Management and outcomes of delayed sternal closure after cardiac surgery in neonates and infants

Abstract

Delayed sternal closure is an effective approach to the management of neonates and infants at risk for hemodynamic, respiratory, or hemostatic instability early after cardiac surgery. Significant changes in hemodynamics and respiratory variables occur during sternal closure, often requiring adjustment of inotropic and ventilatory management. (Crit Care Med 2000; 28: 1180-1184)

Infección del sitio quirúrgico en niños sometidos a cirugía cardíaca con cierre esternal diferido: Estudio de casos y controles

“…Infecciones Asociadas a la atención de Salud se asocian a un mayor riesgo (doble salida del ventrículo derecho, troncos arteriosos, transposición de grandes arterias, principalmente) 6,[21][22][23] . Existe aún escasa información en la literatura científica respecto a los factores de riesgo de ISQ en pacientes con CED.…”

“…Este hecho podría relacionarse con la tasa de ISQ en nuestros pacientes con CED según los datos obtenidos por el estudio multicéntrico de Johnson y cols., quienes reportaron que centros con uso medio o alto de CED en relación a la etapa 1 de la cirugía paliativa de la HVI (más de 75% de los pacientes) tienen significativamente mayor incidencia de ISQ 18 . La incidencia de mediastinitis en nuestros pacientes alcanzó a 3,5%, frecuencia similar a la descrita en estudios más recientes, los que reportan tasas de 1,9 a 7,5% 8,15,[21][22][23]25 . El análisis de regresión logística demostró que el tiempo de CEC mayor a 200 min y el tiempo en VMI por más de 5 días fueron los principales factores de riesgo asociado con la ocurrencia de ISQ con un OR ajustado = 9,53 (IC 95% 1,37-66,35) y OR ajustado = 8,98 (IC 95% 1,16-69,40), respectivamente.…”

Nursing Considerations for Children Undergoing Delayed Sternal Closure After Surgery for Congenital Heart Disease

“…Cardiac compression, which may occur at the time of sternal closure, can lead to decreased cardiac output and elevated pulmonary venous pressure due to decreased ventricular compliance and filling. 5 This ongoing state of cardiac compression can cause a state of progressive low cardiac output that leads to hemodynamic instability and compromise. This clinical situation of low cardiac output has been described in the adult and pediatric literature by different terms: typical tamponade, 6 atypical tamponade, 7 tight mediastinal syndrome, 8 and cardiac compression.…”

“…9 Clinical surgical experience and documented medical literature support leaving the sternum open postoperatively for the following clinical situations: hemodynamic instability, myocardial edema, cardiac dilatation, intractable bleeding and coagulopathy, dysrrhythmias, respiratory compromise, and mediastinal placement of a circulatory assist device. 5 Cardiac surgeons decide to leave the sternum open and use DSC in a variety of clinical scenarios, including but not limited to electively in the operating room after complex neonatal repairs, in the operating room after attempting primary closure that resulted in hemodynamic compromise, after cannulation and/or decannulation from a mediastinal circulatory assist device, or emergently reopening the chest in the ICU at the time of cardiac arrest after primary closure. After the child achieves hemodynamic stability and recovery, he or she will undergo DSC either in the ICU or after a return trip to the operating room.…”

“…9 Gangahar et al 11 Shore et al 7 Bjork et al 12 Jogi and Werner 13 Kay et al 14 Odim et al 15 Ziemer et al 6 Elami et al 16 Hakimi et al 17 Alexi-Meskishvili et al 18 Iyer et al 19 Tabbutt et al 20 McElheinney et al 21 McElheinney et al 5 Amato 22 Walker et al 23 Main et al 24 Samir et al 25 Riphagen et al 10 lifted off of the heart with some form of traction or splinted from touching the heart ( Figure 2) by using surgical tools such as rib spreaders, stents, 16,23 or struts. 20 The splinting device is placed between the sternal edges before the sterile dressing is applied.…”