GoalGoal

One of the complications of a Median SternotomyAnd how to Prevent and Manage it

IndicationsIndications

1. Coronary Artery Bypass Grafting2. Valve Surgeries3. Aortic Surgeries ‘Bentalls’4. Cardiac & Mediastinal Tumours5. ASD VSD Closures6. Re Sernotomy

Sternotomies done in SKMCSternotomies done in SKMC

161161 1515 33 22 11 66

1. Coronary Artery Bypass Grafting

2. Valve Surgeries

3. Aortic Surgeries ‘Bentalls’

4. Cardiac & Mediastinal Tumours

5. ASD VSD Closures

6. Re Sernotomy

Complications of Sternal WoundsComplications of Sternal Wounds

Superficial InfectionSuperficial Infection Deep InfectionDeep Infection

1.1. Sternal OsteomyelitisSternal Osteomyelitis2.2. Sternal DehiscenceSternal Dehiscence

Incidence of Sternal Wound Incidence of Sternal Wound ComplicationsComplications

Sternal wound complications--incidence, microbiology and risk factorsDepartment of Thoracic and Cardiovascular SurgeryUniversity Hospital, Uppsala, SwedenFrom 1980 through 1995 open heart surgery, was performed on 13,285 adult patients

5 out of 195 that is 2.6 %

1-4%

Some Positive Pointers

None of the Valve replacements,Aortic dissections or other

Semi-elective or post emergent surgeries got sternal dehiscence

All the five patients had severe pre morbid factors (Euroscore > 8)

None of the Re Sternotomies got infected

Patho etiologyPatho etiology

Localized area of Sternal OsteomyelitisLocalized area of Sternal Osteomyelitis with minimal external signs with minimal external signs followed by Sternal separation followed by Sternal separation

Sternal instabilitySternal instability, followed by skin breakdown with seepage of , followed by skin breakdown with seepage of bacteriabacteria

Inadequate mediastinal drainageInadequate mediastinal drainage, leading to a large retrosternal , leading to a large retrosternal collectioncollection

Staphylococcus aureus or S epidermidis are identified in 70% to 80% of cases . .Coagulase negativeCoagulase negative

Patho etiologyPatho etiology

So the most important etiological factor So the most important etiological factor which is in our hands iswhich is in our hands is

Sternal StabilitySternal Stability

What are the other etiological factorsWhat are the other etiological factors

EuroscoreEuroscore

Patient-related factorsPatient-related factors Age Age SexSex Chronic pulmonary diseaseChronic pulmonary disease Extracardiac arteriopathyExtracardiac arteriopathy Neurological dysfunction disease Neurological dysfunction disease Previous cardiac surgeryPrevious cardiac surgery Serum creatinineSerum creatinine Active endocarditisActive endocarditis Critical preoperative stateCritical preoperative state

EuroscoreEuroscore

Cardiac-related factorsCardiac-related factors Unstable angina Unstable angina LV dysfunctionLV dysfunction Recent myocardial infarct Recent myocardial infarct Pulmonary hypertensionPulmonary hypertension

EuroscoreEuroscore

Operation-related factorsOperation-related factors Emergency Emergency Any other surgery than isolated CABGAny other surgery than isolated CABG Surgery on thoracic aortaSurgery on thoracic aorta Post infarct septal rupturePost infarct septal rupture

Our Our Four Four Sternal Dehiscence PatientsSternal Dehiscence Patients

ThreeThree are are chronic smokerschronic smokers All All fourfour are are diabeticsdiabetics TwoTwo of them are of them are nephropathsnephropaths All All Four Four had severehad severe triple vessel disease triple vessel disease Two had severe comlications on admisson Two had severe comlications on admisson

Myocardial infractMyocardial infract

PneumoniaPneumonia

Operative FactorsOperative Factors

Sternal StabilitySternal Stability

Operative FactorsOperative Factors

Paramedian SternotomyParamedian Sternotomy

To what lengths the discussion goes…To what lengths the discussion goes…

ManagementManagement

How early you recognize the problemHow early you recognize the problem

3.3. AcuteAcute

4.4. Sub acuteSub acute

5.5. ChronicChronic

2 Wks2-5 Wks>5 Wks

Postoperative Mediastinitis : Classification and Management Reida M. El Oakley, FRCS, John E. Wright, FRCS Ann Thorac Surg 1996;61:1030-1036

ManagementManagement

Close Close examinationexamination to confirm problems with to confirm problems with sternal stability sternal stability

Early and adequateEarly and adequate debridement debridement Prompt application of Prompt application of VAC VAC Sternal debridementSternal debridement if necessary if necessary Tissue cover with local flapTissue cover with local flap..

How to make an early diagnosisHow to make an early diagnosis

The The Classic symptomsClassic symptoms and signs of acute infection are and signs of acute infection are infrequentlyinfrequently encounteredencountered

Fever and LeukocytosisFever and Leukocytosis in the absence of local symptoms or signs may be in the absence of local symptoms or signs may be the only presenting clinical features in a small percentage of patients the only presenting clinical features in a small percentage of patients

Wound dischargeWound discharge is the most common presentation and occurs in 70% to is the most common presentation and occurs in 70% to 90% 90%

Local symptoms include wound pain, tenderness, and sternal instability Local symptoms include wound pain, tenderness, and sternal instability

Chest roentgenogramsChest roentgenograms are rarely helpful in the early diagnosis are rarely helpful in the early diagnosis

Chest computed tomography scanning with mediastinal aspirationChest computed tomography scanning with mediastinal aspiration

CT vs MRI

Retrosternal ShadowRetrosternal Shadow

Osteomyelitic Sternum

Look in your ‘minds eye’Look in your ‘minds eye’

Radical and prompt debridement Radical and prompt debridement with VAC applicationwith VAC application

We We graftedgrafted this sternum to our loss this sternum to our loss

Pectoralis Flap with graftingPectoralis Flap with grafting

Pectoralis major flap as the work Pectoralis major flap as the work horsehorse

OmentoplastyOmentoplasty

Because of the relative degree of skeletal muscle ischemia after its mobilization and because omental lipid extract has been shown to have a powerful angiogenic effect an omentoplasty may be the procedure of choice

El Oakley RM, Jarvis J, Barman D, et al. Factors affecting the integrity of latissimus dorsi muscle grafts: implicationsfor cardiac assistance from skeletal muscle. J Heart Lung Transplant 1995;14:359–65

OmentoplastyOmentoplasty

If your getting any If your getting any freshfresh ideas….. ideas…..

Sternal wound infections in patients undergoing Sternal wound infections in patients undergoing open heart surgery: randomized study comparing open heart surgery: randomized study comparing intracutaneousintracutaneous and and transcutaneoustranscutaneous suture suture techniquestechniques

Risnes, M. Abdelnoor, S. Tore Baksaas, R. Lundblad, and J. L. SvennevigRisnes, M. Abdelnoor, S. Tore Baksaas, R. Lundblad, and J. L. Svennevig

Ann. Thorac. Surg ,November 1, 2001; 72(5): 1587 - 1591. Ann. Thorac. Surg ,November 1, 2001; 72(5): 1587 - 1591.