Asian Cardiovasc Thorac Ann 2002;10:95
© 2002 Asia Publishing EXchange Pte Ltd
Delayed Sternal Closure After Cardiac Operations
A Thomas Pezzella, MD1
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1 Department of Cardiac Surgery Good Samaritan Hospital 605 North 12th Street Mt. Vernon IL 62864, USA
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I read with interest the article submitted by Mubeen and colleagues.1 The authors should be congratulated on a successful experience in a very high-risk group of patients. I have several questions for the authors. Why did all of their patients receive prophylactic antibiotics for a total of six days? The incidence of superficial sternal infection in the primary sternal closure group (13.3%) seems rather high.
The definition of mortality is 30 days. Did any patients die during the initial operation beyond 30 days, never having left the hospital? How long was the sternum left open in their series? Finally, is there a correlation with duration of sternal opening and subsequent morbidity and mortality, especially deep wound infections? In our own experiences, sterile packing of the wound was unnecessary and undesired. Suction drainage was advocated. A sterile iodine Steri-Drape (3M Healthcare, St. Paul, MN, USA) was used in all cases. Closure of the skin and subcutaneous tissue is attempted in all cases. If not feasible, a dressing, usually Esmark (latex-free dressing; American White Cross, Houston, TX, USA), is stapled to the skin edges followed by the sterile iodine Steri-Drape. Occasionally, the sternal retractor is left in place or a steel rod is used to provide a wider opening if hemodynamically necessary.
REFERENCE
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Mubeen M, Dan S, Agarwal SK, Srivastava AK, Kanhere VM. Delayed sternal closure after cardiac operations. Asian Cardiovasc Thorac Ann
2001;9:82–5.[Abstract/Free Full Text]
Ashok K Srivastava, MCh2
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2 Department of Cardiovascular and Thoracic Surgery Sanjay Gandhi Postgraduate Institute of Medical Sciences Raebareli Road Lucknow, Uttar Pradesh 226014, India
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We appreciate and thank the reader for showing interest in our article. In reply to the reader's concerns regarding various issues in our paper, we have the following answers.
It is our departmental policy to use prophylactic antibiotics for 5 days postoperatively. All deaths (4/30) occurred during the immediate postoperative period. Two patients died while the sternum was open, and the other 2 died after delayed sternal closure. No death occurred beyond 30 days after the operation. The 26 survivors were dis-charged from the hospital and are on regular follow-up.
The sternum was left open for a mean of 22 ± 0.3 hours (range, 8 to 48 hours). Only 2 patients whose sternum was left open for 46 to 48 hours developed mediastinitis. Sterile packing of the mediastinum was carried out in cases of severe bleeding due to generalized capillary oozing from raw surfaces, to provide compression and subsequent clot formation. In between, they required frequent dressing changes. Closure of the skin and subcutaneous tissue was attempted, but it was not feasible in the majority of the patients due to unstable hemo-dynamics.
