Vacuum-Assisted Closure for the Treatment of Deep Sternal Wound Infection After Pediatric Cardiac Surgery

Abstract

Objectives: Vacuum-assisted closure is being increasingly used to treat deep sternal wound infection following cardiac surgery, but most of the data refer to adults. This study investigated the safety and efficacy of vacuum-assisted closure in pediatric patients. Design: Retrospective file review. Setting: Tertiary pediatric medical center. Patients: All children with deep sternal wound infection treated with vacuum-assisted closure in 2003–2016. Interventions: Epidemiological, clinical, and microbiological data were collected from the medical records. Measurements and Main Results: The cohort included 50 patients (0.9% of cardiac patients operated during the study period) of median age 6.5 months (interquartile range, 2–12.75 mo; range, 1 wk to 14 yr) and median weight 5.1 kg (interquartile range, 4–9.75 kg). The most frequent heart defects were tetralogy of Fallot (22%) and ventricular septal defect (20%); 38% of patients had cyanotic heart disease. Deep sternal wound infections appeared a median of 10 days postoperatively (interquartile range, 7–14 d; range 3–100 d). Vacuum-assisted closure was applied a median of 13 days postoperatively (interquartile range, 10–18.5 d; range, 5–103 d) for a median duration of 10 days (interquartile range, 7–13.25 d; range, 1–21 d). Wound cultures were positive in 48 patients (96%); most isolates were Gram-positive (76%). The main bacterial pathogen was methicillin-susceptible Staphylococcus aureus (61%). Most patients were treated with cloxacillin for a median of 38 days (interquartile range, 28–42 d; range, 9–189 d). There were no statistically significant differences in clinical or treatment characteristics between bacteremic (56%) and nonbacteremic patients. Compared with older patients, infants less than 3 months old (36%) had a significantly longer hospitalization time (41 vs 25 d; p = 0.001) and higher Society of Thoracic Surgeons-European Association for Cardio-Thoracic Surgery Mortality Category (3 vs 2; p = 0.003). All cases except one (contact dermatitis) were uneventful. In 10 patients, wounds were closed surgically after vacuum-assisted closure. Two patients required a pectoralis flap, both treated before 2005. One of the two deaths was infection-related. Conclusions: Vacuum-assisted closure is a feasible treatment option of deep sternal wound infection after pediatric cardiac surgery and was not associated with independent morbidity.

Is vacuum‐assisted closure therapy feasible for children with deep sternal wound infection after cardiac surgery? The pooling results from current literature

“…Sternal wounds of all but seven patients were healed after VAC therapy without further operations. Additional closure using muscle flap or skin graft was necessary in seven patients (7/201, 3.5%) to approximate the sternal wounds 15,16,18,20,22 . Follow‐up data were only provided in three studies 14,18,19 .…”

“…Five case series studies 14,17,18,20,22 reported overall mortality, and the pooled estimate of overall mortality was 5.8% (95% CI, 2.5%-9.1%, I 2 = 0%, Figure 3B). However, only two deaths resulted from severely infectious complications, one from sepsis and the other from infectious endocarditis.…”

Treatment of Pediatric Sternotomy Wound Complications: A Minimally Invasive Approach

“…Although it usually leads an uneventful course, application of NPWT in pediatric patients necessitates special considerations. 12 The first concern is that the threshold value for causing circulatory instability may be exceptionally lower in small patients, so that NPWT might cause exsanguination and rupture of fragile vital organs. Therefore, a lower negative pressure (À25 to À75 mm Hg) is usually recommended in these patients.…”

“…Therefore, a lower negative pressure (À25 to À75 mm Hg) is usually recommended in these patients. 12,13 The other issue is the small dimension of the wound in infants. To overcome, Padalino et al 8 suggested a modification called "two-layer technique" and prevented the damage of surrounding tissues by correct positioning of the connecting tube.…”

Negative pressure wound treatment in a neonate with epidermolysis bullosa simplex severe generalized: A case report

“…8 Negative pressure wound treatment is also increasingly implemented to manage various difficult-to-treat wounds in children. [9][10][11] A tight and adhesive film dressing on the skin surrounding the wound is typically used and vital to prevent leakage and enable the build-up of negative pressure.…”