tratamiento de la mediastinitis

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The recommended treatment for mediastinitis involves prompt surgical intervention combining debridement, appropriate antimicrobial therapy, and stabilization of the sternum, often aided by advanced wound management techniques.

Treatment begins with extensive surgical debridement to remove all necrotic and infected tissues, including removal of infected sternal wires when present, to eliminate the infectious focus in the mediastinum . Thorough irrigation and drainage of infected spaces are critical steps to reduce bacterial load and prevent further spread . Concomitant systemic antibiotic therapy tailored to the microbiological profile supports eradication of infection .

Following debridement, the goal is to reestablish sternal stability since mediastinitis often coexists with sternal dehiscence or bone loss. If the sternum is stable or partially intact, rewiring techniques (including figure-of-eight or Robicsek methods) or additional wiring may suffice to restore stability . In cases of significant sternal bone loss or instability, reconstructive options with muscle or omental flaps are necessary. Common reconstructive flaps include pedicled bilateral pectoralis major muscle flaps, rectus abdominis flaps (especially for lower sternum defects), latissimus dorsi flaps, or greater omental flaps, which provide well-vascularized tissue coverage and help control infection .

Negative pressure wound therapy (NPWT), also known as vacuum-assisted closure (VAC), plays a central role in managing mediastinitis by promoting wound drainage, reducing edema, enhancing blood flow, and fostering granulation tissue formation , . NPWT may be used as an initial bridge therapy before definitive closure or flap reconstruction, particularly in patients with extensive infection or instability .

Immediate primary closure after debridement may be considered when infection is localized and the sternum is stable, but delayed closure after an interval of NPWT and antibiotic therapy is often preferred to avoid recurrent infection . In patients with severe mediastinitis and exposed cardiac structures, omental flap transposition provides immunologically active and well-vascularized tissue coverage and has demonstrated high success rates , .

Additional supportive measures include optimizing nutritional status, tight glycemic control, minimizing prolonged mechanical ventilation, and preventing further contamination through meticulous aseptic technique . For patients with risk factors like obesity, diabetes, or prior sternotomy, prevention and early detection strategies are critical to reduce incidence and severity .

tratamiento de la mediastinitis

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