Eur J Cardiothorac Surg 2002;22:1029-1031
© 2002 Elsevier Science NL
Vacuum-assisted closure in the paediatric patient with post-cardiotomy mediastinitis
I.R. Ramnarine*,
A. McLean,
J.C.S. Pollock
Royal Hospital for Sick Children, Dalnair Street, Glasgow G3 8SJ, UK
Received 17 January 2002;
received in revised form 26 July 2002;
accepted 21 August 2002.
* Corresponding author. Tel.: +44-141-201-0251; fax: +44-141-201-9204
e-mail: ianrramnarine{at}hotmail.com
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Abstract
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Mediastinitis has a high mortality and is a major cause for concern in the neonatal cardiac surgical population. Vacuum-Assisted Closure (V.A.C.) is a newly established technique for expediting healing in the management of wounds resistant to established treatments; this includes the treatment of post-cardiotomy mediastinitis in the adult cardiac surgical patient. We describe the previously unreported use of the V.A.C. device for the successful treatment of post-cardiotomy mediastinitis in an infant. The device also improved the mechanics of respiration. We discuss potential risks and benefits of V.A.C. and suggest guidelines for its use.
Key Words: Cardiac surgery • Sternotomy infection • Negative pressure therapy
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1. Case report
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A 5-month-old girl weighed only 1.7 kg due to heart failure secondary to a ventricular septal defect and transposition of the great arteries. She had a balloon atrial septostomy at birth. We performed an arterial switch operation with coronary translocation and closure of both atrial and ventricular septal defects. The patient was easily weaned from cardiopulmonary bypass and was initially stable. The sternum was electively left open under an occlusive dressing with the intention of delayed primary closure. After 15 h she deteriorated suddenly with increasing inotropic requirements and extra-corporeal membrane oxygenation (ECMO) was initiated using a cervical percutaneous venous to arterial technique. Her sternotomy remained open and underwent daily lavage and dressing. The patient was weaned successfully from ECMO after 5 days. The sternotomy wound developed a purulent infection. There was gross contamination of the sternum and pericardial cavity with associated left lower lobe collapse and left pleural contamination. All wound swabs and cultures were positive for Escherichia coli. Appropriate systemic antibiotics were commenced and daily wound dressing and lavage continued. Although haemodynamically stable, progress towards self-ventilation and extubation could not be made.
There was soon florid mediastinal sepsis, both pleurae were contaminated and both lungs atelectatic. The heart and pericardium were exposed. The sternal edges were infected and necrotic. There was increasing production of pus and the overall wound area increased in size to 5x12 cm with retraction of the skin edges and involvement of the subcutaneous tissues. Effective chest physiotherapy was impossible, leading to increasing difficulty in maintaining adequate ventilation. The white blood cell count and C-reactive protein were raised throughout. There was great concern for her survival.
On the ninth post-operative day, we proceeded to use the Vacuum-Assisted Closure (V.A.C.) dressing system (KCI, Oxfordshire, UK). A simple non-adherent paraffin tulle dressing (Jelonet, Smith and Nephew, Hull, UK) covered the wound, and the V.A.C. sponge and outflow tube (Fig. 1)
were cut to the appropriate size and fashioned to fit over this. The wound was sealed by a transparent, adhesive drape that overlapped the margin by at lest 5 cm, wrapped the tubing with a mesentery and maintained an airtight seal (Fig. 2) . The tubing was connected to the V.A.C. pump that delivered an intermittent negative pressure of 50 mmHg.
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Fig. 1. The Vacuum-Assisted Closure (V.A.C.) system. (A) The suction pump device, (B) the connecting tubing and interchangeable canister reservoir, and (C) the open cell polyurethane ether foam sponge with pore size ranging from 400–600 micrometers in diameter. This is cut to fit the wound size and shape.
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Fig. 2. The infant patient is asleep and ventilated via a naso-tracheal tube. The Vacuum-Assisted Closure (V.A.C.) system is fitted onto the infant. (A) The suction pump device, (B) the connecting tubing, and (C) the sponge cut fitted into the sternal wound with the suction tubing lying directly on this and the adhesive covering providing an airtight seal.
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The response to V.A.C. was rapid and impressive. Purulence improved dramatically within 24 h. The device was used for the next 14 days with alternate day dressing changes. The wound got smaller and granulation tissue proliferated. The necrotic edges of the sternum demarcated and were excised. During this time the patient had more effective respiratory mechanics. Physiotherapy was productive. Both lungs re-expanded fully and self-ventilation became possible. The V.A.C. was discontinued when the white blood cell count and C-reactive protein fell to normal levels and the wound swabs showed no bacterial growth. On the 23rd post-operative day the sternal remnants were re-wired and the skin was closed. On the following day the baby was extubated and she coped easily.
One week later the patient developed a superficial wound infection and the lower end of the sternum dehisced. This required systemic antibiotics, surgical debridement and closure. The baby made a rapid recovery and did not require prolonged ventilation. She went home on her 48th post-operative day. The sternum was intact and the wound healed. At 20-month follow-up the patient remains well with a completely healed sternotomy wound.
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2. Discussion
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The incidence of post-cardiotomy mediastinitis has been variously reported as between 0.8 and 2.0% in different series of adult cardiac surgical patients [1], but has not been reported in the paediatric cardiac surgical population. The paediatric group with complex cardiac lesions, low body weight, nutritional and biochemical imbalances often undergo prolonged procedures. Delayed sternotomy closure is common following the arterial switch operation in our institution. All of these factors increase susceptibility to mediastinitis.
Only over the last decade has negative pressure therapy as the primary local therapy for grossly infected wounds [2] been studied. Interstitial fluid, which contains inhibitors of wound healing [3], was removed from the wound by negative pressure therapy. The value of V.A.C. has recently been established [4,5] in numerous surgical specialties, especially plastic and reconstructive surgery. This includes patients in the paediatric age group [6]. It results in control of infection and rapid granulation tissue formation, and is now widely used for the treatment of complicated wounds.
Tang et al. [1] treated 15 patients with sternotomy infections using the V.A.C. device with success and only two deaths from overwhelming sepsis. Induction therapy with continuous negative pressure of 125 mmHg for 48 h followed by intermittent (cycles of 5 min on and 2 min off) negative pressure is advocated by different authors [1,2,6]. Because of the small size of the patient and the exposed heart, the V.A.C. device was set to deliver an intermittent negative pressure of 50 mmHg (the lowest allowed). The clinical response was satisfactory and the settings were maintained. The device also served to splint the sternum, diminish paradoxical movement and significantly improve the mechanics of respiration [7]. There were no adverse haemodynamic effects attributable to the dressing, nor any significant change in fluid requirements.
The sternum was closed when there was clinical and laboratory evidence that infection had resolved.
We could no longer use the V.A.C. because the wound was too small to accommodate it effectively. The non-collapsible tubing was so large that suction was applied to the healthy skin edges leading to epidermal injury.
We suggest a modification to accommodate the smaller treatment area in neonates: Sterile release dressings (e.g. Mepore, Mölnlycke Health Care, Sweden) can be cut to the appropriate size and shape and placed on the skin prior to the application of the sponge, suction tubing and adhesive dressing. Alternatively, the dressings may be designed smaller and allow lower pressures to be used. This may allow for much smaller areas to be treated and protects the skin edges.
In conclusion, this case suggests a highly effective role for the V.A.C. device in the management of post-sternotomy mediastinitis. It led to immediate and dramatic local wound improvement, holistic clinical improvement and better chest wall mechanics. There were no significant complications resulting from its use.
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Acknowledgments
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There is no conflict of interest with the company KCI (UK) Ltd., the manufacturers of the V.A.C. device associated with this report. The equipment described has been purchased by the hospital through normal channels without deriving financial or other interest in the company.
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References
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- Tang A.T.M., Ohri S.K., Haw M.P. Novel application of vacuum assisted closure technique to the treatment of sternotomy wound infection. Eur J Cardio-thorac Surg 2000;17:482-484.[Abstract/Free Full Text]
- Morykwas M.J., Argenta L.C., Shelto-Brown E.I., McGuirt W. Vacuum-assisted closure: a new method for wound control and treatment. Animal studies and basic foundation. Ann Plast Surg 1997;38:553-562.[Medline]
- Bucalo B., Eaglstein W.H., Falanga V. Inhibition of cell proliferation by chronic wound fluid. Wound Rep Regen 1993;1:181-186.[Medline]
- Davydov I.A., Larichev A.B., Abramov A.I. Wound healing after vacuum drainage (in Russian). Khirurgiia (Mosk) 1992;7:21-26.
- Obdeijn M.C., de Lange M.Y., Lichtendahl D.H.E., de Boer W.J. Vacuum-assisted closure in the treatment of poststernotomy mediastinitis. Ann Thorac Surg 1999;68:2538-2560.
- Mooney J.F., 3rd, Argenta L.C., Marks M.W., Morykwas M.J., DeFranzo A.J. Treatment of soft tissue defects in pediatric patients using the V.A.C. system. Clin Orthop Rel Res 2000;376:26-31.
- Berg H.F., Brands W.G., van Geldorp T.R., Kluytmans-VandenBergh F.Q., Kluytmans J.A. Comparison between closed drainage techniques for the treatment of postoperative mediastinitis. Ann Thorac Surg 2000;70:924-929.[Abstract/Free Full Text]
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Abstract
1. Case report
