Salica Andrea, Weltert Luca, Scaffa Raffaele, Guerrieri Wolf Lorenzo, Nardella Saverio, Bellisario Alessandro, De Paulis Ruggero
Department of Cardiac Surgery, European Hospital, Rome, Italy.
Department of Cardiac Surgery, European Hospital, Rome, Italy.
J Thorac Cardiovasc Surg. 2014 Nov;148(5):2397-403. doi: 10.1016/j.jtcvs.2014.04.025. Epub 2014 Apr 18.
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.
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.
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%).
Negative pressure promotes a significant improvement in clinical status according to APACHE II score and allows a successful elective surgical closure.
胸骨切开术后纵隔炎的最佳治疗方案存在争议。负压伤口治疗能改善伤口环境并提高胸骨稳定性，且手术侵入性低。我们的方案是以负压治疗为先，随后进行延迟手术闭合。本研究的目的是提供早期随访结果并确定不良结局的危险因素。
在5400例心脏手术中，连续纳入44例纵隔炎患者。纵隔炎治疗以紧急清创和负压作为一线方法。伤口消毒后，通过择期胸大肌推进皮瓣实现胸廓闭合。前瞻性收集每位患者的医院数据。变量包括患者人口统计学资料以及临床和生物学数据。在诊断时和清创后48小时计算急性生理与慢性健康状况评估（APACHE）II评分。重点结局指标是纵隔炎相关死亡以及胸大肌闭合后再次干预的需求。
El Oakley I型和IIIA型纵隔炎是最常见的类型（63.6%）。25例患者（56.8%）存在耐甲氧西林金黄色葡萄球菌。诊断时APACHE II评分的平均值为19.4±4，30例患者（68.2%）在手术清创前需要转入重症监护病房。伤口清创和应用负压48小时后，APACHE II评分有所改善（平均值，19.4±4对7.2±2；P = 0.005），且独立于研究中纳入的任何其他变量。1例诊断时处于感染性休克的患者死亡（2.2%）。
根据APACHE II评分，负压可显著改善临床状况，并允许成功进行择期手术闭合。
