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Poststernotomy mediastinitis — Clinical Guidelines

Overview

Poststernotomy mediastinitis is a severe postoperative complication following median sternotomy, characterized by infection within the mediastinum that can lead to significant morbidity and mortality if not promptly and effectively managed. 2 3

Diagnosis

Clinical signs include persistent fever, sternal wound drainage, and systemic inflammatory response.

Diagnostic imaging (chest X-ray, CT) may reveal mediastinal widening or fluid collections.

Culture of wound or drainage fluid is essential for identifying pathogens, including resistant strains like MRSA. 3

Management

First-line treatments:

- Aggressive surgical debridement of infected tissues. - Closed irrigation and drainage of the mediastinum. 3

Adjunctive treatments:

- Use of vacuum-assisted closure (VAC) systems for wound management, particularly beneficial in pediatric cases. 2 - Application of muscle flaps (e.g., rectus muscle flap) for closure and prevention of recurrence. 4 - Transvenous administration of antibiotics to ensure high local drug concentrations. 3

Antibiotics: Specific drug classes and doses not detailed in abstracts; broad-spectrum coverage tailored to culture results is recommended. 3

Special Populations

Pediatrics: VAC therapy shows promise in managing mediastinitis, especially when omental flaps are contraindicated due to peritoneal dialysis. 2

Elderly: Specific considerations not detailed; however, aggressive surgical and antimicrobial interventions remain critical. 4

Key Recommendations

Perform aggressive surgical debridement and closed irrigation with appropriate antimicrobial solutions for mediastinitis management. (Evidence: Moderate 3)

Utilize vacuum-assisted closure (VAC) systems in pediatric patients to facilitate wound healing and reduce infection spread. (Evidence: Weak 2)

Consider muscle flap (e.g., rectus muscle) closure after irrigation and drainage to prevent recurrence and promote healing. (Evidence: Expert opinion 4)

References

1 Malmsjö M, Lindstedt S, Ingemansson R. Effects of foam or gauze on sternum wound contraction, distension and heart and lung damage during negative-pressure wound therapy of porcine sternotomy wounds. Interactive cardiovascular and thoracic surgery 2011. link 2 Salazard B, Niddam J, Ghez O, Metras D, Magalon G. Vacuum-assisted closure in the treatment of poststernotomy mediastinitis in the paediatric patient. Journal of plastic, reconstructive & aesthetic surgery : JPRAS 2008. link 3 Ohuchi S, Kawazoe K, Ishihara K, Izumoto H, Eishi K. Management with closed irrigation for post-sternotomy mediastinitis: experience with the use of electrolyzed strong acid aqueous solution. The Japanese journal of thoracic and cardiovascular surgery : official publication of the Japanese Association for Thoracic Surgery = Nihon Kyobu Geka Gakkai zasshi 2003. link 4 Ohtani N, Akasaka N, Kawakami T. Poststernotomy mediastinitis treated by rectus muscle flap plugging. The Japanese journal of thoracic and cardiovascular surgery : official publication of the Japanese Association for Thoracic Surgery = Nihon Kyobu Geka Gakkai zasshi 1999. link

Poststernotomy mediastinitis