Influence of sternal size and inadvertent paramedian sternotomy on stability of the closure site: A clinical and mechanical study

Zeitani, Jacob; Peppo, Alfonso Penta de; Moscarelli, Marco; Wolf, Lorenzo Guerrieri; Scafuri, Antonio; Nardi, Paolo; Nanni, Francesca; Marzio, Emanuele Di; Vico, Pasquale De; Chiariello, Luigi

doi:10.1016/j.jtcvs.2006.03.015

Cited by 48 publications

(41 citation statements)

References 22 publications

(22 reference statements)

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“…Of note, the only prospective, randomized, and double-blinded trial of mupirocin in cardiac surgery patients did not show benefit: No patients with poststernotomy mediastinitis caused by methicillin-resistant Staphylococcus aureus (MRSA) had identical isolates in preoperative and surgical-site cultures [46] . Surgical risk factors include prolonged duration of aortic cross clamp, cardiopulmonary bypass perfusion or overall surgery [22,26] , use of internal mammary artery (IMA) grafts-especially bilaterally- [2,24,25,27,30] , inadvertent paramedian sternotomy [47] , use of bone wax, extensive use of electrocauterization [27] , surgical procedures requiring prosthesis implant, use of intra-aortic balloon pump or ventricular assist device [23,27] , postoperative bleeding [10] , blood transfusions, re-exploration for bleeding [6,23,24,48,49] , re-operation, postoperative respiratory failure with prolonged mechanical ventilation [2,6] , and prolonged stay in intensive care unit (ICU) [4,24,26] . Controversial opinions still remain on the IMA harvest technique.…”

Section: Risk Factorsmentioning

confidence: 99%

Deep sternal wound infection after cardiac surgery: Evidences and controversies

Cotogni

Barbero

Rinaldi

2015

WJCCM

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Despite many advances in prevention and perioperative care, deep sternal wound infection (DSWI) remains a pressing concern in cardiac surgery, with a still relevant incidence and with a considerable impact on in-hospital mortality and also on mid-and long-term survival. The permanent high impact of this complication is partially related to the increasing proportion of patients at highrisk for infection, as well as to the many patient and surgical risk factors involved in the pathogenesis of DSWI. The prophylactic antibiotic therapy is one of the most important tools in the prevention of DSWI. However, the choice of antibiotic, the dose, the duration, the adequate levels in serum and tissue, and the timing of antimicrobial prophylaxis are still controversial. The treatment of DSWI ranges from surgical revision with primary closure to surgical revision with open dressings or closed irrigation, from reconstruction with soft tissue flaps to negative pressure wound therapy (NPWT). However, to date, there have been no accepted recommendations regarding the best management of DSWI. Emerging evidence in the literature has validated the efficacy and safety of NPWT either as a single-line therapy, or as a "bridge" prior to final surgical closure. In conclusion, the careful control of patient and surgical risk factors -when possible, the proper antimicrobial prophylaxis, and the choice of validated techniques of treatment could contribute to keep DSWIs at a minimal rate. Core tip: Intensivists and cardiothoracic surgeons are commonly worried about surgical site infections due to increasing length of stay, costs, and mortality. In particular, deep sternal wound infection (DSWI) is a worrying complication after cardiac surgery, with a still relevant incidence. Unfortunately, DWSI appearance is related to a wide number of both patient and surgical factors. This review may be useful for guiding physicians to the knowledge of main risk factors and the choice of the appropriate management of DWSIs with the aim of reducing the rate of this potentially devastating complication in cardiac surgery patients.Cotogni P, Barbero C, Rinaldi M. Deep sternal wound infection after cardiac surgery: Evidences and controversies. World J Crit Care Med 2015; 4(4): 265-273 Available from: URL: http:// www.wjgnet.com/2220-3141/full/v4/i4/265.htm DOI: http:// dx.doi.org/10.5492/wjccm.v4.i4.265 INTRODUCTIONDeep sternal wound infection (DSWI) is one of the most complex and potentially devastating complications following median sternotomy in cardiac surgery with a significant impact on both patient prognosis and hospital budgets [1][2][3][4][5] . Despite many advances in prevention, it still remains significant and ranges between 0.5% and 6.8% [6][7][8][9][10] , with in-hospital mortality rates between 7% and 35% [2,3,7,9,[11][12][13] . Moreover, mid-and long-term survival is significantly reduced in patients that have experienced DSWI. By the end of the first year, Filsoufi et al [6] found a 15% absolute survival difference between patients ...

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Section: Risk Factorsmentioning

confidence: 99%

Deep sternal wound infection after cardiac surgery: Evidences and controversies

Cotogni

Barbero

Rinaldi

2015

WJCCM

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“…Specifically, as SD was, on average, 47% of the value of the corresponding mean (SD of ratio ¼ 20%), a standard deviation of 5.64 mm was employed for tissue layer 4 fat (i.e., 47% of 12 mm). For both males and females, the mean and SD of the sternum thickness was taken to be 11.2 AE 2.2 mm [Zeitani et al, 2006]. For the thermal model, the total depth of the model is 100 mm (i.e., where the tissue is assumed to reach core temperature).…”

Section: Remaining Tissue Thicknessesmentioning

confidence: 99%

SAR versus S_inc: What is the appropriate RF exposure metric in the range 1–10 GHz? Part I: Using planar body models

Anderson

Croft

McIntosh³

2010

Bioelectromagnetics

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This is the first of two articles addressing the most appropriate crossover frequency at which incident power flux density (S(inc)) replaces the spatial peak value of the specific energy absorption rate (SAR) averaged over 1 or 10 g (i.e., peak 1 or 10 g SAR) as the basic restriction for protecting against radiofrequency (RF) heating effects in the 1-10 GHz range. Our general approach has been to compare the degree of correlation between these basic restrictions and the peak induced tissue temperature rise (DeltaT) for a representative range of population/exposure scenarios. In this article we particularly address the effect of human population diversity in the thickness of body tissue layers at eight different sites of the body. We used a Monte Carlo approach to specify 32000 models (400 models for each of 8 body sites for 10 frequencies) which were representative of tissue thicknesses for age (18-74 years) and sex at the eight body sites. Histogram distributions of S(inc) and peak 1 and 10 g SAR corresponding to a peak 1 degrees C temperature rise were obtained from RF and thermal analyses of 1D multiplanar models exposed to a normally incident plane wave ranging from 1 to 10 GHz in thermo-neutral environmental conditions. Examination of the distribution spread of the histograms indicated that peak SAR was a better predictor of peak tissue temperature rise across the entire 1-10 GHz frequency range than S(inc), as indicated by the smaller spread in its histogram distributions, and that peak 10 g SAR was a slightly better predictor than peak 1 g SAR. However, this result must be weighed against partly conflicting indications from complex body modeling in the second article of this series, which incorporates near-field effects and the influence of complex body geometries.

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“…11,15,16 In the United States, more than 400,000 coronary artery bypass procedures were performed in 2009. 8,9,22 It has also spurred efforts to identify improved techniques for creating midline sternotomy. 3,4 The influence of patient-related and procedure-related factors on wound healing, mechanical stability, and dehiscence of the sternum has been well described in the literature.…”

Section: Discussionmentioning

confidence: 99%

“…Among the recognized complications of this technique are deep sternal wound infection (DSWI) dehiscence and nonunion. 3,5Y8 Among the technique-related complications, paramedian or asymmetric sternotomy has been shown to increase the rate of sternal dehiscence 8,9 and wound infections. 3,4 Multiple patient-specific and technique-related risk factors have been found to be associated with these complications.…”

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confidence: 99%

Asymmetric Sternotomy and Sternal Wound Complications: Assessment Using 3-Dimensional Computed Tomography Reconstruction

Jacobson

Doscher

Rahal

et al. 2015

Innovations�(Phila)

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Objective Wound complications after midline sternotomy result in significant morbidity and mortality. Despite many known risk factors, the influence of sternal asymmetry has largely been ignored. The purpose of this study was to assess the utility of 3-dimensional computed tomographic scan reconstructions to assess sternal asymmetry and determine its relationship with sternal wound infection. Methods A retrospective chart review was conducted for patients who underwent midline sternotomy and received a postoperative computed tomographic scan between 2009 and 2010. Cases were composed of all patients who had a sternal wound infection after undergoing sternotomy. Controls were randomly selected from patients without poststernotomy wound complications. Sternal asymmetry was defined as the difference between the left and the right sternal halves and was expressed as a percentage of the total sternal volume. Results Twenty-six cases were identified and 32 controls were selected as described earlier. The patients were similar in baseline characteristics and risk factors including age, sex, smoking status, diabetes, chronic obstructive pulmonary disease, preoperative creatinine, and operative time. Univariate factors associated with sternal wound infection include an asymmetry of 10% or greater, body mass index, and internal mammary artery harvest. In a multivariate logistic regression, independent predictors of sternal wound infection included an asymmetry of 10% or greater (odds ratio, 3.6; P = 0.03) and diabetes (odds ratio, 3.3; P = 0.0442). Conclusions Our data suggest an association between asymmetric sternotomy and sternal wound infections. We recommend an assessment of sternal asymmetry to be performed in patients with sternal wound infection and if it is found to be 10% or greater, the surgeon should implement measures that stabilize the sternum.

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Influence of sternal size and inadvertent paramedian sternotomy on stability of the closure site: A clinical and mechanical study

Abstract: Inadvertent paramedian sternomoty strongly affects postoperative chest wound stability independently from sternal size, requiring prompt reinforcement of chest closure.

Cited by 48 publications

References 22 publications

Deep sternal wound infection after cardiac surgery: Evidences and controversies

Deep sternal wound infection after cardiac surgery: Evidences and controversies

SAR versus S_inc: What is the appropriate RF exposure metric in the range 1–10 GHz? Part I: Using planar body models

Asymmetric Sternotomy and Sternal Wound Complications: Assessment Using 3-Dimensional Computed Tomography Reconstruction

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Influence of sternal size and inadvertent paramedian sternotomy on stability of the closure site: A clinical and mechanical study

Abstract: Inadvertent paramedian sternomoty strongly affects postoperative chest wound stability independently from sternal size, requiring prompt reinforcement of chest closure.

Cited by 48 publications

References 22 publications

Deep sternal wound infection after cardiac surgery: Evidences and controversies

Deep sternal wound infection after cardiac surgery: Evidences and controversies

SAR versus Sinc: What is the appropriate RF exposure metric in the range 1–10 GHz? Part I: Using planar body models

Asymmetric Sternotomy and Sternal Wound Complications: Assessment Using 3-Dimensional Computed Tomography Reconstruction

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SAR versus S_inc: What is the appropriate RF exposure metric in the range 1–10 GHz? Part I: Using planar body models