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CONGENITAL HEART DISEASE REVIEW ARTICLE _______________________________________________________________
Mediastinitis Following Pediatric Cardiac Surgery Chirantan V. Mangukia, M.B.B.S., M.S.,* Saket Agarwal, M.B.B.S., M.S., M.Ch. (C.T.V.S.),* Subodh Satyarthy, M.B.B.S., M.S., M.Ch. (C.T.V.S.),* Vishnu Datt, M.B.B.S., M.D. (Anesthesia),y and Deepak Satsangi, M.B.B.S., M.S., M.Ch. (C.T.V.S.)* *Department of Cardiothoracic and Vascular Surgery, G.B. Pant Hospital, New Delhi, India; and yDepartment of Anesthesiology, G.B. Pant Hospital, New Delhi, India ABSTRACT Background: Mediastinitis following pediatric cardiac surgery is associated with significantly high morbidity and mortality. Method: In our review, 21 studies from 1986 to 2011 (12 retrospective studies, eight prospective studies, and a multi-institutional study) including 44,693 pediatric cardiac patients were analyzed. Results and Conclusion: Younger age, malnutrition, preoperative respiratory tract infection, high American anesthesiology score, longer duration of surgery, prolonged ventilation, and ICU stay were definite risk factors for mediastinitis. Early primary closure over drains, vacuum-assisted closure, muscle flap, and omental flap remain the most frequently performed treatments for post-sternotomy mediastinitis. Vacuumassisted closure has emerged as the technique of choice in recent years. doi: 10.1111/jocs.12243 (J Card
Surg 2014;29:74–82) Neonates with congenital heart defects are a uniquely ill population with an immature immune system to cope with an early surgical intervention. Their fragility makes deep sternal wound infection (SWI) a life-threatening complication.1 Nevertheless, the prognosis is much better in pediatric surgery compared to adult surgery, but prolonged hospital stays with intravenous therapy and frequent dressing changes are necessary and poorly tolerated.2 The spectrum of postoperative wound infection ranges from a superficial wound infection (involving skin or subcutaneous tissue) to fulminate mediastinitis with subsequent involvement of the sternum (sternal dehiscence and osteomyelitis) and organ tissues outside the incision.3 In pediatric cardiac surgical patients, reported surgical site infection (SSI) rates range from 1.7 to 8.0 per 100 cases.4–8 In our study, we have found the incidence of to be SSI 3.2% (0.22%–11%). SWIs and mediastinitis after cardiac surgery are associated with significant morbidity and mortality9,10 with an overall mortality between 10% and 25%.11,12 These infections significantly increase length of hospital stay13 and costs.
Conflict of interest: The authors acknowledge no conflict of interest in the submission. Address for correspondence: Chirantan Mangukia, Department of CTVS, G.B. Pant Hospital, New Delhi. Email: [email protected]
METHODS The review was prepared by searching the terms ‘‘pediatric post-sternotomy mediastinitis,’’ ‘‘vacuumassisted closure in mediastinitis,’’ and ‘‘muscle flap in pediatric post-sternotomy mediastinitis’’ in Google Scholar, PubMed, and PubMed Central. We reviewed 21 studies from 1986 to 2011 (12 retrospective studies, eight prospective studies, and a multi-institutional study) including 44,693 pediatric cardiac patients. Six case series from 1984 to 2007 including 39 patients describing various surgical techniques were also considered. CLASSIFICATION Robicsek has classified postoperative mediastinitis in three types.14 Cases with nonpurulent sterno-mediastinitis and no soft tissue or bone necrosis (type 1) may be treated with reopening, drainage, sternal stabilization, and primary closure. Virulent infections with tissue necrosis (type II) may be best handled with reopening, several days of open management, and debridement then secondary closure with viable tissue (usually muscle) flaps. Chronic, smoldering infections (type III) are usually managed with debridement and muscle-flap coverage.14
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RISK FACTORS Younger age,6,15,16 a higher American Society of Anesthesiologists score,6,15 longer duration of surgery,15,16 and concurrent infections have been shown to increase the SSI risk17,18 (Table 1). Moreover, immune competency is affected by operative trauma, as well as a variety of perioperative factors including underlying malnutrition, transfusion, cardiopulmonary bypass, and anesthesia.19 Costello et al.20 found that age younger than 1 year and duration of cardiopulmonary bypass greater than 105 minutes were independent risk factors for any type of SSI while aortic cross-clamp time greater than 85 minutes and postoperative exposure to at least three red blood cell transfusions were risk factors for organ space SSI. Similarly, Alpress et al.4 in a retrospective study showed that age less than one month and longer time of surgery were risk factors. In a multi-institutional study, Woodward et al. noted neither program size nor delayed sternal closure (DSC) was associated with increased incidence of SWI.21 There is no correlation reported between the type of congenital defect and type of infections.4,7 Programs with protocols to monitor and control blood glucose levels postoperatively had statistically lower infection rates, and those that sent mediastinal cultures at time of DSC reported lower infection rates.21 Type of preoperative measures, postoperative dressing, and antibiotic protocols do not impact the prevention of SSI.21 However, Maher et al.22 noted that antibiotic protocols do impact the incidence of mediastinitis significantly. If a patient had more than one cardiothoracic surgical procedure performed concurrently or had an infection present preoperatively, there was an increased risk of
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SSI because these variables reflect the patient’s underlying severity of illness and/or immune function.17 Pollock et al.8 associated occurrence of SWI to a high PRISM score (Pediatric Risk of Mortality Score). The Pediatric Risk of Mortality (PRISM) score was developed from the Physiologic Stability Index (PSI) to reduce the number of physiologic variables required for pediatric ICU (PICU) mortality risk assessment and to obtain an objective weighing of the remaining variables. Although in some papers prolonged mechanical ventilation was associated with SWIs, Hehrlein et al.23 did not consider it a significant risk factor. A longer stay in the PICU after surgery is also associated with SWIs.6,7 It is not clear whether infection might be the cause rather than the consequence for these infections.6 Re-exploration for bleeding, postoperative openchest, ECMO, and blood transfusion are also risk factors for deep wound infection.20,24,25
DELAYED STERNAL CLOSURE AND MEDIASTINITIS It is well known that potential risks of DSC include sepsis, mediastinitis, bleeding, and late sternal instability. Tabbutt et al.10 reported mortality to be 19%, SSI to be 6.7%, and mediastinitis to be 3.9% in his study of DSC in pediatric patients. Shin et al.26 reported postoperative infection and sterile wound dehiscence rate in DSC patients as 11% and 9%, respectively. These SWIs have been associated with longer postoperative stay.10,27 The group of patients undergoing DSC are believed to have an increased risk for infection because they have predisposing factors such as prolonged CPB time, low cardiac output, tissue edema,
TABLE 1 Major Risk Factors for Mediastinitis Following Pediatric Cardiac Surgery Risk Factor Age and weight
Preoperative infection or URI High ASA score
Longer duration of surgery Prolonged ventilation and longer ICU stay
Studies Showing Significance Costello et al.20 Rosanova et al.7 Allpress et al.16 Mehta et al.6 Galit Holzmann-Pazgal et Brady et al.15 Allpress et al.16 Rosanova et al.7 Galit Holzmann-Pazgal et Malviya et al.18 Rosanova et al.7 Allpress et al.16 Mehta et al.6 Brady et al.15 Galit Holzmann-Pazgal et Costello et al.20 Allpress et al.16 Brady et al.15 Costello et al.20 and Rosanova et al.7 and Allpress et al.16 Galit Holzmann-Pazgal et
al.17
al.17 (preoperative infection)
al.17
al.17
and
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components of inflammation, massive transfusion, and the need for multiple re-explorations of the chest. In contrast, a review of the literature reveals that the incidence of wound infection after DSC is generally less than 10%.10 Some have reported that DSC is not associated with an increase in SSIs;4,6,10,27,28 besides a few authors claim that wound complications are reduced in the DSC technique.29 Others report DSC as a significant risk factor for bloodstream and SSIs.10,30 Al-Sehly et al. reported a 3.4% incidence of superficial SSI and a 1.9% incidence of mediastinitis in patients after DSC. They concluded that DSC was not a major risk factor for mediastinitis, especially if primary skin closure was performed.24
Candida albicans, Mycoplasma hominis, and mixed organisms have also been isolated.24 Staphylococci cultured from the skin of cardiac surgery patients are more resistant after surgery than before surgery and, furthermore, staphylococci causing postoperative infections have the same antimicrobialresistant phenotypes as do colonizing isolates.39 ¨ zker et al.40 reported a higher incidence In contrast, O for gram-negative organisms as compared to grampositive organisms. Outbreaks of mediastinitis caused by specific gram-negative organisms such as Pseudomonas or Serratia suggest nosocomial spread.41 Long reported that DSC was an independent risk factor for gram-negative mediastinitis.25
EVIDENCE OF INFECTION
TREATMENT
Mediastinitis generally presents days to weeks after cardiac surgery.24 Diagnosis is often made on the basis of the appearance of the wound, while retrosternal puncture and computed tomography (CT) scan are useful in the initial stages. Babies often appear irritable, tired, and remain febrile. The incision is erythematous and painful, and wound dehiscence and purulent drainage from the incision are frequent as well as sternal instability. A rise in temperature of 38.58C or greater is the most common early presentation of poststernotomy mediastinitis, followed by purulent discharge from the incision or from pacing wires, erythema of the incision, and sternal wound dehiscence.24 Bacterial examination of the purulent drainage confirms the presence of altered leukocytes and microorganisms. A considerable number of patients might not show a rise in total leukocyte counts.24 C-reactive protein (CRP) may be elevated; many studies have revealed CRP as marker of active ongoing infection.31 The diagnosis may be more difficult when the patient has received antibiotic therapy as the patient may remain afebrile. Epicardial pacing wire cultures are sensitive for the diagnosis of mediastinitis,32 while diagnostic bacteriological samples from the sternal or retrosternal puncture are considered safe and helpful.33 CT scans have been considered of great value to localize infected tissues.34 Misawa et al.35 showed that a mediastinal soft tissue mass combined with a bilateral pleural effusion can be a characteristic CT finding in poststernotomy infectious mediastinitis, and that chest CT is more sensitive for detecting sternal dehiscence, sternal erosion, and subcutaneous fluid accumulation. Erroneous diagnoses due to surgical packing,36 surgical (manufactured by Ethicon—A Johnson & Johnson Family of Companies, Piscataway, NJ, USA), body foreign reaction,37 or iodine accumulation following irrigation38 have been reported.
The treatment of wound dehiscence after sternotomy underwent major advancements in 1963 when Shumacker and Mandelbaum42 introduced closedchest catheter antibiotic irrigation after sternal debridement. Since then, numerous investigators have refined the rewiring techniques and the process of irrigation by modifying irrigation fluids,43 and others have introduced new muscle flaps for the closure of these wounds. The optimal treatment of mediastinitis, once diagnosed, remains controversial. Antibiotic treatment based on empirical probability should be immediately initiated, followed within a few hours by surgical drainage. The following modalities of management were identified for SWI and mediastinitis in this review (comparison between these studies is described in Table 2).
BACTERIOLOGY Staphylococcal species continue to be the most common offending organisms.17,24 Pseudomonas aeruginosa, Enterobacter cloacae, Enterococcus faecalis,
Early primary closure—sternal wounds wired over drains Primary closure is an effective treatment for mediastinitis in children.44 Ohye et al. describes early primary closure over a single chest tube that serves as a routine mediastinal drain (usually removed in one to two days). This simple technique is more comfortable for the patient and achieves a high rate of success.44 However, in three of 42 patients, this approach failed requiring reoperation for continuing sepsis. Furthermore, the medical therapy requires a lengthy course of intravenous antibiotics. The six-week intravenous antibiotic treatment has a significant disadvantage, especially when a central venous line is necessary. Surgical debridement with irrigation Bryant et al.45 described an innovative treatment that entails mediastinal reexploration, placement of mediastinal irrigation tubes, and primary closure of the sternum. Dilute antimicrobial solutions like neomycin, bacitracin, polymyxin B sulfate, kanamycin sulfate, cephalothin sodium, and Dakin’s solution are used to irrigate the mediastinum until cultures of the effluent are negative and the wound infection is clinically resolved. Because of the reported toxicity of many of
Type of Study
Case series Case series
Retrospective study
NA
NA
NA
11
7
17
14.57 days
11.1 days
11.9 days
13 days
16.88 days
18.33 days
8.8 days 1–3 days after DSC
13 days
Interval S/M
25.52 days
37.71 days
15.18 days
14.5 days
88% (15/17)
85.71% (6/7)
100%
100%
100%
NA
9.66
15 days
NA NA
97% (41/42) as compared to 27% (4/15) in conventional group
Hospital Survival
11.3 13
NA
Interval M/D or MDT
2 had 10 PMF, 3 rectus abdominis, and 1 cervical strap pedicle graft mediastinitis 2 DSC, 3 14 days (6–50 NA 93% (14/15) Sternal debridement and rectus emergent days) abdominus flap (n ¼ 7), pectoralis muscle sternotomies, 1 flap (n ¼ 3), omental flap (n ¼ 1), or ventricular assist primary sternal closure (n ¼ 4) device
NA
20
8 patients with SSI
NA
64 (1.7%) 9
3650
0
2 3
15 patients (DSC or muscle flap)
DSC Done or Not
3
3 (8.3%) 3
57 (0.85%), 42 treated by EPC
Cases of Mediastinitis (Incidence)
3
36 3 (DSC after prolonged ECMO)
6705
Study Size
NA
0%
0%
0%
0%
0%
0%
NA 0%
7% (3/42)
Recurrence
1 Sternal reconstruction secondary to nonunion, 3 resternotomies due to next procedures
NA
NA
NA
NA
NA
Second primary closure in 2 cases
NA 2 cases undergone TSG
3% (1/42) recurrent infection lead to muscle flap closure
Reintervention by Other Technique
150 mmHg
50 mmHg
50 mmHg 50 mmHg
Not applicable
Negative Pressure (mmHg)
In 7 of 8 patients, wound healed completely. 4–6 weeks Not applicable
15 days (10–31 days)
NA
11 days (7–28 days)
NA NA (cultures were sterile after 8th day of therapy) NA
6 weeks
Antibiotic Duration
42.5 days (16–163 days)
12 (4–88)
Hospital Stay Median and (Range)
MDT, mean duration of therapy; DSC, delayed sternal closure; EPG, early primary closure; TSG, thin skin grafting; interval S/M, interval between surgery and diagnosis of mediastinitis; interval M/D, interval between diagnosis of mediastinitis and duration of treatment.
Tortoriello et al.71
Case series Kadohama et al.53 Anslot et al.60 Prospective study Isolated mediastinitis in neonates (mean age 14.33 days) Isolated mediastinitis in infants (mean age 4.5 months) Isolated mediastinitis in children (mean age 6.72 years) Mediastinitis associated with endocarditis Mediastinitis associated with organ failure Muscle flap closure Backer et al.67 Case series
VAC Fleck et al.57 Salazard et al.58
Early primary closure Ohye et al.44 Retrospective review
Techniques
TABLE 2 Comparison between Various Surgical Techniques for Treatment of Sternal Wound Infection
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these agents and the occurrence of microbial resistance, an alternative irrigant has been sought.46 Thurer et al.47 described the use of 0.5% povidone–iodine solution as a mediastinal irrigant (50–100 mL/hour) and reported it to be an effective antimicrobial agent and ‘‘non-toxic in the concentrations recommended.’’ Glick et al.46 reported a 34-month-old patient with mediastinitis after median sternotomy who was treated with continuous povidone–iodine irrigation and who absorbed toxic quantities of iodine. Due to complications like fluid overload, metabolic acidosis,46 renal failure,48 seizures,49,50 microbial resistance, and antibiotic toxicity the technique became less popular. Negative pressure wound therapy Negative pressure wound therapy was first introduced by Argenta and Morykwas51,52 and has become a widely used, efficacious, and reliable method for managing different types of open wounds after infection. However, the validity of using the VAC therapy to manage pediatric poststernotomy mediastinitis is not clear because of very few reports published on this topic. The application of negative pressure has several advantages: the negative pressure (1) enhances wound drainage, clearing of putrid secretions and toxic products by the continuous suction, preventing fluid retention in the depth of the wound; (2) avoids any residual mediastinal cavity so that the mediastinum is filled with healthy tissue; (3) helps approximate the wound edges and favors stabilization of the chest; (4) and stimulates the formation of granulation tissue by maintaining a moist environment. Furthermore, patients can be mobilized early and can receive physiotherapy to minimize further complications.53 The most commonly used pressure clinically is 125 mmHg in adults54 based on previous basic research.55 It has been proposed that a less negative pressure might lead to insufficient sternal stability. On the other hand, too high of a negative pressure applied to the mediastinum has been suggested to be a risk for damage of fragile pediatric organs. Mokhtari et al.54 reported that low negative pressures (50 to 100 mmHg) can stabilize the sternum just as efficiently as high negative pressures (150 to 200 mmHg) and that the vacuum dressing adapts better to the shape of the wound at a lower negative pressure in a porcine model.56 Fleck et al.57,58 and Salazard et al.58 reported that low negative pressure VAC therapy lasted for short duration, ranging from 10 to 21 days, resulted in rapid decrease in local purulence and CRP.58 VAC was well tolerated by the children without changes in heart rate, blood pressure, or respiration, even without ventilatory support. Kadohama et al.53 had found no complications such as massive air leakage, insufficient drainage, or tissue damage during VAC therapy under a pressure of 50 mmHg. In contrast, Durandy et al.59 described a simple closed technique with primary closure and high-vacuum drainage in 64 patients. The technique was progres-
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sively modified and reported by Anslot et al.60 The surgical technique includes debridement of all infected or necrotic tissue and sternal edge revision until normal bleeding. Drainage was achieved through high-vacuum R Redon’s catheters (Drainobag Lock 150, Braun, Melsungen, Germany) (2.7 mm in diameter with multi-perforated polyvinyl tubing) connected to lightweight plastic bottles. With two different antibiotics, sterility of the effluent fluids was obtained in four to five days for Staphylococcus aureus or epidermidis, regardless of methicillin sensitivity or resistance and eight days for gram-negative bacilli. Once the effluent is sterile, the catheter is progressively withdrawn (2 cm every day). Patients with endocarditis and organ failure required longer antibiotic therapy. The mortality rate was 4%; all three patients died from associated complications after sterilization of the mediastinal effluent and withdrawal of Redon’s catheters. The high vacuum was well tolerated in this study. This drainage technique used in pediatric or adult cardiac surgery (instead of conventional underwaterseal drains) does not have any hemodynamic drawback61 (except for Norwood stage 1), does not damage surrounding tissue, shortens antibiotic therapy duration, prevents fungal super infection, and results in an overall infection eradication rate of 100%.60 The technique is also cost-effective. Muscle flaps Pectoralis flaps were first described by Jurkiewicz et al.62 as a treatment for these wounds and currently is the standard treatment of this complication in adults. There is, however, scant information regarding the use of these techniques in neonates, and only sporadic case reports on neonates, with no reported follow-up. The principles of reconstruction consist of using a well-vascularized coverage for optimal wound healing, ensuring anterior mediastinal protection, and maintaining chest wall stability.1,63 The dominant blood supply of the pectoralis muscle is based on the thoracoacromial artery with a secondary supply through segmental pedicles from the internal mammary artery located 2–3 cm lateral to the sternum. This has led to the development of various techniques for pectoralis muscle flap (PMF) reconstruction and even with possible preservation of form and function.64,65 With the lateral humeral insertion detached, and based on the internal mammary artery perforators, the muscle can be turned on itself and used to fill mediastinal defects after partial or complete sternectomy.1 When medial rib origins are also detached, the muscle can be easily moved to fill defects in the superior mediastinum, or it can be taken through a window in the anterior ribs to fill the upper chest cavity.66 In cases of superficial sternal wound complications, the medial rib origins alone can be detached, usually bilaterally, and the two muscles are joined at the midline.1 Backer et al.67 described the use of vascularized muscle flaps in eight pediatric patients with lifethreatening mediastinal wounds, only two of whom had mediastinitis.67 They used three different
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reconstruction approaches: unilateral PMF, bilateral PMF, and a rectus abdominis muscle flap, with one case of mortality in the neonatal group. Stahl and Kopf68 reported on four infants, three of them neonates undergoing bilateral PMF with preservation of the humeral attachments, a technique used for superficial operative wound complications. The muscles are very delicate, especially in critically ill neonates, and dissection is more difficult than in adults due to their small size. Moreover, smaller vascular pedicles in these patients are less compliant and less resilient to stretching. Thus, minimal insults, which in adults would be insignificant, can pose a major risk to PMF survival in a suboptimal physiologic state, often characterized by some degree of cardiac failure and decreased oxygen carrying capacity of the blood. The patient’s nutritional status should also be considered.67 Also, reentry should be considered for staged or corrective operations. The pectoralis major flap with a turnover technique is particularly valuable for repairing the upper three fourths of the anterior sternum, but is limited for lower defects.68 Sung et al.69 developed an advanced flap technique using the pectoralis major muscle to fill the whole defect. The use of the rectus abdominis muscle and the omentum requires additional abdominal incisions, increasing postoperative pain, may compromise respiratory functions, may cause cross-contamination, and risks herniation or a diffuse bulging through the defect.70 Finally, the choice of the rotational flap to be used is dependent on surgeon preference and other factors such as patient age, size, gender, and presence of percutaneous enterostomies. Tortoriello et al.71 incorporated an aggressive surgical strategy of extensive surgical debridement and early sternal reconstruction with omental flaps, pectoralis major muscle flaps, or rectus abdominis muscle flaps, that gave better results as compared to previous reports. Because of the increased length of the abdomen in comparison with the chest in small children, a rectus abdominis muscle flap allows complete coverage of the sternal incision and reaches the central extent of the wound. Although previous studies have raised the possibility of an increased risk of reoperation through the reconstructed sternum due to the small amount of tissue that is initially placed over the mediastinum,1 subsequent reoperation has been performed in three patients in the series and has not been problematic. Nevertheless, pectoralis major muscle flaps have potential weaknesses for infants and children. Sung et al.69 could not find any evidence of upper limb or upper trunk motor deficits, except for a minor protrusion of the lower sternum in one reoperated patient and mild asymmetric anterior chest wall deformity in three patients on short-term follow-up. Erez et al.1 reported similar results. Breast hypoplasia, including sensory loss, may occur in late adolescence, especially in females, and should be closely followed. Sung et al.69 used the advanced pectoralis muscle flap (APMF) technique. This maneuver provides an
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additional layer of tissue between the skin and sternum. Muscles provide material to close the defect and obliterate the potential dead space. The technique is easy and there is less distortion of the chest wall contour and symmetry as compared with the pectoralis major turnover flap, which produces a concavity at the donor defect, and a relative prominence at the pedicle site.69 Morbidity associated with the muscle flap technique includes pain, weakness, hernia, and cosmetic appearance, which is of great significance in pediatric patients and more specifically in young girls.71,72 Chest wall in stability,71 bleeding, and recurrence of infection were noticed, and omental transfer was proposed as an alternative to the pectoral flap. Plastic procedures may have short-term and longterm results equivalent to irrigation, but the length of stay in the intensive care is longer for patients treated with muscle flap closure.73 Omental flaps The omentum has been described for treatment of a variety of cardiothoracic infectious complications.71,74 A relatively long vascular pedicle enables omental transfer to the anterior mediastinum as is needed for poststernotomy mediastinitis, and generally the omental flap can be extended easily to the superior aspect of the sternotomy incision in adults. On the other hand, children tend to have less developed omentum as compared to adults, restricting the extent of its utilization. Studies performed on adults show that omental transfer required shorter operative times75,76 but alters respiratory function by decreasing the percent vital capacity and oxygen consumption.77 Similar studies have yet to be performed in neonates and young children. Peritoneal dialysis, ileostomy, the potential for hernia formation, and inability to cover the defect adequately given the thinness of the omental tissue limit the use of omentum in children.71 PREVENTION Woodward showed that the type of the preoperative preparation does not significantly impact the overall incidence of SSI.21 In general, routine preparation with chlorhexidine appears satisfactory. Kluytmans et al.78 noted that perioperative elimination of nasal carriage of Staphylococcus aureus using mupirocin nasal ointment significantly reduces the SSI rate in cardiothoracic surgery patients and it warrants a prospective, randomized, placebo-controlled efficacy trial in children. Vlasselaers et al.79 noted that targeting of blood glucose concentrations to age-adjusted normal fasting concentrations improved short-term outcome and shortened the stay of patients in the ICU. In a recent retrospective case–control study, 24-hour peak blood glucose greater than 130 mg/dL was found to be a multivariate predictor for mediastinitis after pediatric cardiac surgery.80
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CONCLUSION Younger age, preoperative respiratory tract infection, high American anesthesiology score, longer duration of surgery, malnutrition, prolonged ventilation, and ICU stay were definite risk factors for mediastinitis. Controversy remains regarding role of DSC, type of congenital cardiac defects, antibiotic strategy, and glycemic control as risk factors for SWI. Since most of the risk factors are nonmodifiable, prevention of mediastinitis is still a difficult challenge. A primary sternal closure is the technique of choice in pediatric patients whenever possible. We currently lack large standardized studies to compare the described techniques and their outcomes in pediatric population. In addition to microvascular and drainage-related benefits VAC (whether low negative pressure and high negative pressure) provides early freedom from ventilation and reduces cost of therapy. Irrigation, omental flap, and muscle flaps are being performed less frequently. Larger studies are needed to prove if they are superior to the other methods in terms of cost-effectiveness, mortality benefit, and long-term effect.
REFERENCES 1. Erez E, Katz M, Sharoni E, et al: Pectoralis major muscle flap for deep sternal wound infection in neonates. Ann Thorac Surg 2000;69:572–577. 2. Durandy Y: Mediastinitis in pediatric cardiac surgery: Prevention, diagnosis and treatment. World J Cardiol 2010;2:391. 3. Mangram AJ, Horan TC, Pearson ML, et al: Guideline for prevention of surgical site infection, 1999. Am J Infect Control 1999;27:97–134. 4. Allpress AL, Rosenthal GL, Goodrich KM, et al: Risk factors for surgical site infections after pediatric cardiovascular surgery. Pediatr Infect Dis J 2004;23:231–234. 5. Nateghian A, Taylor G, Robinson JL: Risk factors for surgical site infections following open-heart surgery in a Canadian pediatric population. Am J Infect Control 2004; 32:397–401. 6. Mehta PA, Cunningham CK, Colella CB, et al: Risk factors for sternal wound and other infections in pediatric cardiac surgery patients. Pediatr Infect Dis J 2000;19:1000–1004. 7. Rosanova MT, Allaria A, Santillan A, et al: Risk factors for infection after cardiovascular surgery in children in Argentina. Braz J Infect Dis 2009;13:414–416. 8. Pollock EMM, Ford-Jones ELEE, Rebeyka I, et al: Early nosocomial infections in pediatric cardiovascular surgery patients. Crit Care Med 1990;18:378–384. 9. De Feo M, Gregorio R, Della Corte A, et al: Deep sternal wound infection: The role of early debridement surgery. Eur J Cardiothorac Surg 2001;19:811–816. 10. Tabbutt S, Duncan BW, McLaughlin D, et al: Delayed sternal closure after cardiac operations in a pediatric population. J Thorac Cardiovasc Surg 1997;113:886. 11. De Feo M, Renzulli A, Ismeno G, et al: Variables predicting adverse outcome in patients with deep sternal wound infection. Ann Thorac Surg 2001;71:324–331. 12. Loop FD, Lytle BW, Cosgrove DM, et al: Sternal wound complications after isolated coronary artery bypass grafting: Early and late mortality, morbidity, and cost of care. Ann Thorac Surg 1990;49:179–187.
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13. Nelson RM, Dries DJ: The economic implications of infection in cardiac surgery. Ann Thorac Surg 1986;42: 240–246. 14. Robicsek F: Postoperative sterno-mediastinitis. Am Surg 2000;66:184. 15. Brady M, McGlone C, Vinsel J, et al (eds): Sternal wound infections following cardiac surgery in infants. 36th Interscience Conference on Antimicrobial Agents and Chemotherapy, New Orleans, LA, 1996. 16. Allpress AL, Rosenthal GL, Goodrich KM, et al (eds): Risk factors for surgical site infections following pediatric cardiovascular surgery (abstract 407). 40th Infectious Diseases Society of American Annual Meeting, Chicago, 2002. 17. Galit Holzmann-Pazgal MD, Hopkins-Broyles D, Recktenwald AMPH, et al: Case-control study of pediatric cardiothoracic surgical site infections. Infect Control Hosp Epidemiol 2008;29:76–79. 18. Malviya S, Voepel-Lewis T, Siewert M, et al: Risk factors for adverse postoperative outcomes in children presenting for cardiac surgery with upper respiratory tract infections. Anesthesiology 2003;98:628–632. 19. Ulicny KS, Hiratzka LF: The risk factors of median sternotomy infection: A current review. J Card Surg 1991;6:338–351. 20. Costello JM, Graham DA, Morrow DF, et al: Risk factors for surgical site infection after cardiac surgery in children. Ann Thorac Surg 2010;89:1833–1842. 21. Woodward CS, Son M, Calhoon J, et al: Sternal wound infections in pediatric congenital cardiac surgery: A survey of incidence and preventative practice. Ann Thorac Surg 2011;91:799–804. 22. Maher KO, Van Der Elzen K, Bove EL, et al: A retrospective review of three antibiotic prophylaxis regimens for pediatric cardiac surgical patients. Ann Thorac Surg 2002;74:1195–1200. 23. Hehrlein FW, Herrmann H, Kraus J: Complications of median sternotomy in cardiovascular surgery. J Cardiovasc Surg 1972;13:390. 24. Al-Sehly AA, Robinson JL, Lee BE, et al: Pediatric poststernotomy mediastinitis. Ann Thorac Surg 2005;80:2314–2320. 25. Long CB, Shah SS, Lautenbach E, et al: Postoperative mediastinitis in children: Epidemiology, microbiology and risk factors for gram-negative pathogens. Pediatr Infect Dis J 2005;24:315–319. 26. Shin HJ, Jhang WK, Park JJ, et al: Impact of delayed sternal closure on postoperative infection or wound dehiscence in patients with congenital heart disease. Ann Thorac Surg 2011;92:705–709. 27. McElhinney DB, Reddy VM, Parry AJ, et al: Management and outcomes of delayed sternal closure after cardiac surgery in neonates and infants. Crit Care Med 2000; 28:1180–1184. 28. McAnally HB, Cutter GR, Ruttenber AJ, et al: Hypothermia as a risk factor for pediatric cardiothoracic surgical site infection. Pediatr Infect Dis J 2001;20:459. 29. Main E, Elliott MJ, Schindler M, et al: Effect of delayed sternal closure after cardiac surgery on respiratory function in ventilated infants. Crit Care Med 2001;29:1798–1802. 30. Abou Elella R, Najm HK, Balkhy H, et al: Impact of bloodstream infection on the outcome of children undergoing cardiac surgery. Pediatr Cardiol 2010;31: 483–489. 31. Verkkala K, Valtonen V, J€ arvinen A, et al: Fever, leucocytosis and C-reactive protein after open-heart
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surgery and their value in the diagnosis of postoperative infections. Thorac Cardiovasc Surg 1987;35:78–82. Maroto LC, Aguado JM, Carrascal Y, et al: Role of epicardial pacing wire cultures in the diagnosis of poststernotomy mediastinitis. Clin Infect Dis 1997;24: 419–421. o J, Raskine L, et al: Sternal puncture Benlolo S, Mate allows an early diagnosis of poststernotomy mediastinitis. J Thorac Cardiovasc Surg 2003;125:611–617. Goodman LR, Kay HR, Teplick SK, et al: Complications of median sternotomy: Computed tomographic evaluation. Am J Roentgenol 1983;141:225–230. Misawa Y, Fuse K, Hasegawa T: Infectious mediastinitis after cardiac operations: Computed tomographic findings. Ann Thorac Surg 1998;65:622–624. Ju´nior LA, Vicente WVA, Ferreira CA, et al: Surgicel packing and an erroneous diagnosis of mediastinitis in a neonate. Tex Heart Inst J 2010;37:116. Ibrahim MF, Aps C, Young CP: A foreign body reaction to R Surgicel mimicking an abscess following cardiac surgery. Eur J Cardiothorac Surg 2002;22:489–490. Bauernschmitt R, Martinoff S, Poerner M, et al: Pitfall in the computed-tomography-diagnosis of postcardiotomy infection: Iodine accumulation after irrigation mimicking retrosternal abscess. Eur J Cardiothorac Surg 2005; 27:707. Archer GL: Alteration of cutaneous staphylococcal flora as a consequence of antimicrobial prophylaxis. Rev Infect Dis 1991;13:S805–S809. ¨ zker E, SaritaSs B, Vuran C, et al: Delayed sternal closure O after pediatric cardiac operations; single center experience: A retrospective study. J Cardiothorac Surg 2012; 7:102. Ga˚rdlund B, Bitkover CY, Vaage J: Postoperative mediastinitis in cardiac surgery—microbiology and pathogenesis. Eur J Cardiothorac Surg 2002;21:825–830. Shumacker HB Jr, Mandelbaum II: Continuous antibiotic irrigation in the treatment of infection. Arch Surg 1963;86:384–387. Culliford AT, Cunningham JN, Zeff RH, et al: Sternal and costochondral infections following open-heart surgery. A review of 2,594 cases. J Thorac Cardiovasc Surg 1976; 72:714–726. Ohye RG, Maniker RB, Graves HL, et al: Primary closure for postoperative mediastinitis in children. J Thorac Cardiovasc Surg 2004;128:480–486. Bryant LR, Spencer FC, Trinkle JK: Treatment of median sternotomy infection by mediastinal irrigation with an antibiotic solution. Ann Surg 1969;169:914. Glick PL, Guglielmo BJ, Tranbaugh RF, et al: Iodine toxicity in a patient treated by continuous povidone–iodine mediastinal irrigation. Ann Thorac Surg 1985;39:478– 480. Thurer RJ, Bognolo D, Vargas A, et al: The management of mediastinal infection following cardiac surgery. An experience utilizing continuous irrigation with povidone– iodine. J Thorac Cardiovasc Surg 1974;68:962–968. Campistol JM, Abad C, Nogue S, et al: Acute renal failure in a patient treated by continuous povidone–iodine mediastinal irrigation. J Cardiovasc Surg 1988;29:410. Zec N, Donovan JW, Aufiero TX, et al: Seizures in a patient treated with continuous povidone–iodine mediastinal irrigation. N Engl J Med 1992;326:1784. Hauben M, Martin ES III, Godley PJ, et al: Seizures after povidone–iodine mediastinal irrigation. N Engl J Med 1993;328:355–356. Argenta LC, Morykwas MJ: Vacuum-assisted closure: A new method for wound control and treatment: Clinical
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experience. Ann Plast Surg 1997;38:563–576, discussion 577. Morykwas MJ, Argenta LC, Shelton-Brown EI, et al: Vacuum-assisted closure: A new method for wound control and treatment: Animal studies and basic foundation. Ann Plast Surg 1997;38:553–562. Kadohama T, Akasaka N, Nagamine A, et al: Vacuumassisted closure for pediatric post-sternotomy mediastinitis: Are low negative pressures sufficient? Ann Thorac Surg 2008;85:1094–1096. Mokhtari A, Petzina R, Gustafsson L, et al: Sternal stability at different negative pressures during vacuum-assisted closure therapy. Ann Thorac Surg 2006;82:1063–1067. Morykwas MJ, Faler BJ, Pearce DJ, et al: Effects of varying levels of subatmospheric pressure on the rate of granulation tissue formation in experimental wounds in swine. Ann Plast Surg 2001;47:547–551. Sjo¨gren J, Gustafsson R, Wackenfors A, et al: Effects of vacuum-assisted closure on central hemodynamics in a sternotomy wound model. Interact Cardiovasc Thorac Surg 2004;3:666–671. Fleck T, Simon P, Burda G, et al: Vacuum assisted closure therapy for the treatment of sternal wound infections in neonates and small infants. Interact Cardiovasc Thorac Surg 2006;5:285–288. Salazard B, Niddam J, Ghez O, et al: Vacuum-assisted closure in the treatment of poststernotomy mediastinitis in the paediatric patient. J Plast Reconstr Aesthetic Surg 2008;61:302–305. Durandy Y, Batisse A, Bourel P, et al: Mediastinal infection after cardiac operation. A simple closed technique. J Thorac Cardiovasc Surg 1989;97:282. Anslot C, Hulin S, Durandy Y: Postoperative mediastinitis in children: Improvement of simple primary closed drainage. Ann Thorac Surg 2007;84:423–428. Newcomb AE, Alphonso N, Nørgaard MA, et al: Highvacuum drains rival conventional underwater-seal drains after pediatric heart surgery. Eur J Cardiothorac Surg 2005;27:395–400. Jurkiewicz MJ, John B III, Hester TR, et al: Infected median sternotomy wound successful treatment by muscle flaps. Ann Surg 1980;191:738–744. Tobin GR: Pectoralis major muscle-musculocutaneous flap for chest-wall reconstruction. Surg Clin North Am 1989;69:991. Arnold PG, Pairolero PC: Use of pectoralis major muscle flaps to repair defects of anterior chest wall. Plast Reconstr Surg 1979;63:205. Nahai F, Morales L Jr, Bone DK, et al: Pectoralis major muscle turnover flaps for closure of the infected sternotomy wound with preservation of form and function. Plast Reconstr Surg 1982;70:471. De la Rocha AG, Robertson GA: Sealing the postpneumonectomy space: Use of a pectoralis major myodermal flap. Ann Thorac Surg 1984;38:221–226. Backer CL, Pensler JM, Tobin GR, et al: Vascularized muscle flaps for life-threatening mediastinal wounds in children. Ann Thorac Surg 1994;57:797–802. Stahl RS, Kopf GS: Reconstruction of infant thoracic wounds. Plast Reconstr Surg 1988;82:1010. Sung K, Jun TG, Park PW, et al: Management of deep sternal infection in infants and children with advanced pectoralis major muscle flaps. Ann Thorac Surg 2004;77:1371–1375. Nahai F, Rand RP, Hester TR, et al: Primary treatment of the infected sternotomy wound with muscle flaps: A review of 211 consecutive cases. Plast Reconstr Surg 1989;84:434–441.
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71. Tortoriello TA, Friedman JD, McKenzie ED, et al: Mediastinitis after pediatric cardiac surgery: A 15-year experience at a single institution. Ann Thorac Surg 2003; 76:1655. 72. Yuen JC, Zhou AT, Serafin D, et al: Long-term sequelae following median sternotomy wound infection and flap reconstruction. Ann Plast Surg 1995;35:585. 73. Scully HE, Leclerc Y, Martin RD, et al: Comparison between antibiotic irrigation and mobilization of pectoral muscle flaps in treatment of deep sternal infections. J Thorac Cardiovasc Surg 1985;90:523. 74. Mathisen DJ, Grillo HC, Vlahakes GJ, et al: The omentum in the management of complicated cardiothoracic problems. J Thorac Cardiovasc Surg 1988;95:677–784. 75. Krabatsch T, Hetzer R: Infected ascending aortic prosthesis: Successful treatment by thoracic transposition of the greater omentum. Eur J Cardiothorac Surg 1995;9:223– 225.
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76. Milano CA, Georgiade GS, Muhlbaier LH, et al: Comparison of omental and pectoralis flaps for poststernotomy mediastinitis. Ann Thorac Surg 1999;67:377–380. 77. Morotomi N, Saitoh M, Takanashi S, et al: After omental flap transposition, respiratory function and exercise capacity decrease. Ann Thorac Cardiovasc Surg 2010; 16:9–15. 78. Kluytmans JA, Mouton JW, Vanden Bergh MF, et al: Reduction of surgical-site infections in cardiothoracic surgery by elimination of nasal carriage of Staphylococcus aureus. Infect Control Hosp Epidemiol 1996;17:780–785. 79. Vlasselaers D, Milants I, Desmet L, et al: Intensive insulin therapy for patients in paediatric intensive care: A prospective, randomised controlled study. Lancet 2009; 373:547–556. 80. Ghafoori AF, Twite MD, Friesen RH: Postoperative hyperglycemia is associated with mediastinitis following pediatric cardiac surgery. Pediatr Anesth 2008;18:1202–1207.
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CONGENITAL HEART DISEASE REVIEW ARTICLE _______________________________________________________________
Mediastinitis Following Pediatric Cardiac Surgery Chirantan V. Mangukia, M.B.B.S., M.S.,* Saket Agarwal, M.B.B.S., M.S., M.Ch. (C.T.V.S.),* Subodh Satyarthy, M.B.B.S., M.S., M.Ch. (C.T.V.S.),* Vishnu Datt, M.B.B.S., M.D. (Anesthesia),y and Deepak Satsangi, M.B.B.S., M.S., M.Ch. (C.T.V.S.)* *Department of Cardiothoracic and Vascular Surgery, G.B. Pant Hospital, New Delhi, India; and yDepartment of Anesthesiology, G.B. Pant Hospital, New Delhi, India ABSTRACT Background: Mediastinitis following pediatric cardiac surgery is associated with significantly high morbidity and mortality. Method: In our review, 21 studies from 1986 to 2011 (12 retrospective studies, eight prospective studies, and a multi-institutional study) including 44,693 pediatric cardiac patients were analyzed. Results and Conclusion: Younger age, malnutrition, preoperative respiratory tract infection, high American anesthesiology score, longer duration of surgery, prolonged ventilation, and ICU stay were definite risk factors for mediastinitis. Early primary closure over drains, vacuum-assisted closure, muscle flap, and omental flap remain the most frequently performed treatments for post-sternotomy mediastinitis. Vacuumassisted closure has emerged as the technique of choice in recent years. doi: 10.1111/jocs.12243 (J Card
Surg 2014;29:74–82) Neonates with congenital heart defects are a uniquely ill population with an immature immune system to cope with an early surgical intervention. Their fragility makes deep sternal wound infection (SWI) a life-threatening complication.1 Nevertheless, the prognosis is much better in pediatric surgery compared to adult surgery, but prolonged hospital stays with intravenous therapy and frequent dressing changes are necessary and poorly tolerated.2 The spectrum of postoperative wound infection ranges from a superficial wound infection (involving skin or subcutaneous tissue) to fulminate mediastinitis with subsequent involvement of the sternum (sternal dehiscence and osteomyelitis) and organ tissues outside the incision.3 In pediatric cardiac surgical patients, reported surgical site infection (SSI) rates range from 1.7 to 8.0 per 100 cases.4–8 In our study, we have found the incidence of to be SSI 3.2% (0.22%–11%). SWIs and mediastinitis after cardiac surgery are associated with significant morbidity and mortality9,10 with an overall mortality between 10% and 25%.11,12 These infections significantly increase length of hospital stay13 and costs.
Conflict of interest: The authors acknowledge no conflict of interest in the submission. Address for correspondence: Chirantan Mangukia, Department of CTVS, G.B. Pant Hospital, New Delhi. Email: [email protected]
METHODS The review was prepared by searching the terms ‘‘pediatric post-sternotomy mediastinitis,’’ ‘‘vacuumassisted closure in mediastinitis,’’ and ‘‘muscle flap in pediatric post-sternotomy mediastinitis’’ in Google Scholar, PubMed, and PubMed Central. We reviewed 21 studies from 1986 to 2011 (12 retrospective studies, eight prospective studies, and a multi-institutional study) including 44,693 pediatric cardiac patients. Six case series from 1984 to 2007 including 39 patients describing various surgical techniques were also considered. CLASSIFICATION Robicsek has classified postoperative mediastinitis in three types.14 Cases with nonpurulent sterno-mediastinitis and no soft tissue or bone necrosis (type 1) may be treated with reopening, drainage, sternal stabilization, and primary closure. Virulent infections with tissue necrosis (type II) may be best handled with reopening, several days of open management, and debridement then secondary closure with viable tissue (usually muscle) flaps. Chronic, smoldering infections (type III) are usually managed with debridement and muscle-flap coverage.14
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RISK FACTORS Younger age,6,15,16 a higher American Society of Anesthesiologists score,6,15 longer duration of surgery,15,16 and concurrent infections have been shown to increase the SSI risk17,18 (Table 1). Moreover, immune competency is affected by operative trauma, as well as a variety of perioperative factors including underlying malnutrition, transfusion, cardiopulmonary bypass, and anesthesia.19 Costello et al.20 found that age younger than 1 year and duration of cardiopulmonary bypass greater than 105 minutes were independent risk factors for any type of SSI while aortic cross-clamp time greater than 85 minutes and postoperative exposure to at least three red blood cell transfusions were risk factors for organ space SSI. Similarly, Alpress et al.4 in a retrospective study showed that age less than one month and longer time of surgery were risk factors. In a multi-institutional study, Woodward et al. noted neither program size nor delayed sternal closure (DSC) was associated with increased incidence of SWI.21 There is no correlation reported between the type of congenital defect and type of infections.4,7 Programs with protocols to monitor and control blood glucose levels postoperatively had statistically lower infection rates, and those that sent mediastinal cultures at time of DSC reported lower infection rates.21 Type of preoperative measures, postoperative dressing, and antibiotic protocols do not impact the prevention of SSI.21 However, Maher et al.22 noted that antibiotic protocols do impact the incidence of mediastinitis significantly. If a patient had more than one cardiothoracic surgical procedure performed concurrently or had an infection present preoperatively, there was an increased risk of
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SSI because these variables reflect the patient’s underlying severity of illness and/or immune function.17 Pollock et al.8 associated occurrence of SWI to a high PRISM score (Pediatric Risk of Mortality Score). The Pediatric Risk of Mortality (PRISM) score was developed from the Physiologic Stability Index (PSI) to reduce the number of physiologic variables required for pediatric ICU (PICU) mortality risk assessment and to obtain an objective weighing of the remaining variables. Although in some papers prolonged mechanical ventilation was associated with SWIs, Hehrlein et al.23 did not consider it a significant risk factor. A longer stay in the PICU after surgery is also associated with SWIs.6,7 It is not clear whether infection might be the cause rather than the consequence for these infections.6 Re-exploration for bleeding, postoperative openchest, ECMO, and blood transfusion are also risk factors for deep wound infection.20,24,25
DELAYED STERNAL CLOSURE AND MEDIASTINITIS It is well known that potential risks of DSC include sepsis, mediastinitis, bleeding, and late sternal instability. Tabbutt et al.10 reported mortality to be 19%, SSI to be 6.7%, and mediastinitis to be 3.9% in his study of DSC in pediatric patients. Shin et al.26 reported postoperative infection and sterile wound dehiscence rate in DSC patients as 11% and 9%, respectively. These SWIs have been associated with longer postoperative stay.10,27 The group of patients undergoing DSC are believed to have an increased risk for infection because they have predisposing factors such as prolonged CPB time, low cardiac output, tissue edema,
TABLE 1 Major Risk Factors for Mediastinitis Following Pediatric Cardiac Surgery Risk Factor Age and weight
Preoperative infection or URI High ASA score
Longer duration of surgery Prolonged ventilation and longer ICU stay
Studies Showing Significance Costello et al.20 Rosanova et al.7 Allpress et al.16 Mehta et al.6 Galit Holzmann-Pazgal et Brady et al.15 Allpress et al.16 Rosanova et al.7 Galit Holzmann-Pazgal et Malviya et al.18 Rosanova et al.7 Allpress et al.16 Mehta et al.6 Brady et al.15 Galit Holzmann-Pazgal et Costello et al.20 Allpress et al.16 Brady et al.15 Costello et al.20 and Rosanova et al.7 and Allpress et al.16 Galit Holzmann-Pazgal et
al.17
al.17 (preoperative infection)
al.17
al.17
and
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J CARD SURG 2014;29:74–82
components of inflammation, massive transfusion, and the need for multiple re-explorations of the chest. In contrast, a review of the literature reveals that the incidence of wound infection after DSC is generally less than 10%.10 Some have reported that DSC is not associated with an increase in SSIs;4,6,10,27,28 besides a few authors claim that wound complications are reduced in the DSC technique.29 Others report DSC as a significant risk factor for bloodstream and SSIs.10,30 Al-Sehly et al. reported a 3.4% incidence of superficial SSI and a 1.9% incidence of mediastinitis in patients after DSC. They concluded that DSC was not a major risk factor for mediastinitis, especially if primary skin closure was performed.24
Candida albicans, Mycoplasma hominis, and mixed organisms have also been isolated.24 Staphylococci cultured from the skin of cardiac surgery patients are more resistant after surgery than before surgery and, furthermore, staphylococci causing postoperative infections have the same antimicrobialresistant phenotypes as do colonizing isolates.39 ¨ zker et al.40 reported a higher incidence In contrast, O for gram-negative organisms as compared to grampositive organisms. Outbreaks of mediastinitis caused by specific gram-negative organisms such as Pseudomonas or Serratia suggest nosocomial spread.41 Long reported that DSC was an independent risk factor for gram-negative mediastinitis.25
EVIDENCE OF INFECTION
TREATMENT
Mediastinitis generally presents days to weeks after cardiac surgery.24 Diagnosis is often made on the basis of the appearance of the wound, while retrosternal puncture and computed tomography (CT) scan are useful in the initial stages. Babies often appear irritable, tired, and remain febrile. The incision is erythematous and painful, and wound dehiscence and purulent drainage from the incision are frequent as well as sternal instability. A rise in temperature of 38.58C or greater is the most common early presentation of poststernotomy mediastinitis, followed by purulent discharge from the incision or from pacing wires, erythema of the incision, and sternal wound dehiscence.24 Bacterial examination of the purulent drainage confirms the presence of altered leukocytes and microorganisms. A considerable number of patients might not show a rise in total leukocyte counts.24 C-reactive protein (CRP) may be elevated; many studies have revealed CRP as marker of active ongoing infection.31 The diagnosis may be more difficult when the patient has received antibiotic therapy as the patient may remain afebrile. Epicardial pacing wire cultures are sensitive for the diagnosis of mediastinitis,32 while diagnostic bacteriological samples from the sternal or retrosternal puncture are considered safe and helpful.33 CT scans have been considered of great value to localize infected tissues.34 Misawa et al.35 showed that a mediastinal soft tissue mass combined with a bilateral pleural effusion can be a characteristic CT finding in poststernotomy infectious mediastinitis, and that chest CT is more sensitive for detecting sternal dehiscence, sternal erosion, and subcutaneous fluid accumulation. Erroneous diagnoses due to surgical packing,36 surgical (manufactured by Ethicon—A Johnson & Johnson Family of Companies, Piscataway, NJ, USA), body foreign reaction,37 or iodine accumulation following irrigation38 have been reported.
The treatment of wound dehiscence after sternotomy underwent major advancements in 1963 when Shumacker and Mandelbaum42 introduced closedchest catheter antibiotic irrigation after sternal debridement. Since then, numerous investigators have refined the rewiring techniques and the process of irrigation by modifying irrigation fluids,43 and others have introduced new muscle flaps for the closure of these wounds. The optimal treatment of mediastinitis, once diagnosed, remains controversial. Antibiotic treatment based on empirical probability should be immediately initiated, followed within a few hours by surgical drainage. The following modalities of management were identified for SWI and mediastinitis in this review (comparison between these studies is described in Table 2).
BACTERIOLOGY Staphylococcal species continue to be the most common offending organisms.17,24 Pseudomonas aeruginosa, Enterobacter cloacae, Enterococcus faecalis,
Early primary closure—sternal wounds wired over drains Primary closure is an effective treatment for mediastinitis in children.44 Ohye et al. describes early primary closure over a single chest tube that serves as a routine mediastinal drain (usually removed in one to two days). This simple technique is more comfortable for the patient and achieves a high rate of success.44 However, in three of 42 patients, this approach failed requiring reoperation for continuing sepsis. Furthermore, the medical therapy requires a lengthy course of intravenous antibiotics. The six-week intravenous antibiotic treatment has a significant disadvantage, especially when a central venous line is necessary. Surgical debridement with irrigation Bryant et al.45 described an innovative treatment that entails mediastinal reexploration, placement of mediastinal irrigation tubes, and primary closure of the sternum. Dilute antimicrobial solutions like neomycin, bacitracin, polymyxin B sulfate, kanamycin sulfate, cephalothin sodium, and Dakin’s solution are used to irrigate the mediastinum until cultures of the effluent are negative and the wound infection is clinically resolved. Because of the reported toxicity of many of
Type of Study
Case series Case series
Retrospective study
NA
NA
NA
11
7
17
14.57 days
11.1 days
11.9 days
13 days
16.88 days
18.33 days
8.8 days 1–3 days after DSC
13 days
Interval S/M
25.52 days
37.71 days
15.18 days
14.5 days
88% (15/17)
85.71% (6/7)
100%
100%
100%
NA
9.66
15 days
NA NA
97% (41/42) as compared to 27% (4/15) in conventional group
Hospital Survival
11.3 13
NA
Interval M/D or MDT
2 had 10 PMF, 3 rectus abdominis, and 1 cervical strap pedicle graft mediastinitis 2 DSC, 3 14 days (6–50 NA 93% (14/15) Sternal debridement and rectus emergent days) abdominus flap (n ¼ 7), pectoralis muscle sternotomies, 1 flap (n ¼ 3), omental flap (n ¼ 1), or ventricular assist primary sternal closure (n ¼ 4) device
NA
20
8 patients with SSI
NA
64 (1.7%) 9
3650
0
2 3
15 patients (DSC or muscle flap)
DSC Done or Not
3
3 (8.3%) 3
57 (0.85%), 42 treated by EPC
Cases of Mediastinitis (Incidence)
3
36 3 (DSC after prolonged ECMO)
6705
Study Size
NA
0%
0%
0%
0%
0%
0%
NA 0%
7% (3/42)
Recurrence
1 Sternal reconstruction secondary to nonunion, 3 resternotomies due to next procedures
NA
NA
NA
NA
NA
Second primary closure in 2 cases
NA 2 cases undergone TSG
3% (1/42) recurrent infection lead to muscle flap closure
Reintervention by Other Technique
150 mmHg
50 mmHg
50 mmHg 50 mmHg
Not applicable
Negative Pressure (mmHg)
In 7 of 8 patients, wound healed completely. 4–6 weeks Not applicable
15 days (10–31 days)
NA
11 days (7–28 days)
NA NA (cultures were sterile after 8th day of therapy) NA
6 weeks
Antibiotic Duration
42.5 days (16–163 days)
12 (4–88)
Hospital Stay Median and (Range)
MDT, mean duration of therapy; DSC, delayed sternal closure; EPG, early primary closure; TSG, thin skin grafting; interval S/M, interval between surgery and diagnosis of mediastinitis; interval M/D, interval between diagnosis of mediastinitis and duration of treatment.
Tortoriello et al.71
Case series Kadohama et al.53 Anslot et al.60 Prospective study Isolated mediastinitis in neonates (mean age 14.33 days) Isolated mediastinitis in infants (mean age 4.5 months) Isolated mediastinitis in children (mean age 6.72 years) Mediastinitis associated with endocarditis Mediastinitis associated with organ failure Muscle flap closure Backer et al.67 Case series
VAC Fleck et al.57 Salazard et al.58
Early primary closure Ohye et al.44 Retrospective review
Techniques
TABLE 2 Comparison between Various Surgical Techniques for Treatment of Sternal Wound Infection
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these agents and the occurrence of microbial resistance, an alternative irrigant has been sought.46 Thurer et al.47 described the use of 0.5% povidone–iodine solution as a mediastinal irrigant (50–100 mL/hour) and reported it to be an effective antimicrobial agent and ‘‘non-toxic in the concentrations recommended.’’ Glick et al.46 reported a 34-month-old patient with mediastinitis after median sternotomy who was treated with continuous povidone–iodine irrigation and who absorbed toxic quantities of iodine. Due to complications like fluid overload, metabolic acidosis,46 renal failure,48 seizures,49,50 microbial resistance, and antibiotic toxicity the technique became less popular. Negative pressure wound therapy Negative pressure wound therapy was first introduced by Argenta and Morykwas51,52 and has become a widely used, efficacious, and reliable method for managing different types of open wounds after infection. However, the validity of using the VAC therapy to manage pediatric poststernotomy mediastinitis is not clear because of very few reports published on this topic. The application of negative pressure has several advantages: the negative pressure (1) enhances wound drainage, clearing of putrid secretions and toxic products by the continuous suction, preventing fluid retention in the depth of the wound; (2) avoids any residual mediastinal cavity so that the mediastinum is filled with healthy tissue; (3) helps approximate the wound edges and favors stabilization of the chest; (4) and stimulates the formation of granulation tissue by maintaining a moist environment. Furthermore, patients can be mobilized early and can receive physiotherapy to minimize further complications.53 The most commonly used pressure clinically is 125 mmHg in adults54 based on previous basic research.55 It has been proposed that a less negative pressure might lead to insufficient sternal stability. On the other hand, too high of a negative pressure applied to the mediastinum has been suggested to be a risk for damage of fragile pediatric organs. Mokhtari et al.54 reported that low negative pressures (50 to 100 mmHg) can stabilize the sternum just as efficiently as high negative pressures (150 to 200 mmHg) and that the vacuum dressing adapts better to the shape of the wound at a lower negative pressure in a porcine model.56 Fleck et al.57,58 and Salazard et al.58 reported that low negative pressure VAC therapy lasted for short duration, ranging from 10 to 21 days, resulted in rapid decrease in local purulence and CRP.58 VAC was well tolerated by the children without changes in heart rate, blood pressure, or respiration, even without ventilatory support. Kadohama et al.53 had found no complications such as massive air leakage, insufficient drainage, or tissue damage during VAC therapy under a pressure of 50 mmHg. In contrast, Durandy et al.59 described a simple closed technique with primary closure and high-vacuum drainage in 64 patients. The technique was progres-
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sively modified and reported by Anslot et al.60 The surgical technique includes debridement of all infected or necrotic tissue and sternal edge revision until normal bleeding. Drainage was achieved through high-vacuum R Redon’s catheters (Drainobag Lock 150, Braun, Melsungen, Germany) (2.7 mm in diameter with multi-perforated polyvinyl tubing) connected to lightweight plastic bottles. With two different antibiotics, sterility of the effluent fluids was obtained in four to five days for Staphylococcus aureus or epidermidis, regardless of methicillin sensitivity or resistance and eight days for gram-negative bacilli. Once the effluent is sterile, the catheter is progressively withdrawn (2 cm every day). Patients with endocarditis and organ failure required longer antibiotic therapy. The mortality rate was 4%; all three patients died from associated complications after sterilization of the mediastinal effluent and withdrawal of Redon’s catheters. The high vacuum was well tolerated in this study. This drainage technique used in pediatric or adult cardiac surgery (instead of conventional underwaterseal drains) does not have any hemodynamic drawback61 (except for Norwood stage 1), does not damage surrounding tissue, shortens antibiotic therapy duration, prevents fungal super infection, and results in an overall infection eradication rate of 100%.60 The technique is also cost-effective. Muscle flaps Pectoralis flaps were first described by Jurkiewicz et al.62 as a treatment for these wounds and currently is the standard treatment of this complication in adults. There is, however, scant information regarding the use of these techniques in neonates, and only sporadic case reports on neonates, with no reported follow-up. The principles of reconstruction consist of using a well-vascularized coverage for optimal wound healing, ensuring anterior mediastinal protection, and maintaining chest wall stability.1,63 The dominant blood supply of the pectoralis muscle is based on the thoracoacromial artery with a secondary supply through segmental pedicles from the internal mammary artery located 2–3 cm lateral to the sternum. This has led to the development of various techniques for pectoralis muscle flap (PMF) reconstruction and even with possible preservation of form and function.64,65 With the lateral humeral insertion detached, and based on the internal mammary artery perforators, the muscle can be turned on itself and used to fill mediastinal defects after partial or complete sternectomy.1 When medial rib origins are also detached, the muscle can be easily moved to fill defects in the superior mediastinum, or it can be taken through a window in the anterior ribs to fill the upper chest cavity.66 In cases of superficial sternal wound complications, the medial rib origins alone can be detached, usually bilaterally, and the two muscles are joined at the midline.1 Backer et al.67 described the use of vascularized muscle flaps in eight pediatric patients with lifethreatening mediastinal wounds, only two of whom had mediastinitis.67 They used three different
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reconstruction approaches: unilateral PMF, bilateral PMF, and a rectus abdominis muscle flap, with one case of mortality in the neonatal group. Stahl and Kopf68 reported on four infants, three of them neonates undergoing bilateral PMF with preservation of the humeral attachments, a technique used for superficial operative wound complications. The muscles are very delicate, especially in critically ill neonates, and dissection is more difficult than in adults due to their small size. Moreover, smaller vascular pedicles in these patients are less compliant and less resilient to stretching. Thus, minimal insults, which in adults would be insignificant, can pose a major risk to PMF survival in a suboptimal physiologic state, often characterized by some degree of cardiac failure and decreased oxygen carrying capacity of the blood. The patient’s nutritional status should also be considered.67 Also, reentry should be considered for staged or corrective operations. The pectoralis major flap with a turnover technique is particularly valuable for repairing the upper three fourths of the anterior sternum, but is limited for lower defects.68 Sung et al.69 developed an advanced flap technique using the pectoralis major muscle to fill the whole defect. The use of the rectus abdominis muscle and the omentum requires additional abdominal incisions, increasing postoperative pain, may compromise respiratory functions, may cause cross-contamination, and risks herniation or a diffuse bulging through the defect.70 Finally, the choice of the rotational flap to be used is dependent on surgeon preference and other factors such as patient age, size, gender, and presence of percutaneous enterostomies. Tortoriello et al.71 incorporated an aggressive surgical strategy of extensive surgical debridement and early sternal reconstruction with omental flaps, pectoralis major muscle flaps, or rectus abdominis muscle flaps, that gave better results as compared to previous reports. Because of the increased length of the abdomen in comparison with the chest in small children, a rectus abdominis muscle flap allows complete coverage of the sternal incision and reaches the central extent of the wound. Although previous studies have raised the possibility of an increased risk of reoperation through the reconstructed sternum due to the small amount of tissue that is initially placed over the mediastinum,1 subsequent reoperation has been performed in three patients in the series and has not been problematic. Nevertheless, pectoralis major muscle flaps have potential weaknesses for infants and children. Sung et al.69 could not find any evidence of upper limb or upper trunk motor deficits, except for a minor protrusion of the lower sternum in one reoperated patient and mild asymmetric anterior chest wall deformity in three patients on short-term follow-up. Erez et al.1 reported similar results. Breast hypoplasia, including sensory loss, may occur in late adolescence, especially in females, and should be closely followed. Sung et al.69 used the advanced pectoralis muscle flap (APMF) technique. This maneuver provides an
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additional layer of tissue between the skin and sternum. Muscles provide material to close the defect and obliterate the potential dead space. The technique is easy and there is less distortion of the chest wall contour and symmetry as compared with the pectoralis major turnover flap, which produces a concavity at the donor defect, and a relative prominence at the pedicle site.69 Morbidity associated with the muscle flap technique includes pain, weakness, hernia, and cosmetic appearance, which is of great significance in pediatric patients and more specifically in young girls.71,72 Chest wall in stability,71 bleeding, and recurrence of infection were noticed, and omental transfer was proposed as an alternative to the pectoral flap. Plastic procedures may have short-term and longterm results equivalent to irrigation, but the length of stay in the intensive care is longer for patients treated with muscle flap closure.73 Omental flaps The omentum has been described for treatment of a variety of cardiothoracic infectious complications.71,74 A relatively long vascular pedicle enables omental transfer to the anterior mediastinum as is needed for poststernotomy mediastinitis, and generally the omental flap can be extended easily to the superior aspect of the sternotomy incision in adults. On the other hand, children tend to have less developed omentum as compared to adults, restricting the extent of its utilization. Studies performed on adults show that omental transfer required shorter operative times75,76 but alters respiratory function by decreasing the percent vital capacity and oxygen consumption.77 Similar studies have yet to be performed in neonates and young children. Peritoneal dialysis, ileostomy, the potential for hernia formation, and inability to cover the defect adequately given the thinness of the omental tissue limit the use of omentum in children.71 PREVENTION Woodward showed that the type of the preoperative preparation does not significantly impact the overall incidence of SSI.21 In general, routine preparation with chlorhexidine appears satisfactory. Kluytmans et al.78 noted that perioperative elimination of nasal carriage of Staphylococcus aureus using mupirocin nasal ointment significantly reduces the SSI rate in cardiothoracic surgery patients and it warrants a prospective, randomized, placebo-controlled efficacy trial in children. Vlasselaers et al.79 noted that targeting of blood glucose concentrations to age-adjusted normal fasting concentrations improved short-term outcome and shortened the stay of patients in the ICU. In a recent retrospective case–control study, 24-hour peak blood glucose greater than 130 mg/dL was found to be a multivariate predictor for mediastinitis after pediatric cardiac surgery.80
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CONCLUSION Younger age, preoperative respiratory tract infection, high American anesthesiology score, longer duration of surgery, malnutrition, prolonged ventilation, and ICU stay were definite risk factors for mediastinitis. Controversy remains regarding role of DSC, type of congenital cardiac defects, antibiotic strategy, and glycemic control as risk factors for SWI. Since most of the risk factors are nonmodifiable, prevention of mediastinitis is still a difficult challenge. A primary sternal closure is the technique of choice in pediatric patients whenever possible. We currently lack large standardized studies to compare the described techniques and their outcomes in pediatric population. In addition to microvascular and drainage-related benefits VAC (whether low negative pressure and high negative pressure) provides early freedom from ventilation and reduces cost of therapy. Irrigation, omental flap, and muscle flaps are being performed less frequently. Larger studies are needed to prove if they are superior to the other methods in terms of cost-effectiveness, mortality benefit, and long-term effect.
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