Cardiac surgery
Recommendations
| Identify and Treat the Cause | ||
|---|---|---|
| 1 | Take a careful history and conduct an inspection. | Level of Evidence Not Assessed |
| Address Patient-Centered Concerns | ||
|---|---|---|
| 2 | Provide individualized education about post-operative care. | Level of Evidence 5 |
| Provide Local Wound Care | ||
|---|---|---|
| 3 | Monitor sternotomy wound healing closely to ensure early detection of complications. | Level of Evidence Not Assessed |
| 4 | Evaluate sternotomy complications carefully and use imaging as necessary to assess infection. | Level of Evidence Not Assessed |
| 5 | Perform radical debridement of infected sternotomy wounds promptly and close the wound with muscle or omental flaps as necessary. | Level of Evidence Not Assessed |
| 6 | Administer broad-spectrum empiric antibiotic therapy to treat sternotomy infection and modify treatment based on culture results. | Level of Evidence Not Assessed |
| 7 | Consider the use of advanced wound healing modalities. | Level of Evidence Not Assessed |
| Provide Organizational Support | ||
|---|---|---|
| 8 | Establish and empower an interprofessional team to provide post-operative care. | Level of Evidence 5 |
Background
Infection of the sternotomy wound is a devastating complication after cardiac surgery, associated with prolonged hospitalization, high cost, and significant mortality. Management of infection by the previously employed strategy of open packing and antibiotic irrigation was associated with mortality approaching 50%. (Jones et al, Ann Surgery 1997) Use of radical sternal debridement, with removal of all wires and compromised tissue and closure with muscle or omental flaps reduced mortality to less than 10%. A small percentage of patients required additional procedures to treat recurrent infection.Retrosternal complications include mediastinitis, pericardial effusion, hematoma, loculated effusion, and empyema. Early diagnosis and treatment are critical. Flap closure complications included hematoma, partial flap loss, wound dehiscence, wound necrosis and abdominal hernia. Factors associated with flap closure complications, recurrent infection or death include both patient- and technique-related factors. These include obesity, history of smoking, hypertension, diabetes, post sternotomy septicemia, internal mammary artery harvest, use of an intra-aortic balloon pump, and perioperative myocardial infarction. In addition, overt or subclinical malnutrition may play a role, along with immune status.
Today, up to 20% of organisms cultured from infected sternotomy sites are methicillin-resistant Staphylococcus aureus (MRSA) and approximately 20% are gram-negative organisms. Appropriate antibiotic therapy is crucial to successful treatment of mediastinitis. As most patients have already received prophylactic antibiotic therapy, it is important to institute very broad and deep empiric antibiotic coverage including Pseudomonas species. Culture results can then guide antibiotic use. Long-term treatment is often required, usually for several weeks or months.
• Careful evaluation is required of the wound, wound drainage, wire exposure, sternal instability and potential communication with the pleural space to identify all possible problems.
• Early identification of mediastinitis and improvements in perioperative management and critical care of patients with multisystem organ failure can reduce morbidity and mortality rates.
• Successful management requires early recognition based on a high index of suspicion, detailed physical examination, awareness of clinical signs and symptoms, appropriate imaging and prompt surgical therapy.
• Advanced wound therapies, such as the use of Apligraf, a bioengineered skin substitute, or negative-pressure wound therapy, can increase healing of sternotomy wounds.
Consensus on effective prevention techniques has yet to be reached. Careful patient evaluation, meticulous surgical technique, and complete adherence to aseptic protocols within the operating room are required to prevent sternal wound complications.
The following classification of sternal wound infections was developed.
Type Depth Description
1a Superficial Skin and subcutaneous tissue dehiscence
1b Superficial Exposure of sutured deep fascia
2a Deep Exposed bone, stable wired sternotomy
2b Deep Exposed bone, unstable wired sternotomy
3a Deep Exposed necrotic or fractured bone, unstable, heart exposed
3b Deep Type 2 or 3 with septicemia
References
| Essential Publications |
|---|
| 1 | Dressings – Impermeable vs. absorbent |
Quality Indicator
|
Type: RCT |
| Segers P, de Jong AP, Spanjaard L, Ubbink DT, de Mol BA. Randomized clinical trial comparing two options for postoperative incisional care to prevent poststernotomy surgical site infections. Wound Repair Regen 2007;15(2):192-196. | |||
| Adhesive impermeable drapes and permeable absorbent dressings are compared in this study. The difference in incidence of sternal surgical site infection was not significant between the two types of dressings. | |||
| 2 | Prophylactic antibiotics – Gentamicin |
Quality Indicator
|
Type: RCT |
| Friberg O, Dahlin LG, Levin LA, Magnusson A, Granfeldt H, Kallman J, Svedjeholm R. Cost effectiveness of local collagen-gentamicin as prophylaxis for sternal wound infections in different risk groups. Scand Cardiovasc J 2006;40(2):117-125. | |||
| The researchers found that the use of local collagen-gentamicin in addition to a regular prophylaxis regimen significantly reduced the risk of sternal wound infection. This reduction in infection led to lower costs, making the use of local collagen-gentamicin beneficial both clinically and economically. | |||
| 3 | Prophylactic antibiotics - Gentamicin |
Quality Indicator
|
Type: RCT |
| Friberg O, Svedjeholm R, Kallman J, Soderquist B. Incidence, microbiological findings, and clinical presentation of sternal wound infections after cardiac surgery with and without local gentamicin prophylaxis. Eur J Clin Microbiol Infect Dis 2007;26(2):91-97. | |||
| In this study, the effect of local collagen-gentamicin on sternal wound infections was examined. The incidence of some infectious agents was reduced when gentamicin was administered and some symptoms of sternal wound infection were reduced. | |||
| 4 | Vacuum assisted closure |
Quality Indicator
|
Type: Concensus Statement |
| Fleck T, Gustafsson R, Harding K, Ingemansson R, Lirtzman MD, Meites HL, Moidl R, Price P, Ritchie A, Salazar J, Sjogren J, Song DH, Sumpio BE, Toursarkissian B, Waldenberger F, Wetzel-Roth W. The management of deep sternal wound infections using vacuum assisted closure (V.A.C.) therapy. Int.Wound.J 2006;3(4):273-280. | |||
| This guideline presents the VAC Therapy to assist wound closure. VAC Therapy is favoured because the standard approach to management of deep sternal wound infections was labour intensive and had implications for health care costs and staffing. The effects of the VAC Therapy include increased wound perfusion, reduction in inhibitory substances and lowering of bacterial load, oedema and increased granulation tissue formation. The recommendations are based on current evidence or the majority consensus of the international group of experts. | |||