Ann Thorac Surg 2008;85:1094-1096. doi:10.1016/j.athoracsur.2007.09.004
© 2008 The Society of Thoracic Surgeons
Case Reports
Vacuum-Assisted Closure for Pediatric Post-Sternotomy Mediastinitis: Are Low Negative Pressures Sufficient?
Takayuki Kadohama, MD, PhDa,*,
Nobuyuki Akasaka, MD, PhDa,
Akira Nagamine, MDa,
Keisuke Nakanishi, MDa,
Keiko Kiyokawa, MDb,
Kazutomo Goh, MD, PhDb,
Tadahiro Sasajima, MD, PhDa
a Department of Surgery, Asahikawa Medical University, Asahikawa, Japan
b Department of Emergency Medicine, Asahikawa Medical University, Asahikawa, Japan
Accepted for publication September 4, 2007.
* Address correspondence to Dr Kadohama, Asahikawa Medical University, Department of Surgery, Midorigaoka-Higashi 2-1-1-1, Asahikawa, 078-8510, Japan (Email: tkadoha{at}asahikawa-med.ac.jp).
 |
Abstract
|
|---|
We present 3 cases of pediatric post-sternotomy mediastinitis treated by a vacuum-assisted closure (VAC). The patients 2 girls, aged 6 months and 10 months, and a 2-year-old boy. The onset of infection was at 9, 14, and 32 postoperative days. The culture examination detected coagulase-negative Staphylococci strains in 2 cases, and Staphylococcus aureus in 1 case. A VAC was performed at –50 mm Hg for 10, 12, and 7 days. The wounds were closed without vascularized soft tissue. A VAC under a low negative pressure is a useful and safe procedure for the management of pediatric post-sternotomy mediastinitis.
|
Introduction
|
|---|
Post-sternotomy mediastinitis, also commonly called deep sternal wound infection, is one of the most feared complications in patients undergoing cardiac surgery [1]. At the present time, there is no general consensus regarding the appropriate surgical approach to mediastinitis after cardiac surgery. Vacuum-assisted closure (VAC) is a novel treatment with an ingenious mechanism, and recent publications have demonstrated encouraging clinical results [2]. However, the validity of VAC therapy for managing pediatric post-sternotomy mediastinitis remains to be confirmed because there have been very few reports published on this topic [3, 4]. We herein describe 3 cases of pediatric post-sternotomy mediastinitis treated by VAC therapy.
Patient 1 was a 6-month-old girl who underwent a bilateral bidirectional Glenn shunt procedure for a tricuspid atresia with a concomitant pulmonary atresia. The surgery was performed urgently owing to clinical deterioration, as evidenced by the progression of cyanosis, which required intubation and mechanical control of ventilation. Nine days after surgery, she was noted to have a purulent discharge from the median sternal wound and a high-grade fever. Removal of the sternal wires and surgical debridement were performed. Thereafter, polyurethane foam, which was shaped to fit the defect, was placed within the cavity. The area was covered with an adhesive drape, and suction drainage was carried out at –50 mm Hg for 10 days in addition to the administration of appropriate antibiotics. Coagulase-negative Staphylococci strains were detected by the culture examination. The polyurethane foam was replaced every few days. The VAC therapy lasted for 10 days. The wound was closed without any surgical revisions at 3 days after the discontinuation of VAC (Fig 1).
View larger version (75K):
[in this window]
[in a new window]
|
Fig 1. The gross appearance of the sternal wound after vacuum-assisted closure (VAC) in patient 1. (A) The day after the completion of VAC. (B) Five days after VAC, good granulation tissue is seen. (C) One month after VAC.
|
|
Patient 2 was a 2-year old boy who underwent a pacemaker implantation using myocardial leads for a sick sinus syndrome. A total anomalous pulmonary venous connection repair and a release of a pulmonary venous obstruction were performed twice before this operation. The patient was noted to have a high-grade fever and a purulent discharge from the median sternal wound 14 days after surgery. Coagulase-negative Staphylococci strains were detected by the culture examination. Debridement of infected tissue was performed at the time of VAC application. We employed VAC therapy for 12 days until the wound became smaller and granulation tissue proliferated, in addition to the administration of appropriate antibiotics. However, there was still a small defect in the epithelialization. Finally, a second primary closure was performed at 4 weeks after VAC application.
Patient 3 was a 10-month old girl who underwent a ventricular septal defect (VSD) repair. After she was discharged from the hospital (postoperative day 32), she was noted to have a high-grade fever and a purulent discharge from the median sternal wound. Staphylococcus aureus was detected by the culture examination. Debridement of the infected tissue was performed at the time of VAC application. The VAC therapy was applied for a week with the administration of appropriate antibiotics. Subsequently, a second primary closure was carried out.
|
Comment
|
|---|
Mediastinitis is a significant postoperative complication that affects 0.4% to 5.0% of all pediatric patients undergoing median sternotomy [4]. The conventional techniques for the treatment of mediastinitis currently include a debridement followed by a closure with vascularized soft tissue, such as omentum and muscle flaps, and a primary closure with several days to a week of closed suction drainage, with or without antimicrobial irrigation, but the details of the surgical treatment remain controversial [1]. Vacuum-assisted closure is a technical innovation in wound care. However, the validity of using the VAC therapy to manage pediatric post-sternotomy mediastinitis is not clear. We therefore describe 3 cases of pediatric post-sternotomy mediastinitis treated by the VAC therapy. For all 3 cases in our series, surgical debridement was performed at the same time as the VAC therapy. We therefore believe that it is very important to remove necrotic and infected tissue before VAC implantation to obtain successful results.
There are several advantageous features derived from the application of negative pressure to a sternal wound. Vacuum-assisted closure allows for an open drainage, which continuously removes the exudate with a simultaneous stabilization of the chest and the isolation of the wound, and which 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.
The most commonly used pressure in the clinical situation is –125 mm Hg in adults [5]. This pressure is based on the previous basic research [6]. However, there are important aspects that require consideration when VAC is applied to a sternotomy wound. Because of the vital structures in the thoracic cavity, the interaction between the polyurethane foam and the surrounding tissue is of importance. 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 the heart. Furthermore, it seems that the tissue of pediatric organs is more fragile than that of adults. Mokhtari and colleagues [5] reported that low negative pressures (-50 to –100 mm Hg) stabilize the sternum just as efficiently as do high negative pressures (-150 to –200 mm Hg), and the foam at a low negative pressure adapts better to the shape of the wound than at a high negative pressure in a porcine model [7]. In fact, VAC therapy at a low negative pressure (-50 or –75 mm Hg) for pediatric post-sternotomy mediastinitis has been recently reported [3, 4]. No troublesome complications such as massive air leakage, insufficient drainage, or tissue damage were encountered during VAC therapy under a pressure of –50 mm Hg in our series.
In conclusion, VAC therapy can be successfully performed for the treatment of pediatric post-sternotomy mediastinitis, and it is thought to be a useful alternative option for the treatment of pediatric deep sternal infection.
|
References
|
|---|
- Al-Sehly AA, Robinson JL, Lee BE, et al. Pediatric poststernotomy mediastinitis Ann Thorac Surg 2005;80:2314-2320.[Abstract/Free Full Text]
- Fuchs U, Zittermann A, Stuettgen B, Groening A, Minami K, Koerfer R. Clinical outcome of patients with deep sternal wound infection managed by vacuum-assisted closure compared to conventional therapy with open packing: a retrospective analysis Ann Thorac Surg 2005;79:526-531.[Abstract/Free Full Text]
- Salazard B, Niddam J, Ghez O, Metras D, Magalon G. Vacuum-assisted closure in the treatment of poststernotomy mediastinitis in the paediatric patient J Plast Reconstr Aesthet Surg 2007June 21, 2007 [Epub ahead of print].
- Fleck T, Simon P, Burda G, Wolner E, Wollenek G. Vacuum assisted closure therapy for the treatment of sternal wound infections in neonates and small infants Interact Cardiovasc Thorac Surg 2006;5:285-288.[Abstract/Free Full Text]
- 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.[Abstract/Free Full Text]
- Morykwas MJ, Faler BJ, Pearce DJ, Argenta LC. 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.[Medline]
- Sjogren J, Gustafsson R, Wackenfors A, Malmsjo M, Algotsson L, Ingemansson R. Effects of vacuum-assisted closure on central hemodynamics in sternotomy wound model Interact Cardiovasc Thorac Surg 2004;3:666-671.[Abstract/Free Full Text]
This article has been cited by other articles:
|
|
|
|
 
M. Vicchio, M. De Feo, G. Caianiello, and M. Cotrufo
Vacuum for Pediatric Post-Sternotomy Mediastinitis: The Role of Laser Doppler Velocimetry in the Establishment of Adequate Subatmospheric Pressure Intensity
Ann. Thorac. Surg.,
October 1, 2008;
86(4):
1399 - 1399.
[Full Text]
[PDF]
|
|
|
Top
Abstract
Introduction
