Management Approach
Once a diagnosis of DSWI is suspected, broad spectrum antibiotics were
started and a CT of the chest obtained. Fluid resuscitation, nutritional
evaluation, and cardiac optimization were instituted prior
to aggressive and prompt surgical debridement. Initial exploration,
drainage and irrigation of the mediastinum were followed by radical
debridement of all devitalized tissue and removal of sternal wires and
plates. Cultures were routinely obtained. Sternectomy was aggressively
performed for severe infections. Depending on the extent of the
infection and the patients clinical condition, staged debridement with
open chest or negative pressure suction was considered versus immediate
flap coverage. Those with overt sepsis, clinical instability, or
extensive infection were typically treated with staged negative pressure
wound therapy. Aggressive nutritional replacement was instituted, with
enteral feeding if necessary. Once stabilized, and the debridement
completed, soft tissue coverage was performed by our plastic surgeons.
The extent of flap coverage was dependent on the extent of the
debridement and included pectoralis myocutaneous advancement, pectoralis
rotation, and omental flaps. Omental flaps were often selected in the
case of mediastinal grafts or extensive dead space. Skin grafts and free
flaps were considered in patients with inadequate skin coverage.