INTRODUCTION: It is hypothesized that systemically administered antibiotics penetrate wound sites more effectively during negative pressure wound therapy (NPWT). However, there is a lack of clinical data from patients who receive NPWT for deep sternal wound infection (DSWI) after open-heart surgery. Here, we evaluated vancomycin penetration into exudate in this patient group. PATIENTS AND METHODS: For this prospective observational study, we enrolled 10 consecutive patients treated with NPWT for post-sternotomy DSWI. On the first sampling day, serum and exudate samples were synchronously collected at 0 (pre-dose), 0.5, 1, 2, 3 and 6 h after vancomycin administration. On the following three consecutive days, additional samples were collected, only before vancomycin administration. RESULTS: The ratio of average vancomycin concentration in wound exudate to in serum was higher for free (unbound) (1.51 ± 0.53) than for total (bound + unbound) (0.91 ± 0.29) concentration (p = 0.049). The percentage of free vancomycin was higher in wound exudate than serum (0.79 ± 0.19 vs. 0.46 ± 0.16; p = 0.04). Good vancomycin wound penetration was maintained on the following three days (vancomycin trough exudate-to-serum concentration ratio > 1). The total hospital stay was significantly longer in patients with DSWI (46 ± 11.6 days) versus without DSWI (14 ± 11.7 days) (p < 0.001). There was no in-hospital or 90-day mortality. Two patients experienced late DSWI recurrence. All-cause mortality was 4.8% during a median follow-up of 2.5 years. CONCLUSION: Vancomycin effectively penetrates wound exudate in patients receiving NPWT for DSWI after open-heart surgery.The protocol for this study was registered at ClinicalTrials.gov on July 16, 2024 (NCT06506032).
- MeSH
- antibakteriální látky * farmakokinetika aplikace a dávkování MeSH
- exsudáty a transsudáty metabolismus mikrobiologie MeSH
- infekce chirurgické rány * MeSH
- kardiochirurgické výkony * škodlivé účinky MeSH
- lidé středního věku MeSH
- lidé MeSH
- prospektivní studie MeSH
- senioři MeSH
- sternotomie * škodlivé účinky MeSH
- sternum chirurgie MeSH
- terapie ran pomocí řízeného podtlaku * metody MeSH
- vankomycin * aplikace a dávkování farmakokinetika MeSH
- Check Tag
- lidé středního věku MeSH
- lidé MeSH
- mužské pohlaví MeSH
- senioři MeSH
- ženské pohlaví MeSH
- Publikační typ
- časopisecké články MeSH
- pozorovací studie MeSH
Úvod: Střední sternotomie je nejčastěji používaným přístupem v otevřené kardiochirurgii. Stejně jako u jiných operací jsou infekce v místě operace známým jevem. Morbidita však závisí na hloubce infekce. Povrchové infekce rány lze zvládnout konzervativně, avšak hluboké infekce sternální rány vyžadují agresivní přístup, aby se zabránilo katastrofální mediastinitidě. Proto byla provedena tato studie s cílem klasifikovat infekci sternotomické rány a vypracovat algoritmus léčby povrchových a hlubokých infekcí. Materiál a metody: V období od ledna 2016 do srpna 2021 bylo studováno 25 pacientů, kteří měli infekci sternotomické rány. Tyto infekce rány byly klasifikovány jako povrchové nebo hluboké infekce sternotomické rány. Výsledky: V roce 2016 byla provedena analýza sternální stěny a jejího povrchu: Povrchové infekce rány byly ošetřeny zředěnými octovými obvazy a hluboké infekce byly ošetřeny oboustranným posunem velkého prsního svalu. Pacienti byli sledováni až do konečného zahojení ran. Byly analyzovány charakteristiky pacientů, komorbidity, délka léčby a výsledky léčby. Pacienti s povrchovou infekcí sternální rány příznivě reagovali na zředěné octové obvazy a pacienti s hlubokou infekcí sternální rány na posun laloků velkého prsního svalu. Průměrná doba hojení povrchové infekce rány byla 66,2 dne a u hluboké infekce 18 dní. U žádného z pacientů se po léčbě a během sledování nezvýšila závažnost infekce ani nedošlo k opětovné dehiscenci. Závěr: Relativně konzervativní přístup s použitím obvazu ze zředěného octa (1% kyselina octová) u povrchových infekcí sternální rány byl účinný, zatímco u hlubokých infekcí sternální rány je pro příznivé výsledky nutný agresivní debridement a oboustranný posun svalových laloků. K ověření tohoto léčebného algoritmu je však zapotřebí většího počtu studií.
Introduction: Median sternotomy is the most commonly used approach in open cardiac surgery. As in any other surgery, surgical site infections are a known phenomenon, but morbidity depends on the depth of infection. Superficial wound infections can be managed conservatively; however, deep sternal wound infections need an aggressive approach to prevent disastrous consequence like mediastinitis. Hence, this study was conducted with the aim to classify sternotomy wound infection and to develop a treatment algorithm for superficial and deep sternotomy wound infections. Material and methods: Between January 2016 to August 2021, 25 patients who had sternotomy wound infections were studied. These wound infections were classified as superficial or deep sternal wound infections. Results: Superficial wound infections underwent treatment with diluted vinegar dressings and deep infections underwent treatment with bilateral pectoralis major muscle advancement flaps. Patients were followed up till the wounds healed completely without complications. Patient characteristics, comorbidities, duration of treatment and outcomes of treatment were analyzed. Superficial sternal wound infection patients responded favorably to diluted vinegar dressings and deep sternal wound infection patients to pectoralis major muscle advancement flaps. Average time duration of healing for superficial and deep wound infections was 66.2 days and 18 days respectively. None of the patients had an increased severity of infection or re-dehiscence following treatment and during follow-up. Conclusion: Relatively conservative approach using diluted vinegar (1% acetic acid) dressing for superficial sternal wound infections was efficacious, whereas aggressive debridement and bilateral pectoralis major advancement muscle flaps for deep sternal wound infections are necessary for favorable outcomes. However, more studies are needed to ascertain this treatment algorithm.
BACKGROUND: Most cardiac surgery patients undergo median sternotomy during open heart surgery. Sternotomy healing is an arduous, very complex, and multifactorial process dependent on many independent factors affecting the sternum and the surrounding soft tissues. Complication rates for median sternotomy range from 0.5 to 5%; however, mortality rates from complications are very variable at 7-80%. Low calcidiol concentration below 80 nmol/L results in calcium absorptive impairment and carries a risk of bone loss, which is considered as a risk factor in the sternotomy healing process. The primary objective of this clinical trial is to compare the incidence of all postoperative sternotomy healing complications in two parallel patient groups administered cholecalciferol or placebo. The secondary objectives are focused on general patient recovery process: sternal bone healing grade at the end of the trial, length of hospitalization, number of days spent in the ICU, number of days spent on mechanical lung ventilation, and number of hospital readmissions for sternotomy complications. METHODS: This clinical trial is conducted as monocentric, randomized, double-blind, placebo-controlled, with planned enrollment of 600 patients over 4 years, approximately 300 in the placebo arm and 300 in the treatment arm. Males and females from 18 to 95 years of age who fulfill the indication criteria for undergoing cardiac surgery with median sternotomy can be included in this clinical trial, if they meet the eligibility criteria. DISCUSSION: REINFORCE-D is the first monocentric trial dividing patients into groups based on serum calcidiol levels, and with dosing based on serum calcidiol levels. This trial may help to open up a wider range of postoperative healing issues. TRIAL REGISTRATION: EU Clinical Trials Register, EUDRA CT No: 2016-002606-39 . Registered on September 8, 2016.
- MeSH
- hojení ran MeSH
- kardiochirurgické výkony * škodlivé účinky MeSH
- lidé MeSH
- pooperační komplikace etiologie prevence a kontrola MeSH
- sternotomie * škodlivé účinky MeSH
- vitamin D škodlivé účinky MeSH
- Check Tag
- lidé MeSH
- mužské pohlaví MeSH
- ženské pohlaví MeSH
- Publikační typ
- časopisecké články MeSH
- randomizované kontrolované studie MeSH
Principem léčby podtlakovou terapií (NPWT - Negative Pressure Wound Treatment) je vytvoření negativního tlaku v ráně, který z rány průběžně odstraňuje intersticiální tekutinu, redukuje tak bakteriální kolonizaci a urychluje tvorbu granulační tkáně. Tím podstatně zkracuje dobu přípravy podkladu pro definitivní zakrytí rány a celkovou dobu léčení pacienta. Podtlaková terapie je také využívána jako sekundární léčba hojení ran v mnoha chirurgických oborech, břišní, cévní chirurgii a kardiochirurgii nevyjímaje.
The principle of treatment with vacuum therapy is the creation of negative pressure in the wound, which continuously removes interstitial fluid from the wound, reducing bacterial colonization and accelerating the formation of granulation tissue. This significantly shortens the preparation time of the substrate for the final covering of the wound and the total treatment time of the patient. Vacuum therapy is also used as a secondary treatment for wound healing in many surgical fields, including abdominal, vascular surgery and cardiac surgery.
- MeSH
- debridement metody MeSH
- dekubity etiologie patologie MeSH
- fotografování MeSH
- lidé středního věku MeSH
- lidé MeSH
- osteomyelitida etiologie MeSH
- paraplegie MeSH
- poranění míchy MeSH
- progrese nemoci MeSH
- revaskularizace myokardu škodlivé účinky MeSH
- senioři MeSH
- sternotomie škodlivé účinky MeSH
- sutura MeSH
- terapie ran pomocí řízeného podtlaku * ošetřování MeSH
- výsledek terapie MeSH
- zánět chirurgie etiologie terapie MeSH
- Check Tag
- lidé středního věku MeSH
- lidé MeSH
- mužské pohlaví MeSH
- senioři MeSH
- ženské pohlaví MeSH
- Publikační typ
- kazuistiky MeSH
OBJECTIVES: Deep sternal wound infection poses a serious problem in cardiac surgery, with an up to 40% risk of mortality. Massive loss of sternum bone tissue and adjacent ribs results in major chest wall instability causing respiratory insufficiency and defects of soft tissue healing. Proposals for managing the situation have been published but the complexity of the issue precludes unequivocal resolution. Capitalizing on orthopaedic experience, we used allogeneic bone graft of sternum as a viable option. METHODS: We performed the transplantation of allogeneic bone graft in 10 patients. In 9 cases, an allograft of sternum was used and in 1 case an allograft of calva bone. After the primary cardiac surgery, a massive post-sternotomy defect of the chest wall had developed in all 10 patients. Vacuum wound drainage was applied in the treatment of all patients. To stabilize the transverse, titanium plates were used. Bone allograft was prepared by the official Tissue Centre. Crushed allogeneic spongy bone was applied to reinforce the line of contact of the graft and the edges of residual skeleton. In 9 cases, the soft tissue was closed by direct suture of mobilized pectoral flaps. In 1 case, V-Y transposition of pectoral flap was performed. RESULTS: In 6 cases, healing of the reconstructed chest wall occurred without further complications. In 3 cases, additional re-suture of the soft tissues and skin in the lower pole of the wound was necessary. Excellent chest wall stability along with the adjustment of respiratory insufficiency and good cosmetic effect was achieved in all cases. In 1 case, severe concomitant complications and no healing of the wound resulted in death within 6 months after the reconstruction. Median follow-up of all patients in the series was 14.1 months (1-36 months). In 4 patients, scintigraphy of the chest wall was performed. CONCLUSIONS: Our existing results show that allogeneic bone graft transplantation is a promising and easily applied method in the management of serious tissue loss in sternal dehiscence with favourable functional and cosmetic effects. The relatively small number of patients with such severe healing complications of sternotomy however puts critical limits to a more detailed comparison with other practices and evaluation of long-term results.
- MeSH
- časové faktory MeSH
- chirurgické laloky MeSH
- dehiscence operační rány MeSH
- hojení ran MeSH
- homologní transplantace MeSH
- infekce chirurgické rány diagnóza etiologie mortalita chirurgie MeSH
- lidé středního věku MeSH
- lidé MeSH
- osteotomie * MeSH
- pooperační komplikace mortalita MeSH
- prsní svaly chirurgie MeSH
- reoperace MeSH
- senioři nad 80 let MeSH
- senioři MeSH
- šicí techniky MeSH
- sternotomie škodlivé účinky mortalita MeSH
- transplantace kostí škodlivé účinky metody mortalita MeSH
- výsledek terapie MeSH
- zákroky plastické chirurgie škodlivé účinky metody mortalita MeSH
- Check Tag
- lidé středního věku MeSH
- lidé MeSH
- mužské pohlaví MeSH
- senioři nad 80 let MeSH
- senioři MeSH
- ženské pohlaví MeSH
- Publikační typ
- časopisecké články MeSH
Střední sternotomie je nejčastěji používaným operačním přístupem v kardiochirurgii dospělých i dětí. Hluboké poststernotomické defekty představují závažnou pooperační komplikaci, která klade zvýšené nároky na pacienty i kardiochirurgická pracoviště. V naší práci jsme retrospektivně analyzovali 9 110 pacientů operovaných v Centru kardiovaskulární a transplantační chirurgie Brno v letech 2005–2012 s cílem definovat rizikové faktory hlubokých poruch hojení sterna. Jako nejzávažnější rizikové faktory byly v multivariantní analýze zjištěny sepse, odběr mamární tepny (jakožto štěpu k revaskularizaci), hemodynamická nestabilita, reintubace a mužské pohlaví.
Median sternotomy is the most commonly performed surgical procedure in the treatment of heart conditions in both adults and children. Deep sternal wound infections (DSWI) present a serious complication occurring after surgery, highly demanding both of patients and surgery departments. The present study is a retrospective analysis of 9 110 patients who underwent a cardiac surgery at the Center of Cardiovascular Surgery and Transplantations, Brno, Czech Republic, in the years 2005–2012, and as its objective it has a definition of risk factors of DSWI after median sternotomy. In this study, a multivariate analysis found sepsis to be the most serious risk factors, as well as harvesting of the mammary artery (to be used as a graft for revascularisation), hemodynamic instability, reintubation and male sex.
- MeSH
- dehiscence operační rány epidemiologie etiologie chirurgie MeSH
- hojení ran MeSH
- incidence MeSH
- infekce chirurgické rány * epidemiologie chirurgie klasifikace MeSH
- kardiochirurgické výkony * metody mortalita MeSH
- lidé MeSH
- mediastinitida epidemiologie farmakoterapie mikrobiologie MeSH
- perioperační období MeSH
- pooperační období MeSH
- předoperační období MeSH
- rizikové faktory MeSH
- sexuální faktory MeSH
- sternotomie * škodlivé účinky MeSH
- Check Tag
- lidé MeSH
- mužské pohlaví MeSH
- ženské pohlaví MeSH
Thoracic stabilization using transverse plate fixation represents a modern and safe method of sternal dehiscence treatment. However, it still remains difficult to apply in cases of massive loss of bone tissue of the chest wall. An unsatisfactory stability of thorax often results in severe respiratory insufficiency, and also affects healing of soft tissue closure while increasing the risk of development of chronic fistulas and other dehiscences. In the reported case, we opted for a unique treatment of massive post-sternotomy defect using an allogenous bone graft of calva. Transverse titanium plates were applied to achieve stabilization of bone grafts and chest wall.
- MeSH
- chirurgické laloky MeSH
- dehiscence operační rány chirurgie MeSH
- hrudní stěna chirurgie MeSH
- kostní destičky MeSH
- lidé středního věku MeSH
- lidé MeSH
- sternotomie škodlivé účinky MeSH
- sternum chirurgie MeSH
- transplantace kostí metody MeSH
- žebra chirurgie MeSH
- Check Tag
- lidé středního věku MeSH
- lidé MeSH
- mužské pohlaví MeSH
- Publikační typ
- časopisecké články MeSH
- kazuistiky MeSH
The aim of this study was to determine the outcome of patients who had a chest resternotomy and to identify risk factors for higher in-hospital mortality after re-exploration for bleeding and/or tamponade after cardiac operations. We present our experience of an acceptably low re-exploration rate after cardiac surgery, and the outcomes of those re-explored. This was a retrospective analysis of medical records of all patients who had a chest re-exploration for the control of bleeding and cardiac tamponade over a 7-year period (2000-06), at the Cardiothoracic Centre of the Hospital České Budějovice, Czech Republic. Between 2000 and 2006, 152 patients (3.4% of the total heart operations) underwent re-exploration after heart surgery. One hundred and seven (70.4%) were re-explored for bleeding, 36 (23.7%) for possible tamponade and nine (5.9%) for both. An identifiable source of bleeding was found in 72.4% patients. Risk factors associated with higher in-hospital mortality after re-exploration for bleeding and tamponade include delayed resternotomy, higher levels of lactate and lower levels of haematocrit before revision and other well-known risk factors such as older age, more complex cardiac procedures, redo operations, longer cardiopulmonary bypass, renal failure and diabetes mellitus. Patients who need re-exploration are at a higher risk of complications, morbidity and mortality if the time until re-exploration is prolonged.
- MeSH
- časové faktory MeSH
- hodnocení rizik MeSH
- kardiochirurgické výkony škodlivé účinky mortalita MeSH
- lidé středního věku MeSH
- lidé MeSH
- mortalita v nemocnicích MeSH
- pooperační krvácení etiologie mortalita chirurgie MeSH
- reoperace MeSH
- retrospektivní studie MeSH
- rizikové faktory MeSH
- senioři MeSH
- srdeční tamponáda etiologie mortalita chirurgie MeSH
- sternotomie škodlivé účinky mortalita MeSH
- výsledek terapie MeSH
- Check Tag
- lidé středního věku MeSH
- lidé MeSH
- mužské pohlaví MeSH
- senioři MeSH
- ženské pohlaví MeSH
- Publikační typ
- časopisecké články MeSH
- Geografické názvy
- Česká republika MeSH
AIM: We sought to compare clinical outcomes, in-hospital mortality and 1-year survival of two different treatment modalities of deep sternal wound infection, topical negative pressure and the closed irrigation therapy. METHODS: Retrospective analysis of 66 consecutive patients treated for deep sternal infection at our institution. A total of 28 patients (February 2002 through September 2004) underwent primarily closed irrigation therapy, and 34 patients (November 2004 through December 2007) had the application of topical negative pressure. Four patients (July 2004 through December 2004) who underwent a combination of both strategies were excluded from the study. Clinical and wound care outcomes were compared, focusing on therapeutic failure rate, in-hospital stay and the 1-year mortality of both treatment strategies. RESULTS: Topical negative pressure was associated with a significantly lower failure rate of the primary therapy (P<0.05), shortening of the intensive care unit stay (P<0.001), a particular decrease in the in-hospital stay (P<0.05) and the 1-year mortality (P<0.05) in comparison with closed irrigation therapy. Comparable overall length of the therapy, in-hospital stay and the risk of wire-related fistulas after chest reconstruction were found. CONCLUSION: Topical negative pressure is a superior method of treatment for deep sternal wound infection, which is based on lower therapeutic failure rate, significant decrease in-hospital stay, and the decrease of the 1-year mortality rate, compared with primarily applied closed irrigation.
- MeSH
- časové faktory MeSH
- debridement metody MeSH
- délka pobytu trendy MeSH
- hojení ran MeSH
- infekce chirurgické rány terapie MeSH
- kardiochirurgické výkony škodlivé účinky metody MeSH
- léčebná irigace metody MeSH
- lidé MeSH
- mortalita v nemocnicích trendy MeSH
- následné studie MeSH
- retrospektivní studie MeSH
- rizikové faktory MeSH
- senioři MeSH
- sternotomie škodlivé účinky MeSH
- sternum MeSH
- terapie ran pomocí řízeného podtlaku metody MeSH
- výsledek terapie MeSH
- Check Tag
- lidé MeSH
- mužské pohlaví MeSH
- senioři MeSH
- ženské pohlaví MeSH
- Publikační typ
- časopisecké články MeSH
- srovnávací studie MeSH
- Geografické názvy
- Švédsko MeSH
- MeSH
- lidé MeSH
- malé chirurgické výkony MeSH
- sternotomie škodlivé účinky MeSH
- torakotomie využití MeSH
- Check Tag
- lidé MeSH
- Publikační typ
- novinové články MeSH
