This retrospective study evaluated the causative factors, treatment, complications and management outcomes of patients with Descending Necrotising Mediastinitis (DNM) of odontogenic origin treated at Charlotte Maxeke and Chris Hani Baragwanath Academic Hospitals for comparison with other published international studies. It is based on the management of 11 patients with DNM treated over a period of 3 years (2007 to 2010). Five patients had tracheostomies, 10 patients had postero-lateral thoracotomies and 1 patient had a Chamberlain procedure. One patient died of septic shock giving a mortality rate of 9.10%. Future studies are needed to monitor this trend. The management of DNM in this study is comparable with that reported by other clinicians.

Diss. (sammanfattning) Linköping : Univ., 2006. / Härtill 5 uppsatser.

Bakgrund: I sjuksköterskans ansvarsområde ingår det att använda omvårdnadsåtgärder för att förebygga komplikationer efter operation. På thoraxkirurgiska vårdavdelningar skiljer sig rutinerna vid postoperativ vård och på vissa avdelningar används Posthorax-västen för att förhindra instabilitet i sternum efter sternotomi. Syfte: Syftet var att undersöka vilka postoperativa omvårdnadsåtgärder sjuksköterskor använder sig av på sternotomerade patienter för att förebygga mediastinit samt hur sjuksköterskor upplever att omvårdnadsåtgärderna påverkar patienterna. Metod: Data samlades in via en enkätundersökning på tre thoraxkirurgiska vårdavdelningar på tre olika sjukhus i Sverige. Resultat: Enkätundersökningen lyfte fram vilka omvårdnadsåtgärder som vanligtvis används på olika avdelningar, vilka omvårdnadsåtgärder som sjuksköterskor ansåg var viktigast samt faktorer som sjuksköterskor uppger främjar och hämmar omvårdnadsåtgärder. Slutsats: Sjuksköterskor uppgav att den viktigaste postoperativa omvårdnadsåtgärden efter sternotomi var Mobiliseringsrestriktioner. De största hindren var postoperativ förvirring, smärta och illamående samt organisatoriska faktorer som hög arbetsbelastning, stress och bristande rutiner. Klinisk betydelse: Denna studie har visat på behovet av vidare forskning genom att ha lyft fram vilka postoperativa omvårdnadsåtgärder som sjuksköterskor uppger att de använder i klinisk praxis på thoraxkirurgiska vårdavdelningar. / Background: Nurses have a responsibility to use nursing interventions to prevent complications after surgery. There is a difference in which procedures are used in thoracic surgical wards for postoperative prevention and some hospitals use the Posthorax vest to prevent sternal instability. Aims: The aim of this study was to investigate nursing interventions used to prevent mediastinitis on patients who have undergone sternotomy and how nursing interventions affect patients according to nurses. Methods: A survey was used to procure data from three different thoracic surgical wards in hospitals in Sweden. Results: The survey has shown the most commonly used nursing interventions in different thoracic surgical wards and what nursing interventions nurses’ state are most important. The survey also found promoting and inhibiting factors for nursing interventions according to nurses. Conclusion: According to nurses the most important nursing intervention was restricting the use of upper body extremities. The most inhibiting factors for nursing interventions were postoperative confusion, pain, nausea and organizational factors as high workload, stress and inadequate procedures. Clinical implications: This study has shown the need for further research by determining the postoperative nursing interventions used in clinical practice in thoracic surgical wards.

El objetivo del presente estudio es evaluar retrospectivamente los hallazgos tomográficos en pacientes operados de cirugía cardiovascular para identificar signos específicos e inespecíficos de mediastinitis en aquellos con mediastinitis confirmada mediante el análisis microbiológico, comparar su validez diagnostica como única herramienta para el diagnostico de esta entidad, y analizar la frecuencia en nuestros pacientes de los factores de riesgo para la misma con los mencionados en la literatura.

ABSTRAKT Bakgrund: Mediastinit är en allvarlig komplikation efter öppen hjärtkirurgi. Syftet med post- thorax västen är att förebygga och förhindra mediastinit genom att stötta upp instabilitet och minska friktion i sternum efter operation. Uttalade osäkerheter och brister i erfarenheter av att jobba med västen väckte författarnas intresse för att intervjua intensivvårdssjuksköterskor och sjuksköterskor om deras erfarenheter med att arbeta med post-thorax västen. Syfte: Syftet med studien var att belysa sjuksköterskors erfarenheter av att vårda patienter som bar Post-thorax väst. Design: En kvalitativ intervjustudie Metod: Semistrukturerade intervjuer av 14 stycken grundutbildade och intensivvårdsutbildade sjuksköterskor som arbetade vid två enheter på ett sjukhus i Norra Sverige och hade mer än 6 månaders erfarenhet av att arbeta med västen. Intervjuerna analyserades genom en kvalitativ innehållsanalys. Resultat: Sjuksköterskors erfarenheter av att vårda patienter som burit Post-thorax väst resulterade i 4 kategorier och 13 subkategorier. Följande kategorier finns representerade: Ambivanlens, Säkerhet, Svårigheter, Motivation. Konklusion: Resultatet i studien visade att deltagarna hade varierande erfarenheter av att arbeta med patienter som bär väst. Deltagare utryckte svårigheter och fördelar med västen samt sin egen osäkerhet kring den. Deltagare ville ha utbildning och en utvärdering av västen och de beskrev motivationsarbetet och varför det är viktigt. Deltagarnas erfarenheter av patienternas upplevelser var något som genomsyrade alla kategorier. Resultatet kan tala för att implementeringen av västen på berörda enheter inte genomförts på ett optimalt sätt. / ABSTRACT Background: Mediastinitis is an infection in the mediastinum which can be a serious complication after open heart surgery. The purpose of the Post-thorax vest is to prevent mediastinitis by providing the required support to and minimize any friction within the sternum after heart surgery. There are outspoken uncertainties and gaps in the experience of working with the vest which aroused the interest of the authors to interview nurses and intensive care nurses about their experiences of working with the Post-thorax vest. Aim: The aim of this study was to investigate nurses’ experiences of working with patients who wear a Post-thorax vest. Design: A qualitative interview study Method: Semi-structured qualitative interview study of 14 nurses and intensive care nurses who worked at two units in the north of Sweden who had at least 6 months of experience working with the vest. The interviews were analyzed using content analysis. Results: Nurses’ experiences of working with patients who wore Post-thorax vests resulted in 4 categories and 13 sub-categories. The following categories are represented: Ambivalence, Security, Difficulties, Motivation. Conclusion: The result of the study showed that the participants had various experiences of working with patients wearing the vest. Participants expressed difficulties and benefits of the vest, and their own uncertainty about it. Participants wanted education and an evaluation of the vest and they described why motivational work was important. The participants described patients' experiences of the vest in almost every category. The result may indicate that the implementation of the vest at the units in question where not completed in an optimal way.

Para analisar o número e tamanho dos linfonodos mediastinais, cinqüenta cadáveres de brasileiros adultos foram dissecados de acordo com o mapa de Naruke/ATS-LCSG (1997). Foram retirados 1742 linfonodos, com 2,58±1,89 linfonodos por região, e realizadas suas medidas por processo digital. O tamanho médio da área, eixo maior e menor foi maior na cadeia 7 (195mm2, 18,75mm e 10,92mm) e 4R (115mm2, 13,72mm e 8,30mm), apresentando média de 49,41mm2, 9,40mm e 5,76mm para as demais regiões, respectivamente. A distribuição, número e tamanho dos linfonodos não mudou de acordo com a idade, sexo, raça, peso ou altura, contudo o tamanho aumentou em função da coalescência por processos granulomatosos prévios, com diminuição do número total de linfonodos / To analyze the number and sizes of the lymph nodes in the mediastinum, fifth human adult cadavers were dissected according to the Naruke/ATS-LCSG map (1997). It were removed 1742 lymph nodes, with 2,58±1,89 nodes for each region, and measured by a digital process. The mean area, long and minor axis were larger in regions 7 (195mm2, 18,75mm and 10,92mm) and 4R (115mm2, 13,72mm and 8,30mm), with a mean of 49,41mm2, 9,40mm and 5,76mm in the other regions, respectively. The distribution, number and size of the lymph nodes did not showed changes according age, sex, race, weight or high, however the size increases as function of coalescence by previous granulomatous processes, with decrease of the total number of lymph nodes

Para analisar o número e tamanho dos linfonodos mediastinais, cinqüenta cadáveres de brasileiros adultos foram dissecados de acordo com o mapa de Naruke/ATS-LCSG (1997). Foram retirados 1742 linfonodos, com 2,58±1,89 linfonodos por região, e realizadas suas medidas por processo digital. O tamanho médio da área, eixo maior e menor foi maior na cadeia 7 (195mm2, 18,75mm e 10,92mm) e 4R (115mm2, 13,72mm e 8,30mm), apresentando média de 49,41mm2, 9,40mm e 5,76mm para as demais regiões, respectivamente. A distribuição, número e tamanho dos linfonodos não mudou de acordo com a idade, sexo, raça, peso ou altura, contudo o tamanho aumentou em função da coalescência por processos granulomatosos prévios, com diminuição do número total de linfonodos / To analyze the number and sizes of the lymph nodes in the mediastinum, fifth human adult cadavers were dissected according to the Naruke/ATS-LCSG map (1997). It were removed 1742 lymph nodes, with 2,58±1,89 nodes for each region, and measured by a digital process. The mean area, long and minor axis were larger in regions 7 (195mm2, 18,75mm and 10,92mm) and 4R (115mm2, 13,72mm and 8,30mm), with a mean of 49,41mm2, 9,40mm and 5,76mm in the other regions, respectively. The distribution, number and size of the lymph nodes did not showed changes according age, sex, race, weight or high, however the size increases as function of coalescence by previous granulomatous processes, with decrease of the total number of lymph nodes

In cardiac surgery, sternal wound infection (SWI) continues to be one of the most serious postoperative complications. Coagulase-negative staphylococci (CoNS) have become the most common causative agents of SWI. Prophylaxis with intravenous beta-lactam antibiotics (cephalosporins or in Sweden most commonly isoxazolyl penicillins) is routinely practised. However, many CoNS species are resistant to beta-lactam antibiotics. Vancomycin is often the only effective antibiotic available for treatment of these infections, but its use for routine prophylaxis is strongly discouraged because of the risk of increasing the selection of resistant bacteria. The aim of this work was to develop and evaluate a new technique for antibiotic prophylaxis in cardiac surgery consisting of application of drug eluting collagen-gentamicin sponges in the sternal wound in addition to conventional intravenous antibiotics. The antibiotic concentrations in the wound and serum achieved by routine intravenous dicloxacillin prophylaxis and those after application of local collagen-gentamicin in the sternal wound were investigated. These studies showed dicloxacillin levels adequate for prevention of infections by methicillin-susceptible staphylococci, and extremely high gentamicin levels in the wound fluid, during the first 8-12 hours postoperatively with the local application. Two thousand cardiac surgery patients were then randomised to routine prophylaxis with intravenous isoxazolyl penicillin alone (control group) or to this prophylaxis combined with application of collagen-gentamicin (260 mg gentamicin) sponges within the sternotomy before wound closure. The primary end-point was any sternal wound infection within two months postoperatively. Evaluation was possible in 983 and 967 patients in the treatment and control groups, respectively. The incidence of any sternal wound infection was 4.3% in the treatment group and 9.0 % in the control group (relative risk = 0.47, (95% confidence interval 0.33 to 0.68); P<0.001). The most common microbiological agents were CoNS, followed by Staphylococcus aureus. Local gentamicin reduced the incidence of SWIs caused by all major, clinically important microbiological agents except Propionibacterium acnes. Assignment to the control group, high body mass index, diabetes mellitus, younger age, single or double internal mammary artery, left ventricular ejection fraction less than 35% and longer operation time were independent risk factors for SWI in a multivariable risk factor analysis. In patients with additional sternal fixation wires (> six wires) the collagen-gentamicin prophylaxis was associated with an approximately 70 % reduction in the incidence of SWI at all depths and the application of collagen sponges between sternal halves may require particular attention regarding the stability of fixation. A cost effectiveness analysis showed that the application of local collagen-gentamicin as prophylaxis was dominant, i.e. resulted in both lower costs and fewer wound infections. Routine use of the described prophylaxis in all adult cardiac surgery patients could be recommended.

<p>The primary aim was to register the incidence of surgical wound infections (SWI) in sternotomy and leg incisions and potential risk factors for SWI following coronary artery by-pass graft (CAGB) procedures. Patients’ perspectives of SWI and the subsequent treatment were also considered. </p><p>Risk factors were registered for 374 patients. Patients were contacted by telephone 30 and 60 days after surgery and interviewed according to a questionnaire about symptoms and signs of wound infections. SWI was defined according to The Centers for Disease Control. Patients with mediastinitis were also interviewed within four months about how they experienced care, how they coped and how they thought the mediastinitis would influence their future life. </p><p>SWIs were diagnosed in 30 % of the patients. Seventy-three percent of the SWIs of the leg were diagnosed within 30 days of surgery and 27% were diagnosed within 31 to 60 days. Female gender and use of a monofilament suture for skin closure were the most important risk factors for SWI of the leg. Low preoperative haemoglobin concentration was the most important risk factor for sternal SWI. Patients with mediastinitis had higher BMI and had more often received erythrocyte transfusions on postoperative day 2 or later than those without infections. Patients without a diagnosis of diabetes who had increased blood glucose concentrations during the intermediate postoperative period had an increased risk of mediastinitis. It was not possible to separate the effect of diabetes as a risk factor for SWI from that of hyperglycaemia as such. Patients’ experiences were influenced by the staffs’ medical knowledge, how care was given and how well information was provided. Perceived danger and stress influenced how they coped with the situation. The patients believed that the mediastinitis would not affect the final outcome of the CABG procedure, even though their confidence in this was influenced by uncertainties about the rehabilitation process.</p>

The primary aim was to register the incidence of surgical wound infections (SWI) in sternotomy and leg incisions and potential risk factors for SWI following coronary artery by-pass graft (CAGB) procedures. Patients’ perspectives of SWI and the subsequent treatment were also considered. Risk factors were registered for 374 patients. Patients were contacted by telephone 30 and 60 days after surgery and interviewed according to a questionnaire about symptoms and signs of wound infections. SWI was defined according to The Centers for Disease Control. Patients with mediastinitis were also interviewed within four months about how they experienced care, how they coped and how they thought the mediastinitis would influence their future life. SWIs were diagnosed in 30 % of the patients. Seventy-three percent of the SWIs of the leg were diagnosed within 30 days of surgery and 27% were diagnosed within 31 to 60 days. Female gender and use of a monofilament suture for skin closure were the most important risk factors for SWI of the leg. Low preoperative haemoglobin concentration was the most important risk factor for sternal SWI. Patients with mediastinitis had higher BMI and had more often received erythrocyte transfusions on postoperative day 2 or later than those without infections. Patients without a diagnosis of diabetes who had increased blood glucose concentrations during the intermediate postoperative period had an increased risk of mediastinitis. It was not possible to separate the effect of diabetes as a risk factor for SWI from that of hyperglycaemia as such. Patients’ experiences were influenced by the staffs’ medical knowledge, how care was given and how well information was provided. Perceived danger and stress influenced how they coped with the situation. The patients believed that the mediastinitis would not affect the final outcome of the CABG procedure, even though their confidence in this was influenced by uncertainties about the rehabilitation process.