الفهرس | Only 14 pages are availabe for public view |
Abstract One of the greatest worries for patients following cardiac surgery is a condition known as post-sternotomy mediastinitis, or deep sternal wound infection. The CDC in the United States has officially approved the definition of mediastinitis. Preoperative risk factors for mediastinitis include obesity (BMI >40), diabetes mellitis (elevated hemoglobin A1C [HbA1c]), smoking, and chronic obstructive pulmonary disease [COPD]. HF, renal dysfunction, PVD, advanced age, and inadequate nutritional status (low serum albumin) are all risk factors for death. Other significant risk factors for mediastinitis include preoperative colonization with methicillin-resistant staph aureus and steroid usage. Emergency operations, previous operations, and the (debatable) use of both internal thoracic arteries (ITAs) in patients with diabetes are all surgical risk factors for mediastinitis. Instances when CPB or surgery go on for too long, where intra-aortic balloon pressure (IABP) is required, and where excessive bone wax is used. Mediastinitis is more likely to occur in patients who have experienced postoperative complications such as excessive bleeding, reexploration for bleeding, multiple transfusions, prolonged ventilatory support, low cardiac output states (cardiogenic shock) with use of an IABP, refractory hyperglycemia in the ICU, regardless of whether the patient has a history of diabetes, or acute kidney injury. At first surgical revision, staphylococcus aureus and coagulasenegative staphylococcus are the most prevalent pathogens isolated from wound cultures. Klebsiella, Escherichia coli, and Summary 70 Propionibacterium are some of the other bacteria that can cause illness. Many different wound-healing procedures have been developed for the treatment of post-sternotomy mediastinitis in the modern era of cardiac surgery, and there is currently no consensus regarding the best surgical approach to mediastinitis after open-heart surgery. Surgery, either open or closed irrigation, or reconstruction using vascularized soft tissue flaps such omentum or pectoral muscle, is the gold standard for treatment. Unfortunately, standard treatments often result in procedure-related morbidity, and their long-term clinical prognosis has been unsatisfactory. Closure with the help of a vacuum is a cutting-edge technique that uses a clever mechanism. Local negative pressure is the basis of this method of wound healing. Several benefits of traditional surgical treatment are integrated during the process of applying negative pressure to a sternal incision. Recent articles show promising clinical findings, although observations are still limited and the underlying mechanisms are mainly unclear. The purpose of this research was to evaluate the efficacy of early surgical debridement followed by vacuum-assisted closure in the treatment of mediastinitis following heart surgery. At the hospital affiliated with Menoufia University, a prospective study was conducted. Thirty-two patients who developed an infection in their deep sternal wounds following cardiac surgery were included in our study. Summary 71 The main results of the study revealed that: 14 (43.8%) patients were females, while 18 (56.3%) patients were males. The male to female ratio was 1.3: 1 the mean age at the time of the study was 52.3 ± 8.5 years, ranging between 38 and 70 years and patients were classified into three age categories: less than 50 years (n = 13), between 50 and 60 (n = 13), and more than 60 years old (n = 6)and the mean BMI was 33.4 ± 4.9 kg/m2, ranging between 25.9 and 42 kg/m2and patients were classified into four BMI categories: Overweight (n = 10), class I (n = 8), class II (n = 11), and class III (n = 3). 14 (43.8%) patients were hypertensive, 13 (40.6%) were known to be diabetic, eight (25%) patients were diagnosed with chronic obstructive pulmonary disease (COPD), and 11 (34.4%) patients had peripheral vascular disease (PVD). Two (6.3%) patients were on steroid therapy. Regarding to the type of procedure, 14 (43.8%) patients underwent coronary artery bypass graft (CABG) surgery, seven (21.9%) patients underwent mitral valve replacement, five (15.6%) patients underwent aortic valve replacement, and six (18.8%) patients underwent double valve replacement. Regarding classification of intervention according to NCEPOD, 28 (87.5%) interventions were elective, and four (12.5%) were emergent. The mean operating time was 246.8 ± 40.4 minutes, ranging from 157 to 300 minutes. 24 (75%) procedures were primary, whereas eight (25%) procedures were re-do. The mean interval between surgery and SWI was 13.4 ± 6.7 days, ranging from 5 to 25 days, the onset of SWI was on the Summary 72 5th day in three (9.4%) patients, on the 6th day in four (12.5%) patients, between 1 and 2 weeks in 12 (37.5%) patients, and more than 2 weeks in 13 (40.6%) patients. According to microbiological testing, Staph aureus was the causative organism in majority (53.1%) of patients. The causative organism was MRSA in three (9.4%) patients, gram negative organisms in nine (28.1%) patients. Combined multi-microbial infection was reported in three (9.4%) patients. In all, leukocytosis (WBC > 11 x109/L) was reported in 28 (87.5%) patients. All patients demonstrated high levels of CRP. As demonstrated in Table 5, the mean WBC count at time of diagnosis was 18.1 6.2 x109/L, ranging from 9 to 30 x109/L. The mean CRP level was 39.7 9.1 mg/dl, ranging from 25.6 to 54.2 mg/dl. 10 (31.3%) did not demonstrate any CT findings. However, air was found in eight (25%) patients, fluid collection was found in nine (28.1%) patients, and both air and fluid collection were found in five (15.6%) patients. The average interval between the onset of DSWI and surgical debridement was 8.2 ± 3.7 days, ranging from 3 to 14 days. Following surgical debridement, VAC therapy was initiated for all patients. The mean duration of VAC application was 5.9 ± 0.8 days, ranging from 5 to 7 days. The mean percentage of wound size reduction was 16.7 ± 5.2%. The mean percentage of granulation tissue formation was 32.6 ± 4.7%. The average WBC count was 13.5 ± 3.1 x109/L, and the average CRP level was 22.3 ± 4.8 mg/dl. Microbiological culture was negative in 23 (71.9%) patients. |