Asian Cardiovasc Thorac Ann 2008;16:e45-e46
© 2008 Asia Publishing EXchange Ltd
Vacuum-Assisted Closure for Mediastinitis after Pediatric Cardiac Surgery
Takeshi Hiramatsu, MD,
Yoshitaka Okamura, MD,
Shigeru Komori, MD,
Yoshiharu Nishimura, MD,
Hiroyuki Suzuki, MD1,
Takashi Takeuchi, MD1
Department of Thoracic and Cardiovascular Surgery
1 Department of Pediatrics, Wakayama Medical University, Wakayama, Japan
For reprint information contact: Takeshi Hiramatsu, MD, Tel: 81 73 441 0615, Fax: 81 73 446 4761, Email: shiramat{at}hij.twmu.ac.jp, Department of Thoracic and Cardiovascular Surgery, Wakayama Medical University, 811-1 Kimiidera Wakayama City, Wakayama, 641-8509, Japan.
 |
ABSTRACT
|
|---|
Two children, aged 1 and 14 years with methicillin-resistant Staphylococcus aureus mediastinitis after pediatric open-heart surgery, were fitted with a vacuum-assisted closure system. Complete healing was achieved in both cases, and primary wound closure could be carried out without an omental flap after 6 and 16 days.
|
INTRODUCTION
|
|---|
Methicillin-resistant Staphylococcus aureus (MRSA) mediastinitis is an intractable and potentially life-threatening complication after open-heart surgery. Recently, vacuum-assisted closure (VAC) has been introduced for effective treatment of mediastinitis after adult cardiac surgery.1 We describe 2 cases of MRSA mediastinitis after pediatric open-heart surgery successfully treated by VAC.
|
CASE REPORT
|
|---|
Two children, a boy aged 1 year and a girl aged 14 years, with MRSA mediastinitis after pediatric open-heart surgery (definitive repair of double-chambered right ventricle with ventricular septal defect and stage III procedure, total cavopulmonary connection for hypoplastic left heart syndrome), were fitted with a VAC device. Before starting VAC, the boy underwent continuous closed irrigation with warm saline after adequate drainage, but the mediastinitis did not improve, and his chest had to be reopened. After reopening and aggressive debridement with removal of all necrotic tissue and irrigation with dilute povidone-iodine solution and H2O2, iodoform gauge was cut and fitted into the substernal space. An iodine drape was applied over the wound to ensure an airtight seal, leaving a suction tube (Figure 1
). Continuous suction was started at approximately 100 mm Hg. The VAC system was changed under aseptic conditions every 2–3 days. Complete healing was achieved in both children. Vacuum-assisted closure was discontinued, and the sternum could be closed at 6 and 16 days after initiation of VAC, leaving a drainage tube in the substernal space, when systemic signs of infection had resolved and 3 consecutive quantitative cultures were negative. Limited dissection of the substernal space was performed at chest closure, and almost no dead space remained to be filled by material such as an omental flap in either child. Intensive care unit stays were 30 and 37 days, and hospital stays were 105 and 57 days. No thyroid dysfunction was observed in either case during these procedures. Both children were alive with no recurrence of mediastinitis 1 year after the operation.
View larger version (136K):
[in this window]
[in a new window]
|
Figure 1. Iodoform gauge was cut and fitted into the substernal space, and an iodine drape was applied over the wound to ensure an airtight seal, leaving a suction tube.
|
|
|
DISCUSSION
|
|---|
Despite the established treatments for deep sternal wound infection, including antibiotic therapy, surgical debridement, closed irrigation, delayed closure, and plastic reconstruction with muscle and omental flaps, MRSA mediastinitis after open-heart surgery is still associated with a high mortality rate.2,3 Since the introduction of VAC by Argenta and Morykwas1 in 1997, it has become widely accepted in the management of difficult wounds.4,5 The principle of this treatment is based on uniform negative pressure applied to the wound, resulting in arteriolar dilatation, thus promoting granulation tissue proliferation.
There is concern about the use of a vacuum system in pediatric cases because a strong negative pressure might cause circulatory instability. This might be expected in some cases such as a Rastelli-type procedure, but circulatory collapse was not experienced in our patients. Probably, with the large amount of iodoform gauge fitted into the substernal space in our cases, circulatory compression was avoided despite the fairly strong negative pressure. Pediatric patients are often too small for muscle or omental flaps to be constructed, and use of an omental flap should be avoided in a Fontan-type operation because of increasing ascites postoperatively. This experience indicates that VAC can be considered an effective modality for the treatment of MRSA mediastinitis after pediatric open-heart surgery.
|
REFERENCES
|
|---|
- Argenta LC, Morykwas MJ. Vacuum-assisted closure: a new method for wound control and treatment: clinical experience. Ann Plast Surg 1997;38:563–77.[Medline]
- El Oakley RM, Wright JE. Postoperative mediastinitis: classification and management [Review]. Ann Thorac Surg 1996;61:1030–6.[Abstract/Free Full Text]
- Eguia JM, Chambers HF. Methicillin-resistant Staphylococci and their treatment in the intensive care unit. Semin Respir Crit Care Med 2003;24:37–48.[Medline]
- Fleck TM, Fleck M, Moidl R, Czerny M, Koller R, Giovanoli P, et al. The vacuum-assisted closure system for the treatment of deep sternal wound infections after cardiac surgery. Ann Thorac Surg 2002;74:1596–600.[Abstract/Free Full Text]
- Luckraz H, Murphy F, Bryant S, Charman SC, Ritchie AJ. Vacuum-assisted closure as a treatment modality for infections after cardiac surgery. J Thorac Cardiovasc Surg 2003;125:301–5.[Abstract/Free Full Text]
TOP
ABSTRACT
INTRODUCTION
