Negative pressure wound treatment improves Acute Physiology and Chronic Health Evaluation II score in mediastinitis allowing a successful elective pectoralis muscle flap closure: six-year experience of a single protocol.
OBJECTIVE
Optimal management of poststernotomy mediastinitis is controversial. Negative pressure wound treatment improves wound environment and sternal stability with low surgical invasiveness. Our protocol was based on negative pressure followed by delayed surgical closure. The aim of this study was to provide the results at early follow-up and to identify the risk factors for adverse outcome.


METHODS
In 5400 cardiac procedures, 44 consecutive patients with mediastinitis were enrolled in the study. Mediastinitis treatment was based on urgent debridement and negative pressure as the first-line approach. After wound sterilization, chest closure was achieved by elective pectoralis muscle advancement flap. Each patient's hospital data were collected prospectively. Variables included patient demographics and clinical and biological data. Acute Physiology and Chronic Health Evaluation (APACHE) II score was calculated at the time of diagnosis and 48 hours after debridement. Focus outcome measures were mediastinitis-related death and need for reintervention after pectoralis muscle closure.


RESULTS
El Oakley type I and type IIIA mediastinitis were the most frequent types (63.6%). Methicillin-resistant Staphylococcus aureus was present in 25 patients (56.8%). Mean APACHE II score was 19.4±4 at the time of diagnosis, and 30 patients (68.2%) required intensive care unit transfer before surgical debridement. APACHE II score improved 48 hours after wound debridement and negative pressure application (mean value, 19.4±4 vs 7.2±2; P=.005) independently of any other variables included in the study. One patient in septic shock at the time of diagnosis died (2.2%).


CONCLUSIONS
Negative pressure promotes a significant improvement in clinical status according to APACHE II score and allows a successful elective surgical closure.
Department of Cardiac Surgery, European Hospital, Rome, Italy.
Andrea
A
Salica
Department of Cardiac Surgery, European Hospital, Rome, Italy.
Luca
L
Weltert
Department of Cardiac Surgery, European Hospital, Rome, Italy.
Raffaele
R
Scaffa
Department of Cardiac Surgery, European Hospital, Rome, Italy.
Lorenzo
L
Guerrieri Wolf
Department of Cardiac Surgery, European Hospital, Rome, Italy.
Saverio
S
Nardella
Department of Cardiac Surgery, European Hospital, Rome, Italy.
Alessandro
A
Bellisario
Department of Cardiac Surgery, European Hospital, Rome, Italy. Electronic address: depauli@tin.it.
Ruggero
R
De Paulis
D018806:APACHE; D000368:Aged; D003646:Debridement; D017558:Elective Surgical Procedures; D005260:Female; D017052:Hospital Mortality; D006801:Humans; D008297:Male; D008480:Mediastinitis / Q000175:diagnosis / Q000209:etiology / Q000401:mortality / Q000601:surgery*; D008875:Middle Aged; D054843:Negative-Pressure Wound Therapy / Q000009:adverse effects / Q000401:mortality; D010369:Pectoralis Muscles / Q000601:surgery*; D012086:Reoperation; D012189:Retrospective Studies; D012307:Risk Factors; D056346:Sternotomy / Q000009:adverse effects* / Q000401:mortality; D013524:Surgical Flaps / Q000009:adverse effects; D013997:Time Factors; D016896:Treatment Outcome