple primary closure is an effective means to treat selected cases of postoperative mediastinitis in children. The results compare favorably with other more lengthy or debilitating treatments.

Post-Mediastinitis Ventricle Rupture:. Closing the Chest Without Closing the Heart?

Right ventricular rupture following mediastinitis is an unusual but potentially life-threatening complication of cardiac surgery, related to the "open" debridement technique. There are few reports of complex surgical management including repair of the tear and wound closure with omentoplasty or muscle flap with ECC. We report the case of a patient with a right ventricular rupture complicating mediastinitis, which was successfully treated by direct closure of the chest wall without repairing the ventricle tearing and without ECC. We believe that it can be a quick and effective solution at first attempt, and may be a successful and definitive treatment.

The Impact of Methicillin Resistance on the Outcome of Poststernotomy Mediastinitis Due toStaphylococcus aureus

The impact of methicillin resistance on morbidity and mortality among patients with severe Staphylococcus aureus infection remains highly controversial. We retrospectively analyzed patients with mediastinitis due to methicillin-susceptible S. aureus (MSSA; 145 patients) or methicillin-resistant S. aureus (MRSA; 73 patients) who were treated with closed drainage using Redon catheters. Initial empirical antibiotic therapy was appropriate for every patient. Patients with MRSA mediastinitis were older, had higher disease severity scores at admission to the intensive care unit (ICU), and had longer periods of MRSA incubation. Multivariate analysis revealed that ICU mortality was associated with age of > or =65 years, incubation time of < or =15 days, bacteremia, higher Acute Physiology and Chronic Health Evaluation II score, and receipt of mechanical ventilation > or =2 days after surgical debridement, but not with methicillin resistance. After adjustment, durations of mechanical ventilation and Redon catheter drainage were similar for both groups (for patients infected with MRSA, only the time to mediastinal effluent sterilization remained longer). Methicillin resistance did not significantly affect ICU mortality among patients with poststernotomy mediastinitis who benefited from optimal treatments.

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 debridement or before placement of a vascularized tissue flap.

[Plastic surgery procedures in the treatment of mediastinitis in adult]

Closed vacuum drainage is becoming the standard technique in most early postoperative mediastinitis, open wound treatment being only necessary in case of failure of the previous technique or in high grade mediastinitis. The reconstruction technique to be chosen depends on both resulting wound presentation after debridement and thorax morphology. Mediastinal dead space obliteration is a "sine qua non" for success often requiring multiple flap transposition. Since 1983, reconstructive procedures were carried out in 205 patients, of them 95 had bilateral pectoralis major turn-over transposition flaps on internal pedicules, following internal mammary artery coronary revascularisation in 45. Trapezius and latissimus dorsi were the next most used flaps. Transposition of the omentum although especially well suited for torpid wounds was to often precluded by bad abdominal risk factors. Conservative closed drainage salvaged by reconstructive procedures when necessary has greatly improved both survival and functional outcome of these patients.

Sternal puncture allows an early diagnosis of poststernotomy mediastinitis

OBJECTIVES

Poststernotomy mediastinitis after cardiac operations is a nosocomial infection involving the mediastinal space and the sternum, with a high mortality rate mostly related to a late diagnosis. We investigated whether sternal puncture might facilitate and shorten the delay in the diagnosis of mediastinitis.

METHODS

Of 1024 patients undergoing sternotomy for cardiac surgery, sternal puncture was performed in a subgroup of 49 patients in whom mediastinitis was suspected.

RESULTS

Sternal puncture culture results were positive for all patients with true mediastinitis (n = 23) and negative in 24 of 26 patients without mediastinitis. In addition, sternal puncture allowed diagnosis of mediastinitis with a shorter delay (9 +/- 5 days vs 13 +/- 8 days, P =.04) and caused a reduction in the length of mechanical ventilation (3 +/- 4 days vs 10 +/- 13 days, P =.02) and stay in the intensive care unit (9 +/- 7 days vs 18 +/- 15 days, P =.02) compared with that found in another group of patients (n = 20) operated on for true mediastinitis on the basis of the presence of classic, delayed, clinical signs.

CONCLUSIONS

Our study shows that sternal puncture is a rapid and safe method to ensure the diagnosis of poststernotomy mediastinitis.

Nosocomial infections occurring during receipt of circulatory support with the paracorporeal ventricular assist system

This retrospective study sought to report the spectrum of infections in a homogenous group of 39 patients who underwent implantation of the Thoratec paracorporeal ventricular assist device system (Thoratec Laboratories) in an emergency setting. Thirty-one of the 39 patients developed a total of 99 nosocomial infections (attack rate, 79.5%; incidence, 4.9 per 100 support-days). The lungs were the most frequently involved site (31.3%), and coagulase-negative Staphylococcus species were the pathogens most frequently isolated (16.2%). Infected patients required more transfusions and chest surgical revisions, as well as a longer duration of mechanical ventilation and a longer stay in the intensive care unit, compared with uninfected patients. Cox regression analysis revealed that chest surgical revision was the only independent risk factor for infection at any site (odds ratio, 2.6; 95% confidence interval, 1.2-5.7). There was no significant effect of infection on heart transplantation rate and overall survival.

Is it possible to cure mediastinitis in patients with major postcardiac surgery complications?

BACKGROUND

The prognosis for mediastinitis after cardiac operation has improved during the last two decades, but most series do not include patients who already have a major postoperative complication when the infection developed.

METHODS

Our 9-year prospective study of 371 consecutive patients with mediastinitis compared the characteristics of patients admitted to the intensive care unit primarily for mediastinitis with those who developed mediastinitis after intensive care unit admission for severe postoperative organ failure.

RESULTS

We identified 323 (87%) primary and 48 (13%) secondary mediastinitis patients. The incubation time for mediastinitis was longer for secondary mediastinitis patients, despite similar initial operations. Staphylococcus aureus was responsible for approximately 60% of the episodes in both groups; however, the incidence of methicillin resistance was 2.5 times higher in secondary mediastinitis patients (p < 0.0001). The mediastinitis cure rate was similar for both groups. However, intensive care unit mortality (63% versus 21%), duration of mechanical ventilation (40 versus 9 days), and length of intensive care unit stay (53 versus 28 days) were significantly higher for secondary mediastinitis patients (p < 0.0001).

CONCLUSIONS

The presence of a prior major postoperative complication does not alter the cure rate of mediastinal infections, but does greatly reduce the survival rate.