Major bleeding during negative pressure wound/V.A.C.®--therapy for postsurgical deep sternal wound infection--a critical appraisal

Prevention, Diagnosis and Management of Post-Surgical Mediastinitis in Adults Consensus Guidelines of the Spanish Society of Cardiovascular Infections (SEICAV), the Spanish Society of Thoracic and Cardiovascular Surgery (SECTCV) and the Biomedical Research Centre Network for Respiratory Diseases (CIBERES)

This is a consensus document of the Spanish Society of Cardiovascular Infections (SEICAV), the Spanish Society of Thoracic and Cardiovascular Surgery (SECTCV) and the Biomedical Research Centre Network for Respiratory Diseases (CIBERES). These three entities have brought together a multidisciplinary group of experts that includes anaesthesiologists, cardiac and cardiothoracic surgeons, clinical microbiologists, infectious diseases and intensive care specialists, internal medicine doctors and radiologists. Despite the clinical and economic consequences of sternal wound infections, to date, there are no specific guidelines for the prevention, diagnosis and management of mediastinitis based on a multidisciplinary consensus. The purpose of the present document is to provide evidence-based guidance on the most effective diagnosis and management of patients who have experienced or are at risk of developing a post-surgical mediastinitis infection in order to optimise patient outcomes and the process of care. The intended users of the document are health care providers who help patients make decisions regarding their treatment, aiming to optimise the benefits and minimise any harm as well as the workload.

Post-CABG Deep Sternal Wound Infection: A Retrospective Comparative Analysis of Early versus Late Referral to a Plastic Surgery Unit in a Tertiary Care Center

Background  Deep sternal wound infections (DSWI) following median sternotomy are initially treated by the cardiothoracic surgeons and are referred to a plastic surgical unit late in the course of time.

Methods  This is a retrospective review done in a tertiary care teaching institute from January 2005 to June 2018 and the data of 72 patients who had DSWI out of 4,214 patients who underwent median sternotomy for coronary artery bypass grafting (CABG) was collected with respect to the duration between CABG and presentation of DSWI as well as time of referral to a plastic surgery unit. We defined early referral as < or equal to 15 days from presentation and late referral as > 15 days. Both groups were compared with respect to multiple parameters as well as early and late postoperative course, postoperative complications, and mortality.

Results  The early group had 33 patients, while the late group had 39 patients. The number of procedures done by the cardiothoracic team before referral to the plastic surgery unit is significant ( p = 0.002). The average duration from the presentation of DSWI to definitive surgery was found to be 16.58 days in the early group and 89.36 days in the late group. The rest of the variables that were compared in both the groups did not have significant differences.

Conclusion  There is no statistical difference between early and late referral to plastic surgery in terms of mortality and morbidity. Yet, early referrals could lead to highly significant reduction in total duration of hospital stay, wound healing, and costs. Early referral of post-CABG DSWIs to Plastic surgeons by the cardiothoracic surgeons is highly recommended.

Negative Pressure Wound Therapy (Wound VAC) in the Treatment of Chylous Fistula After Neck Dissection

OBJECTIVES

Cervical chylous fistula is an uncommon but potentially severe occurrence associated with neck surgery. Methods for treating this problem have inconsistent efficacy and may result in lengthy hospital stays. Negative pressure wound therapy (NPWT) is a highly effective tool in the management of complex wounds. We report 3 cases where NPWT was successfully used to treat chylous fistulas following neck dissection.

METHODS

This is a retrospective chart review of 3 patients who developed chylous fistulas after neck dissection and were successfully treated with NPWT.

RESULTS

Chylous ouput ceased within 2 to 8 days of proper wound VAC placement. Hospital stays ranged from 6 to 47 days. Patients received altered diets, including TPN for 1 patient with high-flow output and nil-per-os (NPO) or clear liquids for the others. Patients received octreotide throughout their hospitalization.

CONCLUSION

NPWT shows potential as a treatment option for both high-volume and low-volume chylous fistulas following neck dissection.

Reducing Risks Associated With Negative-Pressure Wound Therapy: Strategies for Clinical Practice

Negative-pressure wound therapy represents a relatively new strategy for wound management. Significant, life-threatening complications (bleeding, infection, and retained dressing material) have been associated with negative-pressure wound therapy. As a result, the Food and Drug Administration published several warnings to negative-pressure wound therapy users and recommended that clinicians ordering, managing, and/or monitoring negative-pressure wound therapy be aware of the potential complications and be prepared to take prompt action to reduce patients' risk for harm. This article reviews and organizes published consensus, expert opinion, research, and manufacturer guidelines about patient safety during negative-pressure wound therapy relevant to nurses practicing in acute and critical care settings, including in advanced practice roles.

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.

Management of the Open Abdomen after Liver Transplantation

INTRODUCTION

The optimal management of the open abdomen (OA) after liver transplantation (LT) is unclear. The negative pressure wound therapy (NPWT) has been shown to be safe and can increase the chance for early fascial closure in trauma or septic patients. However, little data are available on the specific setting of LT. We aimed to report our experience of OA after LT, marked by the recent use of NPWT.

METHODS

All patients with postponed wall closure after LT, from 2002 to 2014, in a single institution were included and retrospectively analyzed. Our management of OA after LT has shifted from skin-only closure (SOC) followed by abdominal wall reconstruction at a distance to the use of NPWT with early fascial closure.

RESULTS

Of the 1559 LTs performed during the study period, immediate abdominal wall closure at the end of transplantation could not be achieved in 46 (2.9%) patients. Of them, SOC was performed in 22 (47.8%) patients, whereas vacuum-assisted closure (VAC) therapy was used in 24 (52.1%) patients. The comprehensive complication indexes (CCI) were similar [CCI: 66 (0-100) in the SOC group vs. 56 (0-100) in the VAC group; p = 0.55]. No evisceration or fistula occurred in both groups. One (4.2%) postoperative bleeding case was reported in the VAC group. Early fascial closure was achieved within a median of 5.5 days (1-12) for the 24 patients (100%) of the VAC group. In four of them, a biological mesh was necessary. Only nine patients (52.9%) of the survivors in the SOC group underwent abdominal reconstruction.

CONCLUSION

The NPWT in patients with OA after LT enables early fascial closure with limited morbidity provided a specific attention is given to the risk of bleeding. These results support the use of NPWT as the first option in OA patients after LT.

Negative pressure wound therapy technologies for chronic wound care in the home setting: A systematic review

The use of negative pressure wound therapy (NPWT) is increasing in both the inpatient and outpatient settings. We conducted a systematic review on the efficacy and safety of NPWT for the treatment of chronic wounds in the home setting. We searched MEDLINE, Embase, the Cochrane Central Register of Controlled Trials, and the Cumulative Index to Nursing and Allied Health Literature, up to June 2014. Two independent reviewers screened search results. Seven studies met our criteria for inclusion. Six of the studies compared NPWT devices to other wound care methods and one study compared two different NPWT technologies. Data were limited by variability in the types of comparator groups, methodological limitations, and poor reporting of outcomes. We were unable to draw conclusions about the efficacy or safety of NPWT for the treatment of chronic wounds in the home setting due to the insufficient evidence. Consensus is needed on the methods of conducting and reporting wound care research so that future studies are able inform decisions about the use of NPWT in the home environment for chronic wounds.

Poststernotomy mediastinitis: a classification to initiate and evaluate reconstructive management based on evidence from a structured review

Early recognition and, where possible, avoidance of risk factors that contribute to the development of poststernotomy mediastinitis (PSM) form the basis for successful prevention. Once the presence of PSM is diagnosed, the known risk factors have been shown to have limited influence on management decisions. Evidence-based knowledge on treatment decisions, which include the extent and type of surgical intervention (other than debridement), timing and others is available but has not yet been incorporated into a classification on management decisions regarding PSM. Ours is a first attempt at developing a classification system for management of PSM, taking the various evidence-based reconstructive options into consideration. The classification is simple to introduce (there are four Types) and relies on the careful establishment of two variables (sternal stability and sternal bone viability and stock) prior to deciding on the best available reconstructive option. It should allow better insight into why treatment decisions fail or have to be altered and will allow better comparison of treatment outcomes between various institutions.

Severe complications after negative pressure wound therapy in burned wounds: two case reports

We present two typical cases of severe complications (sepsis and hemorrhage) after negative pressure wound therapy (NPWT) in burned patients. Necrotic tissues in some deep burn wounds are difficult to judge correctly and remove thoroughly. An electrically burned blood vessel looks “intact” but can easily break. Necrotic tissue or injured blood vessels when using NPWT are dangerous, both for causing sepsis and hemorrhage. This is the first article that reports the severe complications of NPWT in burned patients. It is imperative to heed indications and avoid contraindications. Proper preparation of wound beds, close observation, and sufficient irrigation are also crucial to avoid these severe complications, and there is an urgent need to substitute the central vacuum system with the low-pressure system.

Management of chronic osteomyelitis of the tibia with life-threatening complications under negative pressure wound therapy and isolation of Helcococcus kunzii

We report the case of an 86-year-old man with severe wound infection originating from a chronic crural ulcer of the lower limb, which under negative pressure wound therapy led to excessive tissue necrosis and perforation of the anterior tibial artery. A swab taken 10 and 7 days preoperatively was positive for Helcococcus kunzii. H. kunzii has been described as a potentially pathogenic organism. The questions whether the negative pressure wound therapy itself caused the bleeding or the negative pressure wound therapy, which generates an anaerobic atmosphere, has triggered the growth and invasion of the facultative anaerobic bacterium H. kunzii and owing to the infection the artery perforated or whether the bacteria has no influence at all remain currently unanswered. After surgical debridement the signs of infection were completely eliminated, and a free musculocutaneous flap led to rapid healing of the wound. Following which H. kunzii was no longer detectable.

Impact of vacuum-assisted closure (VAC) therapy on clinical outcomes of patients with sternal wound infections: a meta-analysis of non-randomized studies

Objective

To examine the impact of VAC therapy on mortality of patients with sternal wound infections after cardiothoracic surgery.

Summary Background Data

Controversial results regarding mortality of patients with sternal wound infections were published.

Methods

We performed a systematic search in PubMed and Scopus. Mortality was the primary outcome of the meta-analysis. Recurrences, complications and length of stay were secondary outcomes.

Results

Twenty-two retrospective studies including 2467 patients were eligible for inclusion. Patients treated with VAC had significantly lower mortality compared to those treated without VAC [2233 patients, RR = 0.40, (95% CI 0.28, 0.57)]. This finding was consistent regardless of the study design, the exclusion of studies with positive findings, the criteria for establishment of the compared groups, the time of mortality assessment or the type of infections under study, provided that adequate data was available. VAC therapy was associated with fewer recurrences (RR = 0.34, 95% CI: 0.19–0.59). The meta-analysis did not show any difference in the length of stay (RR = −2.25, 95% CI: −7.52–3.02).

Conclusions

VAC therapy was associated with lower mortality than other surgical techniques in retrospective cohorts of patients with DSWIs following cardiothoracic surgery.

Use of a risk assessment method to improve the safety of negative pressure wound therapy

To conduct a risk analysis of the negative pressure wound therapy (NPWT) care process and to improve the safety of NPWT, a working group of nurses, hospital pharmacists, physicians and hospital managers performed a risk analysis for the process of NPWT care. The failure modes, effects and criticality analysis (FMECA) method was used for this analysis. Failure modes and their consequences were defined and classified as a function of their criticality to identify priority actions for improvement. By contrast to classical FMECA, the criticality index (CI) of each consequence was calculated by multiplying occurrence, severity and detection scores. We identified 13 failure modes, leading to 20 different consequences. The CI of consequences was initially 712, falling to 357 after corrective measures were implemented. The major improvements proposed included the establishment of 6-monthly training cycles for nurses, physicians and surgeons and the introduction of computerised prescription for NPWT. The FMECA method also made it possible to prioritise actions as a function of the criticality ranking of consequences and was easily understood and used by the working group. This study is, to our knowledge, the first to use the FMECA method to improve the safety of NPWT.