Negative Pressure Wound Therapy in the Treatment of Sternal Infection after Cardiac Surgery: a Case Report and Literature Review

DOI: https://doi.org/10.30702/ujcvs/23.31(04)/IK049-4956
Keywords: complete median sternotomy, infectious complications, postoperative mediastinitis, methods of wound managing, wound healing

Abstract

The aim. To assess the effectiveness of negative pressure wound therapy (NPWT) in the treatment of sternal infection following heart surgery.

Materials and methods. During 2019-2022, six patients aged from 46 to 69 years underwent NPWT for sternal infection which occurred within 2 to 24 weeks after complete median sternotomy. For the purpose of temporary wound closure, standard dressing kits with sorption sponge were used. Negative pressure was created by electric vacuum pump with a constant vacuum mode at a range of -75 to -115 mm Hg and a duration of 4-5 days per session. In all cases determination of serum procalcitonin, bacteriological examination of wound discharge, computed tomography (CT) of the chest were performed in dynamics.

Results. The study revealed that NPWT in all cases promoted wound cleansing, gradual closing of fistulas and non-grooving pockets, termination of inflammatory process, reduction of the wound cavity, thus accelerating complete wound healing. A significant reduction in the level of wound contamination was revealed after the first NPWT session (below the critical level of 103 CFU), compared to that before treatment (107-108 CFU). Normalization of the level of procalcitonin in the blood serum was determined by day 5-7 of NPWT. CT showed the signs of sternum stability and reduction of inflammatory process in surrounding tissues after treatment. Each treatment case required from 2 to 4 sessions. The duration of hospital stay ranged between 25 and 35 days. A treatment case of one of the 6 patients included in the study is described.

Conclusions. NPWT has proven to have positive clinical effect in the local treatment of postoperative sternal infection and can be applied as an ultimate or a transitional option. Methodology of its clinical application needs further elaboration.

References

  1. Dalton ML, Connally SR, Sealy WC. Julian’s Reintroduction of Milton’s Operation. Ann Thorac Surg. 1992;53(3):532-533. https://doi.org/10.1016/0003-4975(92)90293-D
  2. Perezgrovas-Olaria R, Audisio K, Cancelli G, Rahouma M, Ibrahim M, Soletti GJ, et al. Deep Sternal Wound Infection and Mortality in Cardiac Surgery: A Meta-analysis. Ann Thorac Surg. 2023;115(1):272-280. https://doi.org/10.1016/j.athoracsur.2022.04.054
  3. Downing M, Modrow M, Thompson-Brazill KA, Ledford JE, Harr CD, Williams JB. Eliminating sternal wound infections: Why every cardiac surgery program needs an I hate infections team. JTCVS Tech. 2023;19:93-103. https://doi.org/10.1016/j.xjtc.2023.03.019
  4. Singh K, Anderson E, Harper JG. Overview and Management of Sternal Wound Infection. Semin Plast Surg. 2011;25(1):25-33. https://doi.org/10.1055/s-0031-1275168
  5. Balachandran S, Lee A, Denehy L, Lin KY, Royse A, Royse C, et al. Risk Factors for Sternal Complications After Cardiac Operations: A Systematic Review. Ann Thorac Surg. 2016;102(6):2109-2117. https://doi.org/10.1016/j.athoracsur.2016.05.047
  6. Buja A, Zampieron A, Cavalet S, Chiffi D, Sandonà P, Vinelli A, et al. An update review on risk factors and scales for prediction of deep sternal wound infections. Int Wound J. 2012;9(4):372-386. https://doi.org/10.1111/j.1742-481X.2011.00896.x
  7. Knobloch K, Lichtenberg A, Pichlmaier M, Mertsching H, Krug A, Klima U, et al. Microcirculation of the Sternum Following Harvesting of the Left Internal Mammary Artery. Thorac Cardiovasc Surg. 2003;51(5):255-259. https://doi.org/10.1055/s-2003-43083
  8. Cheng K, Rehman SM, Taggart DP. A Review of Differing Techniques of Mammary Artery Harvesting on Sternal Perfusion: Time for a Randomized Study? Ann Thorac Surg. 2015;100(5):1942-1953. https://doi.org/10.1016/j.athoracsur.2015.06.087
  9. Barner HB. The continuing evolution of arterial conduits. Ann Thorac Surg. 1999;68(3 Suppl):S1-S8. https://doi.org/10.1016/S0003-4975(99)00812-7
  10. Sjögren J, Malmsjö M, Gustafsson R, Ingemansson R. Poststernotomy mediastinitis: a review of conventional surgical treatments, vacuum-assisted closure therapy and presentation of the Lund University Hospital mediastinitis algorithm. Eur J Cardiothorac Surg. 2006;30(6):898-905. https://doi.org/10.1016/j.ejcts.2006.09.020
  11. Al-Ebrahim K, Al-Ebrahim E. Prevention, Classification and Management Review of Deep Sternal Wound Infection. Heart Surg Forum. 2020;23(5):E652-E657. https://doi.org/10.1532/hsf.3153
  12. Elassal AA, Al-Ebrahim KE, Al-Radi OO, Jabbad HH, Eldib OS. Sternal Wound Complications: Objective Reclassification and Surgical Reconsideration. Heart Surg Forum. 2020;23(1):E076-E080. https://doi.org/10.1532/hsf.2649
  13. Song Y, Chu W, Sun J, Liu X, Zhu H, Yu H, et al. Review on risk factors, classification, and treatment of sternal wound infection. J Cardiothorac Surg. 2023 May 19;18(1):184. https://doi.org/10.1186/s13019-023-02228-y
  14. Anger J, Dantas DC, Arnoni RT, Farsky PS. A new classification of post-sternotomy dehiscence. Rev Bras Cir Cardiovasc. 2015;30(1):114-118. https://doi.org/10.5935/1678-9741.20140033
  15. Niclauss L, Delay D, Stumpe F. Right ventricular rupture due to recurrent mediastinal infection with a closed chest. Interact Cardiovasc Thorac Surg. 2010;10(3):470-472. https://doi.org/10.1510/icvts.2009.223891
  16. Vos RJ, van Putte BP, Sonker U, Kloppenburg GT. Primary closure using Redon drains for the treatment of post-sternotomy mediastinitis. Interact Cardiovasc Thorac Surg. 2014;18(1):33-37. https://doi.org/10.1093/icvts/ivt385
  17. Sharif M, Wong CHM, Harky A. Sternal Wound Infections, Risk Factors and Management - How Far Are We? A Literature Review. Heart Lung Circ. 2019;28(6):835-843. https://doi.org/10.1016/j.hlc.2019.01.008
  18. Huang C, Leavitt T, Bayer LR, Orgill DP. Effect of negative pressure wound therapy on wound healing. Curr Probl Surg. 2014;51(7):301-331. https://doi.org/10.1067/j.cpsurg.2014.04.001
  19. Kubat E, Abacı M, Ünal CS. Z-plasty as an alternative choice for the treatment of recurrent local sternal wound infections. Gen Thorac Cardiovasc Surg. 2019;67(6):518-523. https://doi.org/10.1007/s11748-018-1052-5
  20. Kitano D, Takahashi H, Nomura T, Okada K, Terashi H, Sakakibara S. A new clinical classification and reconstructive strategy for post-sternotomy surgical site infection. Regen Ther. 2022;21:519-526. https://doi.org/10.1016/j.reth.2022.10.007
  21. Kamel M, Port J, Altorki NK. Sternal Resections: New Materials for Reconstruction. Curr Surg Rep. 2015;3:16. https://doi.org/10.1007/s40137-015-0094-1
  22. Kim PJ, Attinger CE, Constantine T, Crist BD, Faust E, Hirche CR, et al. Negative pressure wound therapy with instillation: International consensus guidelines update. Int Wound J. 2020;17(1):174-186. https://doi.org/10.1111/iwj.13254
  23. Poteet SJ, Schulz SA, Povoski SP, Chao AH. Negative pressure wound therapy: device design, indications, and the evidence supporting its use. Expert Rev Med Devices. 2021;18(2):151-160. https://doi.org/10.1080/17434440.2021.1882301
  24. Normandin S, Safran T, Winocour S, Chu CK, Vorstenbosch J, Murphy AM, et al. Negative Pressure Wound Therapy: Mechanism of Action and Clinical Applications. Semin Plast Surg. 2021;35(3):164-170. https://doi.org/10.1055/s-0041-1731792
  25. Hever P, Singh P, Eiben I, Eiben P, Nikkhah D. The management of deep sternal wound infection: Literature review and reconstructive algorithm. JPRAS Open. 2021;28:77-89. https://doi.org/10.1016/j.jpra.2021.02.007
Published
2023-12-28
How to Cite
Ivanova, Y. V., Kryvoruchko, I. A., Cheverda, V. M., Minukhin, D. V., Gramatiuk, S., Estrin, S. I., & Kovalchuk, A. O. (2023). Negative Pressure Wound Therapy in the Treatment of Sternal Infection after Cardiac Surgery: a Case Report and Literature Review. Ukrainian Journal of Cardiovascular Surgery, 31(4), 49-56. https://doi.org/10.30702/ujcvs/23.31(04)/IK049-4956
Issue
Ukrainian Journal of Cardiovascular Surgery Vol 31 No 4 2023
Section
ACQUIRED HEART DISEASES