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Ann Thorac Surg 2001;71:1580-1586
© 2001 The Society of Thoracic Surgeons

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Original article: cardiovascular

Closed drainage using Redon catheters for poststernotomy mediastinitis: results and risk factors for adverse outcome

^a Service de Chirurgie Thoracique et Cardiovasculaire, Hôpital Henri Mondor, Créteil, France
^b Intensive Care Unit, Hôpital Henri Mondor, Créteil, France

Accepted for publication December 14, 2000.

Address reprint requests to Dr Kirsch, Service de Chirurgie Thoracique et Cardiovasculaire, Hôpital Henri Mondor, 51, avenue du Maréchal de Lattre de Tassigny, 94010 Créteil Cédex, France
e-mail: loisance{at}univ-paris12.fr

	Abstract

Top Footnotes Abstract Introduction Material and methods Results Comment References

 
Background. Several different surgical techniques have been described for the treatment of poststernotomy mediastinitis. The present study was undertaken to evaluate the midterm results of primary closed drainage using Redon catheters and to identify risk factors for adverse outcome.

Methods. Hospital records of 72 patients in whom poststernotomy mediastinitis developed and who underwent closed drainage with Redon catheters between April 1, 1996, and December 31, 1999, were reviewed. Follow-up was complete and averaged 11.8 ± 11.5 months.

Results. Of the 25 deaths (34.7%) recorded, 15 were directly attributable to mediastinitis. Actuarial estimates for freedom from mediastinitis-related death were 80.1% at 1 month and 77.4% at 1 year, 2 years, and 3 years. Logistic regression identified older age (odds ratio, 1.1; 95% confidence interval, 1.02 to 1.18), incubation time of 14 days or less (6.5; 1.33 to 31.4), and methicillin-resistant Staphylococcus aureus (5.8; 1.2 to 27.2) as independent risk factors for mediastinitis-related death. Reintervention for recurrent mediastinitis was necessary in 9 patients (12.5%) and occurred at a mean interval of 18.7 ± 13.5 days from the first debridement. Actuarial estimates for freedom from reintervention were 87.1% at 1 month and 85.2% at 1 year, 2 years, and 3 years. The combined end point of treatment failure (mediastinitis-related death or reintervention) was recorded in 9 patients (26.4%). Actuarial estimates for freedom from treatment failure were 74.3% at 1 month and 72.7% at 1 year, 2 years, and 3 years. Logistic regression identified older age (1.01; 1.02 to 1.18), preoperative renal insufficiency (6.8; 1.04 to 44.5), and methicillin-resistant S aureus infection (4.8; 1.04 to 22.33) as independent risk factors for treatment failure (includes mediastinitis-related death and reintervention [with or without death]).

Conclusions. Primary closed drainage using Redon catheters is an effective and simple treatment for most patients in whom poststernotomy mediastinitis develops. However, patients with methicillin-resistant S aureus infection or recurrent mediastinitis may benefit from a more aggressive approach.

	Introduction

Top Footnotes Abstract Introduction Material and methods Results Comment References

 
Poststernotomy mediastinitis (PSM) remains one of the most serious and dreaded complications in cardiac surgery. In recent series [1, 2], the incidence of PSM has been reported to range between 1% and 4%, and PSM is still associated with major patient morbidity, mortality, and cost.

The treatment of PSM has evolved over the past 35 years. The classic surgical therapy consisted of surgical debridement followed by open wound drainage. However, this technique was associated with high failure and mortality rates and has progressively been abandoned. In 1963, Shumaker and coworkers [3] described a technique of wound debridement, primary sternal closure, and continuous mediastinal irrigation. Evidence of antibiotic or iodine toxicity [4] and poor results in earlier studies have stimulated the development of several plastic surgical procedures as alternatives to closed mediastinal irrigation [5, 6]. Thus, primary or delayed mediastinal closure using muscle flaps or the greater omentum have gained wide acceptance for the treatment of PSM [7].

In 1989, Durandy and colleagues [8] proposed a simple primary closed drainage technique using Redon catheters. The basis of this technique is, after meticulous wound debridement, to drain all infected areas with small catheters connected to bottles inside of which a strong negative pressure (-700 mm Hg) is created (Redon drainage device). A retrospective study published in 1996 [9] reported significantly reduced failure and 30-day mortality rates in patients treated with this technique in comparison to patients treated with the closed continuous irrigation technique. However, midterm results after closed drainage using Redon catheters have not been published. At Henri Mondor Hospital, we have adopted primary closed drainage using Redon catheters since 1996 and have used it as the primary treatment option for patients with PSM. The present study was undertaken to provide the long-term results of our experience with the closed drainage technique using Redon catheters and to identify risk factors for adverse outcome.

	Material and methods

Top Footnotes Abstract Introduction Material and methods Results Comment References

 
Between April 1, 1996, and December 31, 1999, 3,200 patients underwent a cardiac surgical procedure through a median sternotomy at Henri Mondor Hospital, Créteil, France. Mediastinitis was defined as a deep wound infection associated with sternal osteomyelitis, with or without an infected retrosternal space, and requiring surgical debridement [10]. According to this definition, 81 patients had development of PSM during the study period, for an overall incidence of 2.5%. Patients treated by a closed irrigation technique (n = 1), by primary soft-tissue closure (n = 2), or by open drainage (n = 1) were excluded from analysis. Patients with PSM during or after a period of mechanical circulatory support with implantable or paracorporeal devices were also excluded (n = 5). Thus, the present study comprises 72 patients with PSM.

Surgical management of PSM
As soon as the diagnosis was strongly suspected, intravenous antibiotic treatment was instituted. In the absence of positive cultures, probabilistic antistaphylococcal therapy was used combining either oxacillin or vancomycin with aminoglycosides. All patients underwent surgical intervention on an urgent basis. Under general anesthesia, the sternotomy was totally reopened. Extensive debridement of skin, subcutaneous tissue, nonviable muscle, and bone was performed until normal bleeding was obtained. The use of diathermy and bone wax was avoided. All fibrinopurulent and necrotic material was removed from the pericardial cavity. The wound was copiously irrigated with large amounts of diluted povidone-iodine solution (Betadine). Drainage was accomplished by placing Redon catheters, which are multiperforated small, rigid tubes, in all infected areas of the mediastinum and pleural cavities. The number of Redon catheters used depended on the size of the residual cavity. Finally, the sternum was closed, and subcutaneous tissue and skin were reapproximated using interrupted sutures.

After closure, the Redon catheters were connected to plastic bottles inside of which a strong negative pressure (-700 mm Hg) had been created. Every 3 days, the effluent in the bottles was collected, and cultures were grown. After at least 10 days of closed drainage, catheters were progressively removed (2 cm daily). Redon catheters have to be clamped during removal to avoid suction-induced tissue injury. Antibiotics adapted to the organisms cultured were continued for an overall treatment duration of 4 to 6 weeks.

Data collection
Hospital records were reviewed retrospectively. Variables included in the study are listed in the Appendix. Obesity was defined as a body weight greater than 20% of normal weight as estimated by the Lorentz formula. Diabetes was defined as the need of medication with an antidiabetic drug. Preoperative renal insufficiency was determined by serum creatinine levels higher than 1.5 mg/dL (130 µmol/L). The duration of the incubation period was defined as the interval between the initial surgical procedure and reoperation for PSM. Poststernotomy mediastinitis was classified into four subtypes based on the presence or absence of incremental risk factors for PSM, the duration of the incubation period, and previous failed therapeutic trials according to El Oakley and Wright [10]. Recorded life-threatening complications were secondary prosthetic valve endocarditis, massive mediastinal hemorrhage caused by vascular or cardiac rupture, and occurrence of multiple-organ dysfunction. Hospital death was defined as death occurring within 30 days of debridement for PSM. Mediastinitis-related death was defined as death occurring as a consequence of uncontrollable sepsis leading to multiple-organ failure, massive mediastinal hemorrhage, or secondary prosthetic valve endocarditis. Treatment failure was defined as the need of reintervention because of continued local infection or as the death of the patient as a consequence of mediastinal infection. Follow-up information was obtained during January 2000 by telephone interview with the patient, the patient’s relatives, or the referring physician. Questions were asked in regard to reintervention for recurrent mediastinitis and cause and date of death. Complete follow-up information was available for all patients. Mean follow-up time was 11.8 ± 11.5 months.

Statistical analysis
Statistical analysis was performed using SPSS Base 8.0 statistical software (SPSS Inc, Chicago, IL). Continuous variables were expressed as the mean ± one standard deviation and were compared using an unpaired two-tailed t test. Categorical variables, expressed as percentages, were analyzed with a ² test or Fisher’s exact test. Survival data were analyzed with standard Kaplan-Meier actuarial techniques for estimation of survival probabilities. To identify risk factors for mediastinitis-related death, need of reintervention because of recurrent mediastinitis, and treatment failure, univariate analysis of preoperative, procedure-related, and mediastinitis-related variables was performed by comparing different subsets of independent patients. To evaluate independent risk factors for mediastinitis-related death and treatment failure, significant or marginally significant (p 0.2) univariate risk factors were examined in multivariate fashion using forward stepwise logistic regression analysis. Coefficients were computed by the method of maximum likelihood. A two-tailed p value of less than 0.05 was taken to indicate significance.

	Results

Top Footnotes Abstract Introduction Material and methods Results Comment References

 
Patient characteristics and details of initial cardiac surgical procedure
Mean patient age was 65.9 ± 12.4 years (range, 30 to 87 years). The series comprised 51 men and 21 women. Mean preoperative functional status as assessed by New York Heart Association functional classification was 2.27 ± 0.8. Preoperative risk factors for mediastinitis included obesity in 35 patients (48.6%), diabetes in 23 (31.9%), renal insufficiency in 11 (15.3%), chronic obstructive pulmonary disease in 10 (13.9%), and requirement of immunosuppressive drugs in 4 (5.6%). Details of the initial surgical procedure are presented in Table 1. The immediate postoperative course was characterized by the need of autologous blood transfusions in 55 patients (76.4%). Six patients (8.3%) underwent mediastinal reexploration for postoperative bleeding or pericardial effusion.

View larger version (14K): [in this window] [in a new window]   Fig 1. Actuarial survival estimates for entire patient population (n = 72, events = 25). Error bars represent ± standard error of the mean. (Nbr = number.)

View larger version (13K): [in this window] [in a new window]   Fig 2. Actuarial estimates for freedom from mediastinitis-related death (n = 72, events = 15). Error bars represent ± standard error of the mean. (Nbr = number.)

View larger version (13K): [in this window] [in a new window]   Fig 3. Actuarial estimates for freedom from reintervention for recurrent mediastinitis (n = 72, events = 9). Error bars represent ± standard error of the mean. (Nbr = number.)

View larger version (13K): [in this window] [in a new window]   Fig 4. Actuarial estimates for freedom from treatment failure (n = 72, events = 19). Error bars represent ± standard error of the mean. (Nbr = number.)

	Comment

Top Footnotes Abstract Introduction Material and methods Results Comment References

One limitation of our study is that it provides no comparison with other techniques currently used for the treatment of PSM. Calvat and colleagues [9] compared the results of primary closed drainage using Redon catheters in 70 patients with those obtained in 38 patients who underwent continuous povidone-iodine mediastinal irrigation. They showed significantly reduced failure and 30-day mortality rates in the group treated with primary closed drainage using Redon catheters. In several recent series [5, 6, 11, 12], the reported incidence of mediastinitis-related death after muscle flap or omental transfer procedures ranged between 0% and 28.6%. More recently, vacuum-assisted closure has been applied successfully in the treatment of PSM [13]. This technique combines the benefits of continuous low-pressure suction and open wound drainage.

However, comparison of the results of different surgical techniques is awkward in the absence of randomized clinical trials using a comprehensive definition and classification of PSM and standardized end points [10]. Therefore, the exact place of primary closed drainage using Redon catheters among the wide array of techniques currently available for the treatment of PSM remains to be defined. Thus, one of the objectives of our study was to identify risk factors for adverse outcome after primary closed drainage using Redon catheters to allow a more efficient patient selection for this technique.

Older age has been shown to be a risk factor for the development of PSM [7]. In the present study, older age was identified by multivariate analysis as a significant risk factor for mediastinitis-related death and treatment failure. A similar finding was reported by Valla and coworkers [14]. It is now well established that many infections are both more frequent and more often lethal in older individuals [15]. In the elderly, age-related decline in cell-mediated and humoral immunity, impaired circulation, poorer wound healing, and a high incidence of comorb illnesses, all contribute to an adverse prognosis in the case of PSM. We believe that compared with the more aggressive muscle flap or omental transfer procedures, primary closed drainage using Redon catheters is an interesting option in elder patients because of its simplicity and the possibility of rapid postoperative readaptation.

It has been hypothesized that closed drainage techniques are most effective in patients in whom PSM develops within 2 to 3 weeks of the initial surgical intervention [16]. In the early postoperative period, mediastinal tissues are still soft and pliable, which allows easy obliteration of any dead space by suction [17]. However, our experience shows that the use of closed drainage using Redon catheters in patients with incubation times longer than 14 days was not associated with an increased incidence of treatment failure or recurrent mediastinitis. On the contrary, an incubation time of 14 days or less appeared as a significant risk factor for mediastinitis-related death. This finding was independent of any specific microorganism. The occurrence of surgical wound infection and its incubation time are determined by a complex interplay of patient-related factors such as host systemic and local immunity, wound-related factors such as extent of tissue trauma, dead space, and hematoma, and microbial factors such as microbial load and virulence [18]. The adverse prognostic significance of a shorter incubation time in our study is probably the reflection of an imbalance in these factors in favor of infection.

Since methicillin-resistant S aureus was first described in 1961, it has become endemic in hospitals in many countries. The impact of methicillin resistance on mortality of various infections remains controversial. Several studies [19–21] have observed similar mortality after methicillin-resistant S aureus and methicillin-susceptible S aureus bacteremia. In contrast, other groups [22, 23] have reported that methicillin-resistant S aureus infection is a significant and independent risk factor for death. In our study, methicillin-resistant S aureus was independently associated with higher rates of mediastinitis-related death and treatment failure. The exact reasons for these findings are unknown but do not appear to be related to an increased virulence of methicillin-resistant strains [24]. However, given its prognostic significance, preventive measures against colonization with methicillin-resistant S aureus appear warranted for cardiac surgical patients.

Most of our patients had type I, IIIA, or IIIB mediastinitis according to the recent-classification of El Oakley and Wright [10]. We found no prognostic significance for classification by univariate or multivariate analysis. However, our population did not comprise patients with mediastinitis type IVA or IVB at initial presentation. Therefore, we undertook a separate analysis of those patients with development of recurrent mediastinitis after a first treatment attempt with closed drainage using Redon catheters. When repeated closed drainage using Redon catheters was done, the incidence of both mediastinitis-related death and recurrent mediastinitis was unacceptably high. Thus, our results do not support the use of this technique in the setting of recurrent PSM. Patients with recurrent PSM would probably benefit more from open drainage followed by a delayed reconstructive surgical procedure.

In summary, primary closed drainage using Redon catheters is an effective and simple treatment for most patients in whom PSM develops. However, patients with methicillin-resistant staphylococcal infection or recurrent mediastinitis (El Oakley and Wright type IVA or IVB) might benefit from a more aggressive initial approach. This technique warrants further evaluation as a first-line treatment for PSM in the form of randomized clinical trials comparing it with muscle or omental flap closure.

	Footnotes

Top Footnotes Abstract Introduction Material and methods Results Comment References

 
This article has been selected for the open discussion forum on the STS Web site: http://www.sts.org/section/atsdiscussion/

	Appendix

 

Variables included in studya Preoperative Age Sex Diabetes Obesity Requirement of immunosuppressive agents Chronic obstructive bronchopulmonary disease Renal insufficiency Initial surgical procedure Redo operation Timing of operation Type of procedure Use of bilateral internal mammary artery grafts Cardiopulmonary bypass time Aortic cross-clamp time Transfusion requirements Reexploration Mediastinitis Length of incubation period Concomitant bloodstream infection Preoperative septic shock Type of mediastinitis Causative organisms No. of intrathoracic and presternal Redon catheters Duration of closed drainage Mechanical ventilation for more than 1 day Duration of stay in intensive care unit Occurrence of life-threatening complications Treatment failure Survival at follow-up

^a See text for definitions.

	References

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This Article Abstract Full Text (PDF) Online Discussion Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Rémi Houël Daniel Y. Loisance Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Kirsch, M. Articles by Loisance, D. Y. Search for Related Content PubMed PubMed Citation Articles by Kirsch, M. Articles by Loisance, D. Y. Related Collections Mediastinum