Mediastinal Infection after Cardiac Surgery

Sarr, Michael G.; Gott, Vincent L.; Townsend, Timothy R.

doi:10.1016/s0003-4975(10)62300-4

Cited by 301 publications

(126 citation statements)

References 82 publications

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“…An important advance in the treatment of mediastinitis occurred in 1963 when, for the first time, the use of continuous mediastinal irrigation with saline solution using routine chest drainage tubes after closure of the sternum was proposed [14]. Afterward, the addition of antibiotics in the irrigation was suggested, which was associated with an increase in bacterial resistance and fungal contamination, especially of the genus Candida [13]. As an alternative, then, the use of PVPI was started for continuous mediastinal cavity wash since it is a fungicidal and bactericidal solution associated with low toxicity.…”

Section: Discussionmentioning

confidence: 99%

“…Surgical management of postoperative mediastinitis counts on several techniques described in the literature [5,[10][11][12][13][14][15][16][17]. Treatment may include single-or multiple-stage procedures, with or without the use of muscle or omental flap [11,12,18].…”

Section: Introductionmentioning

confidence: 99%

“…However, mortality associated with such surgical complications, even after appropriate treatment, is extremely high, ranging between 14% and 47% [1,6,7]. Several studies have identified risk factors such as obesity, diabetes, reoperation, smoking, prolonged operative time, bilateral use of the internal thoracic artery, and postoperative bleeding [4,5,8,9].Surgical management of postoperative mediastinitis counts on several techniques described in the literature [5,[10][11][12][13][14][15][16][17]. Treatment may include single-or multiple-stage procedures, with or without the use of muscle or omental flap [11,12,18].…”

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confidence: 99%

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Mediastinitis: mortality rate comparing single-stage surgical approach and preconditioning of wound

Gib¹,

Alvarez²,

Wender³

2013

Revista Brasileira De Cirurgia Cardiovascular

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200Rev Bras Cir Cardiovasc | Braz J Cardiovasc SurgRev Bras Cir Cardiovasc 2013;28(2):200- INTRODUCTIONMedian sternotomy is the technical approach most used in the surgical treatment of cardiopathies. Mediastinitis is a severe complication leading to an increase in hospital costs, morbidity and mortality [1,2]. The treatment, however, has progressed with new antibiotics, along with technical and surgical care.Postoperative incidence of mediastinitis ranges from 0.5% to 5% [3][4][5]. However, mortality associated with such surgical complications, even after appropriate treatment, is extremely high, ranging between 14% and 47% [1,6,7]. Several studies have identified risk factors such as obesity, diabetes, reoperation, smoking, prolonged operative time, bilateral use of the internal thoracic artery, and postoperative bleeding [4,5,8,9].Surgical management of postoperative mediastinitis counts on several techniques described in the literature [5,[10][11][12][13][14][15][16][17]. Treatment may include single-or multiple-stage procedures, with or without the use of muscle or omental flap [11,12,18]. Therapeutic modalities encompass two options: preconditioning of the wound, leaving the wound open for a better cleaning and mediastinal drainage with dressings, or using one of the several closure techniques available. Singlestage closure shows a recurrence rate between 5%-50% in comparison to two-stage closure whose rate ranges from 2%-30% [19,20], however the long term exposure of the mediastinum enhances the morbidity.The present study aims to compare inpatient mortality rate from surgical debridement followed by primary wound closure with that from surgical debridement with closure after preconditioning of the wound. METHODSFrom January 2000 to December 2008, at Hospital de Clínicas de Porto Alegre (HCPA), southern Brazil, 3,166 cardiac surgeries were performed in adults using median sternotomy and extracorporeal circulation (ECC). A historical cohort of patients who had postoperative mediastinitis was followed up during hospital stay after the first surgery and reintervention(s). From 2007, we implemented the protocol of preconditioning of the wound for all patients. Data were abstracted from the patient's medical records. The entire patient sample that showed mediastinitis during this period was identified through the Cardiovascular Surgery Division records in combination with those from the Commission on Hospital Infection Control (CCIH) of HCPA. Mediastinitis was defined as deep surgical wound infection with clinical and microbiologic evidence of compromised retrosternal space. During this period, 49 patients developed mediastinitis, an incidence of 1.55%. Of these, 43 patients met the classification criteria (El Oakley) [3] as type III or IV and were included in the study.The diagnosis of mediastinitis was based on physical examination and laboratory tests. Three diagnostic criteria were elected during initial evaluation: sternal instability; leukocytosis of more than 15,000; and wound secretion. All patients w...

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Section: Discussionmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

mentioning

confidence: 99%

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Mediastinitis: mortality rate comparing single-stage surgical approach and preconditioning of wound

Gib¹,

Alvarez²,

Wender³

2013

Revista Brasileira De Cirurgia Cardiovascular

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“…(11) High rates of severe complications, such as hemorrhage of exposed mediastinal vessels, as well as high mortality rates (up to 45%), have been reported. (12) At the time, some authors (13) described the technique of closed irrigation of the mediastinum with antibiotic solutions via a catheter, together with debridement and sternal resuture; a technique that is still used today. (12) This technique reduced mortality to 20%, although reinterventions for resection of fistulae and areas of costochondritis were frequent.…”

Section: Methodsmentioning

confidence: 99%

“…(12) At the time, some authors (13) described the technique of closed irrigation of the mediastinum with antibiotic solutions via a catheter, together with debridement and sternal resuture; a technique that is still used today. (12) This technique reduced mortality to 20%, although reinterventions for resection of fistulae and areas of costochondritis were frequent. (14,15) Studies have identified excessive fungal growth, especially of the genus Candida, (16) which is why the use of dilute solutions of polyvinylpyrrolidone-iodine, which is bactericidal and fungicidal, and has low toxicity, has been recommended.…”

Section: Methodsmentioning

confidence: 99%

Tratamento agressivo com retalho muscular e/ou omentopexia nas infecções do esterno e mediastino anterior em pós-operatório de esternotomia

et al. 2008

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OBJETIVO: Avaliar o impacto do tratamento agressivo com retalho muscular e/ou omentopexia nas infecções do esterno e mediastino anterior em pós-operatório de esternotomia sobre a mortalidade, comparando-o ao do tratamento conservador. MÉTODOS: Foram coletados dados pré-, trans- e pós-operatórios. O grupo A (n = 44) incluiu pacientes submetidos ao tratamento conservador-desbridamento associado a ressutura e/ou a irrigação contínua com solução de polivinilpirrolidona-iodo, ou ainda a cicatrização por segunda intenção (dados retrospectivos). O grupo B (n = 9) incluiu pacientes nos quais não houve resolução da infecção com o tratamento conservador e que, por isso, foram submetidos ao tratamento agressivo (fase intermediária). O grupo C (n = 28) incluiu pacientes submetidos primariamente ao tratamento agressivo (dados prospectivos). RESULTADOS: Identificou-se menor tempo de internação pós-operatória nos pacientes submetidos ao tratamento agressivo (p < 0,046). Houve 7 óbitos no grupo A, 1 no grupo B e 2 no grupo C. Entretanto, o nível de significância clássico de α = 0,05 não foi atingido. CONCLUSÕES: O tratamento agressivo mostrou-se também adequado para aquelas infecções em que o tratamento conservador não foi resolutivo. Esses achados demonstram que o tratamento proposto tem excelentes resultados.

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Poststernotomy Infections Presenting as Deep Neck Abscess

Simpson

Peters²

1988

Archives of Otolaryngology - Head and Neck Surgery

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\s=b\A review of the world literature has failed to reveal any published reports of poststernotomy mediastinitis presenting as a deep neck infection. This article presents two such cases. Since the fascial layers of the mediastinum are a direct continuation of the cervical fascia, a number of potential pathways between the neck and mediastinum exist. Descending infection from the neck into the mediastinum is well documented. The reverse situation, an ascending infection from the mediastinum into the neck, is not described despite the potential natural pathways available for spread of infection. Our proposed mechanism for these two cases is that a surgically created pathway from the mediastinum to the lower neck allows for mediastinitis to point in the intercommunicating fascial spaces of the neck. Recognition of this clinical presentation will allow the surgeon to use prompt intervention for such a serious complication.(Arch Otolaryngol Head Neck Surg 1988;114:909-912) Otol aryngol ogi sts and thoracic sur¬ geons are aware of the potential for the development of mediastinitis secondary to deep neck abscess. The cervical fascia and the spaces between its layers communicate directly or indirectly with the fascia of the medi¬ astinum, providing natural pathways for the spread of infection from the neck to the chest. We should, there¬ fore, theoretically see some cases of neck infection resulting from medias-tinitis. However, there are no pub¬ lished reports of this clinical picture.This article presents two cases of poststernotomy mediastinitis that resulted in deep neck infection. More¬ over, the neck abscess was the initial sign, and the only clue that a more life-threatening infectious process was ongoing.Although infections can spread along natural pathways, we propose that a pathway from the mediastinum to the neck was created surgically, allowing for the sternotomy infection to point in the lower neck in the fasciai spaces that had been entered.Though obviousy rare, knowing this scenario of silent mediastinitis will allow the surgeon to take early and aggressive surgical measures that could significantly decrease the mor¬ bidity and mortality associated with such a serious complication. REPORT OF CASESCase 1.-A 66-year-old man with a fiveyear history of syncopal episodes was eval¬ uated at the University of Alabama at Birmingham. Cardiac catheterization showed calcific aortic stenosis. On July 16, 1985, a median sternotomy incision for aortic valve replacement was performed. Cephapirin sodium therapy was used for four days postoperatively. On the fifth postoperative day, the patient had lowgrade fever, along with an enlarging tender left-sided neck mass. Physical examination revealed induration, warmth, and exquisite tenderness of the entire left sternocleidomastoid muscle. Also noted were erosions in the subglottic area bilat¬ erally. A chest roentgenogram was normal. Computed tomographic scan of the neck revealed an abscess within the belly of the sternocleidomastoid muscle as demon¬ strated in Fig 1. Th...

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Mediastinal Infection after Cardiac Surgery

Cited by 301 publications

References 82 publications

Mediastinitis: mortality rate comparing single-stage surgical approach and preconditioning of wound

Mediastinitis: mortality rate comparing single-stage surgical approach and preconditioning of wound

Tratamento agressivo com retalho muscular e/ou omentopexia nas infecções do esterno e mediastino anterior em pós-operatório de esternotomia

Poststernotomy Infections Presenting as Deep Neck Abscess

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