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Is mediastinitis a preventable complication? A 10-year review
R J Baskett1, C E MacDougall, D B Ross
1Department of Cardiovascular Surgery, Dalhousie University and The Queen Elizabeth II Health Sciences Centre, Halifax, Nova Scotia, Canada.
Background:
The incidence of mediastinitis after cardiac surgical intervention is reported to be between 0.15% and 5% and is a major cause of postoperative morbidity. A number of risk factors have been identified, most of which are not modifiable. It is our contention that this complication can be reduced to a minimum by the consistent application of good operative technique and postoperative management.
Methods:
We reviewed the records of all 9,771 patients who underwent cardiac surgical procedures between 1987 and 1997. All operations were performed using a common skin preparation, draping, and antibiotic prophylaxis. Cases of mediastinitis were defined according to Centers for Disease Control and Prevention criteria and were identified from three sources: medical records database, hospital infection control, and the Society of Thoracic Surgeons database. Risk factors were assessed using chi2 and Fisher's exact tests.
Results:
Of 24 patients identified as having deep sternal wound infection (incidence, 0.25%), 2 died (mortality rate, 8.3%), 18 required reoperation (75%), and only 4 needed pectoral muscle flaps. Statistical analysis revealed only the presence of chronic obstructive pulmonary disease as a significant risk factor (p < 0.01). Other factors, including diabetes, renal failure, smoking, sex, age, reoperation, morbid obesity, and steroid use, were not significant. The use of internal mammary arteries (single or bilateral) was not associated with mediastinitis. Postoperative complications, including prolonged ventilation, inotropic support, and the need for blood products, were not significant risk factors. The patients who developed mediastinitis were more likely to be readmitted to the hospital (p < 0.005) and more likely to require reoperation (p < 0.005).
Conclusions:
In a large patient series we found a low incidence of mediastinitis (0.25%) and an even lower incidence of required reoperation (0.19%). Except for the use of bone wax and the use of bilateral mammary arteries in diabetic patients, none of the previously identified risk factors are modifiable. We believe that with strict adherence to perioperative aseptic technique, attention to hemostasis, and precise sternal closure, a very low incidence of mediastinitis can be achieved.
Insights
Minimizing mediastinitis after cardiac surgery is achievable through strict adherence to aseptic techniques and meticulous surgical practices. This study found a low incidence of mediastinitis and reoperation, emphasizing the importance of operative technique over modifiable risk factors.
Area of Science:
- Cardiovascular Surgery
- Infectious Disease Epidemiology
- Surgical Outcomes Research
Background:
- Mediastinitis is a serious complication following cardiac surgery, with reported incidences ranging from 0.15% to 5%.
- Numerous risk factors for mediastinitis have been identified, but many are not amenable to modification.
- Effective operative technique and postoperative management are crucial for minimizing this complication.
Purpose of the Study:
- To evaluate the incidence of mediastinitis in a large cohort of cardiac surgery patients.
- To identify significant risk factors associated with mediastinitis.
- To assess the impact of surgical technique on mediastinitis rates.
Main Methods:
- A retrospective review of 9,771 cardiac surgical procedures performed between 1987 and 1997.
- Standardized protocols for skin preparation, draping, and antibiotic prophylaxis were applied.
- Mediastinitis cases were identified using multiple data sources and analyzed for risk factors.
Main Results:
- The incidence of deep sternal wound infection (mediastinitis) was 0.25%, with a mortality rate of 8.3%.
- Chronic obstructive pulmonary disease was the only significant risk factor identified (p < 0.01).
- Factors such as diabetes, smoking, obesity, and steroid use were not significant predictors.
Conclusions:
- A low incidence of mediastinitis (0.25%) and reoperation (0.19%) was observed in this large patient series.
- Except for bone wax and bilateral mammary arteries in diabetic patients, identified risk factors are largely non-modifiable.
- Strict adherence to perioperative aseptic technique, hemostasis, and sternal closure can achieve very low mediastinitis rates.