LETTERS TO EDITOR Is it possible to eliminate sternal wound infection after cardiac surgery? (original) (raw)
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Reduction in incidence of deep sternal wound infections: Random or real
Journal of Thoracic and Cardiovascular Surgery, 2010
Objective: Comorbidities predisposing cardiac surgical patients toward deep sternal wound infection, such as diabetes and obesity, are rising in the United States. Longitudinal analysis of risk factors, morbidity, and mortality was performed to assessed effects of these health trends on deep sternal wound infection rates.
Deep sternal wound infection: the role of early debridement surgeryq
Objective: This retrospective chart review study aimed to evaluate whether a more aggressive staged approach can reduce morbility and mortality following post-cardiotomy deep sternal wound infection. Methods: Between 1979 and 2000, 14 620 patients underwent open heart surgery: mediastinitis developed in 124 patients (0.85%). Patients were divided in two groups: in 62 patients (Group A) (1979±1994) an initial attempt of conservative antibiotic therapy was the rule followed by surgical approach in case of failure; in 62 patients (Group B) (1995±2000) the treatment was staged in three phases: (1) wound debridment, removal of wires and sutures, closed irrigation for 10 days; (2) in case of failure open dressing with sugar and hyperbaric therapy (11 patients, 17%); (3) delayed healing and negative wound cultures mandated plastic reconstruction (three patients, 4%). Categorical values were compared using the Chi-square test, continuous data were compared by unpaired t-test. Results: Incidence of mediastinitis was higher in Group B (62 out of 5535; 1.3%) than in Group A (62 out of 9085; 0.7%) (P 0:007). Mean interval between diagnosis and treatment was shorter in Group B (18^6 days) than in group A (38^7 days) (P 0:001). Hospital mortality was higher in Group A (19/62; 31%) than in Group B (1 out of 62; 1.6%) (P , 0:001). Hospital stay was shorter in Group B (30.5^3 days) than in group A (44^9 days) (P 0:001). In Group B complete healing was observed in all the 61 survivors: 47 cases (76%) after Stage 1; 11 (18%) after Stage 2; three (4.8%) after Stage 3. Conclusions: Although partially biased by the fact that the two compared groups draw back to different decades, this study showed that an aggressive therapeutic protocol can signi®cantly reduce morbility and mortality of deep sternal wound infection. q
Prevention, Classification and Management Review of Deep Sternal Wound Infection
The Heart Surgery Forum
Sternal wound complications are significant problems in cardiac surgery and cause challenges to surgeons as they are associated with high mortality, morbidity, and a tremendous load on the hospital budget. Risk factors and preventive measures against sternal wound infection need to be in focus. Classification of different types of sternotomy complications post cardiac surgery is important for specific categorization and management. Reviewing the literature, a variety of classifications was introduced to help understand the pathophysiology of these wounds and how best to manage them. Initial classifications were based on the postoperative period of the infectious process and risk factors. Recently, the anatomical description of sternal wound, including the depth and location, was shown to be more practical. There is a lack of evidence-based surgical consensus for the appropriate management strategy, including type of closure, choice of sternal coverage post sternectomy, whether prima...
Deep sternal wound infection: the role of early debridement surgery
European Journal of Cardio-thoracic Surgery, 2001
Objective: This retrospective chart review study aimed to evaluate whether a more aggressive staged approach can reduce morbility and mortality following post-cardiotomy deep sternal wound infection. Methods: Between 1979 and 2000, 14 620 patients underwent open heart surgery: mediastinitis developed in 124 patients (0.85%). Patients were divided in two groups: in 62 patients (Group A) (1979±1994) an initial attempt of conservative antibiotic therapy was the rule followed by surgical approach in case of failure; in 62 patients (Group B) (1995±2000) the treatment was staged in three phases: (1) wound debridment, removal of wires and sutures, closed irrigation for 10 days; (2) in case of failure open dressing with sugar and hyperbaric therapy (11 patients, 17%); (3) delayed healing and negative wound cultures mandated plastic reconstruction (three patients, 4%). Categorical values were compared using the Chi-square test, continuous data were compared by unpaired t-test. Results: Incidence of mediastinitis was higher in Group B (62 out of 5535; 1.3%) than in Group A (62 out of 9085; 0.7%) (P 0:007). Mean interval between diagnosis and treatment was shorter in Group B (18^6 days) than in group A (38^7 days) (P 0:001). Hospital mortality was higher in Group A (19/62; 31%) than in Group B (1 out of 62; 1.6%) (P , 0:001). Hospital stay was shorter in Group B (30.5^3 days) than in group A (44^9 days) (P 0:001). In Group B complete healing was observed in all the 61 survivors: 47 cases (76%) after Stage 1; 11 (18%) after Stage 2; three (4.8%) after Stage 3. Conclusions: Although partially biased by the fact that the two compared groups draw back to different decades, this study showed that an aggressive therapeutic protocol can signi®cantly reduce morbility and mortality of deep sternal wound infection. q
Deep Sternal Wound Infection: Risk Factors and Outcomes
The Annals of Thoracic Surgery, 1998
Background. Deep sternal wound infection (DSWI) is a serious complication of cardiac operations performed by median sternotomy. We attempted to define the predictors of DSWI and to describe the outcomes of two treatment strategies used at our institution.
Deep sternal wound infections: Evidence for prevention, treatment, and reconstructive surgery
Archives of Plastic Surgery
Median sternotomy is the most popular approach in cardiac surgery. Post-sternotomy wound complications are rare, but the occurrence of a deep sternal wound infection (DSWI) is a catastrophic event associated with higher morbidity and mortality, longer hospital stays, and increased costs. A literature review was performed by searching PubMed from January 1996 to August 2017 according to the guidelines in the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement. The following keywords were used in various combinations: DSWI, post-sternotomy complication, and sternal reconstruction. Thirty-nine papers were included in our qualitative analysis, in which each aspect of the DSWI-related care process was analyzed and compared to the actual standard of care. Plastic surgeons are often involved too late in such clinical scenarios, when previous empirical treatments have failed and a definitive reconstruction is needed. The aim of this comprehensive review was to create an up-to-date operative flowchart to prevent and properly treat sternal wound infection complications after median sternotomy.
Risk factors of infected sternal wounds versus sterile wound dehiscence
Journal of Surgical Research, 2016
Background: Sterile sternal dehiscence (SSD) and sternal wound infections (SWIs) are two complications of median sternotomy with high rates of morbidity. Sternal wound complications also carry significant economic burden, almost tripling patients' hospital costs and are considered a nonreimbursable "never event" for Medicare. Historically, SDD and SWI have been recognized as discrete entities, but nonetheless continue to be categorized as a singular complication in literature. The purpose of this study was to determine specific patient demographic and perioperative predictors of SSD and SWI. Materials and methods: An institutional review boardeapproved, retrospective study of 8098 consecutive patients who underwent cardiac surgery at Columbia University Medical Center between January 2008 and December 2013 was conducted. Patients were categorized into three groups: no sternal wound complication, SSD, or SWI. Statistical analysis was performed using univariate and multivariate logistic regression analysis. Results: Of 8098 patients, there were 73 patients (0.9%) with SSD and 40 (0.5%) with SWI who required plastic surgical consultation, debridement, and flap closure. In univariate analysis of SSD, positive predictors (i.e., "risk" factors) were age >42 years, prior surgery this admission, ‡2 arterial conduits, internal mammary artery (IMA) grafting with or without previous IMA grafting, body mass index (BMI) >30 (obese), CHF, diabetes requiring medication, respiratory failure, and unplanned cardiac reoperation; negative predictors (i.e., "protective" factors) were no arterial conduits and extubation within 24 h. In univariate analysis of SWI, positive predictors were IMA grafting with or without previous IMA grafting, postoperative hematocrit urgent/emergent surgical priority, BMI >30 (obese), cardiac ejection fraction <40%, and respiratory failure; negative predictors were no arterial conduits and elective surgical priority. In multivariate regression, BMI >30, diabetes requiring medication, and respiratory failure were determined to be significant positive predictors of SSD, and IMA grafting with or without prior IMA grafting and respiratory failure were significant positive predictors for SWI; no significant negative predictors were identified.
Journal of the Egyptian Society of Cardio-Thoracic Surgery, 2016
Objective: To evaluate outcome of modalities for management of deep sternal wound infection (DSWI) defined as peri-procedural mortality and to determine the predictors for this outcome. Patients & Methods: Management plan was controlled by the findings after sternal wound debridement till the patient was bacteriologically negative. This plan ranged between simple rewiring of sternal remnants, if appropriate, rewiring and bilateral pectoralis major advancement flap (PMF) coverage, vascularized omental flap (VOF) or PMF coverage without rewiring if sternal remnants were inappropriate and combined VOF and PMF coverage in case of wide sternal defect and/or absence of any trustable sternal remnants. Results: Throughout the study duration 121 out of 7850 patients underwent sternotomy for open cardiac surgery developed DSWI for a frequency of 1.54%. Nineteen patients died for a total mortality rate of 15.7%, 9 patients developed complications for a morbidity rate of 7.4% and 93 patients passed their postoperative (PO) course uneventfully for a total success rate of 76.9%. PMF and VOF showed success rates of 94.7% and 81.8%, respectively. Wiring only and wiring followed by PMF showed success rates of 78.6% and 75%, respectively. Combined VOF and PMF showed a success rate of 72.2% for selected cases with wide sternal wound. Number of risk factors/patient was significantly higher in non-survivors than in survivors. Obesity and multiplicity of risk factors were the most significant predictors for mortality. Individually obesity and diabetes mellitus were the significant predictors for mortality. Conclusion: Management of DSWI is tedious, has prolonged hospital stay and is associated with high morbidity and mortality rates. Management of DSWI must be personalized according to findings on exploration of the sternal wound and flap coverage must be initiated only when the patient is bacteriologically free. Both PMF and/or VOF provided high acceptable success rate defined as survival free of DSWI recurrence.
Prevention and management of sternal wound infections
The Journal of thoracic and cardiovascular surgery, 2016
Although the incidence of sternal wound infections has decreased to 1% to 4% of all cardiac surgery procedures, they continue to be associated with increased morbidity and mortality, and decreased long-term life expectancy. 1-3 They prolong hospital length of stay and can raise hospital costs by as much as US$62,000. 4 Sternal wound infections are now publicly reported, and the US Center for Medicare and Medicaid services will no longer reimburse hospital costs incurred in the treatment of deep sternal wound infections (DSWI) following coronary artery bypass graft (CABG) surgery. 5 Despite the significant clinical and economic consequences of sternal wound infections, there are currently no specific guidelines in cardiac surgery for the prevention and treatment of sternal wound infections. What follows are recommendations for the prevention of wound infections during the preoperative, intraoperative, and postoperative periods, as well as principles for the most effective methods and techniques to treat sternal wound infections to achieve the lowest morbidity and mortality as derived from evidence-based recommendations (Tables 1 and 2). METHODS A literature search was performed using PubMed and Google Scholar up to March 2015 using the MeSH headings ''Sternal Wound Infections-Prevention and Treatment,'' ''Treatment of Mediastinitis,'' ''Topical Antibiotics in Cardiac Surgery,'' ''Wound VAC Therapy for Sternal Wound Infections,'' and ''Prevention and Treatment of Sternal Instability.'' Editorials and articles involving prevention and therapy for wound infections in noncardiac, nonsternotomy patients were excluded. The systemic review was reported according to the Preferred Reporting Items for Systemic Reviews and Meta-Analyses (PRISMA) guidelines 6 (Figure 1). DEFINITIONS In defining sternal wound infections it is important to distinguish between DSWI and superficial sternal wound infections (SSWI). 7,8 A SSWI involves only the skin, subcutaneous tissue, and/or pectoralis fascia. There is no bony involvement. The incidence of SSWI ranges from 0.5% to 8% with a combined morbidity and mortality of 0.5% to 9%.