Cardiac Device Implant Wound Closure with 2-Octyl Cyanoacrylate

Comparison of skin adhesive and absorbable intracutaneous suture for the implantation of cardiac rhythm devices

AIMS

Wound healing is a major determent in the post-surgical course of patients (pts) after pacemaker (PM) and implantable cardioverter defibrillator (ICD) implantation. Insufficient closure may lead to serious complications with pocket infections leading to the device's explantation as the worst case scenario. In addition to the different types of suture and suture clips, a novel topical skin adhesive containing 2-octyl-cyanoacrylate is commercially available.

METHODS AND RESULTS

Over a period of 18 months, we prospectively assigned all cases of PM, ICD, and loop recorder implants either to skin adhesive (Group 1) or to absorbable intracutaneous polydioxanon suture (Group 2). Data were analysed with respect to operation time, wound infections, and healing disorders. One hundred and eighty-three pts were randomized into Group 1 [71 PMs, 60 ICD, 15 cardiac resynchronization therapy (CRT), 11 loop recorders, and 26 generator replacements]. One hundred and eighty-five pts were assigned to Group 2 (62 PMs, 70 ICD, 30 CRT, 7 loop recorders, and 16 generator replacements). There were no differences regarding sex, diabetes, renal insufficiency, corticosteroid therapy, oral anticoagulants, and acetylsalicylic asa/clopidogrel (P = n.s.). For the significantly higher amount of CRT devices (P < 0.05) in Group 2, the procedure times are given for surgeries except CRT. It was 49.1 ± 27.7 min for Group 1 and 53.4 ± 31.9 min for Group 2 (P = n.s.). Adverse events as insufficient closure, major and minor bleeding, pocket haematoma, erythema, incrustation, dehiscence, keloid, and explantation due to infection occurred significantly more often in the adhesive group (P = 0.02). The greatest impact on this result had early adverse events as insufficient closure, wound incrustation, and inflammation (9.3 vs. 6.0%; P = 0.02). We did not find any difference in long-term adverse events, infections in particular (2.7 vs. 1.6%; P = 0.47).

CONCLUSION

This study shows no benefit using skin adhesive in comparison to absorbable intracutaneous suture regarding surgery times for the implantation of cardiac rhythm devices. The rate of early adverse events after wound closure is higher after skin adhesive but no difference in long-term adverse events occurred.

Is skin closure with cyanoacrylate glue effective for the prevention of sternal wound infections?

A best evidence topic in cardiac surgery was written according to a structured protocol. The question addressed whether cyanoacrylate glue was effective at preventing wound infection following sternotomy incision. Altogether more than 108 papers were found using the reported search, of which seven represented the best evidence to answer the clinical question. The authors, journal, date and country of publication, patient group studied, study type, relevant outcomes and results of these papers are tabulated. We conclude that applying cyanoacrylate glue to a sternal wound has superior outcomes in terms of infection rates, both if applied preoperatively (decreasing from 10.8% to 2.7% or 7.8% to 1.1%, according to two studies) and postoperatively (4.9%-2.1%). This trend is true of both deep surgical site infections (0.6%-0%) and superficial site infections (4.3%-2.1%). Furthermore, in patients who had developed mediastinitis following cardiac surgery rates of recurrent sternal detachment and osteomyelitis were significantly reduced in cases where sealant was applied compared to controls (35.3% vs. 0%). In all studies examining hospital stay, duration was reduced in cases where cyanoacrylate glue was used, both in patients treated for recurrent mediastinitis (24.06 vs. 14.16 days) and those with uncomplicated recovery following cardiac surgery (13 vs. 9 days). In addition, two studies examining the use of cyanoacrylate glue to secure the sternum in complicated cases of recurrent detachment report success rates of 86% and 100%.

Wound management and restrictive arm movement following cardiac device implantation - evidence for practice?

BACKGROUND

The rate of cardiac device implantation has risen significantly secondary to an increase in the number of indications. Wound infection and lead displacement are two common and potentially life-threatening complications. No national/international guidelines address postoperative care and controversy exists regarding wound management and arm movement following cardiac device implantation.

AIMS

We aimed to explore and review the evidence behind current practice but found that certain aspects of established practice.

METHODS

An electronic search of the databases EMBASE, British Nursing Index, CINAHL, Cochrane and PubMed to identify evidence regarding wound management and lead displacement.

FINDINGS

We found that certain aspects of established practice are based on tradition rather than evidence. Recent guidelines on wound management published by The National Institute for Health and Clinical Excellence in the UK recommend covering the wound postoperatively for 48 h with a low-adherent transparent dressing and letting patients shower thereafter. Since specific guidelines for cardiac device patients are lacking, we suggest that further research address whether or not the NICE guidelines can be extrapolated to this area. Studies showed that early mobilisation and allowing a full range of arm movements following device implantation is safe. Further research must validate these findings.

CONCLUSION

We discuss the reasons behind these gaps in the evidence base and support the idea that nursing education has not placed enough emphasis on how to critically appraise research. This accounts for the very small proportion of nurses that get involved in conducting research and generating guidelines. Additionally, we argue that nurses can play a key role in identifying and addressing research questions that lead to improved patient outcome. Thus, we support proposals to enhance nurses' opportunities to pursue academic careers to achieve adequate research skills.

A mouse model to evaluate the interface between skin and a percutaneous device

Percutaneous medical devices are integral in the management and treatment of disease. The space created between the skin and the device becomes a haven for bacterial invasion and biofilm formation and results in infection. We hypothesize that sealing this space via integration of the skin into the device will create a barrier against bacterial invasion. The purpose of this study was to develop an animal model in which the interaction between skin and biomaterials can be evaluated. Porous poly(2-hydroxyethyl methacrylate) [poly(HEMA)] rods were implanted for 7 days in the dorsal skin of C57 BL/6 mice. The porous poly(HEMA) rods were surface-modified with carbonyldiimidazole (CDI) or CDI plus laminin 5; unmodified rods served as control. Implant sites were sealed with 2-octyl cyanoacrylate; corn pads and adhesive dressings were tested for stabilization of implants. All rods remained intact for the duration of the study. There was histological evidence of both epidermal and dermal integration into all poly(HEMA) rods regardless of treatment. This in vivo model permits examination of the implant/skin interface and will be useful for future studies designed to facilitate skin cell attachment where percutaneous devices penetrate the skin.

The cyanoacrylate topical skin adhesives

Each year there are over 7 million lacerations requiring wound closure in the emergency department. Traditionally, most lacerations have been closed with sutures. Topical cyanoacrylate skin adhesives offer many advantages over traditional wound closure devices. Recently, the Food and Drug Administration (FDA) has reclassified the topical skin adhesives. As a result, new topical skin adhesives are expected to enter the market in the near future. This article will review the structure and function of cyanoacrylates as well as their advantages, indications, and usage.

Use of 2-octyl cyanoacrylate for skin closure of sternal incisions in cardiac surgery: observations of microbial barrier effects

INTRODUCTION

The systematic use of 2-octyl cyanoacrylate (2-OCA) became routine in our cardiac unit in 2000. This topical skin adhesive has been used in conjunction with conventional suturing for skin closure and prevention of postoperative wound infections by means of its performance as a microbial barrier to exogenous bacteria. It is, therefore, important to validate its effectiveness in the reduction of infection rates and, consequently, in the length of postoperative hospital stays.

OBJECTIVE

To evaluate the impact of the use of 2-OCA as an add-on measure in the closure of sternotomy incision wounds by comparing postoperative infection rates and length of hospital stays before and after this procedural change.

METHODS

We reviewed the records of 680 patients whose cardiovascular surgery performed between 2000 and 2004 included the use of 2-OCA and an equal number of patients who did not receive the topical skin adhesive (surgeries performed between 1995 and 1999), used as a control group.

RESULTS

From 1995 to 1999 (without the topical skin adhesive) the infection rate was 4.9%. This rate was reduced to 2.1% after the systematic use of the topical skin adhesive (p < 0.001). Superficial and deep infection rates decreased from 4.3% and 0.6% to 2.1% and 0%, respectively. Postoperative hospital stays were also significantly reduced, decreasing from a median of 13 days to 9 days (p < 0.001).

CONCLUSION

From the patient records reviewed in this study, it was found that the routine use of 2-octyl cyanoacrylate as an add-on measure to conventional sutures was associated with a significant reduction in infection rates for cardiovascular surgery patients.