Post-sternotomy mediastinitis in the modern era

Goh, Siew Simg Christine

doi:10.1111/jocs.13189

Cited by 70 publications

(88 citation statements)

References 118 publications

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“…The use of chlorhexidine was instructed to be performed for 5 days before surgery since chlorhexidine has the theoretical advantage of longer antimicrobial activity (>48 hours), compared with 2 hours of isopropyl alcohol alone . The prevalence of mediastinitis before implementation of the CCPPM was 1.4%, which is similar to the general incidence previously described in the literature . After the implementation of the CCPPM occurred an expressive reduction of mediastinitis to 0.09% (virtually null).…”

Section: Discussionsupporting

confidence: 64%

“…13 The prevalence of mediastinitis before implementation of the CCPPM was 1.4%, which is similar to the general incidence previously described in the literature. 14,15 After the implementation of the CCPPM occurred an expressive reduction of mediastinitis to 0.09% (virtually null). The findings of the post-CCPPM period cannot be attributed to the higher prevalence of comorbidities 16…”

Section: Discussionmentioning

confidence: 99%

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Clinical‐care protocol for preventing mediastinitis after coronary artery bypass graft surgery: A quality improvement initiative from a private hospital

et al. 2019

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Background Surgical site infections after cardiac surgery are associated with severe outcomes, including reoperation and death. We aimed to describe the effect of a standardized clinical‐care protocol for preventing mediastinitis in patients who underwent coronary artery bypass graft surgery (CABG). Methods In a hospital certified by Joint Commission International, all patients who underwent CABG from January 2011 to December 2016 were compared in two periods according to the moment of implementation of a standardized clinical‐care protocol for prevention of mediastinitis (CCPPM): pre‐protocol (January 2011‐December 2012) and post‐protocol (January 2013‐December 2016). The CCPPM consisted of the patient using a kit containing chlorhexidine 2% for bathing, mupirocin 20 mg/g for nasal topical use and chlorhexidine 0.12% for oral hygiene for 5 days before surgery, in addition to prophylaxis with a glycopeptide antimicrobial and strict glucose control (110‐140 mg/dL) during surgery and immediate postoperative. Results We evaluated 1760 patients who underwent CABG in both periods. The occurrence of mediastinitis before protocol implementation was 1.44% (10 of 692 CABG). After the implementation of the protocol, there was an important reduction in the incidence of mediastinitis to 0.09% (1 of 1068 CABG) (P = 0.002). Although we did not observe a significant difference in mortality between the groups (2.3% vs 1%, P = 0.77), there was fewer in‐hospital mortality due to mediastinitis after the CCPPM (0.2% vs 0%, P < 0.001). Conclusion Implementation of a standardized CCPPM was associated with a significant reduction in the incidence of mediastinitis after CABG and reduction of mortality in the group of patients with mediastinitis.

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Section: Discussionsupporting

confidence: 64%

Section: Discussionmentioning

confidence: 99%

Clinical‐care protocol for preventing mediastinitis after coronary artery bypass graft surgery: A quality improvement initiative from a private hospital

et al. 2019

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“…In the present study, an association was verified between S. aureus or Gram-negative rod infections and mediastinitis. Other descriptive studies of mediastinitis after cardiothoracic surgery also point out that staphylococci is the leading agent, but gram-negative rods also had a high prevalence, up to 40% (Paul et al, 2007;Lemaignen et al, 2015;Goh, 2017).…”

Section: Discussionmentioning

confidence: 98%

Derivation and validation of an early diagnostic score for mediastinitis after cardiothoracic surgery

Siciliano

Medina

Bittencourt

et al. 2020

International Journal of Infectious Diseases

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Objectives: The aim of this study was to elaborate on and validate a score for the early diagnosis of mediastinitis after cardiothoracic surgery. Methods: Between 2007 and 2017, patients who experienced thoracic surgical-site infection after cardiothoracic surgery were enrolled. Laboratory, clinical, and chest CT findings were retrospectively analyzed. Patients were followed up until hospital discharge or intra-hospital death. Univariate and multivariate regression analyses were performed. Results: 950 surgical-site infections were found and analyzed (131 mediastinitis, 819 superficial/deep infections). Of the 131 mediastinitis episodes, 88% required surgical thoracic debridement,Staphylococcus aureus was identified in 43%, and overall mortality was 42%. The following variables were related to mediastinitis diagnosis: sternal diastasis (OR = 2.5; 95% confidence interval [95%CI]: 1.2-5.3; P = 0.012), bilateral pleural effusion (OR = 1.9; 95%CI: 1.0-3.6; P = 0.04), leukocyte count !14,000cells/mm 3 (OR = 2.5; 95%CI: 1.3-4.7; P = 0.006), male sex (OR = 2; 95%CI: 1.11-4; P = 0.022), and positive blood culture (OR = 3.0; 95%CI: 1.6-5.6; P = 0.001). The score predicted with reasonable accuracy mediastinitis in the derivation cohort (AUC-ROC, 0.7476) and the validation cohort (AUC-ROC, 0.7149). Groups with high (31%) and low (5%) risk of mediastinitis were identified. Conclusions: An early diagnostic score in patients with surgical-site infection after cardiothoracic surgery identified groups with a low and high risk for mediastinitis.

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“…The standard closure technique for median sternotomy remains the wire cerclage. Other described methods of closure include the Robiscek technique (18) and rigid plate fixation (19). While Allen et al reported the method of sternal closure as the only predictor of sternal complications and wound infections, rigid plate fixation has been performed less often than circular wire cerclage due to concerns of drilling near and around the heart, extended operative time, increased expense, and increased time for emergent reentry (7,16).…”

Section: Management Of Sternotomy and Closurementioning

confidence: 99%

Operative techniques for improving surgical exposure in basic cardiac surgery

et al. 2018

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Operative exposure is key to ensuring surgical efficiency and patient safety in cardiac surgery. As the population ages and the prevalence of obesity increases, cardiac surgeons will be challenged to consider obese patient physiology and body habitus, surgical exposure and sternotomy closure techniques, and postoperative medical management to ensure optimal outcomes. In this article, we describe techniques to improve operative exposure in both obese and non-obese patients undergoing basic cardiac surgery and highlight the roles of surgical team members to ensure patient safety and provide optimal anesthetic management. We describe pre-operative techniques regarding incision-site marking and alternative positioning techniques on the operating table to improve visualization and decrease risk of upper extremity injury. We summarized the roles of surgical team members regarding patient positioning, especially in those that are obese, and the challenges associated for anesthesia staff pre- and intraoperatively. Procedural techniques regarding sternotomy management and closure, cannulation, internal mammary harvest, and mitral valve exposure are discussed. Cardiac surgical teams must consider the risks associated with the obese patient population undergoing cardiac surgery procedures and employ techniques pre-, intra-, and postoperatively in a multidisciplinary fashion. Safe and efficacious techniques are paramount to optimal patient outcomes.

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Post-sternotomy mediastinitis in the modern era

Abstract: Post-sternotomy mediastinitis remains a potentially fatal complication of cardiac surgery despite the advancements in the perioperative care in the modern era. Management on preventative measures, prompt diagnosis, and managements are crucial in reducing associated mortality and morbidity.

Cited by 70 publications

References 118 publications

Clinical‐care protocol for preventing mediastinitis after coronary artery bypass graft surgery: A quality improvement initiative from a private hospital

Clinical‐care protocol for preventing mediastinitis after coronary artery bypass graft surgery: A quality improvement initiative from a private hospital

Derivation and validation of an early diagnostic score for mediastinitis after cardiothoracic surgery

Operative techniques for improving surgical exposure in basic cardiac surgery

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