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Noninfectious sternal wound inflammation after coronary artery bypass grafting in a patient with myelodysplastic syndrome: A no-touch approach.

ABSTRACT: Pyoderma gangrenosum (PG) is a rare, chronic inflammatory noninfectious dermatosis. It is associated with underlying systemic or hematological diseases such as myelodysplastic syndrome (MDS) and can be triggered after surgery. Recognition and diagnosis of PG can be difficult as it can mimic a wound infection. Misdiagnosis could lead to invasive procedures which worsen the disease and have possible disastrous aftermath. A 74-year-old male with a history of MDS presents with an atypical sternal wound inflammation. Diagnosis confirmed PG after skin biopsy. No surgical or invasive procedures were performed and the patient was treated on an outpatient basis with prednisolone, clobetasol cream, and cyclosporine. This case shows the importance of a rapid diagnosis of the disease. Awareness is required for the diagnosis of PG in a wound with pronounced livid borders, without improvement after antibiotic treatment or worsening after debridement. Rapid diagnosis and treatment reduce high healthcare costs, morbidity, and mortality.

SUBMITTER: Ten Dam L

PROVIDER: S-EPMC9321867 | biostudies-literature | 2022 Aug

REPOSITORIES: biostudies-literature

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Noninfectious sternal wound inflammation after coronary artery bypass grafting in a patient with myelodysplastic syndrome: A no-touch approach.

Ten Dam Lotte L Ten Broeke Miarca M Poot Angelique M AM Gilbers Martijn D MD Halfwerk Frank R FR

Journal of cardiac surgery 20220506 8

Pyoderma gangrenosum (PG) is a rare, chronic inflammatory noninfectious dermatosis. It is associated with underlying systemic or hematological diseases such as myelodysplastic syndrome (MDS) and can be triggered after surgery. Recognition and diagnosis of PG can be difficult as it can mimic a wound infection. Misdiagnosis could lead to invasive procedures which worsen the disease and have possible disastrous aftermath. A 74-year-old male with a history of MDS presents with an atypical sternal wo ...[more]

PMID: 35524433

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Project description:BackgroundDeep sternal wound infection (DSWI) following open heart surgery is associated with excessive morbidity and mortality. Contemporary DSWI risk prediction models aim at identifying high-risk patients with varying complexity and performance characteristics. We aimed to optimize the DSWI risk factor set and to identify additional risk factors for early postoperative detection of patients prone to DSWI.MethodsSingle-centre retrospective analysis of patients with isolated multivessel coronary artery disease undergoing myocardial revascularization at Paracelsus Medical University Nuremberg between 2007 and 2022 was performed to identify risk factors for DSWI. Three data sets were created to examine preoperative, intraoperative, and early postoperative parameters, constituting the "Baseline", the "Improved Baseline" and the "Extended" models. The "Extended" data set included risk factors that had not been analysed before. Univariable and stepwise forward multiple logistic regression analyses were performed for each respective set of variables.ResultsFrom 5221 patients, 179 (3.4%) developed DSWI. The "Extended" model performed best, with the area under the curve (AUC) of 0.80, 95%-CI: [0.76, 0.83]. Pleural effusion requiring intervention, postoperative delirium, preoperative hospital stay > 24 h, and the use of fibrin sealant were new independent predictors of DSWI in addition to age, Diabetes Mellitus on insulin, Body Mass Index, peripheral artery disease, mediastinal re-exploration, bilateral internal mammary harvesting, acute kidney injury and blood transfusions.ConclusionsThe "Extended" regression model with the short-term postoperative complications significantly improved DSWI risk discrimination after surgical revascularization. Short preoperative stay, prevention of postoperative delirium, protocols reducing the need for evacuation of effusion and restrictive use of fibrin sealant for sternal closure facilitate DSWI reduction.Trial registrationThe registered retrospective study was registered at the study centre and approved by the Institutional Review Board of Paracelsus Medical University Nuremberg (IRB-2019-005).

Project description:Background/objectivesSternal-wound infections (SWIs) are rare but consequential healthcare-healthcare-associated infections following coronary artery bypass graft surgery (CABG). The impact of SWIs associated on the cost of health care provision is unknown. The aim of this study was to quantify the burden of CABG-related SWIs across countries with mature health care systems and estimate value-based purchasing (VBP) levels based on the local burden.MethodsA structured literature review identified relevant data for 14 countries (the Netherlands, France, Germany, Austria, the United Kingdom, Canada, Italy, Japan, Spain, the United States, Brazil, Israel, Taiwan, and Thailand). Data, including SWI rates, CABG volume, and length of stay, were used to populate a previously published Markov model that simulates the patient's CABG-care pathway and estimates the economic (US$) and care burden of SWIs for each country. Based on this burden, scenarios for VBP were explored for each country. A feasible cost of intervention per patient for an intervention providing a 20% reduction in the SWI rate was calculated.ResultsThe SWI burden varied considerably between settings, with SWIs occurring in 2.8% (the United Kingdom) to 10.4% (the Netherlands) of CABG procedures, while the costs per SWI varied between US$8172 (Brazil) to US$54 180 (Japan). Additional length of stay after SWI was the largest cost driver. The overall highest annual burden was identified in the United States (US$336 million) at a mean cost of US$36 769 per SWI. Given the SWI burden, the median cost of intervention per patient that a hospital could afford ranged from US$20 (US$13 to US$42) in France to US$111 (US$65 to US$183) in Japan.ConclusionsSWIs represent a large burden with a median cost of US$13 995 per case and US$900 per CABG procedure. By tackling SWIs, there is potential to simultaneously reduce the burden on health care systems and improve outcomes for patients. Mutually beneficial VBP agreements might be one method to promote uptake of novel methods of SWI prevention.

Dataset Information

Noninfectious sternal wound inflammation after coronary artery bypass grafting in a patient with myelodysplastic syndrome: A no-touch approach.

Publications

Noninfectious sternal wound inflammation after coronary artery bypass grafting in a patient with myelodysplastic syndrome: A no-touch approach.

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