Overview and Management of Sternal Wound Infection

Singh, Kimberly A.; Anderson, Erica; Harper, J. Garrett

doi:10.1055/s-0031-1275168

Cited by 130 publications

(133 citation statements)

References 65 publications

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“…Tracheostomy prior to any identified SWI occurred in 411 patients (2.2%), and the median [IQR] time from post-surgical ICU admission to tracheostomy was 14 [10][11][12][13][14][15][16][17][18][19] Table 2. Tracheostomy was an independent predictor of SWI (adjusted OR 2.8; 95% CI 1.9 to 4.2).…”

Section: Resultsmentioning

confidence: 99%

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The association between tracheostomy and sternal wound infection in postoperative cardiac surgery patients

Sun

Boodhwani

Baer

et al. 2013

Can J Anesth/J Can Anesth

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Purpose To investigate whether tracheostomy increases the risk of sternal wound infection (SWI) post cardiac surgery. Methods All patients undergoing cardiac surgery via median sternotomy from September 1997 to October 2010 were included in this retrospective observational study. Primary exposure was tracheostomy performed during admission to the cardiac surgical intensive care unit. The primary outcome was SWI during hospital admission. Multivariable logistic regression was used to determine if tracheostomy was an independent predictor of SWI. Restriction and propensity score analyses were then used to assess if tracheostomy is a causal risk factor for SWI. Results Four hundred and eleven of 18,845 patients (2.2%) were treated with tracheostomy. Incidences of SWI in tracheostomy and non-tracheostomy groups were 19.5% (80/411) and 0.8% (154/18,434), respectively. Using multivariable logistic regression analysis, tracheostomy was found to be an independent predictor of SWI (odds ratio [OR] 2.8; 95% confidence interval [CI] 1.9 to 4.2). In an analysis restricted to respiratory failure patients, tracheostomy was associated with sternal wound infection (OR 3.4; 95% CI 2.4 to 4.9). When the analysis was stratified by the risk of receiving tracheostomy as represented by propensity score (PS), 46 patients (12%) in the intermediate risk category (PS 0.2-0.4) had SWIs (adjusted OR 2.97; 95% CI 1.6 to 5.6), and 52 patients (14%) in the highest risk category (PS [ 0.4) had SWIs (OR 1.52; 95% CI 0.85 to 2.87). Discussion Our single-centre observational study of cardiac surgery patients found tracheostomy to be an independent risk factor for SWI. Our analysis showed a robust association when restricted to patients with respiratory failure and after the population was stratified by the propensity to have a tracheostomy. Résumé

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Section: Resultsmentioning

confidence: 99%

“…16 As a result, many clinicians are concerned about proceeding with tracheostomy, as direct soiling of the healing sternal wound could result. Tracheostomy in critically ill patients does not lend itself easily to a randomized interventional trial.…”

Section: Discussionmentioning

confidence: 99%

The association between tracheostomy and sternal wound infection in postoperative cardiac surgery patients

Sun

Boodhwani

Baer

et al. 2013

Can J Anesth/J Can Anesth

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“…Wound infection is life-threatening complication associated with an increased risk of short and long term morbidity and mortality in patient undergoing (CABG) surgery [4,5]. According to the Nork-Marash Medical Center (NMMC), the new cases of wound infection are 7.4% in patients after CABG, a further study found to be range from 1-10% [3,5].…”

Section: Introductionmentioning

confidence: 99%

“…Pre and intra-operative predictors are significantly associated withthe increase risk of wound infection. Although in the advance revolution of cardiac surgery the optimization/development of sternal wound infectionsisless decreased [11].…”

Section: Introductionmentioning

confidence: 99%

Incidence and Predictor of Post-Operative Wound Infection in Patients Underwent Coronary Artery Bypass Grafting

Gull¹,

Hussain²,

Farogh³

et al. 2018

JCTCD

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Objective: To determine the incidence and predictor of postoperative wound infection in patients underwent coronary artery bypass grafting (CPB). Methods:This was a prospective comparative study of 577 patients who underwent cardiac surgery with (CPB) was conducted at cardiac surgery department of Punjab Institute of cardiology, Lahore from 1st March 2012 to 31st March 2017. Consecutive patients undergoing elective and isolated CABG, both genders age ≥20 years, with normal ejection fraction were included in the study Results: Out of 577 patients of which 166(87.83%) were male while 23(12.16%) were female. The mean age of the patient was 53.23 ± 8.43. Incidence of post-operative wound infection in patients underwent coronary artery bypass grafting (CPB) was 73(12.65%). Common co morbid conditions were hypertension 50%, diabetes mellitus (43.5%), smoking (31.1%), hyperlipidemia (20.3%), prior of stoke (12.2%), Prior Surgery (6.8%) and prior renal failure (4.1%), mean CPB time (61.69 ± 32.27), ICU stay 976.03 ± 31.93), mean Cross clamp time(25.27 ± 19.17mg/dl) and Hospital stay (10.16 ± 5.6 day) were more in WI group. Themortality was found to be high in WI group (23.3%). Logistic regression showed that significantly predicted of the post-operative WI were elder age,diabetes mellitus, smoking, family history of IHD, hyperlipidemia, cardiopulmonary bypass time, ICU stay, hospital stay. Conclusion:We can conclude that wound infected patients are at significantly greater risk of incidence, morbidity and mortality after cardiac surgery.

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“…Despite its widespread utility, this incision is not free of complications, which include infected median sternotomy wounds (IMSWs) that can progress to mediastinitis with potentially fatal consequences. The incidence of post-sternotomy mediastinitis ranges from 1 to 5 % with a mortality rate of 10-47 % [2].…”

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confidence: 99%

An unusual variant of infected median sternotomy wound: an addition to the Pairolero classification

2014

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Sir, Median sternotomy is the most commonly used incision in cardiothoracic surgery since its introduction in 1957 [1]. Despite its widespread utility, this incision is not free of complications, which include infected median sternotomy wounds (IMSWs) that can progress to mediastinitis with potentially fatal consequences. The incidence of post-sternotomy mediastinitis ranges from 1 to 5 % with a mortality rate of 10-47 % [2].The most commonly used classification system for IMSW is the Pairolero classification where IMSW is divided into three types, based on timing of presentation and clinical findings [3]. Type I infections occur within the first week after sternotomy and typically have serosanguineous drainage, but no cellulitis, osteomyelitis or costochondritis. Type II infections occur during the second to fourth weeks and involve purulent drainage, cellulitis and mediastinal suppuration. Costochondritis is rare, but osteomyelitis is frequent. Type III infections occur months to years after sternotomy and typically involve chronic sinus tracts and localized cellulitis. Although mediastinitis is rare, osteomyelitis and costochondritis are often present.Two additional classifications exist for IMSW. The Oakley and Wright classification is based on the timing of presentation, presence of risk factors and number of failed interventions [4]. This classification, however, does not include the extent of infection nor the structures involved. The Jones classification considers the exact wound but fails to distinguish sterile instability of the sternum or sterile wound dehiscence with viable bone [5]. A good classification system logically suggests the management plan. Regarding IMSW, the Pairolero classification, to our knowledge, is the most commonly used classification since it indicates the treatment plan. We, however, have recently managed two cases, which did not correspond to the three types of IMSW described by the Pairolero classification, where the patients presented systemically unwell between 10 and 20 days post-sternotomy, with minimal clinical evidence of infection on examination.One patiens was a 68-year-old male who underwent coronary artery bypass graft (CABG) and aortic valve replacement. Ten days post-operatively, he became pyrexial (38.4°C), tachycardic and hypotensive. Clinical examination revealed no purulent discharge from the wound and no cellulitis. Bloods tests revealed leucocytosis, and blood culture later grew Staphylococcus aureus.The patient was immediately started on intravenous antibiotics and taken to theatre for exploration. Intraoperative exploration revealed no superficial infection, and the sternum was healthy. However, there was purulent fluid in the mediastinum with necrotic debris, and a pyogenic membrane was closed to the aortic suture line (Fig. 1). The wound was washed, and the sternal wires were removed. The patient returned to theatre 48 h later for re-exploration, and the chest wall was reconstructed using an omental flap. The patient made an uneventful recovery.The other p...

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Overview and Management of Sternal Wound Infection

Cited by 130 publications

References 65 publications

The association between tracheostomy and sternal wound infection in postoperative cardiac surgery patients

The association between tracheostomy and sternal wound infection in postoperative cardiac surgery patients

Incidence and Predictor of Post-Operative Wound Infection in Patients Underwent Coronary Artery Bypass Grafting

An unusual variant of infected median sternotomy wound: an addition to the Pairolero classification

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