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Médiastinites après chirurgie cardiaque DESC réanimation médicale Saint-Etienne 2005
Guillaume Dray DES cardiologie 2eme année DESC réanimation médicale CHU Nice
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Définition Infection de l’espace médiastinal d’origine 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 médiastinitis:five year audit. Upton A et al.ANZ J Surg.2005 Apr;75: Postoperative mediastinitis in cardiac surgery-microbiologie and pathogenesis. Gardlund B et al. Eur J cardiothorax Surg.2002 May;21:825-30 Simplified Treatement of Postoperative Mediastinitis.Walter H et al.Ann Thorax Surg 2004;78:608-12
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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 % Staphylococcal post sternotomy médiastinitis:five year audit. Upton A et al.ANZ J Surg.2005 Apr;75: Postoperative mediastinitis in cardiac surgery-microbiologie and pathogenesis. Gardlund B et al. Eur J cardiothorax Surg.2002 May;21:825-30 Simplified Treatement of Postoperative Mediastinitis.Walter H et al.Ann Thorax Surg 2004;78:608-12 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:
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Facteurs de risque de médiastinite
Obésité Diabète Hospitalisation S.I. > 5j Ventilation mécanique > 3j Age > 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; 50:87-91 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: Postoperative mediastinitis in cardiac surgery-microbiologie and pathogenesis. Gardlund B et al. Eur J cardiothorax Surg.2002 May;21:825-30 Risk factors for mediastinitisafter cardiac surgery.Abboud CS et al.Ann Thorac Surg 2004 Feb;77:676-83 Surgical-site infection rates and risk factor analysis in coronary artery bypass graft surgery.Harrington G et al. Infect Control Hosp Epidemiol.2004 Jun;25:472-6
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Facteurs de risque Staph Meti-R
Hospitalisation prolongée Traitement antibiotique avant l’épisode Porteur nasal pré-op d’un 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 2004;38:822-9
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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 May;21:825-30 The impact of Methicillin Resistance on the Outcome of Poststernotomy Mediastinitis due to Staphylococcus Aureus Alain Combes et al.Clinical Infectious Diseases 2004;38:822-9
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Diagnostic clinique Instabilité sternale Douleur Désinsertion osseuse
Fièvre inexpliquée ( > 38°c)
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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 médiastinitis:five year audit. Upton A et al.ANZ J Surg.2005 Apr;75: 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 8;108:73-8 Procalcitonin is a valuable prognostic marqueur in cardiac surgery but not specific for infection Dorge H et al. Thorc Cardiovasc Surg 2003 Dec;51:322-6
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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 Apr;7:94-8 Computed tomography of the sternum and mediastinum after mdian sternotomy. Bitkover CY et al. Ann Thorac Surg.1999 Sep;68:858-63
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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 Sep;84:434-41 - The impact of Methicillin Resistance on the Outcome of Poststernotomy Mediastinitis due to Staphylococcus Aureus Alain Combes et al.Clinical Infectious Diseases 2004;38:822-9 Primary or delayed closure for the treatement of poststernotomy wound infection? Fleck TM et al. Ann Plast Surg.2004 Mar;52:310-4 Management of the infected median sternotomy wound with muscle flaps.The Emory 20-year experience. Jones G et al.Ann Surg 1997 Jun ;225:766-76 Simplified treatment of postoperative mediastinitis. Walter H et al.Ann Thorac Surg 2004;78:608-12 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 2004;25:218-23
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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.2003;35:251-4
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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. Close this Window Close this Window Khoynezhad, Ali, Abbas, Ghulam, Palazzo, Robert S. & Graver, L. Michael Spontaneous Right Ventricular Disruption Following Treatment of Sternal Infection. Journal of Cardiac Surgery 19 (1), doi: /j x Khoynezhad, Ali, Abbas, Ghulam, Palazzo, Robert S. & Graver, L. Michael Spontaneous Right Ventricular Disruption Following Treatment of Sternal Infection. Journal of Cardiac Surgery 19 (1), doi: /j x Back to top Back to top
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