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Poorly managed diabetes and hypertensives are risk factors for deep sternal wound infection (DSWI) following cardiac surgery; leading to increased morbidity and mortality. To reappraise the effectiveness of omental flap in the management of High risk patient with DSWI. A middle aged man with extensive mediastinitis following cardiac surgery (from outside referral). He was a known Diabetic and Hypertensive who was poorly compliant on medications. The history, physical examination, gycosylated Haemoglobin (HbA1c) and microbiological analyses showed high blood pressure, poor glycaemic control, septicaemia with staphylococcal DSWI. Resuscitation was achieved with the use of oral antihypertensives, Human insulin and antibiotics respectively. The DSWI was managed with serial debridement and subsequent wound cover with omental flap. The hospital stay was shorter and outcome was good. The management of DSWI with omental flap may be an effective surgical modality that reduces morbidity and mortality even in high risk patients.
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PMID:Omentoplasty as an effective surgical modality for managing a high risk patient with deep sternal wound infection. 2323 2

We report a case with an atypical presentation of descending necrotizing mediastinitis (DNM). A 47-year-old woman with a medical history of untreated type 2 diabetes mellitus and influenza type A virus infection 2 weeks prior to admission was referred to our hospital complaining of right cervical pain and right upper limb swelling. A chest enhanced computed tomographic (CT) scan showed a ring-enhanced mass-like shadow extending from the right sternomastoid muscle down to the right upper mediastinum, compressing the right subclavicular vein. We diagnosed the patient as having DNM based on a physical examination and the CT findings. Because the abscess extended from deep in the neck to the upper mediastinum and right upper pleural space, emergent abscess debridement and drainage was required. After hospitalization, antibiotics (Ampicillin/Sulbactam 12 g/day) were also administered based on Gram-stain findings from the drainage fluid, which showed Gram-positive cocci resembling a string of beads. A culture of the drainage fluid identified Streptococcus agalactiae. Aggressive abscess drainage and early antibiotic therapy resulted in a favorable response. She was discharged without complications on the 33rd hospital day. DNM is well known as a rare but lethal disease. In this case, the presence of diabetes mellitus and post-influenza infection might have been risk factors for a serious S. agalactiae infection. Early aggressive therapy and adequate drainage are recommended for patients with DNM.
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PMID:[A case of descending necrotizing mediastinitis caused by infection with Streptococcus agalactiae in a patient with diabetes mellitus]. 2336 53

With an incidence rate of 1-4%, mediastinitis following cardiac surgery is a rarely occurring complication, but may show a mortality rate of up to 50%. Risk factors for sternal instability are insulin-dependent diabetes mellitus, obesity, immunosuppressed state, chronic obstructive pulmonary disease, osteoporosis, history of radiation, renal failure, body height, smoking and nutritional state. The aim of this paper is to show an overview of this clinical picture, present the risk factors and elucidate the therapy options chronologically. As a result of interdisciplinary cooperation, a therapy concept has developed which is adapted to the patient individually. Therapy begins with the simplest measures and, if deemed necessary, this is then escalated step by step. The aim of the treatment is to bring the infection under control, which requires radical surgical debridement, removal of infected and necrotic tissue, removal of all foreign bodies (including wires and osteosynthesis material) and the removal of all infected, necrotic osseous material if necessary followed by vacuum-assisted closure therapy. The reconstruction of defects of the anterior chest wall is achievable using different muscle flaps. Mostly the muscle pectoralis major is used unilaterally or bilaterally with or without disinsertion of the tendon. Other options are the omental flap, the muscle latissimus dorsi flap or the muscle rectus abdominis flap. A combined approach comprising surgical debridement, short-term vacuum therapy and subsequent myoplastic coverage has proved successful and can be carried out with a high standard of safety.
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PMID:Management of sterno-mediastinitis. 2343 88

The consequences of deep wound infections before, during, and after coronary artery bypass grafting have prompted research to clarify risk factors and explore preventive measures to keep infection rates at an irreducible minimum. An analysis of 42 studies in which investigators used multivariate logistic regression analysis revealed that diabetes mellitus and obesity are by far the chief preoperative risk factors. A 4-point preoperative scoring system based on a patient's body mass index and the presence or absence of diabetes is one practical way to determine the risk of mediastinitis, and other risk-estimate methods are being refined. Intraoperative risk factors include prolonged perfusion time, the use of one or more internal mammary arteries as grafts, blood transfusion, and mechanical circulatory assistance. The chief postoperative risk factor is reoperation, usually for bleeding. Unresolved issues include the optimal approach to Staphylococcus aureus nasal colonization and the choice of a prophylactic antibiotic regimen. We recommend that cardiac surgery programs supplement their audit processes and ongoing vigilance for infections with periodic, multidisciplinary reviews of best-practice standards for preoperative, intraoperative, and postoperative patient care.
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PMID:Preventing deep wound infection after coronary artery bypass grafting: a review. 2367 10

We conducted a retrospective study of deep surgical site infections (SSIs) among consecutive patients who underwent lung transplantation (LTx) at a single center from 2006 through 2010. Thirty-one patients (5%) developed SSIs at median 25 days after LTx. Empyema was most common (42%), followed by surgical wound infections (29%), mediastinitis (16%), sternal osteomyelitis (6%), and pericarditis (6%). Pathogens included Gram-positive bacteria (41%), Gram-negative bacteria (41%), fungi (10%) and Mycobacterium abscessus, Mycoplasma hominis and Lactobacillus sp. (one each). Twenty-three percent of SSIs were due to pathogens colonizing recipients' native lungs at time of LTx, suggesting surgical seeding as a source. Patient-related independent risk factors for SSIs were diabetes and prior cardiothoracic surgery; procedure-related independent risk factors were LTx from a female donor, prolonged ischemic time and number of perioperative red blood cell transfusions. Mediastinitis and sternal infections were not observed among patients undergoing minimally invasive LTx. SSIs were associated with 35% mortality at 1 year post-LTx. Lengths of stay and mortality in-hospital and at 6 months and 1 year were significantly greater for patients with SSIs other than empyema. In conclusion, deep SSIs were uncommon, but important complications in LTx recipients because of their diverse microbiology and association with increased mortality.
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PMID:Epidemiology and outcomes of deep surgical site infections following lung transplantation. 2371 May 93

Necrotizing fasciitis (NF) is a rare polymicrobial infection that can be life-threatening. It is a rapidly progressive inflammatory process affecting the deep fascia, with secondary necrosis of the subcutaneous tissue. It is characterized by its fulminant course and its high mortality rate. Most cases of NF affect the abdomen, groin, and extremities. NF in the neck is reported to be rare and most cases are odontogenic in origin. Misdiagnosis and delayed treatment can result in death from sepsis, mediastinitis, carotid artery erosion, jugular vein thrombophlebitis, or aspiration pneumonia. The diagnosis is based on a combination of clinical history and predisposing factors, Gram staining and culture, imaging, and surgical exploration. Early and aggressive surgical treatment and intensive medical care are essential. The aim of this article is to report a case of severe and extensive cervical NF worsened by a diabetic ketoacidosis as a first appearance of diabetes mellitus.
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PMID:Cervical necrotizing fasciitis and diabetic ketoacidosis: literature review and case report. 2379 Aug 8

Deep sternal wound infection is the major infectious complication in patients undergoing cardiac surgery, associated with a high morbidity and mortality rate, and a longer hospital stay. The most common causative pathogen involved is Staphylococcus spp. The management of post sternotomy mediastinitis associates surgical revision and antimicrobial therapy with bactericidal activity in blood, soft tissues, and the sternum. The pre-, per-, and postoperative prevention strategies associate controlling the patient's risk factors (diabetes, obesity, respiratory insufficiency), preparing the patient's skin (body hair, preoperative showering, operating site antiseptic treatment), antimicrobial prophylaxis, environmental control of the operating room and medical devices, indications and adequacy of surgical techniques. Recently published scientific data prove the significant impact of decolonization in patients carrying nasal Staphylococcus aureus, on surgical site infection rate, after cardiac surgery.
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PMID:Epidemiology and prevention of surgical site infections after cardiac surgery. 2398 75

Steel wires are commonly used to close median sternotomy during adult cardiac surgery. Disruption or infection of the sternum can occure in 0.3~8% of those patients. We report the use of absorbable sutures for the closure of sternotomy. Three figure of 8 ligations were made. Cranial side suture was placed through the sternal manubrium. Other sutures were placed through the intercostal spaces.Sutures were tied 6 or 7 times. Braided #2 polyglactin suture were used in a consecutive 150 patients. Looped (double) #1 monofilament polyglyconate sutures were used in a subsequent 150 patients. Both sutures with blunt needle are commercially available. None of the patients in either group required re-exploration of the sternum for bleeding and tamponade, and none developed wound infections or mediastinitis. Five patients in the polyglactin group developed seroma and/or instability of the sternum after more than 2 postoperative weeks, but none required surgical refixation of the sternum. These 5 patients had diabetes, chronic renal failure, autoimmune disease and/or chronic lung diseases. None of the patients in the polyglyconate group developed any trouble in their sternum. We conclude that polyglyconate sutures demonstrate good potential for use in closure of the sternum.
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PMID:[Feasibility of the use of absorbable sutures for closure of the sternum in adult cardiac surgery]. 2432 54

Mediastinitis is a devastating sternal wound complication. The aim of this study was to identify the incidence, risk factors, mortality, and different treatment modalities of mediastinitis after isolated coronary artery bypass grafting. From January 2007 to May 2010, 1424 patients who underwent isolated coronary artery bypass grafting were studied retrospectively; 1398 (group 1) had no mediastinitis, and 26 (group 2) developed mediastinitis. The diagnosis and classification of mediastinitis were based on the criteria of the Center for Disease Control and Prevention and the Emory classification, respectively. Multivariate analysis showed only 4 risk factors: diabetes mellitus, obesity, prolonged postoperative intensive care unit stay, and prolonged intubation time. On univariate analysis, female sex, renal failure, and reexploration for bleeding were also significant risk factors. The incidence of mediastinitis (1.83%) and the subsequent mortality rate (7.69%) were comparable to those of previous reports. Early detection and aggressive management of mediastinitis play major roles in decreasing the related mortality and morbidity. The Emory classification with some modification is very helpful in choosing the proper treatment modality.
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PMID:Deep sternal wound infection after coronary artery bypass: How to manage? 2482 26

The descending necrotizing mediastinitis is a rare but life-threatening inflammation, and occurs as a complication of deep inflammation of the neck. The mortality rate is still high by 40% despite the use of a variety of potent antimicrobial drugs. We describe 7 patients with the descending necrotizing mediastinitis treated in our hospital during the last 12 years. The primary site of infection in 5 patients were tonsils and pharynx, and in the other two patients odontogenic inflammation of the lower molars. Most of the patients belonged to the risk groups (diabetes mellitus, alcoholism), the average age of 60.4 years. After the diagnosis with computed tomography (CT), we surgically intervened in all patients. Deep neck infections are treated with aggressive surgical cervicotomy and high quality mediastinal drainage was performed with transcervical approach in all patients. Perioperative tracheotomy (n=3) was performed for the upper airway edema and postoperative tracheostomy for extended intubation (n = 1).Only in one case, we subsequently conducted a secondary surgical procedure, lateral thoracotomy because of pleural decortication. All patients were successfully cured with an average length of hospitalization was 24.6 days. For successful treatment of the descending necrotizing mediastinitis diagnosis must be set as early as possible and with the use of computed tomography scanning. Treatment requires the simultaneous application of potent antimicrobial drugs, aggressive surgical debridement of the neck and high-quality drainage of the mediastinum, which can be achieved through the transcervical approach.
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PMID:[Descendending necrotizing mediastinitis single center experience]. 2532 5


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