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Dr. Rezwanul HoqueAssociate Professor, Cardiac Surgery

BSMMU, Dhaka, Bangladesh

POSTOPERATIVE STERNALWOUND COMPLICATION &

MANAGEMENT

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MEDIAN STERNOTOMY- STANDARD APPROACH

FOR CARDIAC SURGERY

ROBERT C. KING, ANDREW D. BARNES, CURRENT TREATMENT OPTIONS IN INFECTIOUSDISEASES2003, 5:377386

Median sternotomy- first described by Milton in 1897

Abandoned due to incidence of fatal mediastinal complication

Julian re-introduced Milton's operation for median sternotomy in 1957

Resurfaced after CPB opened the door of modern day cardiac surgery

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INCIDENCE OF STERNAL WOUND INFECTION

BRAXTONJH, MARRINCA, MCGRATH PD, ETAL.:MEDIASTINITIS AND LONG-TERM SURVIVAL AFTERCORONARY ARTERY BYPASS GRAFT SURGERY. ANNTHORAC SURG 2000, 70:20042007.

In a survey of most recent studies, the incidence of deep sternal wound infection has

plateaued at 1% to 4% .

The true incidence of deep sternal wound infection is thought to be less than 2% when

considering all cardiac operations.

Deep sternal wound infection after cardiac surgery can be associated with mortality rates

approaching 50% . Studies published in the past 5 years report a 10% to 20% in-hospital

mortality rate.

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DIAGNOSING MEDIASTINITIS

HORANTC, ANDRUS A, DUDECK MA. CDC/NHSNSURVEILLANCE DEFINITIONOF H EALTHCARE -ASSOCIATED INFE CTIONAND CRITERIA FOR SPECIFICTYPE S OF INFE CTIONS INTHEACUTE CARE S ETTING .

AMERICAN JOURNALOF INFE CTIONCONTROL. 2008;36:309-332.

The Centers for Disease Control and Prevention (CDC) has established standardized clinicaldefinitions of health care-associated infections (HAI). Mediastinitis is established when

(1) organisms are cultured from mediastinal tissue or fluid obtained during an operation orneedle aspiration and/or

(2) evidence of mediastinitis is visible during an operation or on histopathology and/or

(3) fever, chest pain or sternal instability without another recognized cause. The signs andsymptoms must be accompanied by purulent discharge from the mediastinum and/or organismscultured from blood or discharge from the mediastinum and/or mediastinal widening on chest x-ray. Mediastinitis, a deep SSI, is differentiated from superficial SSI, which is limited to skin andsubcutaneous tissue.

The incidence of mediastinitis ranges from

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RISK FACTOR FOR MEDIASTINITIS

. KOHUT K. GUIDE FOR THE PREVENTION OF MEDIASTINITIS SURGICAL SITE INFECTIONS FOLLOWING CARDIAC SURGERY.

ASSOCIATION FOR PROFESSIONALS IN INFECTION CONTROL AND EPIDEMIOLOGYWASHINGTON, D.C.; 2008.

Key factors reduce perfusion and oxygen delivery to the surgical area: chronic obstructivepulmonary disease, diabetes, obesity (BMI >30), cigarette smoking, evidence of peripheral vasculardisease, decreased cardiac output and use of internal mammary artery (IMA) for graft.

Other factors include: infection at another site, renal insufficiency, emergency surgery,hospitalization prior to the procedure, longer duration operations, older persons, male gender, andrepeat CABG

Median sternotomy presents much higher risk than minimally invasive approaches

Women with larger breast size were 38 times more likely to develop mediastinitis compared withwomen with

smaller breast size due to tension on the sternal incision the same mechanism causing risk inobese patients. Large breast size increases vascular demand and internal mammary artery graftsmay decrease vascular supply, which can impair healing.

Conversely, male chest hair acts as a bacterial reservoir and preoperative hair removal can abradethe skin and provide an area for bacterial growth

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STAGING OF WOUND INFECTION AFTER MEDIAN

STERNOTOMY

MARGGRAF G, SPLITTGERBERFH, KNOXM, ETAL.:MEDIASTINITIS AFTER CARDIAC SURGERY EPIDEMIOLOGY ANDCURRENT TREATMENT. EUR J SURG 1999, 584(SUPPL):1216.

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CLASSIFICATION OF STERNAL WOUND ON

TIMING

HTTP://EMEDICINE.MEDSCAPE.COM/ARTICLE/1278627-OVERVIEW#AW2AAB6B2B1AA

Pairolero and Arnold have based their classification of sternal wounds on timing ofpresentation of infection; this classification divides wounds into 3 categories.[15]Thisclassification system does not indicate the type of reconstruction necessary formanagement of each type of sternal wound. Type II and III wounds are typically referredto plastic surgeons for reconstruction.

Type I: Type I wounds occur in the first few days postoperatively, contain early woundseparation with or without sternal instability, and are characterized by serosanguineousdrainage without cellulitis, osteomyelitis, or costochondritis.

Type II: Type II wounds occur within the first few weeks and are characterized bydrainage, cellulitis, mediastinal suppuration, and positive cultures. Type II wounds arecharacterized by fulminant mediastinitis.

Type III: Type III wounds occur months to years after surgery and are characterized by thepresence of chronic draining sinus tracts, localized cellulites, osteomyelitis, or retainedforeign bodies. Mediastinitis is a rare complication of type III wounds.

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INFECTED STERNAL WOUND

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MEDIASTINITIS-TYPES

GARDLUND B, BI TKOVERCY, VAAGE J:POSTOPERATIVE MEDIASTINITIS IN CARDIAC SURGERY MICROBIOLOGY ANDPATHOGENESIS. EUR J CARDIOTHORAC SURG 2002, 21 :825830

Three types of postoperative mediastinitis described:

Mediastinitis associated with obesity, chronic obstructive pulmonary disease,and sternal dehiscence usually caused by coagulase-negative staphylococci.

Mediastinitis associated with contamination of the deep sternal space, oftencaused by Staphylococcus aureus.

Mediastinitis occurring secondary to contamination from concomitantinfections usually caused by gram-negative rods.

Candidal and fungal deep mediastinal wound infections are relatively rare but associatedwith mortality rates approaching 50%.Infectious mediastinitis caused by methicillin-resistant S. aureus has become more common during the past decade and has beenassociated with a higher mortality rate than infections caused by methicillin-sensitiveS. aureus.Overall, coagulase-negative Staphylococcus species tend to predominate

in most institutions and are responsible for35% to 50% of deep sternal woundinfections after cardiac operations. S. aureus is isolated from deep sternal wounds in25% to 35% of the cases. Gram-negative species are responsible for 3% to 18% ofthe cases .

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DIAGNOSIS OF STERNAL WOUND INFECTION

MOSTPATIENTS DEVELOPINFE CTIOUS MEDIASTINITIS AFTERDISC HARGEORAT 10TO 30 DAYS AFTERTHEIROPERATION. SOMEINDOLENTOR CHRONICINFE CTIONS MAYNOTBE EVIDENT FOR MONTHS . PAIN, INSTABILITY, FEVER, AND DRAINAGEARE COMMONSIGNS.LEU KOCYTOSIS AND POSITIVEBLOOD C ULTURERES ULTS FURTHERHEIGHTENSUSPICION.IMAGING MAYOR MAYNOTBEREVEALING BECAUSEINFLAMMATIONAFTERSTERNOTOMYIS COMMONINTHENORMAL HEALING

PROCESS.

Early deep sternal wound infections (7 to 10 days after operation) usually have increasedserous drainage from the wound associated with sternal instability.

Fever and leukocytosis may or may not occur.

A shift in the sternal wires or cables on chest radiography, associated with patient complaintsof increased pain, associated with clicking, popping, or motion, should result in furtherinvestigation and treatment.

A computed tomography scan or magnetic resonance imaging can further delineate sternalseparation while characterizing the degree of soft tissue inflammation

and/or documenting the presence of suspicious fluid collections.

To secure an accurate and rapid diagnosis of the offending organism, fluid collections should besampled with radiologic guidance as necessary before the administration of antibiotics.

Tagged white cell scans, bone scans, and thermography have demonstrated some degree ofinstitution-dependent diagnostic effectiveness in accurately determining the presence of a deepsternal wound infection.

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PRINCIPLES OF MANAGEMENT

CONTINUED

The goals of therapy for treating patients with deep sternal wound infection aresimple: prevent or treat septicemia, remove all infected and devitalized tissuesand/or hardware, provide mediastinal or cardiac coverage, and re-establish sternalstability when possible.

Early recognition and initiation of therapy are essential in decreasing patientmorbidity and mortality.

Antibiotic therapy should be administered after cultures and narrowed as thereturning sensitivities dictate.

Prompt surgical debridement of all infected and devitalized tissues is essential. Asecond attempt at primary closure should be considered if the bone is not necroticand the residual soft tissue defect is not prohibitive.

All fluid collections identified by preoperative imaging should be evacuated andcultured.

Soft tissue and bone should be sent for quantitative culture at the time of operation.If bone culture results are positive, administer a minimum of 6 weeks of intravenousantibiotics for presumed osteomyelitis

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PRINCIPLES OF MANAGEMENT

CONTINUED FROM PREVIOUS PAGE

Sternal rewiring has proven effective in treating patients with early deep sternal contaminationand associated sternal dehiscence

Wounds with obvious purulence and significant sternal necrosis should not be considered forrewiring and primary reclosure.

Drains should be placed in the mediastinum and superficial tissues before closure.Intermittent closed irrigation of an antibiotic solution has been proven to increase thelikelihood of successful sternal rewiring

Primary soft tissue coverage is provided most commonly by myocutaneous flap or pedicled

omental packing. Both have proven effective in facilitating healing and decreasing theassociated morbidity and mortality of infectious mediastinitis.Myocutaneous flaps routinely are based from the pectoralis major, rectus abdominis, or

latissimus dorsi muscles, depending on prior surgical interventions and vascular integrityof the pedicle. Despite internal mammary artery grafting, the ipsilateral pectoralis flap canbe mobilized preserving its thoracoacromial vascular pedicle. Ipsilateral rectus flaps canbe accomplished with caution if epigastric arterial flow is adequate and no priortransverse abdominal incision has been performed . The latissimus can be broughtthrough the second or third intercostal space less commonly when the first two anteriorflap options are unavailable.

The omentum can provide immediate cardiac coverage when myocutaneous flaps areunavailable. Complications associated with omental packing result from vascular tensionresulting in omental necrosis or gastric outlet compression. Herniation of abdominalviscera can occur through the diaphragmatic defect.

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PRIMARY STERNAL REWIRING

Standard procedure

Debride all devitalized tissues. Quantitative wound and bone cultures. Pressureirrigation of 3 to 6 L of antibiotic irrigation of all wound surfaces. Robicsek weave oflateral sternal borders. Reinforce sternal fractures. figure of eight wire/cable lateral toRobicsek weave. Close soft tissues.

Contraindications

Significant sternal necrosis or osteomyelitis, hemodynamic or respiratory compromise,and gross purulence or obvious residual infected tissues.

Complications

Recurrent infection and/or sternal dehiscence.

Special points

Closed irrigation/drainage catheters or VAC may be useful adjuncts.

Cost effectivenessAvoids prolonged hospital stay of open wound. No need for reconstructive

surgery if successful. Usually no need for long-term drainage or VAC.

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STERNAL REWIRING

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WEAVING OF WIRE DONE

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DRAINAGE AND IRRIGATION CHANNEL PLACED DEEP TO STERNUM

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SOFT TISSUE CLOSURE

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DEVICE CLOSURE OF STERNUM

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DEVICE, VERTICAL BLADE THROUGH INTERCOSTAL SPACE, HORIZONTAL ON THE STERNUM

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DEVICE IS POSITIONED

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VERTICAL PLATE THROUGH INTERCOSTAL SPACE

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VERTICAL PLATE BENT AROUND THE RIB FOR RIGID FIXATION

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WIRE PASSED THROUGH THE INTERCOSTAL SPACES ARE TIGHTENED

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DEVICE CLOSURE OF STERNUM

To facilitate insertion of the device, the fascia is dissected from the sternal border with

electrocautery, and if necessary, perforating vessels are clipped .

Once the fascia is mobilized, the hemisternum is elevated by two hand retractors to

optimize exposure. The clips are assembled to form a device of a suitable length (up to 5

clips for each one) and the vertical segments of the clips are inserted into the intercostals

spaces .

The two pliable vertical fingers of each unit are then bent outwards to wrap around the

ribs, so that the clips are held firmly in place .

Re-approximation of the sternum is then achieved by means of single interrupted

stainless steel wires. Two to 3 are placed through the manubrium, and the others are

placed around the grooved arms of the clips at the level of the intercostal spaces . The fascia, subcutaneous layers, and skin are closed in a routine manner.

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PRIMARYFLAPRECONSTRUCTION

Standard procedure

Open original incision and remove all prior hardware. Debride all devitalized tissues including bone.Quantitative wound and bone cultures. Pressure irrigation of 3 to 6 L of antibiotic irrigation of allwound surfaces. Mobilization of preferred myocutaneous flap or omentum. Mediastinal,superficial, and donor site (as necessary) drain placement. Coverage of defect and woundclosure.

Contraindications

Need for further wound debridement because of extensive necrosis and purulence. Hemodynamicor respiratory compromise. Myocutaneous flap unavailable for closure.

Complications

Omental or myocutaneous flap necrosis. Diaphragmatic or ventral hernia.

Hemorrhage. Prolonged sternal instability. Recurrent infection and/or wound dehiscence.

Special points

Careful selection of flap based on preserved vascular pedicles. Carefully monitored return to

activities to preserve repair. Closed irrigation/drainage catheters or VAC may be usefuladjuncts.

Cost effectivenessAvoids prolonged hospital stay of open wound. Usually no need for long-termdrainage or VAC.

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FLAP RECONSTRUCTION OF STERNAL WOUNDDEHISCENCE

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DELAYED FLAPRECONSTRUCTION

VA C

Standard procedureOpen original incision and remove all prior hardware. Debride all devitalized tissues,

including bone. Quantitative wound and bone cultures. Pressure irrigation of 3 to 6 L ofantibiotic irrigation of all wound surfaces. Placement of VAC, drainage, or dressingsystem. Coverage of wound with impenetrable barrier.

ContraindicationsHemodynamic or respiratory compromise. Myocutaneous flap unavailable for closure.

ComplicationsCare of open wound, hemorrhage, cardiac laceration, and prolonged mediastinal exposure.

Special pointsCarefully select flap based on preserved vascular pedicles. Carefully monitor return toactivities to preserve repair. Irrigation catheters, drains, or VAC may be useful adjuncts.

Cost effectiveness

Avoids prolonged hospital stay of open wound, but requires longer hospital staythan primary reconstruction. Usually no need for long-term drainage or VAC ifwound closure accomplished shortly after debridement

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PECTORALS MAJOR MUSCLE FLAP RECONSTRUCTION

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BILATERAL PECTORALIS MAJOR FLAP RECONSTRUCTION

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DOUBLE BREASTING OF PECTORALIS MAJOR FLAP

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POST OPERATIVE STATUS

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TITANIUM PLATING

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STERNAL OSTEOSYNTHESIS WITH TITANIUM PLATES.

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PROSTHESIS USED FOR STERNAL CLOSURE

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PROSTHESIS USED IN STERNAL FIXATION

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PREVENTION

PREVENTIONIS BETTER

Meticulous skin preparation before surgery./ Timely administration of perioperative antibiotics.

Meticulous sterile operative technique./ Avoid bilateral mammary harvest in select patients.

Avoid excessive cauterization or tissue damage./ Meticulous hemostasis.

Avoid nonabsorbable hemostatics./ Reduce operative and bypass times.

Perfect midline sternotomy. /Perfect sternal reapproximation and immobilization.

Perfect sealing of skin and subcutaneous tissues.

Aggressive diagnostic and therapeutic approach if suspicion of evolving sternal wound infection.

The effectiveness of various immunoglobulins in preventing infectious mediastinitis must be investigated adequately.

The use of the VAC system as a primary treatment modality awaits further investigation.

Culture-specific antibiotic therapy should be administered to avoid increasing resistance.

Consider individual health care workers as vector in specific organism outbreaks.

Precise coverage, duration, and antibiotic dosing to decrease fungal/yeast superinfection.

Meticulous environmental cleansing and isolation to reduce incidence of postoperative mediastinitis and resistant organisminfections.