1
|
Horriat NL, McCandless MG, Humphries LS, Ghanamah M, Kogon BE, Hoppe IC. Management of pediatric sternal wounds following congenital heart surgery: The role of the plastic surgeon in debridement and closure. J Card Surg 2022; 37:3695-3702. [PMID: 35979680 DOI: 10.1111/jocs.16841] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2022] [Revised: 07/23/2022] [Accepted: 07/25/2022] [Indexed: 11/30/2022]
Abstract
BACKGROUND Management of sternal wound infections (SWIs) in pediatric patients following congenital heart surgery can be extremely difficult. Patients with congenital cardiac conditions are at risk for complications such as sternal dehiscence, infection, and cardiopulmonary compromise. In this study, we report a single-institution experience with pediatric SWIs. METHODS Fourteen pediatric patients requiring plastic surgery consultation for complex sternal wound closure were included. A retrospective chart review was performed with the following variables of interest: demographic data, congenital cardiac condition, respective surgical palliations, development of mediastinitis, causative organism, number of debridements, presence of sternal wires, and choice of flap coverage. Primary endpoints included achieved chest wall closure and overall survival. RESULTS Of the 14 patients, 8 (57%) were diagnosed with culture-positive mediastinitis. The sternum remained wired at the time of final flap closure in eight (57%) patients. All patients were reconstructed with pectoralis major flaps, except one (7%) who also received an omental flap and two (14%) who received superior rectus abdominis flaps. One patient (7%) was treated definitively with negative pressure wound therapy, and one (7%) was too unstable for closure. Six patients developed complications, including one (7%) with persistent mediastinitis, two (14%) with hematoma formation, one (7%) with abscess, and one (7%) with skin necrosis requiring subsequent surgical debridement. There were three (21%) mortalities. CONCLUSIONS The management of SWI in congenital cardiac patients is challenging. The standard tenets for management of SWI in adults are loosely applicable, but additional considerations must be addressed in this unique subset population.
Collapse
Affiliation(s)
- Narges L Horriat
- Division of Plastic and Reconstructive Surgery, Department of Surgery, University of Mississippi Medical Center, Jackson, Mississippi, USA
| | - Martin G McCandless
- Division of Plastic and Reconstructive Surgery, Department of Surgery, University of Mississippi Medical Center, Jackson, Mississippi, USA
| | - Laura S Humphries
- Division of Plastic and Reconstructive Surgery, Department of Surgery, University of Mississippi Medical Center, Jackson, Mississippi, USA
| | - Mohammed Ghanamah
- Division of Cardiothoracic Surgery, Department of Surgery, University of Mississippi Medical Center, Jackson, Mississippi, USA
| | - Brian E Kogon
- Division of Cardiothoracic Surgery, Department of Surgery, University of Mississippi Medical Center, Jackson, Mississippi, USA
| | - Ian C Hoppe
- Division of Plastic and Reconstructive Surgery, Department of Surgery, University of Mississippi Medical Center, Jackson, Mississippi, USA
| |
Collapse
|
2
|
Wang G, Gao Y, Zhou G, Feng Z. Pectoralis major muscle turnover flap reconstruction for treatment of deep sternal wound infection in infants and children. J Card Surg 2022; 37:2309-2314. [PMID: 35506747 DOI: 10.1111/jocs.16567] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2022] [Revised: 03/23/2022] [Accepted: 03/26/2022] [Indexed: 11/28/2022]
Abstract
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.
Collapse
Affiliation(s)
- Gang Wang
- The Second School of Clinical Medicine, Southern Medical University, Guangzhou, China.,Department of Pediatric Cardiac Surgery, The Seventh Medical Center of the PLA General Hospital, Beijing, China
| | - Yongshun Gao
- Department of Pediatric Cardiac Surgery, The Seventh Medical Center of the PLA General Hospital, Beijing, China
| | - Gengxu Zhou
- The Second School of Clinical Medicine, Southern Medical University, Guangzhou, China.,Department of Pediatric Cardiac Surgery, The Seventh Medical Center of the PLA General Hospital, Beijing, China
| | - Zhichun Feng
- The Second School of Clinical Medicine, Southern Medical University, Guangzhou, China.,Department of Pediatrics, The Seventh Medical Center of the PLA General Hospital, Beijing, China
| |
Collapse
|
3
|
Tsuji S, Ikai A, Oyama K, Kin H, Koizumi J. Outcomes of primary sternal closure for postoperative mediastinitis in children. Eur J Cardiothorac Surg 2021; 59:951-957. [PMID: 33576375 DOI: 10.1093/ejcts/ezaa477] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/29/2020] [Revised: 11/15/2020] [Accepted: 12/05/2020] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVES We retrospectively analysed outcomes of debridement and primary sternal closure for postoperative mediastinitis in children. METHODS Between January 2007 and July 2019, 1285 patients under the age of 20 years underwent congenital heart surgery at the Iwate Medical University. Of these, 22 children had postoperative mediastinitis (1.7%). We performed adequate debridement and primary sternal closure with pectoralis major muscle advancement flaps. We evaluated hospital survival rates, reintervention, duration of intravenous antibiotic treatment, intensive care unit (ICU) stay and hospital stay. RESULTS The median age and weight at surgery were 12.5 months (range 0-228 months) and 7.8 kg (range 2.2-64.2 kg), respectively. Two patients (9%) had a history of delayed sternal closure. Staphylococcus was the most common causative agent for infection (82%). All cases were categorized as Robicsek's classification type II mediastinitis. The hospital survival rate was 95%, and freedom from reintervention for infectious complications was observed in 91% of the patients. The median durations of intravenous antibiotic treatment, ICU stay and hospital stay were 18 days (range 9-46 days), 4 days (range 1-87 days) and 22.5 days (range 11-87 days). The median follow-up time was 89 months (range 2-148 months), and there was no evidence of recurrent mediastinitis, musculoskeletal growth, physical deformity, breast development and upper trunk or limb movement. CONCLUSIONS Primary sternal closure is an effective procedure for children as it can significantly shorten treatment duration and reduce physical and psychological burdens. Its results compare favourably with those of conventional therapy in terms of mortality and complications.
Collapse
Affiliation(s)
- Shigeto Tsuji
- Department of Cardiovascular Surgery, Iwate Medical University, Morioka, Iwate, Japan
| | - Akio Ikai
- Department of Cardiovascular Surgery, Mt. Fuji Shizuoka Children's Hospital, Shizuoka, Japan
| | - Kotaro Oyama
- Department of Pediatrics, Iwate Medical University, Morioka, Iwate, Japan
| | - Hajime Kin
- Department of Cardiovascular Surgery, Iwate Medical University, Morioka, Iwate, Japan
| | - Junichi Koizumi
- Department of Cardiovascular Surgery, Iwate Medical University, Morioka, Iwate, Japan
| |
Collapse
|
4
|
Barlas V, Ali B, Shetty A. Safety of neonatal sternal wound reconstruction after open heart surgery. BMJ Case Rep 2020; 13:13/12/e237573. [PMID: 33370984 PMCID: PMC7757464 DOI: 10.1136/bcr-2020-237573] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
An open sternal wound is a dreaded complication after open heart surgery for neonatal congenital cardiac anomalies. Vascularised muscle flap reconstruction of sternal wound defects, to prevent life-threatening mediastinal infections, is the standard of care in adults and children. However, there is paucity of published literature regarding the safety of this technique in neonates. We describe a successful operative technique for complex reconstruction of an open heart sternal defect on a neonatal male patient. On 6 months postoperative follow-up, we identified an issue with sternal instability. Patient underwent a subsequent operation for reinforcement of the sternal wound repair with Vicryl mesh. The authors report safety of using three separate vascularised muscle flaps in a single neonatal operation. Long-term follow-up of the sternal wound reconstruction is warranted to determine need for secondary procedures.
Collapse
Affiliation(s)
- Venus Barlas
- School of Medicine, University of New Mexico, Albuquerque, New Mexico, USA
| | - Barkat Ali
- Department of Surgery, Division of Plastic and Reconstructive Surgery, University of New Mexico Health Sciences Center, Albuquerque, New Mexico, USA
| | - Anil Shetty
- Department of Surgery, Division of Plastic and Reconstructive Surgery, University of New Mexico Health Sciences Center, Albuquerque, New Mexico, USA
| |
Collapse
|
5
|
Sugiyama K, Watanuki H, Okada M, Futamura Y, Imazu R, Makino S, Matsuyama K. Resternotomy and coronary artery bypass grafting after omental flap procedure: A case report. Clin Case Rep 2020; 8:3154-3157. [PMID: 33363897 PMCID: PMC7752500 DOI: 10.1002/ccr3.3356] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2020] [Accepted: 08/30/2020] [Indexed: 11/09/2022] Open
Abstract
Few studies have reported resternotomy after an omental flap procedure. We describe the case of a 78-year-old man who received resternotomy after omental flap procedure for deep sternal wound infection and successfully underwent coronary artery bypass grafting. Although preoperative computed tomography showed funnel chest and limited space between the sternum and omentum, resternotomy was performed safely using circular electric sternum saw under partial cardiopulmonary bypass. Because the omentum functioned as cushioning material between the sternum and mediastinal organs, no injuries of the mediastinal organs occurred. An ultrasonic scalpel effectively dissected between the omentum and mediastinal organs, especially above the ascending aorta. The targeted coronary arteries were easily detected. The patient experienced no major cardiac or infectious events for three months. An ultrasonic scalpel is recommended for dissecting between the omentum and mediastinal organs.
Collapse
Affiliation(s)
- Kayo Sugiyama
- Department of Cardiac SurgeryAichi Medical University HospitalNagakuteJapan
| | - Hirotaka Watanuki
- Department of Cardiac SurgeryAichi Medical University HospitalNagakuteJapan
| | - Masaho Okada
- Department of Cardiac SurgeryAichi Medical University HospitalNagakuteJapan
| | - Yasuhiro Futamura
- Department of Cardiac SurgeryAichi Medical University HospitalNagakuteJapan
| | - Rintaro Imazu
- Department of Cardiac SurgeryAichi Medical University HospitalNagakuteJapan
| | - Satoshi Makino
- Department of Cardiac SurgeryAichi Medical University HospitalNagakuteJapan
| | | |
Collapse
|
6
|
Wyckman A, Abdelrahman I, Steinvall I, Zdolsek J, Granfeldt H, Sjöberg F, Nettelblad H, Elmasry M. Reconstruction of sternal defects after sternotomy with postoperative osteomyelitis, using a unilateral pectoralis major advancement muscle flap. Sci Rep 2020; 10:8380. [PMID: 32433505 PMCID: PMC7239941 DOI: 10.1038/s41598-020-65398-y] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2020] [Accepted: 05/04/2020] [Indexed: 11/24/2022] Open
Abstract
Background: The pectoralis major flap, which is usually harvested bilaterally, is considered a workhorse flap in the reconstruction of sternal defects. After a median sternotomy for open heart surgery, 1%-3% of patients develop deep infection and dehiscence of the sternal wound, some of which will eventually require reconstructive surgery. Our aim was to describe the clinical feasibility and associated complications of the unilateral pectoralis major advancement flap in the reconstruction of sternal defects. Methods: A retrospective analysis of all adult patients who were operated on using a unilateral pectoralis major flap for reconstruction of the chest wall at the Linköping University Hospital during 2008–18 was made using data retrieved from medical records. Results: Forty-three patients had reconstructions with unilateral pectoralis major flaps. Three flaps failed completely, and another 10 patients developed complications that required further operation. The factors that were independently associated with loss of the flaps and complications were: older age, male sex, the number of different antibiotics used, and a long duration of treatment with negative wound pressure. Fewer wound revisions before the reconstruction resulted in more complications. The factors that were independently associated with prolonged time to complete healing were emergency reoperation after the initial operation and complications after reconstruction. Conclusion: The unilateral pectoralis major advancement flap has proved to be a useful technique in the reconstruction of most sternal defects after sternal wound infection in older patients. There is, however, need for a follow-up study on a larger number of procedures to evaluate the long-term outcome compared with other methods of sternal reconstruction.
Collapse
Affiliation(s)
- Alexander Wyckman
- Department of Hand Surgery, Plastic Surgery and Burns, and Department of Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden.
| | - Islam Abdelrahman
- Department of Hand Surgery, Plastic Surgery and Burns, and Department of Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden.,Plastic Surgery Unit, Surgery Department, Suez Canal University, Ismailia, Egypt
| | - Ingrid Steinvall
- Department of Hand Surgery, Plastic Surgery and Burns, and Department of Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden
| | - Johann Zdolsek
- Department of Hand Surgery, Plastic Surgery and Burns, and Department of Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden
| | - Hans Granfeldt
- Department of Thoracic and Vascular Surgery in Östergötland, and Department of Health, Medicine and Caring Sciences, Linköping University, Linköping, Sweden
| | - Folke Sjöberg
- Department of Hand Surgery, Plastic Surgery and Burns, and Department of Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden
| | - Hans Nettelblad
- Department of Hand Surgery, Plastic Surgery and Burns, and Department of Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden
| | - Moustafa Elmasry
- Department of Hand Surgery, Plastic Surgery and Burns, and Department of Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden
| |
Collapse
|
7
|
Willy C, Engelhardt M, Stichling M, Grauhan O. The impact of surgical site occurrences and the role of closed incision negative pressure therapy. Int Wound J 2016; 13 Suppl 3:35-46. [PMID: 27547962 DOI: 10.1111/iwj.12659] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2016] [Accepted: 07/13/2016] [Indexed: 12/15/2022] Open
Abstract
Surgical site occurrences are observed in up to 60% of inpatient surgical procedures in industrialised countries. The most relevant postoperative complication is surgical site infection (SSI) because of its impact on patient outcomes and enormous treatment costs. Literature reviews ('SSI', 'deep sternal wound infections' (DSWI), 'closed incision negative pressure wound therapy' (ciNPT) were performed by electronically searching MEDLINE (PubMed) and subsequently using a 'snowball' method of continued searches of the references in the identified publications. Search criteria included publications in all languages, various study types and publication in a peer-reviewed journal. The SSI literature search identified 1325, the DSWI search 590 and the ciNPT search 103 publications that fulfilled the search criteria. Patient-related SSI risk factors (diabetes mellitus, obesity, smoking, hypertension, female gender) and operation-related SSI risk factors (re-exploration, emergency operations, prolonged ventilation, prolonged operation duration) exist. We found that patient- and operation-related SSI risk factors were often different for each speciality and/or operative procedure. Based on the evidence, we found that high-risk incisions (sternotomy and incisions in extremities after high-energy open trauma) are principally recommended for ciNPT use. In 'lower'-risk incisions, the addition of patient-related or operation-related risk factors justifies the application of ciNPT.
Collapse
Affiliation(s)
- Christian Willy
- Department of Traumatology/Orthopedic Surgery, Septic and Reconstructive Surgery, Research and Treatment Centre for Complex Combat Injuries, Bundeswehr Hospital Berlin, Berlin, Germany
| | - Michael Engelhardt
- Department Vascular and Endovascular Surgery, Center of Vascular Medicine, Bundeswehr Hospital Ulm, Ulm, Germany
| | - Marcus Stichling
- Section Vascular and Thoracic Surgery of Department of Traumatology/Orthopedic Surgery, Septic and Reconstructive Surgery, Research and Treatment Centre for Complex Combat Injuries, Bundeswehr Hospital Berlin, Berlin, Germany
| | - Onnen Grauhan
- Cardiac Surgery, German Heart Center Berlin, Berlin, Germany
| |
Collapse
|
8
|
Takahara S, Sai S, Kagatani T, Konishi A. Efficacy and haemodynamic effects of vacuum-assisted closure for post-sternotomy mediastinitis in children. Interact Cardiovasc Thorac Surg 2014; 19:627-31. [DOI: 10.1093/icvts/ivu234] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
|
9
|
Kawajiri H, Aeba R, Takaki H, Yozu R, Iwata S. Negative pressure therapy for post-sternotomy wound infections in young children. Interact Cardiovasc Thorac Surg 2014; 19:102-6. [PMID: 24648466 DOI: 10.1093/icvts/ivu050] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023] Open
Abstract
OBJECTIVES Post-sternotomy wound infection remains a significant morbidity in congenital and paediatric cardiac surgery. However, the techniques used for this complication in children are not optimal in terms of mortality, morbidity and the use of medical resources. Negative pressure therapy is an effective modality in the treatment in adults, but reports of its use in children are limited. This study evaluated the use of negative pressure therapy in young children for post-sternotomy wound infections. METHODS From October 2004 to June 2012, 15 consecutive cases of post-sternotomy wound infections in patients ≤6 years of age were managed with negative pressure therapy, and these patients were followed up for ≥12 months after wound closure. The median Aristotle comprehensive complexity score was 9.9 ± 4.0. The infection was identified at a median of 16 days after surgery, and the procedure was performed within 24 h of diagnosis. No additional surgical procedures were applied. RESULTS No cases of hospital mortality or second surgery for infection control occurred. The median duration until wound closure was 25 days (range: 5-92 days). Further, no patient showed sternal instability at treatment termination. During the mean follow-up period of 45.8 ± 31.3 months after wound closure, no admission occurred for infection recurrence. According to a multivariable analysis, the infection depth and patient weight significantly lengthened treatment duration (P = 0.008 and 0.046, respectively). CONCLUSIONS Negative pressure therapy is an effective treatment modality for wound infections in paediatric cardiac surgery and results in low morbidity, mortality and medical resource use.
Collapse
Affiliation(s)
| | - Ryo Aeba
- Division of Cardiovascular Surgery, Keio University, Tokyo, Japan
| | - Hidenobu Takaki
- Division of Cardiovascular Surgery, Keio University, Tokyo, Japan
| | - Ryohei Yozu
- Division of Cardiovascular Surgery, Keio University, Tokyo, Japan
| | - Satoshi Iwata
- Center for Infectious Diseases and Infection Control, Keio University, Tokyo, Japan
| |
Collapse
|
10
|
Huang JH, Sunstrom R, Munar MY, Cherala G, Legg A, Olyeai AJ, Langley SM. Are children undergoing cardiac surgery receiving antibiotics at subtherapeutic levels? J Thorac Cardiovasc Surg 2014; 148:1591-6. [PMID: 24521951 DOI: 10.1016/j.jtcvs.2013.12.043] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/25/2013] [Revised: 12/04/2013] [Accepted: 12/24/2013] [Indexed: 12/01/2022]
Abstract
OBJECTIVES Perioperative antibiotics have decreased-but not eradicated-postoperative infections. In patients undergoing cardiac surgery with cardiopulmonary bypass, the dilutional effect of the priming and any additional volume given during the procedure may lead to subtherapeutic antibiotic levels. Our aim was to determine if children undergoing cardiac surgery with cardiopulmonary bypass receive perioperative antibiotics at subtherapeutic levels. METHODS Using published pharmacokinetic data on cefuroxime, we developed a computer simulation model to generate a nomogram predicting patients at risk for subtherapeutic cefuroxime levels based on time from initial dosing and additional volume given. RESULTS A computer-generated 1-compartment pharmacokinetic model was created to predict cefuroxime plasma levels over time for patients of all weights and additional volumes given for both a 25- and 50-mg/kg intravenous dose. For example, following a 25-mg/kg dose, a patient receiving an additional volume of 275 mL/kg is predicted to be subtherapeutic (<16 mg/L=4×minimum inhibitory concentration) at 4 hours. Our nomogram predicts all patients will be subtherapeutic at 8 hours, consistent with general pediatrics dosing schemes. Following a 50-mg/kg dose, levels are predicted to be subtherapeutic after an additional volume of 315 mL/kg at 5.5 hours. CONCLUSIONS Our model predicts which patients undergoing cardiac surgery with cardiopulmonary will have subtherapeutic cefuroxime levels. This nomogram enables providers to determine when to administer additional antibiotics in patients receiving large additional volumes during cardiac surgeries. This rational approach to perioperative antibiotic dosing may result in a reduction in postoperative infection in this vulnerable patient population.
Collapse
Affiliation(s)
- Jennifer H Huang
- Division of Pediatric Cardiology, Doernbecher Children's Hospital, Oregon Health Science University, Portland, Ore.
| | - Rachel Sunstrom
- Division of Pediatric Cardiac Surgery, Oregon Health Science University, Doernbecher Children's Hospital, Portland, Ore
| | - Myrna Y Munar
- College of Pharmacy, Oregon State University, Corvallis, Ore
| | - Ganesh Cherala
- College of Pharmacy, Oregon State University, Corvallis, Ore
| | - Arthur Legg
- Division of Pediatric Cardiology, Doernbecher Children's Hospital, Oregon Health Science University, Portland, Ore
| | - Ali J Olyeai
- College of Pharmacy, Oregon State University, Corvallis, Ore
| | - Stephen M Langley
- Division of Pediatric Cardiac Surgery, Oregon Health Science University, Doernbecher Children's Hospital, Portland, Ore
| |
Collapse
|
11
|
Mangukia CV, Agarwal S, Satyarthy S, Datt V, Satsangi D. Mediastinitis Following Pediatric Cardiac Surgery. J Card Surg 2013; 29:74-82. [DOI: 10.1111/jocs.12243] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Affiliation(s)
- Chirantan V. Mangukia
- Department of Cardiothoracic and Vascular Surgery; G.B. Pant Hospital; New Delhi India
| | - Saket Agarwal
- Department of Cardiothoracic and Vascular Surgery; G.B. Pant Hospital; New Delhi India
| | - Subodh Satyarthy
- Department of Cardiothoracic and Vascular Surgery; G.B. Pant Hospital; New Delhi India
| | - Vishnu Datt
- Department of Anesthesiology; G.B. Pant Hospital; New Delhi India
| | - Deepak Satsangi
- Department of Cardiothoracic and Vascular Surgery; G.B. Pant Hospital; New Delhi India
| |
Collapse
|
12
|
The Neonate After Cardiac Surgery: What do You Need to Worry About in the Emergency Department? CLINICAL PEDIATRIC EMERGENCY MEDICINE 2011. [DOI: 10.1016/j.cpem.2011.09.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
|
13
|
Knoderer CA, Saft SA, Walker SG, Rodefeld MD, Turrentine MW, Brown JW, Healy DP, Sowinski KM. Cefuroxime Pharmacokinetics in Pediatric Cardiovascular Surgery Patients Undergoing Cardiopulmonary Bypass. J Cardiothorac Vasc Anesth 2011; 25:425-30. [DOI: 10.1053/j.jvca.2010.07.022] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/01/2010] [Indexed: 11/11/2022]
|
14
|
Durandy Y. Mediastinitis in pediatric cardiac surgery: Prevention, diagnosis and treatment. World J Cardiol 2010; 2:391-8. [PMID: 21179306 PMCID: PMC3006475 DOI: 10.4330/wjc.v2.i11.391] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/06/2010] [Revised: 10/07/2010] [Accepted: 10/14/2010] [Indexed: 02/06/2023] Open
Abstract
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.
Collapse
Affiliation(s)
- Yves Durandy
- Yves Durandy, Perfusion and Intensive Care Unit in Pediatric Cardiac Surgery, Institut Hospitalier Jacques Cartier, Avenue du Noyer Lambert, 91300 Massy, France
| |
Collapse
|
15
|
Knoderer CA, Morris JL, Cox EG. Continuous Infusion of Nafcillin for Sternal Osteomyelitis in an Infant After Cardiac Surgery. J Pediatr Pharmacol Ther 2010. [DOI: 10.5863/1551-6776-15.1.49] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
We report the use of the continuous infusion of nafcillin for the treatment of an infant who had methicillinsusceptible Staphylococcus aureus sternal osteomyelitis not responsive to traditional nafcillin dosing. The patient was successfully treated with surgical debridement and the continuous infusion of nafcillin. To our knowledge, this is the first report describing the successful use of the continuous infusion of nafcillin to treat an infant who had sternal osteomyelitis after cardiac surgery.
Collapse
Affiliation(s)
- Chad A. Knoderer
- Department of Pharmacy Practice, College of Pharmacy and Health Sciences, Butler University, Indianapolis, Indiana
- Department of Pharmacy, Riley Hospital for Children, Clarian Health, Indianapolis, Indiana
- Department of Pediatrics, Ryan White Center for Pediatric Infectious Disease, Indiana University School of Medicine, Indianapolis, Indiana
| | - Jennifer L. Morris
- Department of Pharmacy, Riley Hospital for Children, Clarian Health, Indianapolis, Indiana
- Department of Pharmacy Practice, Purdue University School of Pharmacy and Pharmaceutical Sciences, Indianapolis, Indiana
| | - Elaine G. Cox
- Department of Pediatrics, Ryan White Center for Pediatric Infectious Disease, Indiana University School of Medicine, Indianapolis, Indiana
| |
Collapse
|
16
|
Anslot C, Hulin S, Durandy Y. Postoperative mediastinitis in children: improvement of simple primary closed drainage. Ann Thorac Surg 2007; 84:423-8. [PMID: 17643610 DOI: 10.1016/j.athoracsur.2007.03.064] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/08/2006] [Revised: 03/21/2007] [Accepted: 03/21/2007] [Indexed: 11/28/2022]
Abstract
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.
Collapse
Affiliation(s)
- Christine Anslot
- Intensive Care Unit of Pediatric Cardiac Surgery, Institut Jacques Cartier, Massy, France
| | | | | |
Collapse
|
17
|
Al-Sehly AA, Robinson JL, Lee BE, Taylor G, Ross DB, Robertson M, Rebeyka IM. Pediatric Poststernotomy Mediastinitis. Ann Thorac Surg 2005; 80:2314-20. [PMID: 16305896 DOI: 10.1016/j.athoracsur.2005.05.035] [Citation(s) in RCA: 47] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/14/2005] [Revised: 05/10/2005] [Accepted: 05/12/2005] [Indexed: 11/30/2022]
Abstract
BACKGROUND Mediastinitis results in significant morbidity in pediatric cardiac patients. It is not clear whether delayed sternal closure is a risk factor for these infections. Management of mediastinitis remains controversial. METHODS Cases of mediastinitis at the Stollery Children's Hospital from January 1, 1991, to June 30, 2004, were reviewed. RESULTS There were 29 cases of mediastinitis in 2,675 open cardiac procedures for an overall incidence of 1.1%. Infection was diagnosed 5 to 27 days after the original surgical procedure (median, 10 days). The odds ratio for infection with delayed sternal closure versus primary sternal closure was 1.88 (95% confidence interval, 0.63 to 5.60). Signs at the onset of infection included fever (86%), incisional erythema (69%), purulent drainage from the incision or pacer wire sites (83%), and wound dehiscence (23%). Debridement was followed by primary sternal closure in all but three cases in which the sternum had not been closed before debridement and rotational muscle flaps were not used. Continuous irrigation systems were used only in the first 7 patients. One patient died of mediastinitis complicated by infective endocarditis, and 2 patients died of multiorgan failure. CONCLUSIONS Delayed sternal closure was not a major risk factor for mediastinitis, especially if primary skin closure was used with delayed sternal closure. Excellent results were attained with debridement and primary closure of these infections.
Collapse
Affiliation(s)
- Abdullah A Al-Sehly
- Department of Pediatrics, Stollery Children's Hospital, University of Alberta, Edmonton, Alberta, Canada
| | | | | | | | | | | | | |
Collapse
|
18
|
Lee SS, Lin SD, Chen HM, Lin TM, Yang CC, Lai CS, Chen YF, Chiu CC. Management of Intractable Sternal Wound Infections with Topical Negative Pressure Dressing. J Card Surg 2005; 20:218-22. [PMID: 15854081 DOI: 10.1111/j.1540-8191.2005.200416.x] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
BACKGROUND Sternal osteomyelitis after cardiac surgery is a life-threatening complication. The potential spread of infection into the mediastinum, involving the prosthetic valve, grafts, and suture lines, makes this an extremely serious complication confronting both cardiac and plastic surgeons. AIM Topical negative pressure (TNP) dressing has been proven to be effective for wound healing. We want to take advantages of this equipment to improve the results of intractable sternal wound infection. The results are discussed. METHODS From December 1996 to July 2002, 25 patients with sternal wound infections were treated at Kaohsiung Medical University Hospital. Nine patients suffering intractable sternal osteomyelitis were managed with debridement and TNP dressings. These patients received 1-3 debridements (an average of 2.2 debridements), and the average TNP dressing treatment period was 20.2 days (ranging from 3 to 43 days). After management, the infections were controlled and healthy vascularized wounds were achieved. Then, flap reconstruction could be performed for complete wound closure. Seven of the nine patients survived, and there was no recurrence of sternal osteomyelitis during follow-up period (ranging from 5 to 70 months). CONCLUSION The advantages of applying TNP dressings in cases of intractable sternal wound infections include (1) protecting the underlying mediasternal structure from infection, (2) permitting delayed sternal closure to avoid cardiac compression induced compromised cardiopulmonary function, (3) possibility of repeated wound inspection and bedside debridement, (4) cost-effectiveness of wound care, and (5) providing an option to promote sternal wound secondary healing for patients in poor physical condition.
Collapse
Affiliation(s)
- Su-Shin Lee
- Division of Plastic and Reconstructive Surgery, Chung-Ho Memorial Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan.
| | | | | | | | | | | | | | | |
Collapse
|
19
|
Long CB, Shah SS, Lautenbach E, Coffin SE, Tabbutt S, Gaynor JW, Bell LM. Postoperative mediastinitis in children: epidemiology, microbiology and risk factors for Gram-negative pathogens. Pediatr Infect Dis J 2005; 24:315-9. [PMID: 15818290 DOI: 10.1097/01.inf.0000157205.31624.ed] [Citation(s) in RCA: 70] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
BACKGROUND Mediastinitis, although an infrequent complication of median sternotomy, represents a significant source of morbidity and mortality. OBJECTIVE To determine the incidence and describe the epidemiology and microbiology of mediastinitis in children after cardiac surgery and to identify risk factors for the development of Gram-negative mediastinitis. STUDY DESIGN This was a retrospective case-control study nested within the cohort of children, birth to 18 years of age, undergoing median sternotomy between January 1, 1995 and December 31, 2003. RESULTS Forty-three cases of mediastinitis were identified. The incidence of mediastinitis was 1.4%. Median patient age at time of inciting sternotomy was 32 days (interquartile range, 5 days-9 months). Twenty-three (54%) cases occurred in girls. Median time to onset of infection after surgery was 11 days (range, 4-34 days). Overall Gram-positive organisms were present in 29 (67%) cases, and Gram-negative organisms were present in 13 (30%) cases. The organisms most commonly isolated from mediastinal culture were Staphylococcus aureus (46%), coagulase-negative staphylococci (17%) and Pseudomonas aeruginosa (17%). The rate of concurrent bacteremia was 53% (95% confidence interval, 38-69%). In multivariable analysis, delayed sternal closure was an independent risk factor for the development of Gram-negative mediastinitis (odds ratio, 9.3; 95% confidence interval, 1.5-56.8; P = 0.016). CONCLUSIONS Although Gram-positive organisms were the most common cause of infection, Gram-negative organisms accounted for one-third of all isolates. More than one-half of patients with mediastinitis had concurrent bacteremia. Delayed sternal closure was an independent risk factor for Gram-negative mediastinitis.
Collapse
Affiliation(s)
- Caroline B Long
- Divisions of General Pediatrics, The Children's Hospital of Philadelphia, 34th Street and Civic Center Boulevard, Philadelphia, PA 19104, USA
| | | | | | | | | | | | | |
Collapse
|
20
|
Ohye RG, Maniker RB, Graves HL, Devaney EJ, Bove EL. Primary closure for postoperative mediastinitis in children. J Thorac Cardiovasc Surg 2004; 128:480-6. [PMID: 15354112 DOI: 10.1016/j.jtcvs.2004.04.023] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
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.
Collapse
Affiliation(s)
- Richard G Ohye
- Division of Pediatric Cardiovascular Surgery, University of Michigan Medical School, Ann Arbor, Mich, USA.
| | | | | | | | | |
Collapse
|
21
|
Sung K, Jun TG, Park PW, Park KH, Lee YT, Yang JH. Management of deep sternal infection in infants and children with advanced pectoralis major muscle flaps. Ann Thorac Surg 2004; 77:1371-5. [PMID: 15063269 DOI: 10.1016/j.athoracsur.2003.06.020] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/06/2003] [Indexed: 11/18/2022]
Abstract
BACKGROUND Advanced pectoralis major muscle flaps can be used to treat deep sternal wound infections in children; however, the long-term outcomes have not been widely reported. METHODS We retrospectively reviewed 11 patients (median age, 3.8 months), who had developed deep sternal wound infections following median sternotomy, among 1380 consecutive pediatric cardiac procedures from January 1995 to July 2001. RESULTS Advanced pectoralis major muscle flaps were used in 10 patients bilaterally and in 1 patient unilaterally. All survived and were discharged without evidence of infection. During a mean +/- standard deviation follow-up of 42.1 +/- 20.9 months, there was no evidence of recurrent or chronic infection. All patients demonstrated normal development with no limitations to their upper trunk or limb movements. All of the 6 patients who had undergone a palliative operation initially had additional operations without difficulty through the existing sternotomy incision. CONCLUSIONS This technique proved to be easy and promoted wound healing that covered all of the sternal wound defects without tension and without requiring additional flaps. It produced minimal growth and developmental problems, and it might facilitate additional operations.
Collapse
Affiliation(s)
- Kiick Sung
- Department of Thoracic and Cardiovascular Surgery, Samsung Seoul Hospital, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | | | | | | | | | | |
Collapse
|
22
|
Tortoriello TA, Friedman JD, McKenzie ED, Fraser CD, Feltes TF, Randall J, Mott AR. Mediastinitis after pediatric cardiac surgery: a 15-year experience at a single institution. Ann Thorac Surg 2003; 76:1655-60. [PMID: 14602304 DOI: 10.1016/s0003-4975(03)01025-7] [Citation(s) in RCA: 71] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
BACKGROUND The spectrum of sternal wound infections after cardiac surgery ranges from superficial infections to a deep sternal infection known as mediastinitis. Mediastinitis is a rare but clinically relevant source of postoperative morbidity and mortality in adult and pediatric patients after cardiac surgery. METHODS We retrospectively identified all patients diagnosed with mediastinitis after cardiac surgery from January 1987 to December 2002 (17 patients/7,616 surgeries = 0.2%). Demographic data, cardiac diagnosis, cardiac surgery, hospital length of stay, associated medical diagnosis, and surgical treatment for mediastinitis were collected. RESULTS Fifteen pediatric patients (age < 18 years) were diagnosed with mediastinitis (mean age at diagnosis 37.5 months, range 21 days to 17 years. The median postoperative day of diagnosis was 14 days (6 to 50 days). The most common organism was Staphylococcus species (n = 9). Six patients had an associated bacteremia. The median hospital length of stay for all patients was 42.5 days (range 16 to 163 days). The hospital mortality was 1 of 15 (6%). Each patient was treated with intravenous antibiotics; sternal debridement; and rectus abdominus flap reconstruction (n = 7), pectoralis muscle flap reconstruction (n = 3), omentum reconstruction (n = 1), or primary sternal closure (n = 4). Three patients have undergone redo-sternotomy with orthotopic heart transplantation, bidirectional cavopulmonary anastomosis, and replacement of a right ventricle to pulmonary artery homograft. CONCLUSIONS Timely diagnosis, aggressive sternal debridement, and liberal use of rotational muscle flaps can potentially minimize the morbidity and mortality in pediatric postoperative cardiac patients. Subsequent redo-sternotomy has not been problematic.
Collapse
Affiliation(s)
- Tia A Tortoriello
- The Lillie Frank Abercrombie Section of Pediatric Cardiology, The Heart Center, Texas Children's Hospital, Baylor College of Medicine, Houston, Texas, USA
| | | | | | | | | | | | | |
Collapse
|
23
|
Kollar A, Drinkwater DC. Bilateral pectoral myocutaneous advancement flaps and anatomic sternal wound reconstruction in cyanotic infants with mediastinitis. J Card Surg 2003; 18:245-52. [PMID: 12809399 DOI: 10.1046/j.1540-8191.2003.02038.x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
OBJECTIVE The purpose of this study was to assess the results and applicability of a modified chest closure technique employing bilateral pectoral myocutaneous advancement flaps after sternal re-approximation for postoperative mediastinitis in cyanotic infants. METHODS The study population is of a single surgeon's pediatric cardiac experience (n = 253) over a 2-year period. With retrospective hospital chart review six cases with deep sternal wound complications were identified (five mediastinitis and one hypoxemic wound necrosis). Sternal wound reconstruction was done with the above technique in all cases. Follow up was completed by outpatient record review and with telephone interviews. RESULTS All six cases presented in this paper were neonates or infants with complex cyanotic cardiac malformations. Following chest wall reconstruction all had complete resolution of their mediastinitis with no mortality and no wound healing complications. Three of them have since undergone elective staged repair, with no evidence of residual wound infection. Two babies died during follow-up as a result of progressive respiratory compromise. CONCLUSION For postcardiotomy mediastinitis in cyanotic infants we recommend limited debridement and anatomic sternal reconstruction supported by bilateral pectoral myocutaneous advancement flap closure.
Collapse
Affiliation(s)
- Andras Kollar
- Department of Cardiac and Thoracic Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | | |
Collapse
|
24
|
Gursel E, Pummill K, Hakimi M, Ozolins E. Pectoralis major muscle flap for the treatment of mediastinal wound infection in the pediatric population. Plast Reconstr Surg 2002; 110:844-8. [PMID: 12172149 DOI: 10.1097/00006534-200209010-00020] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Affiliation(s)
- Eti Gursel
- Division of Plastic and Reconstructive Surgery, Wayne State University and Detroit Medical Center, 4201 St. Antoine, Suite #400, Detroit, MI 48201, USA
| | | | | | | |
Collapse
|
25
|
|