Mediastinitis Following Pediatric Cardiac Surgery

MEDIASTINITIS AFTER CONGENITAL HEART SURGERY: EPIDEMIOLOGY, CLINICAL FEATURES AND OUTCOMES

Mediastinitis after surgery for congenital heart disease has a great impact on morbidity and mortality. However, there are scarce studies focused on the epidemiology of postsurgical mediastinitis in pediatric patients. In this 18-year period retrospective study, the cumulative incidence of mediastinitis was low: 0.64%, (95% confidence interval: 0.36-1.1). Gram-negative bacilli were common (35%). The mortality rate was 7.1%, associated with fungal infection.

Efficacy of Primary Closure Technique in Treatment of Post-Sternotomy Mediastinitis in Paediatric Group: A Randomized Controlled Trial

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.

Pectoralis major muscle turnover flap reconstruction for treatment of deep sternal wound infection in infants and children

OBJECTIVE

The aim of the study is to assess the therapeutic effect and applicability of pectoralis major muscle turnover flap (PMMTF) reconstruction for treatment of deep sternal wound infection (DSWI) after cardiac surgery in infants and children.

METHODS

From March 2013 to October 2021, 23 patients with DSWI after cardiac surgery underwent PMMTF reconstruction. The data and outcomes of the patients were retrospectively analyzed.

RESULTS

Twenty patients were treated with unilateral PMMTF reconstruction, and three patients were treated by bilateral PMMTF. All of the sternal wounds healed successfully. All patients survived and were discharged without evidence of infection. In a follow-up period, ranging from 15 to 83 months (mean 32.6 months), all patients demonstrated normal development with no limitations to limb movements. There were no signs of chronic sternal infection in all of them.

CONCLUSION

PMMTF reconstruction is a simple, feasible, and effective treatment of DSWI after cardiac surgery in infants and children, with minimal developmental problems.

Is vacuum-assisted closure therapy feasible for children with deep sternal wound infection after cardiac surgery? The pooling results from current literature

Vacuum-assisted closure (VAC) has been used for children with deep sternal wound infections (DSWI); however, the safety and efficiency have not been determined. A meta-analysis was performed for outcomes of VAC therapy in children with DSWI after cardiac surgery. Electronic databases, including PubMed, Scopus, and Cochrane Library CENTRAL were searched systematically from January 1990 to October 2020 for the literature which reported the outcomes of VAC therapy for children with DSWI after cardiac surgery. Meta-regression and subgroup analyses were performed to find risk factors for prolonged length of VAC therapy and hospital stay. Eleven studies were included in this study, involving 217 subjects. VAC therapy was performed due to mediastinitis after congenital heart diseases (CHD) repair. In children with DSWI after cardiac surgery, length of VAC therapy, and hospital stay were 11.1 days (95% CI, 9.6-12.5 days) and 29.8 days (95% CI, 22.8-36.9 days), respectively. Incidence of infectious and wound-related complications was 8.5% (95% CI, 4.1%-13.0%). Overall mortality in this setting was 5.8% (95% CI, 2.5%-9.1%). In conclusion, in children with DSWI after cardiac surgery, length of VAC therapy and hospital stay were 11.1 and 29.8 days, respectively. Overall mortality was 5.8%. Although not significant, delayed chest closure, complex CHD, and Gram-negative bacilli/fungal infections may potentially contribute to prolonged duration of VAC treatment.

Extracardiac Complications in Intensive Care Units after Surgical Repair for Congenital Heart Disease: Imaging Review with a Focus on Ultrasound and Radiography

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.

Negative-Pressure Wound Therapy in Infants and Children: A Population-Based Study

BACKGROUND

Although the safety and benefits of negative-pressure wound therapy (NPWT) have been clearly demonstrated in the adult population, studies evaluating the safety and describing the use of NPWT in the pediatric population have been limited. Given this paucity, the goals of this study were to (1) evaluate the literature dedicated to NPWT use in infants and children and (2) leverage a population-level analysis to describe the experience of NPWT use in the pediatric population.

MATERIALS AND METHODS

We performed a literature review and analyzed the Truven Health Analytics MarketScan Commercial Claims Databases from 2006 to 2014 to identify infants and children treated with NPWT. We evaluated patient characteristics, indications, complications before and after NPWT placement, and health care utilization within 30 d of NPWT placement.

RESULTS

We identified 457 articles, 11 of which fit our inclusion criteria. Most studies (65.2%) were case reports or series with less than 10 patients. In addition, we identified 3184 patients aged younger than of 18 y who were treated with NPWT between 2006 and 2014. Serious incident complications within 30 d after NPWT placement were rare (bleeding 0.6%, septicemia 0.5%, and sepsis 0.5%).

CONCLUSIONS

Despite the lack of robust studies, NPWT is widely used for many indications and across different ages and providers. Given the low incidence of serious complications, we conclude that NPWT use in infants and children is safe and can be effectively used by different providers spanning surgical and nonsurgical disciplines.

Role of Negative Pressure Wound Care and Hyperbaric Oxygen Therapy for Sternal Wound Infections After Pediatric Cardiac Surgery

BACKGROUND

Sternal wound infections after pediatric cardiac surgery are uncommon but can be morbid.

METHODS

We describe an institutional protocol for complicated sternal wounds utilizing hyperbaric oxygen therapy (HBO) and negative pressure wound therapy (NPWT).

PARTICIPANTS

A retrospective chart review (2001-2013) of 4,028 pediatric cardiac operations in 3,264 patients less than 18 years of age.

RESULTS

Fifty-three patients (1.62%; 53/3,264) were diagnosed with clinical sternal wound infections. There were 27 (50.9%) males and 26 (49.1%) females. Thirty-seven (69.8%) patients received antibiotics and/or debridement; sixteen (30.2%) patients had more complicated infections requiring NPWT and/or HBO therapy. The time to heal for wounds treated with HBO and HBO + NPWT was a mean of 43.75 (±24.27) days (range: 21-98 days; median: 35 days). Among all infected patients, the time from diagnosis of the infection to resolution of the infection for all survivors was 7 to 98 days (mean: 26.41 days; median: 21 days). Forty-eight (90.6%) patients completely healed their wounds, and 45 (84.9%) patients are currently alive. Thirty-eight patients had a cyanotic cardiac diagnosis and 15 had an acyanotic cardiac diagnosis. The most common bacteria isolated from the blood or wound cultures was Staphylococcus aureus. Six of 53 patients died. Causes of death are as follows: three from respiratory failure, one from sepsis, one from hypoxic ischemic encephalopathy, and one from exsanguination leading to cardiac arrest Conclusions: Complicated sternal wound infections after pediatric cardiac surgery refractory to antibiotic therapy and/or debridement can be successfully treated with NPWT and/or HBO therapy.

Retrospective Review of Management and Outcomes of Pediatric Descending Mediastinitis

Objectives

To review the management and outcomes of pediatric patients treated for descending mediastinitis at a single institution and contribute to an updated mortality rate.

Study Design

Case series with chart review.

Setting

Tertiary care pediatric hospital.

Subjects and Methods

This study is a 19-patient case series of all patients treated for descending mediastinitis at a tertiary pediatric hospital from 1997 to 2015, and it serves as an update to the case series published from this institution in 2008. Review of management included time to diagnosis, time to surgery, surgical procedures performed, and antibiotics administered. The primary outcomes measured were length of hospitalization and mortality.

Results

In addition to 8 previously reported patients, we identified 11 pediatric patients treated for descending mediastinitis in the period of review. All 19 patients were <18 months old, and all survived their hospitalization. Fourteen patients underwent surgical drainage at least twice. The median length of hospital stay was 15 days. Retropharyngeal abscess was the source of infection in 16 of 19 patients, and methicillin-resistant Staphylococcus aureus (MRSA) was the isolated organism in 14 of 15 positive cultures.

Conclusion

This review represents the largest reported series of pediatric patients with descending mediastinitis. With 100% survival, our results suggest that pediatric descending mediastinitis can be safely managed by prompt surgical drainage. Broad-spectrum antibiotics covering MRSA and a low threshold for repeat surgical intervention have been an important part of our successful approach and may decrease length of stay.

Successful treatment of mediastinitis in a young child by omental translocation following extracardiac Fontan graft placement

Mediastinitis after a midline sternotomy can become a serious complication, especially after implantation of prosthetic vascular grafts. We present a case of a three-year-old boy with hypoplastic left heart syndrome who developed mediastinitis following his third-stage palliation (Fontan operation). Rather than following the "traditional" surgical therapy of graft explantation, debridement, and replacement, we chose to preserve the graft and protect it by omental translocation. The relative merits of this therapeutic approach, which is rarely utilized and underappreciated in children, are outlined and discussed.