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J Thorac Cardiovasc Surg 2007;134:254-255
© 2007 The American Association for Thoracic Surgery

Brief Communication

Treatment of deep thoracotomy wound infection in neonatal age: A case report

Mariano Vicchio, MDa,*, Alessandra Amato, MDb, Ettore Merlino, MDa, Alessandro Nava, MDa, Marisa De Feo, MD, PhDa, Giuseppe Caianiello, MDa, Maurizio Cotrufo, MDa

a Department of Cardiothoracic Sciences, Second University of Naples and Department of Cardiovascular Surgery and Transplants, V. Monaldi Hospital, Naples, Italy
b Department of Pediatrics, Second University of Naples, Naples, Italy.

Received for publication March 14, 2007; accepted for publication March 26, 2007.

* Address for reprints: Mariano Vicchio, MD, Via Cassano 150, 80144, Naples, Italy. (Email: marianovicchio{at}libero.it).


Figure 1
Dr Vicchio


In 1997 Argenta and Morykwas1Go reported the use of negative pressure to enhance wound granulation and closure. Since then, more studies have reported good results with the application of vacuum in the treatment of deep sternal wound infection after cardiac surgery.2,3Go

No study has described the use of negative pressure and the therapeutic intensity of vacuum in the neonatal age group. We report our experience in a 28-day-old female neonate with a thoracotomy wound infection treated with vacuum application.

Clinical Summary

A 14-day-old female infant (weight 3,260 kg) with aortic coarctation, cleft palate, hypertelorism, and low-set ears underwent surgical correction of the coarctation. Patch aortoplasty was performed through a left thoracotomy. The surgical procedure and early postoperative period did not show complications, and 6 days after the operation the infant was transferred to a pediatric facility to investigate the presence of a genetic syndrome.

Eight days later the patient returned to our surgical department with dehiscence of the thoracotomy (Figure 1, A), fever, a white blood cell count of less than 23,600/µL, and a polymerase chain reaction of 9 mg/L.


Figure 1
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  		Figure 1. A, Thoracotomy wound before the surgical revision. B, Surgical tampon, transparent film dressing, and pediatric enteral feeding tube used in the sterile medications. C, Neonate with vacuum applied to the sterile medication. D, Thoracotomy wound after 3 weeks of treatment.

 
We performed a surgical revision of the wound, scraping the infected tissue and obtaining a necrotic fragment for a microbiologic evaluation. At the end of the revision, we prepared a sterile medication with a surgical tampon inserted into the wound, covered by a film dressing. We applied vacuum through a pediatric enteral feeding tube inserted under the film dressing and attached to an electronic aspirator (Figure 1, B and C). We performed a Doppler examination at the margins of the wound to evaluate the increase in the microvascular blood flow determined by rising intensity of negative pressure. In this way we determined that the most advantageous intensity of depression to apply in our patient was –80 mm Hg.

Antibiotic therapy was started with amoxicillin and clavulanic acid and was continued after the microbiologic response revealed that the infection was caused by a methicillin-sensitive Staphylococcus aureus. A daily sterile medication was applied in the first 3 weeks, with insertion of a surgical tampon into the lesion to allow granulation tissue to refill the cavity of the wound (Figure 1, D). The presence of the tampon avoided the spontaneous approach of the epidermal layer of the wound before the granulation tissue would have refilled the cavity of the wound. For each of the next 10 days of the treatment, we positioned the tampon over the wound to allow the margins of the lesion to close. We continued the vacuum treatment for 31 days until the wound completely healed, avoiding a late surgical closure with a very satisfactory result (Figure 2).


Figure 2
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  		Figure 2. Thoracotomy wound immediately after the end of treatment.

 
Our infant was transferred to a pediatric department for the study and treatment of noncardiac diseases with a white blood cell count of 8000/µL, a polymerase chain reaction of 0.8 mg/L, and negative microbiologic test results.

Discussion

Since its introduction into clinical use by Argenta and Morykwas,1Go negative pressure has been applied in various types of infected wounds, including deep sternal wound infection after cardiac surgery. The intensity of vacuum to use for healing has been widely established in the treatment of infected sternal lesions in adult patients. All articles reported a negative pressure –125 mm Hg to be associated with an optimal rate of successful treatments and low incidence of complications related to use of depression.2,3Go

Mechanisms responsible for the effectiveness of this method have been partially identified, despite its rapid diffusion. Some authors maintained that the application of negative pressure avoids local wound ischemia and increases microvascular blood flow, accelerating the migration of cells responsible for cicatrization.4Go

Recently, Wackenfors and colleagues5Go demonstrated, in an experimental study in pigs, a correlation between intensity of negative pressure and blood flow at the microvascular level. They identified the range between –75 and –100 mm Hg as being responsible for maximal increase in blood flow at the muscular microvascular level around the wound.

In the literature, no study has reported on the use of vacuum in a neonatal patient. Therefore, we performed a test similar to that of Wackenfors and associates5Go on our infant to identify the extent of depression producing an equal microvascular blood flow increase. We feared that in so small a patient a negative pressure of –125 or –100 mm Hg could have caused pain or skin necrosis. Our vacuum intensity of –80 mm Hg allowed healing of the wound in a satisfactory time, and the infant has tolerated the treatment well.

References

  1. Argenta LC, Morykwas MJ. Vacuum-assisted closure: a new method for wound control and treatment—clinical experience. Ann Plast Surg 1997;38:563-577.[Medline]
  2. Gustafsson RI, Sjögren J, Ingemansson R. Deep sternal wound infection: a sternal-sparing technique with vacuum-assisted closure therapy. Ann Thorac Surg 2003;76:2048-2053.[Abstract/Free Full Text]
  3. Domkowski PW, Smith ML, Gonyon DL, Drye C, Wooten MK, Levin LS, et al. Evaluation of vacuum-assisted closure in the treatment of poststernotomy mediastinitis. J Thorac Cardiovasc Surg 2003;126:386-390.[Abstract/Free Full Text]
  4. Morykwas MJ, Argenta LC, Shelton-Brown EI, McGuirt W. Vacuum-assisted closure: a new method for wound control and treatment—animal studies and basic foundation. Ann Plast Surg 1997;38:553-562.[Medline]
  5. Wackenfors A, Gustafsson R, Sjögren J, Algotsson L, Ingemansson R, Malmsjo M. Blood flow responses in the peristernal thoracic wall during vacuum-assisted closure therapy. Ann Thorac Surg 2005;79:1724-1730.[Abstract/Free Full Text]



This article has been cited by other articles:


Home page
 Ann. Thorac. Surg.Home page
M. Vicchio, M. De Feo, G. Caianiello, and M. Cotrufo
Vacuum for Pediatric Post-Sternotomy Mediastinitis: The Role of Laser Doppler Velocimetry in the Establishment of Adequate Subatmospheric Pressure Intensity
Ann. Thorac. Surg., October 1, 2008; 86(4): 1399 - 1399.
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