Sternal wound complications after isolated coronary artery bypass grafting: Early and late mortality, morbidity, and cost of care

doi:10.1016/0003-4975(90)90136-T

The Annals of Thoracic Surgery

Volume 49, Issue 2, February 1990, Pages 179-187

https://doi.org/10.1016/0003-4975(90)90136-T Get rights and content

Abstract

Of 6,504 consecutive patients who underwent isolated coronary bypass grafting in 1985 to 1987, 72 (1.1%) patients experienced sternal wound complications. Ten patients (14%) with wound complications died of multi-system failure. Only the patients with negative cultures fated well; of the bacterial culture categories, polymicrobial infection carried the worst prognosis. Effect of recurring infection were seen throughout the first year. Patients, grouped according to conduits received, experienced these wound complication rates: vein grafts only, 11/1,085 (1.0%); one internal thoracic artery, 38/4,073 (0.9%); and bilateral internal thoracic artery grafts, 23/ 1,346 (1.7%), There were no significant differences in wound complication rates between primary and reoperation patients or among conduit groups. By logistic regression analysis, the relative risk for patients with diabetes and bilateral internal thoracic artery grafting was 5.00 (95% confidence interval, 2.4 to 10.5). Operation time as a continuous variable increased the relative risk of wound complication 1.47 times per hour (1.3 to 1.7); obesity, 2.90 times (1.8 to 4.8); and blood units as continuous variable, 1,05 times per unit (1.01 to 1.10). Bilateral internal thoracic artery grafting in nondiabetic patients carried no grsater risk of wound complication than that in patients with vein grafts only or with one internal thoracic artery graft.

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Cited by (622)

Factors associated with deep sternal wound infection after open-heart surgery in a Danish registry
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To conduct a comprehensive multivariate analysis of variables associated with deep sternal wound infection, after open-heart surgery via median sternotomy.
A retrospective cohort of all adult patients, who underwent open-heart surgery at Odense University Hospital between 01‐01-2000 and 31-12-2020 was extracted from the West Danish Heart Registry. Data were analyzed using maximum likelihood logistic regression.
A total of 15,424 patients underwent open-heart surgery and 244 developed a deep sternal wound infection, equivalent to 1,58 %. After data review 11,182 entries were included in the final analysis, of which 189 developed DSWI, equivalent to 1,69 %. Multivariate analysis found the following variables to be associated with the development of deep sternal wound infection (odds ratios and 95%confidens intervals in parentheses): Known arrhythmia (1.70; 1.16–2.44), Left Ventricular Ejection Fraction (1.66; 1.02–2.58), Body Mass Index 25–30 (1.66; 1.12–2.52), Body Mass Index 30–35 (2.35; 1.50–3.71), Body Mass Index 35–40 (3.61; 2.01–6.33), Body Mass Index 40+ (3.70; 1.03–10.20), Age 60–69 (1.64; 1.04–2.67), Age 70–79 (1.95; 1.23–3.19), Chronic Obstructive Pulmonary Disease (1.77; 1.21–2.54), Reoperation (1.63; 1.06–2.45), Blood transfusion in surgery (1.09; 1.01–1.17), Blood transfusion in intensive care unit (1.03; 1.01–1.06), Known peripheral atherosclerosis (1.82; 1.25–2.61), Current smoking (1.69; 1.20–2.35), Duration of intubation (1.33; 1.12–1.57).
Increased risk of deep sternal wound infection after open-heart surgery is a multifactorial problem, while some variables are unchangeable others are not. Focus should be on optimizing the condition of the patient prior to surgery e.g. weight loss and smoking. But also factors surrounding the patient e.g. preventing blood loss and minimizing intubation time.
Putting patient value first: Using a modified nominal group technique for the implementation of enhanced recovery after cardiac surgery recommendations
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In 2019, the Society for Enhanced Recovery After Cardiac Surgery (ERAS-CS) published perioperative guidelines to optimize the care of patients undergoing cardiac surgery. For centers with limited capacity, a sequential approach to the implementation of the full guidelines may be more feasible. Therefore, we aimed to explore the priority of implementation of the ERAS-CS guideline recommendations from a patient and caregiver perspective.
Using a modified nominal group technique, individuals who previously underwent cardiac surgery and their caregivers ranked ERAS-CS recommendations within 3 time points (ie, preoperative, intraoperative, and postoperative) and across 2 to 3 voting rounds. Final round rankings (median, mean and first quartile) were used to determine relative priorities.
Seven individuals (5 patients and 2 caregivers) participated in the study. Patient engagement tools (2, 2.29, and 1.50), surgical site infection reduction (2, 1.67, and 1.25), and postoperative systematic delirium screening (1, 2.43, and 1.00) were the top-ranked ERAS-CS recommendations in the preoperative, intraoperative, and postoperative time points, respectively.
Exploration of patient and caregiver priorities may provide important insights to guide the healthcare team with clinical pathway development and implementation. Further study is needed to understand the impact of the integration of patient and caregiver values on effective and sustainable clinical pathway implementation.
Pharmacokinetics of Cefazolin in Patients With Obesity Undergoing Surgery Requiring Cardiopulmonary Bypass
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The authors’ objective was to determine the adequacy of an institutional standard dosing practice for infection prophylaxis in open cardiac surgery in patients heavier than 120 kg undergoing cardiopulmonary bypass.
A prospective, single-center, open-label study was used to determine if cefazolin serum concentrations were maintained above the minimum inhibitory concentration (MIC) throughout surgery. A pharmacokinetic model describing cefazolin disposition was developed for perioperative patients with morbid obesity, based on these values. Probability of target attainment was evaluated across the clinically relevant MIC spectrum.
Maine Medical Center is an academic hospital in Portland, Maine, affiliated with Tufts University School of Medicine.
Twenty patients scheduled for cardiac surgery requiring cardiopulmonary bypass who weighed at least 120 kg.
All patients received 2 g of cefazolin intravenously (IV) within 1 hour before incision, an additional 1 g injected into the cardiopulmonary bypass circuit at the initiation of bypass, and 2 g administered IV every 3 hours after the initial IV dose.
Cefazolin serum concentrations were collected after incision, after initiation of bypass, each hour of bypass, at the end of bypass, and at sternal closure. For patients weighing >120 kg undergoing cardiac surgery, the studied dosing regimen met or exceeded targeted cefazolin concentrations for all study patients. The authors conducted probability of target attainment analyses using both 65% and 100% of time with unbound drug concentrations across clinically relevant MICs.
The authors found that their current dosing strategy achieved a probability of target attainment >90% throughout surgery for both total and unbound cefazolin concentrations, independent of cardiopulmonary bypass times.
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Sequential antimicrobial therapy in mediastinitis after cardiac surgery: An observational study of 81 cases
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Mediastinitis is an infrequent but serious complication of cardiac surgery. Antimicrobial treatment guidelines are not well established. The aim was to describe the efficacy of sequential intravenous to oral therapy in selected post-surgical mediastinitis patients.
A retrospective observational study including cases of mediastinitis after cardiac surgery, defined according to CDC criteria, at a third-level university hospital between January 2002 and December 2016. Sequential antimicrobial therapy was proposed in clinically stable patients. Rates of cure, relapse, and hospital stay were compared between patients who received sequential intravenous to oral therapy and those who received therapy exclusively by the intravenous route.
Eighty-one cases were included. Sequential intravenous to oral therapy was performed in 48 (59.3%) patients on median day 15. No differences in baseline characteristics or causal microorganisms were found between the two cohorts. The average duration of antibiotic therapy was 41.2 ± 10.09 days. The most commonly used drugs in sequential therapy were quinolones in 31 (64.6%) cases and rifampicin, always in association with another antibiotic, in 25 (52.1%). Hospital stay was shorter in the sequential therapy group (57.57 ± 34.03 vs. 84.35 ± 45.67; P = 0.007). Cure was achieved in 77 (92.8%) patients. Overall in-hospital mortality was less frequent in the group that received sequential therapy (2.1% vs. 15.2%; P = 0.039). There were no differences in relapse between the two cohorts (4.2% vs 9.1%; P = 0.366).
Sequential antimicrobial treatment in selected patients with post-surgical mediastinitis may be as effective as exclusively intravenous treatment, reducing risks, hospital stay and associated costs.
La mediastinitis es una complicación grave pero infrecuente de la cirugía cardiaca. Las pautas de tratamiento antimicrobiano no han sido bien definidas. El objetivo es describir la eficacia del tratamiento antimicrobiano secuencial, de intravenoso a oral, en pacientes seleccionados con mediastinitis.
Estudio observacional retrospectivo en el que se incluyeron los casos de mediastinitis relacionados con la cirugía cardiaca, según criterios del CDC, en un hospital universitario entre enero de 2002 y diciembre de 2016. Una vez estabilizados los pacientes, se propuso completar el tratamiento antimicrobiano de forma secuencial, pasando de la vía intravenosa a la oral. Se compararon las tasas de curación, las recidivas y la estancia hospitalaria entre los pacientes que recibieron ambos regímenes.
Se incluyeron 81 casos. El tratamiento antimicrobiano secuencial se utilizó en 48 (59,3%) pacientes, en una media de 15 días. No se encontraron diferencias respecto a las características basales y microorganismos causales en ambos grupos. La duración media del tratamiento antibiótico fue de 41,2 ± 10,09 días. Los antimicrobianos más utilizados en el tratamiento secuencial fueron quinolonas en 31 (64,6%) y rifampicina, siempre asociada a otro antibiótico, en 25 (52,1%). La estancia hospitalaria fue menor en el grupo con tratamiento secuencial (57,57 ± 34,03 vs. 84,35 ± 45,67; p = 0,007). En conjunto, curaron 77 (92,8%) pacientes. La mortalidad hospitalaria fue inferior en el grupo tratado secuencialmente (2,1% vs. 15,2%; p = 0,039). No hubo diferencias en recidivas entre ambos grupos (4,2% vs 9,1%; p = 0,366).
El tratamiento antimicrobiano secuencial en pacientes con mediastinitis posquirúrgica seleccionados puede tener una eficacia similar al tratamiento exclusivamente intravenoso, permitiendo reducir riesgos y costes asociados.
Extended arc of rotation of Latissimus Dorsi Musculocutaneous Flap providing well-vascularized tissue for reconstruction of complete defects of the sternum: An anatomical study of flap pedicle modification
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^☆: Presented at the Twenty-fifth Anniversary Meeting of The Society of Thoracic Surgeons, Baltimore, MD, Sep 11–13, 1989.

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Original articleSternal wound complications after isolated coronary artery bypass grafting: Early and late mortality, morbidity, and cost of care☆

Abstract

Lancet

Am J Med

Surg Clin North Am

J Thorac Cardiovasc Surg

Ann Thorac Surg

Am Heart J

Ann Thorac Surg

J Thorac Cardiovasc Surg

The nationwide nosocomial infection rate: a new need for vital statistics

Am J Epidemiol

Mediastinitis following open-heart surgery: review of two years' experience

Arch Surg

Factors predisposing to wound infection in cardiac surgery: a prospective study of 517 patients

Eur J Cardiothorac Surg

Mediastinal infection after cardiac surgery

Ann Thorac Surg

Original article
Sternal wound complications after isolated coronary artery bypass grafting: Early and late mortality, morbidity, and cost of care☆