povidone-iodine and Mediastinitis

Infection of an ascending aortic prosthesis is a grave complication associated with a high mortality. In most cases, extraanatomic bypass and removal of the infected vascular graft are not possible. Furthermore, the standard approach to this problem, which includes excision and replacement or debridement and repair of infected thoracic aortic grafts, carries a high early mortality. We report the successful treatment of this life-threatening complication using a conservative strategy in which the aortic prosthesis was salvaged by in situ disinfection followed by coverage with tissue flaps.

Topics: Adult; Aortic Aneurysm, Thoracic; Aortic Dissection; Blood Vessel Prosthesis; Humans; Male; Mediastinitis; Povidone-Iodine; Prosthesis-Related Infections; Proteus Infections; Proteus vulgaris; Reoperation; Surgical Flaps; Surgical Wound Infection; Therapeutic Irrigation

Mediastinitis is one of severe and fatal complications after cardiac surgery, especially in the presence of a prosthetic graft. A 70-year-old male, who was suffered from chronic sternal osteomyelitis and mediastinitis after ascending aorta and hemiarch reconstruction was reported. He developed high fever and leucocytosis on the 16th postoperative day. Wound culture was positive for Grampositive organisms. He was diagnosed as having sternal osteomyelitis and mediastinitis and treated by sternal bone debridement and irrigation with dilute povidone iodine solution with no effects. Total excision of the infected sternum, irrigation with non-diluted solution of povidone iodine and omental transfer were performed successfully. The literature regarding omental transfer for mediastinitis and infected prosthetic grafts was briefly reviewed.

Topics: Aged; Aortic Aneurysm, Thoracic; Blood Vessel Prosthesis; Chronic Disease; Humans; Male; Mediastinitis; Omentum; Osteomyelitis; Povidone-Iodine; Prosthesis-Related Infections; Staphylococcal Infections; Staphylococcus epidermidis; Sternum; Therapeutic Irrigation

Mediastinitis is a devastating complication following median sternotomy. Continuous povidone-iodine (PVP-I) irrigation has been advocated as therapy because of its broad antimicrobial spectrum and its apparent safety. However, several recent clinical reports have warned of suspected local and systemic iodine toxicity. The purpose of this study is to determine if significant amounts of iodine can be absorbed systemically via the mediastinum, and if so, what toxicity (local and/or systemic) may result. PVP-I (0.5%) was continuously irrigated into the pericardial sacs of three dogs via catheters for 48 hr. Serial serum and urine iodine levels were determined. The serum steady-state concentration (Css), the rate elimination constant (k), the urinary clearance (Cl), and the serum half-life (t 1/2) for iodine were assessed. Serum electrolytes, Bun, Cr, and arterial pH were measured to assess systemic iodine toxicity. Tissue samples of the heart, pericardium, liver, and kidney were examined histologically for evidence of local or end-organ iodine toxicity. This study demonstrated that the absorption of iodine during continuous mediastinal irrigation with PVP-I follows zero-order pharmacokinetics, just as if it were being given by continuous intravenous infusion. The baseline serum iodine concentration was 145.9 +/- 64.3 micrograms/dl, Css was 29,290 +/- 101.4 micrograms/dl, k was 0.0996 +/- 0.009/hr, Cl was 872.4 +/- 119.3 ml/hr, and t1/2 was 6.22 hr. Urinary excretion of iodine increased in proportion to the serum iodine. Measured serum chloride increased in a linear manner (r = 0.949), while serum Na, K, Bun, Cr, and pH were unchanged.(ABSTRACT TRUNCATED AT 250 WORDS)

Topics: Absorption; Animals; Dogs; Iodine; Mediastinitis; Mediastinum; Myocardium; Pericarditis; Povidone-Iodine; Therapeutic Irrigation

We report a case of mediastinitis successfully treated with autovaccine therapy, once conventional surgical and medical therapies had failed.

Topics: Aged; Anti-Bacterial Agents; Anti-Infective Agents, Local; Coronary Artery Bypass; Coronary Stenosis; Debridement; Gentamicins; Humans; Male; Mediastinitis; Methicillin Resistance; Povidone-Iodine; Staphylococcal Infections; Staphylococcal Vaccines; Staphylococcus aureus; Surgical Wound Infection; Teicoplanin; Therapeutic Irrigation; Treatment Failure; Treatment Outcome; Vancomycin

Continuous mediastinal irrigation with povidone-iodine is used commonly for treating severe postoperative mediastinitis. However, concurrent iodine toxicity has been reported, particularly in patients with renal dysfunction (likely because absorbed iodine is renally excreted). The authors were consulted on a 45-year-old patient with mediastinitis who had renal and hepatic dysfunction while being treated with mediastinal irrigation of povidone-iodine. The povidone-iodine irrigation was discontinued because he had toxic plasma iodine levels. Despite this, his condition worsened, and the iodine levels remained elevated. Thus, hemodialysis (HD) was initiated using high-flux membranes followed by continuous venovenous hemodiafiltration (CVVHDF; 2 L/h of hemofiltration and 2 L/h of HD). Plasma and effluent iodine levels were measured repeatedly to determine iodine clearance by these 2 modalities (HD, 120 mL/min; CVVHDF, 37 mL and 44 mL/min on days 1 and 2, respectively). Hepatic and renal functions improved with decreasing plasma iodine levels. Based on this experience and after reviewing the literature the authors conclude that: (1) iodine irrigation can increase blood iodine levels significantly, especially in the setting of renal failure, and lead to increased morbidity and mortality; (2) plasma iodine levels should be monitored in patients with renal insufficiency; and (3) HD and CVVHDF are effective at clearing iodine. The authors suggest that patients that are at high risk or already developing signs of iodine toxicity should have the iodine irrigation discontinued and may benefit from renal replacement therapy (RRT). Alternatively, concomitant RRT during iodine irrigation may be attempted to maintain the systemic iodine levels at nontoxic levels.

Topics: Hemodiafiltration; Humans; Iodine; Liver Failure; Male; Mediastinitis; Mediastinum; Middle Aged; Poisoning; Povidone-Iodine; Referral and Consultation; Renal Dialysis; Renal Insufficiency; Therapeutic Irrigation

Between October of 1992 and September of 1998, we performed 604 open heart operations. Among them, 12 cases (1.9%) were complicated with postoperative infectious mediastinitis. Five patients (Group A) were treated by conservative therapy which consists of open drainage and intermittent closed irrigation with dilute povidone iodine solution. Seven patients (Group B) were treated surgically in addition to the above-mentioned conservative treatment. Among those patients, one patient developed fatal complication. We have realized that mental care of the patients was also very important when long term hospitalization was necessitated. The hyperbaric oxygen therapy seemed to be also effective for postoperative mediastinitis caused by MRSA.

Topics: Aged; Coronary Artery Bypass; Drainage; Female; Humans; Hyperbaric Oxygenation; Male; Mediastinitis; Middle Aged; Postoperative Complications; Povidone-Iodine; Prognosis; Staphylococcal Infections; Surgical Procedures, Operative; Therapeutic Irrigation

Severe wound infection after open-heart surgery is a potentially life-threatening complication, which is mostly treated by re-operation with debridement, and insertion of closed irrigation drainage. Until now there is no consensus about the appropriate duration of irrigation therapy. Since the retrosternal irrigation cavity is likely to become continually smaller as the infection heals, this study was intended to answer the question, as to whether this process can be made visible by the use of contrast media radiography, and whether this information could be used to determine when an irrigation therapy can safely be discontinued. In 1997, 34 patients suffered from sternal wound healing disturbances which required re-operation at our institution (incidence = 0.97%). During the re-operation, a closed retrosternal irrigation drainage was inserted. Of the 34 patients contrast media radiography examinations were carried out on the first, 4th and 12th postoperative day (POD), which consisted of an antero-posterior x-ray of the chest after contrast media injection through each inlet tube. At POD 4 and 12 in the majority of cases, the retrosternal irrigation cavity became smaller when compared with the previous x-ray examination. Only in three of the non-survivors there was a huge irrigation cavity visible at the 12th POD, which sometimes even included the pleural cavity. We conclude that in patients with mediastinitis treated by insertion of a closed irrigation drainage, the retrosternally irrigated cavity seems to become smaller over the therapeutic course of treatment. This process can be visualized by contrast media radiography. Results from this examination should be included in decision making about the best time for discontinuation of the irrigation therapy.

Topics: Anti-Infective Agents, Local; Aortic Valve; Contrast Media; Coronary Artery Bypass; Debridement; Decision Making; Drainage; Follow-Up Studies; Heart Valve Prosthesis Implantation; Humans; Iohexol; Mediastinitis; Middle Aged; Pleura; Povidone-Iodine; Radiography, Thoracic; Reoperation; Sternum; Surgical Wound Dehiscence; Surgical Wound Infection; Therapeutic Irrigation

Topics: Acute Kidney Injury; Anti-Infective Agents, Local; Coronary Artery Bypass; Female; Humans; Mediastinitis; Mediastinum; Middle Aged; Povidone-Iodine; Suppuration; Therapeutic Irrigation

We present a patient who suffered from composite graft infection and mediastinitis. After replacement of the infected composite graft, in addition to administration of antibiotics, continuous irrigation of the mediastinum with solutions containing povidone-iodine and cefazolin sodium and transposition of the greater omentum were performed. His postoperative course was uneventful. Combined therapies including mediastinal irrigation and omental transposition should be considered after an operation for composite graft infection complicated with mediastinitis.

Topics: Anti-Bacterial Agents; Anti-Infective Agents, Local; Blood Vessel Prosthesis Implantation; Cefazolin; Cephalosporins; Heart Valve Prosthesis Implantation; Humans; Male; Mediastinitis; Middle Aged; Omentum; Povidone-Iodine; Prosthesis-Related Infections; Staphylococcal Infections; Therapeutic Irrigation

Continuous irrigation has been used worldwide for the treatment of acute poststernotomy mediastinitis. However, its high rate of failure led to the development of new methods, among them closed drainage with Redon catheters.. We evaluated the results obtained with Redon catheters in 70 patients, and compared them to those obtained in 38 patients treated with continuous irrigation.. The two treatment groups were not different for age, type of cardiac operation, and initial severity of illness. Local failure of Redon catheter drainage occurred less frequently (20 of 38 versus 9 of 70 patients; p = 0.0001). This reduced failure rate was mainly attributable to a lower incidence of superinfections (10 of 38 versus 2 of 70 patients; p = 0.0002), but also to a lower incidence of primary failure (10 of 38 versus 7 of 70 patients; p = 0.026). Mortality was significantly decreased (15 of 38 versus 12 of 70 patients; p = 0.01). The other major advantage of this technique was the simplicity of its use.. The technique using Redon catheters should be considered an effective and convenient treatment of acute poststernotomy mediastinitis.

Topics: Acute Disease; Catheterization; Female; Humans; Male; Mediastinitis; Middle Aged; Postoperative Complications; Povidone-Iodine; Retrospective Studies; Sternum; Suction; Surgical Wound Infection; Therapeutic Irrigation; Treatment Failure; Treatment Outcome

Topics: Humans; Hyperthyroidism; Infant, Newborn; Male; Mediastinitis; Povidone-Iodine; Therapeutic Irrigation

Of 1067 consecutive patients who underwent cardiac surgery from 1985 to 1992, 19 (1.7%) patients experienced sternal wound complications. All patients required operative intervention with positive bacterial cultures. Before 1990, a group of 13 patients were treated by continuous closed irrigation with dilute povidone-iodine solution. Four patients died (30%). In another group of 6 patients who received omental or pectral muscle flap transfer after 1990, 2 patients died (33%). The mean duration of hospitalization for mediastinitis was 63 days in this group, which was significantly shorter than that of the former group (105 days). From these experiences, we conclude that omental or pectral muscle transfer is an excellent method of management for mediastinitis after cardiac surgery, and is better than continuous closed irrigation method.

Topics: Adult; Aged; Cardiac Surgical Procedures; Female; Humans; Male; Mediastinitis; Middle Aged; Muscles; Povidone-Iodine; Surgical Wound Infection; Therapeutic Irrigation

Following cardiac transplantation bacterial mediastinitis is a severe early complication. Between March 1986 and September 1993, cardiac transplant operations were performed in 101 patients, of whom six developed purulent mediastinitis. Treatment consisted of surgical débridement, closed local irrigation, drainage and systemic antibiotics. No patient died as a result of bacterial mediastinitis. Low cardiac output and requirements for resternotomy for bleeding and prolonged artificial ventilation were significantly higher in the group with sternal infection. In contrast, since January 1991 the dose of corticosteroid was decreased from 5 mg/kg per day to 1.5 mg/kg per day beginning on the first day after operation. A total of 51 heart transplant operations have been subsequently performed without sign of mediastinal infection.

Topics: Adult; Bacterial Infections; Combined Modality Therapy; Debridement; Dose-Response Relationship, Drug; Enterococcus; Female; Heart Transplantation; Humans; Immunosuppressive Agents; Male; Mediastinitis; Middle Aged; Postoperative Complications; Povidone-Iodine; Reoperation; Rifampin; Serratia Infections; Staphylococcal Infections; Surgical Wound Infection; Therapeutic Irrigation

Fifteen cases of suppurative mediastinitis secondary to perforation of pharynx or esophagus are reported. The cervical fascial spaces are the main route of spread of infection from the neck to the mediastinum. The infection is caused by both aerobic and anaerobic bacteria. Major treatments for suppurative mediastinitis are early surgical drainage and proper use of antibiotics; Irrigation of the mediastinum with povidone-iodine is a safe and effective treatment. Of these 15 patients, 11 survived and 4 died. One case complicated by common carotid artery rupture was cured by surgical repair.

Topics: Adolescent; Adult; Anti-Bacterial Agents; Child; Child, Preschool; Drainage; Esophagus; Female; Foreign Bodies; Humans; Infant; Male; Mediastinitis; Middle Aged; Povidone-Iodine; Suppuration; Therapeutic Irrigation

Two patients aged 2 months and 9 days with postoperative mediastinal infection were treated by continuous closed irrigation with 0.5% povidone-iodine solution. Satisfactory eradication was achieved in both two patients. Although serum iodine level was elevated as high as 7,610 micrograms/dl in the neonatal patient, no disturbances of the thyroid function and the acid-base balance were seen. The usefulness of continuous closed irrigation in the neonatal or infantile period was suggested.

Topics: Cardiac Surgical Procedures; Female; Humans; Infant; Klebsiella Infections; Mediastinitis; Postoperative Complications; Povidone; Povidone-Iodine; Therapeutic Irrigation

Topics: Child; Humans; Mediastinitis; Mediastinum; Povidone; Povidone-Iodine; Therapeutic Irrigation

Between January of 1978 and December of 1983, 41 patients developed deep sternal infections with mediastinitis after cardiac operations. Between January of 1978 and December of 1981, 19 of these patients were treated with débridement, primary wound closure, and mediastinal antibiotic irrigation (Group I). Between January of 1982 and December of 1983, 22 patients were treated with débridement, open "clean" packing, and delayed wound closure by the technique of pectoral muscle flap mobilization, which preserves the thoracoacromial pedicles and the pectoral humeral attachments (Group II). The purpose of this study was to compare the results of the treatment of deep sternal infections after cardiac operations with these two techniques. The perioperative hemodynamic, operation, functional, and pathological profiles of both groups of patients were the same. The cosmetic and functional results were the same in both groups as were shoulder girdle and torso mobility. We conclude that either technique is equally effective in the management of patients in whom the serious complication of deep sternal infection with mediastinitis develops after cardiac operation, and we now recommend débridement and pectoral muscle flap closure in one stage.

Topics: Anti-Bacterial Agents; Bacterial Infections; Cardiac Surgical Procedures; Debridement; Drainage; Humans; Mediastinitis; Pectoralis Muscles; Povidone; Povidone-Iodine; Sternum; Surgical Flaps; Surgical Wound Infection; Suture Techniques; Therapeutic Irrigation

This report described a case in which purulent mediastinitis involving a Hancock prosthesis developed after repair of truncus arteriosus in a 6-year-old boy. The graft and surrounding area became sterilized after having been irrigated with povidone-iodine and antibiotic solutions for 6 weeks. At his most recent visit, the child was completely active and asymptomatic.

Topics: Animals; Anti-Bacterial Agents; Blood Vessel Prosthesis; Child; Child, Preschool; Heart Valve Prosthesis; Humans; Infant; Male; Mediastinitis; Povidone-Iodine; Pulmonary Valve; Surgical Wound Infection; Swine; Therapeutic Irrigation; Transplantation, Heterologous; Truncus Arteriosus, Persistent