Mediastinitis in the intensive care unit patient: a narrative review

BackgroundMediastinitis is a rare but severe infection, defined as an inflammation of the connective tissues and structures within the mediastinum. Due to its proximity to vital structures, mediastinitis represents a highly morbid pathological process associated with a high risk of mortality. In most cases mediastinitis requires treatment in the intensive care unit.ObjectivesTo highlight to the reader the clinical features of mediastinitis, to attempt to define each clinical scenario, to describe the responsible pathogens and finally to depict both the medical and surgical treatments.SourcesWe performed a literature search of the PubMed and Cochrane libraries, limited for articles published between January 2003 and December 2018, reporting on acute mediastinitis.ContentThe term covers different entities of different aetiologies including deep sternal wound infection related to sternotomy; oesophageal perforation or anastomosis leakage; and finally descending necrotizing mediastinitis, often secondary to oropharyngeal abscess. The responsible pathogens and therefore subsequent management depends on the underlying aetiology. Empirical antimicrobial therapy should cover the suspected microorganisms while surgery and supportive measures should aim to reduce the inoculum of pathogens by providing adequate drainage and debridement.ImplicationsLiterature concerning mediastinitis in the intensive care unit is relatively scarce. We have collated the evidence and reviewed the different causes and treatment options of acute mediastinitis with a particular focus on microbiological epidemiology. Future research in larger cohorts is needed to better understand the treatment of this difficult disease.     

Videothoracoscopic drainage for esophageal perforation with mediastinitis in children

Background

Esophageal perforation remains a devastating event that is difficult to diagnose and manage. The overall mortality associated with esophageal perforation can approach 20%, and delay in treatment of more than 24 hours after perforation can result in a doubling of mortality. The treatment option for esophageal perforation with mediastinitis is not very clear and still controversial.

Methods

Between April 2000 and March 2004, 6 males and 2 females, with ages ranging from 2 to 6 years (mean, 3.8 years), underwent videothoracoscopic drainage for esophageal perforation with mediastinitis.

Results

The mean hospital length of stay for patients in our series was 34.1 days (range, 14-47 days). There was no perioperative mortality. All patients were discharged from hospital without major sequelae.

Conclusions

Minimally invasive videothoracoscopic drainage is a feasible and effective method for esophageal perforation with mediastinitis in children.     

Vacuum-assisted closure therapy for deep sternal wound infections: the impact of learning curve on survival and predictors for late mortality

The aim of this study was to evaluate the possible learning curve effects on survival during the introduction of vacuum-assisted closure (VAC) therapy in patients with deep sternal wound infection (DSWI). Furthermore, predictors of late mortality were analysed and causes of late death were examined. Fifty-three patients (early Group, n = 26, January 1999 to July 2001 versus late group, n = 27, August 2001 to March 2003) were all treated with VAC for DSWI. A follow-up was carried out in September 2006. Multivariate analyses were used to evaluate the predictors of late mortality. The 90-day mortality was 0% in both groups. The survival rates at 5 years were 69.2 +/- 9.1% (early group) versus 58.5 +/- 11.7% (late group), P = ns (non significant). The time interval from cardiac surgery to diagnosis of DSWI and prolonged VAC therapy were identified as independent predictors of late mortality. Our concept for VAC therapy in DSWI seems to be readily introduced in clinical practice. There was no difference in survival between our initial cases and later cases. Late diagnosis and prolonged wound therapy were identified as predictors for late mortality.     

下行性坏死性纵隔炎二例并文献复习

报道2例下行性坏死性纵隔炎并复习相关文献，从病因、临床表现、影像学表现、诊断标准及治疗手段等方面进行讨论。结果表明，下行性坏死性纵隔炎病死率高，容易误诊；早期诊断和使用强效广谱抗生素，并早期采取适当的手术方式引流有助于改善下行性坏死性纵隔炎的预后。     

Poststernotomy mediastinitis: a review of conventional surgical treatments, vacuum-assisted closure therapy and presentation of the Lund University Hospital mediastinitis algorithm

Poststernotomy mediastinitis, also commonly called deep sternal wound infection, is one of the most feared complications in patients undergoing cardiac surgery. The overall incidence of poststernotomy mediastinitis is relatively low, between 1% and 3%, however, this complication is associated with a significant mortality, usually reported to vary between 10% and 25%. At the present time, there is no general consensus regarding the appropriate surgical approach to mediastinitis following open-heart surgery and a wide range of wound-healing strategies have been established for the treatment of poststernotomy mediastinitis during the era of modern cardiac surgery. Conventional forms of treatment usually involve surgical revision with open dressings or closed irrigation, or reconstruction with vascularized soft tissue flaps such as omentum or pectoral muscle. Unfortunately, procedure-related morbidity is relatively frequent when using conventional treatments and the long-term clinical outcome has been unsatisfying. Vacuum-assisted closure is a novel treatment with an ingenious mechanism. This wound-healing technique is based on the application of local negative pressure to a wound. During the application of negative pressure to a sternal wound several advantageous features from conventional surgical treatment are combined. Recent publications have demonstrated encouraging clinical results, however, observations are still rather limited and the underlying mechanisms are largely unknown. This review provides an overview of the etiology and common risk factors for deep sternal wound infections and presents the historical development of conventional therapies. We also discuss the current experiences with VAC therapy in poststernotomy mediastinitis and summarize the current knowledge on the mechanisms by which VAC therapy promotes wound healing. Finally, we suggest a structured algorithm for using VAC therapy for treatment of poststernotomy mediastinitis in clinical practice.     

Vacuum-assisted closure for postcardiac surgery mediastinitis in a patient on hemodialysis

A 66-year-old man on hemodialysis underwent off-pump coronary artery bypass grafting. He was discharged in good condition on postoperative day (POD) 16. A high-grade fever and a purulent discharge emerged on POD 30. Methicillin-resistant Staphylococcus aureus was identified by culturing material from the wound. On admission, vacuum-assisted closure (VAC) therapy was applied for 80 days. Finally, good wound healing allowed us to perform simple wound closure without using muscle flaps or omentoplasty. VAC therapy is a useful and safe procedure for postcardiac surgery mediastinitis.