Mediastinitis in pediatric cardiac surgery: Prevention, diagnosis and treatment

[Flail chest and mediastinitis with total sternal loss post pediatric heart surgery. Reconstruction technique and case report]

We present the case of a two-year-old girl, with a history of pulmonary banding surgery who underwent a chest wall stabilization technique with titanium rods and muscle flaps coverage, due to post-surgical mediastinitis associated with total sternal loss after ventricular septal defect closure surgery, debanding, and pulmonary artery plasty. The patient had a favorable postsurgical evolution.

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.

Case Report: 18F-FDG PET-CT for Diagnosing Prosthetic Device-Related Infection in an Infant With CHD

Patients who have undergone cardiac surgery using prosthetic devices have an increased risk of developing prosthetic device-related infection and mediastinitis. However, accurate diagnosis of prosthetic device-related infection can be difficult to evaluate and treat with antibiotic therapy alone. In recent years, ¹⁸F-fluorodeoxyglucose positron emission tomography-computed tomography (¹⁸F-FDG PET-CT) has made promising contributions to detect infective endocarditis, pacemaker infections, or other inflammations. Nevertheless, ¹⁸F-FDG PET-CT for congenital heart disease (CHD) with device infection has been sparsely reported. We present an infantile girl diagnosed with pulmonary atresia with a ventricular septal defect who underwent replacement of the right ventricle-to-pulmonary artery (RV-PA) conduit for improvement cyanosis. She developed high fever and was diagnosed with mediastinitis and bacteremia by Pseudomonas aeruginosa (P. aeruginosa) on postoperative day 4. Mediastinal drainage and 6 weeks of antibiotic therapy improved her condition, but bacteremia flared up on postoperative day 56. Despite a long course of antibiotic therapy, she had two more recurrences of bacteremia with the detection of P. aeruginosa. Echocardiography and chest contrast CT showed no evidence of vegetation and mediastinitis. On postoperative day 115, ¹⁸F-FDG PET-CT revealed an accumulation on the RV-PA conduit (SUV max 3.4). Finally, she developed an infectious ventricular pseudo-aneurysm on postoperative day 129 and underwent aneurysm removal and RV-PA conduit replacement on postoperative day 136. Our case showed the importance of ¹⁸F-FDG PET-CT for diagnosing specific localization of prosthetic device-related infection which is hard to detect using other imaging techniques. It can be a useful diagnostic tool for infantile patients with CHD with cardiac prosthetic devices and improve subsequent clinical treatments.

Enterococcus faecium Mediastinitis Complicated by Disseminated Candida parapsilosis Infection after Congenital Heart Surgery in a 4-Week-Old Baby

Background. Cardiac surgery offers multiple treatment options for children with congenital heart defects. However, infectious complications still remain a major cause of morbidity and mortality in these patients. Mediastinitis is a detrimental complication in children undergoing cardiac surgery. The risk of mediastinitis after delayed sternal closure is up to 10%. Case Presentation. We report a case of Enterococcus faecium mediastinitis in a 4-week-old female baby on extracorporeal membrane oxygenation after Norwood procedure. Although repeated antibiotic irrigation, debridement, and aggressive antibiotic treatment were started early, the pulmonary situation deteriorated. Candida parapsilosis was isolated from bronchoalveolar lavage after pulmonary hemorrhage. Disseminated C. parapsilosis infection with pulmonary involvement was treated with liposomal amphotericin B. Subsequently, inflammatory markers increased again and eventually C. parapsilosis was isolated from the central venous catheter. Conclusion. Children undergoing delayed sternal closure have a higher risk of mediastinitis. Therefore, antibiotic prophylaxis, for example, for soft tissue infection seems justified. However, long-term antibiotic treatment is a risk factor for fungal superinfection. Antifungal treatment of disseminated C. parapsilosis infection may fail in PICU patients with nonbiological material in place due to capacity of this species to form biofilms on medical devices. Immediate removal of central venous catheters and other nonbiological material is life-saving in these patients.

Acute mediastinitis in children: a nine-year experience

BACKGROUND

Acute mediastinitis is a serious medical condition with a mortality rate of 30 to 40% or even higher. Early diagnosis with prompt and aggressive treatment is essential to prevent its rapid progression. We evaluated acute mediastinitis cases and analyzed the outcomes.

MATERIALS AND METHODS

A retrospective chart review was conducted on patients diagnosed with acute mediastinitis who were admitted to Mofid Children's Hospital from January 2001 to January 2010.

RESULTS

Seventeen patients aged 1 to 10 yrs. (mean =3.8 yrs) were evaluated including 12 (70%) boys and 5 (30%) girls. The most common symptoms were fever, dyspnea, cyanosis, tachycardia and tachypnea. The etiology of mediastinitis was iatrogenic esophageal perforation (EP), and related to manipulation in 13(77%), and leakage of esophageal anastomosis in 4 cases (33%). The underlying diseases were esophageal atresia in 2(12%), corrosive injury of the esophagus in 13(76%), congenital esophageal stenosis in one (6%), and gastroesophageal reflux esophagitis also in one (6%) patient. Patients with clinical symptoms were evaluated by immediate chest radiography, and gastrografin swallow. After early diagnosis, the patients received wide spectrum antibiotics and immediate mediastinal or thoracic drainage, followed by esophagostomy and gastrostomy. Only one case of endoscopic perforation was managed by NG tube. Fifteen patients (88%) survived successfully. We had 2(12%) cases of mortality in our study (one patient after esophageal substitution, mediastinal abscess and septicemia, and the other one developed esophageal perforation 6 months after early management and died of cardiac arrest during endoscopic dilation).

CONCLUSION

Prevention of acute mediastinitis is still a difficult challenge. As the prognosis is not good and patients have high mortality, rapid management is mandatory.

Reducing mortality related to adverse events in children

Since the launch of the 100,000 Lives Campaign by the Institute for Healthcare Improvement (IHI), preventing medical adverse events to reduce avoidable mortality has emerged as a central focus for health care providers, institutions, regulators, insurance companies, and patients. Evidence-based interventions targeting the 6 interventions in the campaign have been associated with a reduction in preventable hospital deaths in the United States. The generalizability of the IHI's campaign to the pediatric population is only partly applicable. Pediatric experiences with rapid response teams and preventing central-line infections parallel the published experience of adults, with promise to significantly reduce preventable pediatric mortality.