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.