[Examination of the opportunity costs and turnover situation in patients with deep sternal infections]. / Kostennutzenanalyse der Therapie von Risikopatienten am Beispiel tiefer Sternuminfektionen.

BACKGROUND: Each and every hospital of any kind is forced, due to increased cost pressure, to work as economically and as efficiently as possible. This even applies when the operational orientations of the hospitals institutions are different. In the present article an analysis of the repercussions of the treatment of postoperative complications in terms of entrepreneurial practice is given. Our focus is on the opportunity cost. METHOD: A theoretical calculation of opportunity costs is made based on the example of postoperative infections following cardiac surgery and the resulting treatment. The bases of the examinations are the results collected at the hospital Mediclin Herzentrum Lahr / Baden in 2008. The wound healing disorders were recorded from November 2004 until November 2007 and include 3675 patients who were operated on using a median sternotomy. Out of the 3675 patients 45 (1.2 %) were affected. Various treatment options are at hand. The used therapy algorithm in our practice is dependent on the stage and the development of the infection. RESULTS: If the high trim point, the medial trim point and the low trim point of the mediastinitis patients, as well as the average revenue and the surcharge omission on exceeding the high trim point (these data can be found in the annual accounts) and knowledge of the actual length of stay of the mediastinitis patient are known, the opportunity cost, respectively potential turnover increases, can be calculated. Reducing the medial trim point from 48.43 to, for example, 36.37 days could potentially produce a turnover increase of as much as 10 633.41 €. CONCLUSION: Keeping patient safety in mind, significant turnover increases can be achieved with adequate planning. The considered sales situation, however, can only be achieved under the same terms: these being free operating room and bed capacities, available personnel, equal cost of materials as well as enough patients. The consideration of opportunity costs could be important for entrepreneurs if staff shortage continues and, in economical terms, non-expendable capacities are created.

[Mediastinitis following cardiac surgery. Patient insurance reports]. / Mediastinitis efter hjertekirurgi. Et patientforsikringsmateriale.

INTRODUCTION: Mediastinitis in cardiac surgery is a well-known complication associated with high morbidity, invalidity, and mortality. Since the establishment by law of patients insurance in Denmark 1992, it has been possible to get compensation in some instances. MATERIALS AND METHODS: During a period of 8 years (1996-2003) 30 cases of mediastinitis were reported to the Danish Patient Insurance Association (DPIA). The initial cardiac operations consisted of 28 coronary artery bypass graft operations (CABG), 1 CABG associated with substitution of the aortic valve, and 1 CABG with cryoablation because of atrial fibrillation. The median preoperative mortality risk (EuroSCORE) was 2 (0-6+). The treatment of mediastinitis consisted of open revision or closed rinsing-system and of vacuum assisted closure in the later part of the period. RESULTS: Eighty percent of the patients had a transposition of thoracic muscle undertaken as a compensation for the lack of sternum. The median number of universal anaesthesias was 23 (3-32). The median admission time was 73 days (21-180), hospital mortality was 6.7%. A patient may receive compensation for an injury sustained during treatment if: 1) the best specialist would have acted differently, 2) the injury was caused by defect or malfunction of equipment, 3) the injury could have been prevented by using a different similar method of treatment, or 4) the patient had suffered more than is acceptable given the severity of the disease. Seventeen claims were approved (57%), the remainders were rejected. The criteria for acceptance according to the law of patient insurance are presented. In the actual period 511 cases of deep sternal infection after cardiac surgery were reported to the Danish Patient Registry. CONCLUSION: The majority of mediastinitis cases were not reported to the DPIA. The parties involved (patients, patient advisors, general practitioners, and hospital departments) are asked to concentrate on the need of reporting these cases to the DPIA.

Use of the greater omentum for reconstruction of infected sternotomy wounds: a prognostic indicator.

INTRODUCTION: Use of the omentum for poststernotomy mediastinitis is typically viewed as a last resort. Formal debridement and muscle flap coverage is sufficient most of the time; however, there are situations when the omental flap is more appropriate. The purpose of this series is to critically evaluate the outcome in those patients who require omental flap reconstruction of poststernotomy mediastinitis. METHODS: A retrospective review was performed on consecutive patients undergoing omentum flap transposition for poststernotomy mediastinitis from 1990-2005 at Emory University Hospitals. Data points queried included patient demographics, risk factors, type of reconstruction, and outcome. Patient survival was determined at 60 days and 1, 3, and 5 years postomentum reconstruction using the Social Security Death Index. These data points were compared with age- and risk-matched patients from our institution, treated during the same time period with muscle flaps alone. RESULTS: Fifty-two patients had omental flap reconstruction, with an average age of 61 years (range: 35 to 78). The average follow-up was 5.1 years (range: 1 day to 15 years). Methicillin-resistant Staphylococcus aureus (MRSA) was the most common organism identified at time of omental transfer (56%). The omentum was used either for primary reconstruction, n = 35/52 (67%), or as a salvage procedure following failed muscle flap coverage, n = 17/52 (33%). Complications included donor site 27%, flap related 23%, and general 71% of patients. Those patients undergoing salvage reconstruction had a proportionally greater 60-day mortality (24%) and complication rate. The overall mortality was higher in those patients who required an omental flap transfer when compared with 52 muscle-flap controls (42% versus 18% at 3 years). DISCUSSION: The greater omentum is still an invaluable tool in the management of mediastinal wound infections when other options have failed or are insufficient. Although reliable and well indicated, the omental flap appears to be a marker for increased mortality, especially when used as a salvage procedure. This association is not directly related to the omental flap but rather to the complexity of the clinical situation leading up to its use. Patients who require omental flap coverage should be counseled and treated appropriately.

Mediastinitis in pediatric cardiac surgery: treatment and cost-effectiveness in a low-income country.

Mediastinitis is a serious postoperative complication following pediatric cardiac surgery. The objective of this study is to evaluate the cost-effectiveness of surgical treatment for mediastinitis in Guatemala. All children who underwent a median sternotomy and developed postoperative mediastinitis between January 2004 and December 2005 were evaluated. Type of surgical treatment for mediastinitis, hospital outcome, and costs were analyzed. Eighteen (3.3%) of the 535 children who underwent a median sternotomy developed mediastinitis. Two patients underwent debridement of the infected tissues and delayed sternal closure, whereas 16 patients had debridement, primary chest closure, and continuous antibiotic irrigation of the mediastinum. All 11 patients who had the diagnosis of mediastinitis within 2 weeks after the operation survived. Three of the 7 patients (43%) who had delayed diagnosis died (p = 0.0003); all 3 had osteomyelitis (p = 0.0007). Primary closure with antibiotic irrigation was associated to a lower mortality rate and proved less expensive in comparison to delayed sternal closure (p = 0.003) mainly due to the shorter intensive care requirement. Debridement followed by primary closure of the chest and continuous antibiotic irrigation of the mediastinum seems to be a feasible and less expensive method to treat selected cases of postoperative mediastinitis in children.

["Descending necrotizing mediastinitis" due to deep neck infections. Incidence and management]. / "Descending necrotizing mediastinitis" infolge tiefer Halsinfektionen. Inzidenz und Management.

BACKGROUND: "Descending necrotizing mediastinitis" (DNM) is a rare but potentially life-threatening complication of deep neck infections caused by the rapid downward spread of a oropharyngeal infection along the facial planes into the mediastinum. MATERIAL AND METHODS: Between June 1997 and December 2004, 6 patients with DNM were treated in our department. The primary etiology was a peritonsillar abscess in 2 cases, a parapharyngeal abscess in 3 cases and in 1 case an odontogenic abscess. Most patients presented with risk factors such as diabetes mellitus or alcoholism, the mean age was 44.3 years and the mean duration of signs before diagnosis was 6.3 days. Thoracotomy was associated with the cervical approach in 4 cases and tracheostomy was also performed in 4 cases. RESULTS: Four patients were successfully treated, the mean duration of hospitalisation was 48.2 days and 2 patients died from sepsis and multiorgan failure despite intensive treatment. CONCLUSIONS: Descending necrotizing mediastinitis must be detected as soon as possible. The mean symptoms are persistent complaints after treatment of oropharyngeal infections, which may be masked by analgetic treatment. Only an immediate computer tomographic scanning, aggressive surgical drainage and debridement of the neck and the mediastinum can reduce the high mortality rate.

[Cost effectiveness of V.A.C. therapy after post-sternotomy mediastinitis]. / Kosteneffektivität der V.A.C.-Therapie nach Poststernotomie Mediastinitis.

Since November 2001 all patients with postoperative sternum bone infections were treated with V.A.C. therapy. The mean length of stay at intensive care unit was reduced from 9 to 1 day and reduces costs for 33 714.- USD per patient. Additionally patients who had to be closed with pectoralis muscle flap had significant reduced length of stay at ICU (1 vs 4 days, cost effectiveness 14 984.- USD per patient). The V.A.C. therapy after post-sternotomy mediastinitis significantly reduces morbidity and mortalità and is cost effective.

Regarding three cases of descending necrotizing mediastinitis: spiral CT assessment.

Descending necrotizing mediastinitis (DNM) is a rare and life-threatening complication of deep neck space infection which occurs when infection spreads from the deep spaces of the neck, propagating within the soft tissue into the mediastinal spaces. The disease has a high mortality rate due to frequent delay in diagnosis and treatment. Computed Tomography (CT) is important in determining the level of infection, showing the presence and extension of fluid collections (with or without gas bubbles) and diffuse soft-tissue infiltration of the mediastinal fat, and indicating the best surgical approach and progress of treatment. Three cases of DNM evaluated with spiral CT from June 1999 to June 2001 are presented.

Mediastinitis postoperatoria: estudio comparativo de costos / Postoperative mediastinitis: comparative study of costs

Objetivos: Comparar los resultados del tratamiento de la mediatinitis en dos series sucesivas y homogéneas empleando dos modalidades terapéuticas diferentes y analizar su influencia sobre la morbimortalidad y los costos. Material y métodos: Treinta pacientes con diagnóstico de mediastinitis son comparados en este reporte. Dieciséis casos consecutivos fueron tratados con debridamiento, curas abiertas y plástica muscular diferida empleando ambos músculos pectorales (Serie A). Los siguientes 14 casos fueron tratados con debridamiento y deslizamiento miocutáneo pectoral bilateral simultáneo (Serie B). Resultados: La mortalidad hospitalaria fue del 31,2 por ciento para la Serie A y 0 por ciento para la Serie B. El promedio de internación desde el diagnóstico de mediastinitis hasta el alta fue de 47 días (rango: 20-66 días) para la Serie A y 15 días (rango: 7-32 días) para la Serie B. Requirieron hemodiálisis 25 por ciento de los pacientes de la Serie A y 7,1 por ciento de los pacientes en la Serie B. En los pacientes de la Serie A fueron necesarios al menos dos procedimientos quirúrgicos, mientras que los pacientes de la Serie B se resolvieron con un solo acto quirúrgico. Nosotros concluimos que, empleando el debridamiento y deslizamiento miocutáneo pectoral simultáneo, podemos reducir sensiblemente la morbimortalidad hospitalaria, los días de internación y los costos

J. Maxwell Chamberlain memorial paper. Sternal wound complications after isolated coronary artery bypass grafting: early and late mortality, morbidity, and cost of care.

Of 6,504 consecutive patients who underwent isolated coronary bypass grafting in 1985 to 1987, 72 (1.1%) patients experienced sternal wound complications. Ten patients (14%) with wound complications died of multi-system failure. Only the patients with negative cultures fared well; of the bacterial culture categories, polymicrobial infection carried the worst prognosis. Effects of recurring infection were seen throughout the first year. Patients, grouped according to conduits received, experienced these wound complication rates: vein grafts only, 11/1,085 (1.0%); one internal thoracic artery, 38/4,073 (0.9%); and bilateral internal thoracic artery grafts, 23/1,346 (1.7%). There were no significant differences in wound complication rates between primary and reoperation patients or among conduit groups. By logistic regression analysis, the relative risk for patients with diabetes and bilateral internal thoracic artery grafting was 5.00 (95% confidence interval, 2.4 to 10.5). Operation time as a continuous variable increased the relative risk of wound complication 1.47 times per hour (1.3 to 1.7); obesity, 2.90 times (1.8 to 4.8); and blood units as continuous variable, 1.05 times per unit (1.01 to 1.10). Bilateral internal thoracic artery grafting in nondiabetic patients carried no greater risk of wound complication than that in patients with vein grafts only or with one internal thoracic artery graft.