Journal of Plastic, Reconstructive & Aesthetic Surgery (2008) 61, 302e305

Vacuum-assisted closure in the treatmentof poststernotomy mediastinitisin the paediatric patient*

B. Salazard a,*, J. Niddam a, O. Ghez b, D. Metras b, G. Magalon a

a Department of Paediatric Plastic Surgery, Timone Children’s Hospital,264 rue Saint-Pierre, 13385 Marseille Cedex 05, Franceb Department of Paediatric Thoracic and Cardiac Surgery, Timone Children’s Hospital,264 rue Saint-Pierre, 13385 Marseille Cedex 05, France

Received 3 April 2006; accepted 11 May 2007

KEYWORDSMediastinitis;Negative pressuretherapy;Sternal dehiscencetreatment

* Presented at The French SocietyMarch 2006.

* Corresponding author. Address: Sede la Conception, 147 boulevard Ba05, France. Tel.: þ33610310380; fax:

E-mail address: bruno.salazard@w

1748-6815/$-seefrontmatterª2007Bridoi:10.1016/j.bjps.2007.05.004

Summary Introduction: Delayed sternal closure after paediatric open heart procedure is of-ten necessary. The risk of delayed sternal closure is infection: superficial wound or sternal andmediastinal infection. The incidence of sternal wound infection reported in the literature var-ies from 0.5 to 10%. The mortality for poststernotomy deep sternal infection continues to behigh e from 14 to 47%. Established treatment includes surgical debridement, drainage andirrigation, antibiotics, frequent change of wound dressing and direct or secondary closure withomentum or pectoral muscle flap.Patients and methods: Between October 2003 and August 2005, three children, aged from 9days to 2 years and who had developed severe mediastinitis after cardiac surgery were treatedwith the vacuum-assisted closure (VAC) system.Results: The duration of VAC treatment ranged from 12 to 21 days. The response to VAC wasrapid with local purulence and C-reactive protein (CRP) both decreasing within 72 h in allcases. After good granulation was obtained, two patients required a thin skin graft.Discussion: All three children had peritoneal dialysis which did not permit omental use. Theuse of pectoralis major is a difficult technique in neonates and the haemodynamic conditionswere poor in our cases. The VAC technique is a good indication in post-cardiotomy mediastinitisin children: it plays a role in the reduction of infection and provides good healing.ª 2007 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published byElsevier Ltd. All rights reserved.

of Plastic Surgery, Brussels,

rvice du Pr Magalon, Hopitalille, 13385 Marseille Cedexþ33491384307.anadoo.fr (B. Salazard).

tishAssociationofPlastic,Reconstruc

Delayed sternal closure after paediatric open heart pro-cedure is often necessary, especially when extracorporealmembrane oxygenation (ECMO) is used. Postoperative

tiveandAestheticSurgeons.PublishedbyElsevierLtd.All rightsreserved.

Figure 1

Vacuum-assisted closure in the treatment of poststernotomy mediastinitis 303

oedema can cause cardiac compression which limits end-diastolic volume. So the sternum is closed within a few days.

The risk of delayed sternal closure is infection: superfi-cial wound, or sternal and mediastinal infection. In mostadult series, the reported incidences of sternal woundinfection range from 0.5 to 10%.1 The mortality for post-sternotomy deep sternal infection continues to be high (be-tween 14 and 47%). Mediastinitis must have a cleardefinition: clinical and culture evidence of deep infectioninvolving the pericardial space. Mediastinitis is consideredsevere when there is a sternal separation with involvementof the entire pericardial space.2

The established treatment in most centres includessurgical debridement, drainage and irrigation, antibiotics,frequent change of wound dressing and direct or secondaryclosure with omentum or pectoral muscle flap.2,3 Suchtreatment is complex and invasive, especially in the paedi-atric population. The use of sub-atmospheric pressure tothe wound environment for tissue repair with vacuum-assis-ted closure (VAC) was used until 1997 for chronic debilitat-ing wounds. In 1999, Obdeijn used this technique for deepsternal infection.4

In the present report, we describe treatment using thevacuum-assisted closure technique for poststernotomymediastinitis in three children.

Patients and methods

Patient selection

Between October 2003 and August 2005, three childrenhad developed severe mediastinitis after cardiac surgery.These three children, aged from 9 days to 2 years, weretreated with the VAC system. Patient data are summarisedin Table 1.

After 6 to 18 days of ECMO, primary closure of thesternum was performed. Infection was detected between 1and 3 days after this delayed sternal closure. Diagnosis wasbased on: temperature> 38.5 �C, sternal dehiscence, localpurulence (Fig. 1), positive microbiological cultures, ele-vated C-reactive protein (CRP) (Table 2).

Methods

Debridement of necrotic and infected tissue was performedat the time of VAC application. Sterile polyurethane foamdressing with an open-pore structure (400 to 600 mm poresize) was then trimmed to fit the geometry of each woundand placed into the defect (Fig. 2). The open wound was

Table 1

Patient Age(days)

Weight(kg)

Gender

1 9 2.85 M2 630 7.80 M

3 480 5.60 M

sealed by a transparent adhesive drape. A non-collapsibleevacuation tube was used to connect the controlled closedwound to a vacuum source that delivered continuousnegative pressure of 75 mmHg. The polyurethane foamdressing was changed every 48 h until VAC treatment was

Cardiacmalformation

PRISM score

Transposition of large vessels 23Ventricular septaldefect with pulmonary atresia

27

Tetralogy fallotþ pulmonaryatresiaþmitral malformation

19

Table 2

Patient Clinical and radiologic aspect Maximumtemperature (�C)

Microbiologicalculture

CRP (mg/l)

1 Necrotic woundwith a largecutaneousþ sternal defect

39.7 Pseudomonas aeruginosas 242

2 Cutaneous defectþwhitemembranesþ retrosternal air

39.2 Candida parapsilosis 193

3 Inflammatory woundþ pus flow out 40.0 Pseudomonas aeruginosas 259

304 B. Salazard et al.

discontinued. Children were also treated with antibioticsor antifungals adapted to the results of microbiologicalcultures.

Results

The duration of VAC treatment ranged from 12 to 21 days.The response to VAC was rapid with local purulence andCRP both decreasing within 72 h in all cases (Table 3). After8 days, all of the microbiological cultures were negative.During this period, the patients had more effective respira-tory mechanics and physiotherapy was productive.

The wound became smaller and granulation tissue pro-liferated (Fig. 3). In patients 1 and 3, there was still a smalldefect in epithelialisation after VAC treatment, which hadbeen closed with a thin skin graft (Fig. 4). In patient 2,the wound healed completely with VAC alone. In patients2 and 3, a quick stable sternal repair was achieved by fi-brous fusion, whereas patient 1 had sternal instability afterwound healing.

Discussion

Paediatric patients with complex cardiac lesions, low bodyweight and nutritional and biochemical imbalances oftenundergo prolonged procedures. Delayed sternotomy closurecommonly follows the arterial switch operation in ourinstitution. All of these factors increase susceptibility tomediastinitis. Mediastinitis affects approximately 1% of

Figure 2

children undergoing median sternotomy. It appears to behigher in neonatal patients.5

There are two problems in these deep sternal infections:treatment of the infection and closure of the skin andsternal defect.

Large debridement of the necrotic tissues is the mostimportant action to stop infection. An intravenous antibi-otic treatment is administered which is adapted to theresults of microbiological culture. Closed suction andantimicrobial irrigation is the most conventional therapyassociated with debridement for mediastinal infection. Thistechnique can cause metabolic derangement related to thesystemic toxicity of antimicrobials.6 A major advantage ofVAC therapy is the clearing of putrid secretions and toxicproducts which inhibit wound healing. VAC therefore accel-erates resolution of local and general signs of infection. Inour experience, CRP level decreased in 72 h with VAC ther-apy despite the fact that the children had been adminis-tered antibiotics before the beginning of VAC therapy.This means of decreasing infection is now well known.7

The device also served to splint the sternum, diminishparadoxical movement and significantly improve the me-chanics of respiration.8 There were no haemodynamic ef-fects attributable to the dressing.

Second primary closure was not possible in these threecases. There was extensive tissue destruction. The optionsfor reconstruction include muscular flap (unilateral orbilateral pectoralis major flap, rectus abdominis flap) oromental flap. The omentum is very thin9 so its use is not de-scribed in neonates. Before using the VAC therapy, we usedbilateral pectoralis major flap, omental flap in one case orirrigation and healing of secondary intention. In our threerecent cases, all of the children had peritoneal dialysiswhich did not permit omental use. Muscular flaps have

Table 3

Period ofVAC treatment(days)

CRP (mg/l) atthe beginningof VACtreatment

CRP (mg/l)after 72 h

Results

16 242 32 Healed witha thinskin graft

12 193 45 Wound healedcompletely

21 259 54 Healed with athin skin graft

Figure 3

Figure 4

Vacuum-assisted closure in the treatment of poststernotomy mediastinitis 305

been used with success by some teams. In our three pa-tients, haemodynamics and oxygenation were very poorand there was a risk of necrosis.

The use of the rectus abdominis muscle is technicallydifficult given the small size of the pedicle.10 Hernia forma-tion, impaired spinal growth and visceral organ damage areoften cited as morbidities of the rectus abdominis flap.11

The pectoralis major flap is often used for mediastinitis inchildren when primary closure is not possible. The tech-nique is less difficult than the rectus abdominis flap but,in neonates, it is not a simple technique. The authorswho used this technique described no effect on breast de-velopment, no deficiencies in chest wall development andsternal stability and no deficiencies in upper limb or truncalmovement.5,8,10 So this technique can be used in children.

In conclusion, these cases suggest a highly effective rolefor the VAC device in the treatment of poststernotomymediastinitis in infants. The VAC technique can be consid-ered as a method that combines the benefits of both closedand open wound treatment. It led to local wound improve-ment, holistic clinical and biological improvement, andbetter chest wall mechanics. There were no complicationsresulting from its use. The main disadvantage is the needfor frequent dressing changes.

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