[Results of vacuum-assisted wound closure system in the treatment of sternotomy wound infections following cardiac surgery]

[Negative pressure wound therapy for deep sternal wound infections: microbiological characteristics and antibiotic resistance]

OBJECTIVE

To evaluate bacterial flora in patients with deep sternal wound infection and the effect of negative pressure wound therapy on eradication of the pathogen.

MATERIAL AND METHODS

There were 102 patients with deep wound infection after cardiac surgery. Mean age was 66.9±9.9 years. Diabetes mellitus was detected in 21 (20.5%) cases, chronic obstructive pulmonary disease - in 15 (14.7%). Wound debridement via daily dressings was performed in 64 patients; vacuum-assisted dressings were applied in 38 patients. Bacteriological analysis of discharge was carried out every week.

Results. Mixed infection was observed in 38 (37.3%) patients. S.aureus was the most common pathogen (n=51, 50%), Gram negative bacteria were found in 36 (35.3%) patients. Negative pressure wound therapy ensured eradication of S.aureus within 3 weeks while dressings were associated with only 40% decrease of the incidence of positive analyses (p<0.05). Effectiveness of the method was not obtained for Gram negative bacteria.

CONCLUSION

Negative pressure wound therapy accelerates eradication of Gram positive pathogens but does not affect eradication of Gram negative microbes.

EWMA Document: Negative Pressure Wound Therapy

1. Introduction Since its introduction in clinical practice in the early 1990's negative pressure wounds therapy (NPWT) has become widely used in the management of complex wounds in both inpatient and outpatient care.¹ NPWT has been described as a effective treatment for wounds of many different aetiologies^2,3 and suggested as a gold standard for treatment of wounds such as open abdominal wounds,^4-6 dehisced sternal wounds following cardiac surgery^7,8 and as a valuable agent in complex non-healing wounds.^9,10 Increasingly, NPWT is being applied in the primary and home-care setting, where it is described as having the potential to improve the efficacy of wound management and help reduce the reliance on hospital-based care.¹¹ While the potential of NPWT is promising and the clinical use of the treatment is widespread, highlevel evidence of its effectiveness and economic benefits remain sparse.^12-14 The ongoing controversy regarding high-level evidence in wound care in general is well known. There is a consensus that clinical practice should be evidence-based, which can be difficult to achieve due to confusion about the value of the various approaches to wound management; however, we have to rely on the best available evidence. The need to review wound strategies and treatments in order to reduce the burden of care in an efficient way is urgent. If patients at risk of delayed wound healing are identified earlier and aggressive interventions are taken before the wound deteriorates and complications occur, both patient morbidity and health-care costs can be significantly reduced. There is further a fundamental confusion over the best way to evaluate the effectiveness of interventions in this complex patient population. This is illustrated by reviews of the value of various treatment strategies for non-healing wounds, which have highlighted methodological inconsistencies in primary research. This situation is confounded by differences in the advice given by regulatory and reimbursement bodies in various countries regarding both study design and the ways in which results are interpreted. In response to this confusion, the European Wound Management Association (EWMA) has been publishing a number of interdisciplinary documents^15-19 with the intention of highlighting: The nature and extent of the problem for wound management: from the clinical perspective as well as that of care givers and the patients Evidence-based practice as an integration of clinical expertise with the best available clinical evidence from systematic research The nature and extent of the problem for wound management: from the policy maker and healthcare system perspectives The controversy regarding the value of various approaches to wound management and care is illustrated by the case of NPWT, synonymous with topical negative pressure or vacuum therapy and cited as branded VAC (vacuum-assisted closure) therapy. This is a mode of therapy used to encourage wound healing. It is used as a primary treatment of chronic wounds, in complex acute wounds and as an adjunct for temporary closure and wound bed preparation preceding surgical procedures such as skin grafts and flap surgery. Aim An increasing number of papers on the effect of NPWT are being published. However, due to the low evidence level the treatment remains controversial from the policy maker and health-care system's points of view-particularly with regard to evidence-based medicine. In response EWMA has established an interdisciplinary working group to describe the present knowledge with regard to NPWT and provide overview of its implications for organisation of care, documentation, communication, patient safety, and health economic aspects. These goals will be achieved by the following: Present the rational and scientific support for each delivered statement Uncover controversies and issues related to the use of NPWT in wound management Implications of implementing NPWT as a treatment strategy in the health-care system Provide information and offer perspectives of NPWT from the viewpoints of health-care staff, policy makers, politicians, industry, patients and hospital administrators who are indirectly or directly involved in wound management.

Sternal reconstruction after post-sternotomy mediastinitis

Background

Deep sternal wound complications are uncommon after cardiac surgery. They comprise sternal dehiscence, deep sternal wound infections and mediastinitis, which will be treated as varying expressions of a singular pathology for reasons explained in the text.

Methodology and review

This article reviews the definition, prevalence, risk factors, prevention, diagnosis, microbiology and management of deep sternal wound infections and mediastinitis after cardiac surgery. The role of negative pressure wound therapy and initial and delayed surgical management is discussed with special emphasis on plastic techniques with muscle and omental flaps. Recent advances in reconstructive surgery are presented.

Conclusions

Deep sternal wound complications no longer spell debilitating morbidity and high mortality. Better understanding of risk factors that predispose to deep sternal wound complications and general improvement in theatre protocols for asepsis have dramatically reduced the incidence of deep sternal wound complications. Negative pressure wound therapy and appropriately timed and staged muscle or omental flap reconstruction have transformed the outcomes once these complications occur.

[Vacuum assisted closure (VAC) of pyothorax with bronchial fistula following radiotherapy, pneumonectomy and thoraco-myoplasty]

Pulmonary fibrosis and impeding gangrene as complications of radiotherapy and chemotherapy developed in a patient who previously underwent right upper lobectomy. Following completion pneumonectomy, bronchopleural fistula and consecutive thoracic empyema formed. This case presentation is to demonstrate the vicious circle of severe complications following oncological treatment. The role of vacuum assisted closure and other management options are discussed which resulted in full recovery of the patient after three years finally.

Silver toxicity with the use of silver-impregnated dressing and wound vacuum-assisted closure in an immunocompromised patient

Silver-containing topical agents are used to help prevent infectious complications in wound therapy. Toxicity from topical silver agent exposure was initially reported in 1975 and was clinically characterized by granulocytopenia. Currently, the data regarding potential toxicity associated with silver-impregnated devices are limited. A 23-year-old patient receiving chemotherapy for acute lymphoblastic leukemia presented with necrotizing fasciitis of the abdominal wall and scrotum from a Crohn disease-related psoas-enteric fistula. Surgical debridement of the soft-tissue and abdominal musculature was performed to the peritoneum. Silver-containing foam sponges and wound vacuum-assisted closure were applied directly to the peritoneum 2 weeks after initial debridement. Subsequently, the patient developed leukopenia, and workup revealed the serum silver level was 4 times normal level. Silver-impregnated sponges were discontinued and silver-free sponges and wound vacuum-assisted closure therapy resumed, followed by leukopenia resolution. Silver toxicity associated with routine application of silver-impregnated sponges has not been previously reported.

[Osteosynthesis with plates for full sternal dehiscence (Titanium Sternal Fixation System Synthes) -- first use in Hungary]

The prevalence of deep sternal infection after cardiac surgery is between 0,5 and 5%, with an average mortality up to 50%. The authors present the case of the rst sternal osteosynthesis carried out in Hungary after postoperative deep sternal infection. Using this orthopedic reconstructive surgical technique in this patient group, an anatomical reconstruction and reposition of the sternum is feasible. With the Titanium Sternal Fixation Synthes system reconstruction of total or partial sternal absence is possible.