Ann Thorac Surg 2008;86:1399. doi:10.1016/j.athoracsur.2008.04.030
© 2008 The Society of Thoracic Surgeons
Correspondence
Vacuum for Pediatric Post-Sternotomy Mediastinitis: The Role of Laser Doppler Velocimetry in the Establishment of Adequate Subatmospheric Pressure Intensity
Mariano Vicchio, MD, PhDa,b,
Marisa De Feo, MD, PhDa,b,
Giuseppe Caianiello, MDa,b,
Maurizio Cotrufo, MDa,b
a Department of Cardiothoracic and Respiratory Sciences, Second University of Naples, Naples, Italy
b Department of Cardiovascular Surgery and Transplants, V. Monaldi Hospital, Naples, Italy
(Email: marianovicchio{at}libero.it).
To the Editor:
We read with interest the article by Kadohama and colleagues [1], and we would like to congratulate the authors for the very interesting management of three pediatric patients with mediastinitis. The entire article is based on a question by the authors of whether or not a lower negative pressure than that used in the adults is sufficient for treatment of this life-threatening complication after open heart surgery. The authors assert that the debate regarding the level of negative pressure for neonates, infants, and small children has not been sufficiently investigated.
We would like to share our experience on this subject. We have studied this question for some time, and we recently published our experience with vacuum treatment in a neonate with an infected thoracotomy associated with extensive loss of tissue [2]. We used the laser Doppler velocimetry (Periflux System 5000, Perimed [Stockholm, Sweden]) to decide which negative pressure to use to achieve complete healing of the wound in a reasonable timeframe. We have now treated 12 neonates and infants affected by deep sternal wound infection treated with vacuum therapy. The age of the patients ranges between 7 days and 8 months. We performed early surgical revision followed by vacuum application in all patients. In recent years, various studies have published that vacuum therapy produces optimal results from continuous drainage of the infection and capillary vasodilatation of muscular and subcutaneous tissue, which increases local blood perfusion as demonstrated by Wackenfors and colleagues [3].
We also tried to optimize capillary vasodilation by using laser Doppler velocimetry to measure the increase in blood flow around the sternal wound and to relate values to changes in negative pressure. We discovered that maximum blood flow in tissues surrounding the surgical wound occurs between –80 and –100 mm Hg of negative pressure. We maintained these pressures for a mean of 16 days and had no complications. The treatment was well tolerated, and it did not interfere with early extubation after surgical revision. In 11 of 12 patients we obtained a complete closure of the wound without the need for surgical reconstruction. One patient died from cardiac complications.
We recommend using laser Doppler velocimetry to regulate the appropriate intensity of the negative pressure for every patient to obtain the best increase in perfusion. In our experience, the best results were noted with pressure values ranging between –80 and –100 mm Hg, because these values are safe both in neonatal and pediatric patients.
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References
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- Kadohama T, Akasaka N, Nagamine A, et al. Vacuum-assisted closure for pediatric post-sternotomy mediastinitis: are low negative pressures sufficient? Ann Thorac Surg 2008;85:1094-1096.[Abstract/Free Full Text]
- Vicchio M, Amato A, Merlino E, et al. Treatment of deep thoracotomy wound infection in neonatal age: a case report J Thorac Cardiovasc Surg 2007;134:254-255.[Free Full Text]
- Wackenfors A, Gustafsson R, Sjögren J, Algotsson L, Ingemansson R, Malmsjo M. Blood flow responses in the peristernal thoracic wall during vacuum-assisted closure therapy Ann Thorac Surg 2005;79:1724-1730.[Abstract/Free Full Text]
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