Surgical management of staphylococcal pericarditis.

Abstract

-681. Surgical management of staphylococcal pericarditis. The surgical management of 10 patients with staphylococcal pericarditis is described. Of the 10, seven were children aged 12 years or under. A variety of procedures was used to drain the pericardium at open operation; these included left anterior thoracotomy, left anterolateral thoracotomy, median sternotomy, and the transdiaphragmatic approach to the pericardium. The pathological findings at operation are described. Two patients died; one of the deaths was related to operation, the other was not. The remaining eight patients were ultimately well although two required reoperation before recovery was achieved. After the initial diagnosis of pyopericardium, early consideration of operative drainage is advocated. An effective means of surgical management is dependent, open drainage of the pericardium approached by the transdiaphragmatic route.In each patient purulent pericarditis caused by a Staphylococcus aureus was proven by culture of pus from the pericardial cavity and by histological examination of resected pericardium. Earlier conservative management had failed and the patients therefore had to be managed by operation. THE PATIENTS CASE 1 A 9-year-old boy presented with staphylococcal osteomyelitis of both tibiae. The lower limbs were immobilized and a course of benzylpenicillin and cloxacillin was begun. The infecting organism was sensitive in vitro to both antibiotics. The clinical course ofthe osteomyelitis was thereafter satisfactory. However, two weeks after admission the patient developed a pyopericardium. Despite repeated aspiration over three days the severity of cardiac tamponade increased. The pericardium was then approached through a median sternotomy and the pus was drained. Five weeks after operation the patient was well.CASE2 A38-year-old man with a history of dysentery one month previously presented with a pericardial effusion. 'Anchovy-sauce' pus was aspirated from the pericardium. The pus was sterile on culture. The amoebic gel diffusion test was positive and the diagnosis of rupture into the pericardium of an amoebic abscess of the liver was made. A course of metronidazole was begun. Because of persistent reaccumulation of the effusion, repeated pericardial aspirations were performed. On the third occasion, seven days after the initial aspiration, yellow pus was obtained from which coagulase-positive Staph. aureus was cultured. Despite intravenous cephalothin and oral cloxacillin the patient's clinical condition deteriorated. A left anterior subcostal incision was made with excision of the sixth and seventh costal cartilages. There was a left subphrenic abscess communicating inferiorly with a cavity in the left lobe of the liver and superiorly with the pericardium. The abscess was drained. Three weeks after operation the patient was well.

Purulent pericarditis in children: an analysis of 28 cases

“…We would agree that 'pericardiostomy is advisable in those patients in whom recurrent cardiac tamponade develops in spite of repeated aspirations and in those in whom the fluid is thick or aspirated with difficulty' (Benzing and Kaplan, 1963). Different surgical approaches to drainage have recently been reviewed (Cameron, 1975). However, pericardiostomy is not without complications (Boyle et al, 1961), and the statement made in 1941 that 'needle aspiration almost uniformly fails to save the patient' (Adams and Polderman, 1941) is no longer true.…”