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Médiastinites après chirurgie cardiaqueDESC
réanimation médicaleSaint-Etienne 2005

• Guillaume Dray
• DES cardiologie
• 2eme année DESC réanimation médicale
• CHU Nice

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Définition

• Infection de lespace médiastinal dorigine
  nosocomiale

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Épidémiologie

• Incidence 0.8-2.3
• 72-79 staphylocoques
• Staphylocoques aureus 63-82
• Staphylocoques coag (-) 18-36
• BGN 10-18
• Pas de germe retrouvé 10
• Staphylococcal post sternotomy médiastinitisfive
  year audit. Upton A et al.ANZ J Surg.2005
  Apr75198-203
• Postoperative mediastinitis in cardiac
  surgery-microbiologie and pathogenesis. Gardlund
  B et al. Eur J cardiothorax Surg.2002
  May21825-30
• Simplified Treatement of Postoperative
  Mediastinitis.Walter H et al.Ann Thorax Surg
  200478608-12

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Épidémiologie II

• Médiane de survenue 7-11.5 j
• 90 avant le 28eme jour post-opératoire
• Double le temps hospitalisation
• Mortalité 19-20.3
• Staphylococcal post sternotomy médiastinitisfive
  year audit. Upton A et al.ANZ J Surg.2005
  Apr75198-203
• Postoperative mediastinitis in cardiac
  surgery-microbiologie and pathogenesis. Gardlund
  B et al. Eur J cardiothorax Surg.2002
  May21825-30
• Simplified Treatement of Postoperative
  Mediastinitis.Walter H et al.Ann Thorax Surg
  200478608-12
• Acute poststernotomy mediastinitis managed with
  debridement and closed-drainage aspiration
  factor associated with death in the intensive
  care unit. Trouillet JL et al.J Thorac Cardiovasc
  Surg 2005 Mar 129 518-24

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Facteurs de risque de médiastinite

• Obésité
• Diabète
• Hospitalisation S.I. gt 5j
• Ventilation mécanique gt 3j
• Age gt 70 ans
• Réinterventions
• Tabac / BPCO
• Autres pathologies associées
• Mediastinitis and cardiac surgery-an updated risk
  factor analysis in 10,373consecutive adult
  patients.Gummer JF et al.thorac cardiovasc
  Surg.2002 Apr 5087-91
• Acute poststernotomy mediastinitis managed with
  debridement and closed-drainage aspiration
  factor associated with death in the intensive
  care unit. Trouillet JL et al.J Thorac Cardiovasc
  Surg 2005 Mar 129 518-24
• Postoperative mediastinitis in cardiac
  surgery-microbiologie and pathogenesis. Gardlund
  B et al. Eur J cardiothorax Surg.2002
  May21825-30
• Risk factors for mediastinitisafter cardiac
  surgery.Abboud CS et al.Ann Thorac Surg 2004
  Feb77676-83
• Surgical-site infection rates and risk factor
  analysis in coronary artery bypass graft
  surgery.Harrington G et al. Infect Control Hosp
  Epidemiol.2004 Jun25472-6

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Facteurs de risque Staph Meti-R

• Hospitalisation prolongée
• Traitement antibiotique avant lépisode
• Porteur nasal pré-op dun Staph Meti-R
• Age élevé
• The impact of Methicillin Resistance on the
  Outcome of Poststernotomy Mediastinitis due to
  Staphylococcus Aureus Alain Combes et al.Clinical
  Infectious Diseases 200438822-9

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Facteurs de risque de Mortalité

• Age important
• Ré opérations
• Temps opératoire
• Septicémies à Staph Meti-R augmentent la
  mortalité mais pas pour les médiastinites.
  Cependant augmentation de la morbidité
• Postoperative mediastinitis in cardiac
  surgery-microbiologie and pathogenesis. Gardlund
  B et al. Eur J cardiothorax Surg.2002
  May21825-30
• The impact of Methicillin Resistance on the
  Outcome of Poststernotomy Mediastinitis due to
  Staphylococcus Aureus Alain Combes et al.Clinical
  Infectious Diseases 200438822-9

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Diagnostic clinique

• Instabilité sternale
• Douleur
• Désinsertion osseuse
• Fièvre inexpliquée ( gt 38c)

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Diagnostic Para clinique

• Hémocultures
• Ponction sternale
• Dg rapide, diminution temps hospitalisation,
  diminution temps de ventilation mécanique
• Prélèvements locaux et chirurgicaux
• Syndrome inflammatoire biologique
• Pas de marqueur précoce (échec de la
  procalcitonine ( marqueur pronostique))
• Staphylococcal post sternotomy
  médiastinitisfive year audit. Upton A et al.ANZ
  J Surg.2005 Apr75198-203
• Staphylococcus aureus bacteriemia after mediane
  sternotomy clinical utility of blood culture
  result in the identification of post operative
  mediastinitis. Fowler VG jr et al.Circulation
  2003 Jul 810873-8
• Procalcitonin is a valuable prognostic marqueur
  in cardiac surgery but not specific for infection
  Dorge H et al. Thorc Cardiovasc Surg 2003
  Dec51322-6

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Diagnostic para clinique II

• Scanner thoracique aucun intérêt
• Diagnostic validity of computed tomography for
  mediastinitis after cardiac surgery. Yamaguchi H
  et al. Ann Thorac Cardiovasc Surg.2001 Apr794-8
  
• Computed tomography of the sternum and
  mediastinum after mdian sternotomy. Bitkover CY
  et al. Ann Thorac Surg.1999 Sep68858-63

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Traitement I

• Débridement chirurgical des tissus infectés
• Fermeture par flap musculaire pectoral
  (bilatéral si résection sternale, nécrose,
  débridement extensif)
• Drainage fermé avec redons mediastinaux (diminue
  les échecs du ttt, surinfection, mortalité)
• Lavage solution antiseptique ou antibiotique
  (vanco ou C3G secondairement adapté)
• Primary treatement of the infected sternotomy
  wound with muscle flaps a review of 211
  consecutive cases.Nahai F et al. Plast Reconstr
  Surg 1989 Sep84434-41
• - The impact of Methicillin Resistance on the
  Outcome of Poststernotomy Mediastinitis due to
  Staphylococcus Aureus Alain Combes et al.Clinical
  Infectious Diseases 200438822-9
• Primary or delayed closure for the treatement of
  poststernotomy wound infection? Fleck TM et al.
  Ann Plast Surg.2004 Mar52310-4
• Management of the infected median sternotomy
  wound with muscle flaps.The Emory 20-year
  experience. Jones G et al.Ann Surg 1997 Jun
  225766-76
• Simplified treatment of postoperative
  mediastinitis. Walter H et al.Ann Thorac Surg
  200478608-12
• Successful treatment of deep sternal infections
  following open heart surgery by bilateral
  pectoralis major flaps.Armin Alex Klesius et al.
  Eur J Card Thorac Surg 200425218-23

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Traitement II

• Plus utilisé drainage ouvert
  (sauf nécrose sternale et cutanée massive)
• Culture
• tissus débridés
• Liquide de drainage tous les 3 jours
• J10 liquide stérile retrait des redons de 2-3
  cm/j

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Traitement III

• Antibiothérapie
• Absence de germe
• C3G vancomycine gentamycine
• Staphylocoque Aureus Meti-S
• C3G gentamycine 3-5j
• C3G Rifampicine Ofloxacine 10-15j
• Rifampicine Ofloxacine 3semaines
• Staphylocoque Aureus Meti-R
• Vancomycine C3G ou Imipeneme 6 semaines

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Traitement IV

• Antibioprophylaxie
• Oxacilline IV
• Gentamycine locale avant fermeture sternale
• Antibiotic concentrations in serum and wound
  fluid after local gentamicin or intravenous
  dicloxacillin prophylaxis in cardiac
  surgery.Friberg O et al.Scand J Infect
  Dis.200335251-4

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Complications

• Choc septique
• Rupture VD

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Figure 1. Mechanism of right ventricular
disruption following sternal debridement (A) The
adhesions from the thin-walled right ventricle to
the sternum remain after the removal of sternal
wires. (B) The distraction of sternal edges
caused by respiratory motion, coughing, or
vomiting distracts the right ventricle and
disrupts the free wall. IVC, inferior vena cava
LV, left ventricle RV, right ventricle.
                                                  
                                                  
                                                  
                              
                                                  
                                                  
        
Figure 1. Mechanism of right ventricular
disruption following sternal debridement (A) The
adhesions from the thin-walled right ventricle to
the sternum remain after the removal of sternal
wires. (B) The distraction of sternal edges
caused by respiratory motion, coughing, or
vomiting distracts the right ventricle and
disrupts the free wall. IVC, inferior vena cava
LV, left ventricle RV, right ventricle.
                                                  
                                                  
                                                  
                              
                                                  
                                                  
        
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Khoynezhad, Ali, Abbas, Ghulam, Palazzo, Robert S. Graver, L. MichaelSpontaneous Right Ventricular Disruption Following Treatment of Sternal Infection.Journal of Cardiac Surgery 19 (1), 74-78.doi 10.1111/j.0886-0440.2004.04015.x
   
   
Khoynezhad, Ali, Abbas, Ghulam, Palazzo, Robert S. Graver, L. MichaelSpontaneous Right Ventricular Disruption Following Treatment of Sternal Infection.Journal of Cardiac Surgery 19 (1), 74-78.doi 10.1111/j.0886-0440.2004.04015.x
   




 
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