POSTOPERATIVE STERNAL WOUND COMPLICATION & MANAGEMENT

Dr. Rezwanul Hoque

Associate Professor, Cardiac Surgery BSMMU, Dhaka, Bangladesh

MEDIAN STERNOTOMY- STANDARD APPROACH FOR CARDIAC SURGERY

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

ROBERT C. KING, ANDREW D. BARNES, CURRENT TREATMENT OPTIONS IN INFECTIOUS

DISEASES 2003, 5:377386

INCIDENCE OF STERNAL WOUND INFECTION

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.

BRAXTON JH, MARRIN CA, MCGRATH PD, ET AL.: MEDIASTINITIS AND LONG-TERM SURVIVAL AFTER CORONARY ARTERY BYPASS GRAFT SURGERY. ANN THORAC SURG 2000, 70:20042007.

DIAGNOSING MEDIASTINITIS
The Centers for Disease Control and Prevention (CDC) has established standardized clinical definitions of health care-associated infections (HAI). Mediastinitis is established when (1) organisms are cultured from mediastinal tissue or fluid obtained during an operation or needle 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 and symptoms must be accompanied by purulent discharge from the mediastinum and/or organisms cultured from blood or discharge from the mediastinum and/or mediastinal widening on chest xray. Mediastinitis, a deep SSI, is differentiated from superficial SSI, which is limited to skin and subcutaneous tissue. The incidence of mediastinitis ranges from <1% to 4% of all adults undergoing cardiac surgery . Most are S. aureus or S. epidermidis, confirming that these infections result from contaminating skin flora at the time of operation

HORAN TC, ANDRUS A, DUDECK MA. CDC/NHSN SURVEILLANCE DEFINITION OF HEALTHCARE ASSOCIATED INFECTION AND CRITERIA FOR SPECIFIC TYPES OF INFECTIONS IN THE ACUTE CARE SETTING. AMERICAN JOURNAL OF INFECTION CONTROL. 2008;36:309-332.

RISK FACTOR FOR MEDIASTINITIS

Key factors reduce perfusion and oxygen delivery to the surgical area: chronic obstructive pulmonary disease, diabetes, obesity (BMI >30), cigarette smoking, evidence of peripheral vascular disease, 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, and repeat 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 with women with smaller breast size due to tension on the sternal incision the same mechanism causing risk in obese patients. Large breast size increases vascular demand and internal mammary artery grafts may decrease vascular supply, which can impair healing. Conversely, male chest hair acts as a bacterial reservoir and preoperative hair removal can abrade the skin and provide an area for bacterial growth

. KOHUT K. GUIDE FOR THE PREVENTION OF MEDIASTINITIS SURGICAL SITE INFECTIONS FOLLOWING CARDIAC SURGERY. ASSOCIATION FOR PROFESSIONALS IN INFECTION CONTROL AND EPIDEMIOLOGY WASHINGTON, D.C.; 2008.

STAGING OF WOUND INFECTION AFTER MEDIAN STERNOTOMY

MARGGRAF G, SPLITTGERBER FH, KNOX M, ET AL.: MEDIASTINITIS AFTER CARDIAC SURGERY EPIDEMIOLOGY AND CURRENT TREATMENT. EUR J SURG 1999, 584(SUPPL):1216.

CLASSIFICATION OF STERNAL WOUND ON TIMING

Pairolero and Arnold have based their classification of sternal wounds on timing of presentation of infection; this classification divides wounds into 3 categories.[15]This classification system does not indicate the type of reconstruction necessary for management of each type of sternal wound. Type II and III wounds are typically referred to plastic surgeons for reconstruction. Type I: Type I wounds occur in the first few days postoperatively, contain early wound separation with or without sternal instability, and are characterized by serosanguineous drainage without cellulitis, osteomyelitis, or costochondritis. Type II: Type II wounds occur within the first few weeks and are characterized by drainage, cellulitis, mediastinal suppuration, and positive cultures. Type II wounds are characterized by fulminant mediastinitis. Type III: Type III wounds occur months to years after surgery and are characterized by the presence of chronic draining sinus tracts, localized cellulites, osteomyelitis, or retained foreign bodies. Mediastinitis is a rare complication of type III wounds.

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

INFECTED STERNAL WOUND

MEDIASTINITIS-TYPES
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, often caused by Staphylococcus aureus. Mediastinitis occurring secondary to contamination from concomitant infections usually caused by gram-negative rods.
Candidal and fungal deep mediastinal wound infections are relatively rare but associated with mortality rates approaching 50%. Infectious mediastinitis caused by methicillinresistant S. aureus has become more common during the past decade and has been associated with a higher mortality rate than infections caused by methicillin-sensitive S. aureus. Overall, coagulase-negative Staphylococcus species tend to predominate in most institutions and are responsible for35% to 50% of deep sternal wound infections after cardiac operations. S. aureus is isolated from deep sternal wounds in 25% to 35% of the cases. Gram-negative species are responsible for 3% to 18% of the cases .

GARDLUND B, BITKOVER CY, VAAGE J: POSTOPERATIVE MEDIASTINITIS IN CARDIAC SURGERY MICROBIOLOGY AND PATHOGENESIS. EUR J CARDIOTHORAC SURG 2002, 21:825830

DIAGNOSIS OF STERNAL WOUND INFECTION

Early deep sternal wound infections (7 to 10 days after operation) usually have increased serous 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 complaints of increased pain, associated with clicking, popping, or motion, should result in further investigation and treatment. A computed tomography scan or magnetic resonance imaging can further delineate sternal separation 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 be sampled with radiologic guidance as necessary before the administration of antibiotics. Tagged white cell scans, bone scans, and thermography have demonstrated some degree of institution-dependent diagnostic effectiveness in accurately determining the presence of a deep sternal wound infection.

MOST PATIENTS DEVELOP INFECTIOUS MEDIASTINITIS AFTER DISCHARGE OR AT 10 TO 30 DAYS AFTER THEIR OPERATION. SOME INDOLENT OR CHRONIC INFECTIONS MAY NOT BE EVIDENT FOR MONTHS. PAIN, INSTABILITY, FEVER, AND DRAINAGE ARE COMMON SIGNS. LEUKOCYTOSIS AND POSITIVE BLOOD CULTURE RESULTS FURTHER HEIGHTEN SUSPICION. IMAGING MAY OR MAY NOT BE REVEALING BECAUSE INFLAMMATION AFTER STERNOTOMY IS COMMON IN THE NORMAL HEALING PROCESS.

PRINCIPLES OF MANAGEMENT
The goals of therapy for treating patients with deep sternal wound infection are simple: prevent or treat septicemia, remove all infected and devitalized tissues and/or hardware, provide mediastinal or cardiac coverage, and re-establish sternal stability when possible. Early recognition and initiation of therapy are essential in decreasing patient morbidity and mortality. Antibiotic therapy should be administered after cultures and narrowed as the returning sensitivities dictate. Prompt surgical debridement of all infected and devitalized tissues is essential. A second attempt at primary closure should be considered if the bone is not necrotic and the residual soft tissue defect is not prohibitive. All fluid collections identified by preoperative imaging should be evacuated and cultured. 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 intravenous antibiotics for presumed osteomyelitis

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PRINCIPLES OF MANAGEMENT
Sternal rewiring has proven effective in treating patients with early deep sternal contamination and associated sternal dehiscence Wounds with obvious purulence and significant sternal necrosis should not be considered for rewiring 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 the likelihood 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 the associated 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 integrity of the pedicle. Despite internal mammary artery grafting, the ipsilateral pectoralis flap can be mobilized preserving its thoracoacromial vascular pedicle. Ipsilateral rectus flaps can be accomplished with caution if epigastric arterial flow is adequate and no prior transverse abdominal incision has been performed . The latissimus can be brought through the second or third intercostal space less commonly when the first two anterior flap options are unavailable. The omentum can provide immediate cardiac coverage when myocutaneous flaps are unavailable. Complications associated with omental packing result from vascular tension resulting in omental necrosis or gastric outlet compression. Herniation of abdominal viscera can occur through the diaphragmatic defect.

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PRIMARY STERNAL REWIRING

Standard procedure Debride all devitalized tissues. Quantitative wound and bone cultures. Pressure irrigation of 3 to 6 L of antibiotic irrigation of all wound surfaces. Robicsek weave of lateral sternal borders. Reinforce sternal fractures. figure of eight wire/cable lateral to Robicsek 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 effectiveness Avoids prolonged hospital stay of open wound. No need for reconstructive surgery if successful. Usually no need for long-term drainage or VAC.

STERNAL REWIRING

WEAVING OF WIRE DONE

DRAINAGE AND IRRIGATION CHANNEL PLACED DEEP TO STERNUM

SOFT TISSUE CLOSURE

DEVICE CLOSURE OF STERNUM

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

DEVICE IS POSITIONED

VERTICAL PLATE THROUGH INTERCOSTAL SPACE

VERTICAL PLATE BENT AROUND THE RIB FOR RIGID FIXATION

STERNAL REWIRING WITH PLATE

WIRE PASSED THROUGH THE INTERCOSTAL SPACES ARE TIGHTENED

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.

PRIMARY FLAP RECONSTRUCTION

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 all wound surfaces. Mobilization of preferred myocutaneous flap or omentum. Mediastinal, superficial, and donor site (as necessary) drain placement. Coverage of defect and wound closure. Contraindications Need for further wound debridement because of extensive necrosis and purulence. Hemodynamic or 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 useful adjuncts. Cost effectiveness Avoids prolonged hospital stay of open wound. Usually no need for long-term drainage or VAC.

FLAP RECONSTRUCTION OF STERNAL WOUND DEHISCENCE

DELAYED FLAP RECONSTRUCTION

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 all wound surfaces. Placement of VAC, drainage, or dressing system. Coverage of wound with impenetrable barrier.

Contraindications
Hemodynamic or respiratory compromise. Myocutaneous flap unavailable for closure.

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

Special points
Carefully select flap based on preserved vascular pedicles. Carefully monitor return to activities 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 stay than primary reconstruction. Usually no need for long-term drainage or VAC if wound closure accomplished shortly after debridement

VAC

PECTORALS MAJOR MUSCLE FLAP RECONSTRUCTION

BILATERAL PECTORALIS MAJOR FLAP RECONSTRUCTION

DOUBLE BREASTING OF PECTORALIS MAJOR FLAP

POST OPERATIVE STATUS

TITANIUM PLATING

STERNAL OSTEOSYNTHESIS WITH TITANIUM PLATES.

PROSTHESIS USED FOR STERNAL CLOSURE

PROSTHESIS USED IN STERNAL FIXATION

PREVENTION
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 organism infections.

PREVENTION IS BETTER