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Kamensek T, Kalisnik JM, Ledwon M, Santarpino G, Fittkau M, Vogt FA, Zibert J. Improved early risk stratification of deep sternal wound infection risk after coronary artery bypass grafting. J Cardiothorac Surg 2024; 19:93. [PMID: 38355514 PMCID: PMC10865600 DOI: 10.1186/s13019-024-02570-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2023] [Accepted: 01/30/2024] [Indexed: 02/16/2024] Open
Abstract
BACKGROUND Deep sternal wound infection (DSWI) following open heart surgery is associated with excessive morbidity and mortality. Contemporary DSWI risk prediction models aim at identifying high-risk patients with varying complexity and performance characteristics. We aimed to optimize the DSWI risk factor set and to identify additional risk factors for early postoperative detection of patients prone to DSWI. METHODS Single-centre retrospective analysis of patients with isolated multivessel coronary artery disease undergoing myocardial revascularization at Paracelsus Medical University Nuremberg between 2007 and 2022 was performed to identify risk factors for DSWI. Three data sets were created to examine preoperative, intraoperative, and early postoperative parameters, constituting the "Baseline", the "Improved Baseline" and the "Extended" models. The "Extended" data set included risk factors that had not been analysed before. Univariable and stepwise forward multiple logistic regression analyses were performed for each respective set of variables. RESULTS From 5221 patients, 179 (3.4%) developed DSWI. The "Extended" model performed best, with the area under the curve (AUC) of 0.80, 95%-CI: [0.76, 0.83]. Pleural effusion requiring intervention, postoperative delirium, preoperative hospital stay > 24 h, and the use of fibrin sealant were new independent predictors of DSWI in addition to age, Diabetes Mellitus on insulin, Body Mass Index, peripheral artery disease, mediastinal re-exploration, bilateral internal mammary harvesting, acute kidney injury and blood transfusions. CONCLUSIONS The "Extended" regression model with the short-term postoperative complications significantly improved DSWI risk discrimination after surgical revascularization. Short preoperative stay, prevention of postoperative delirium, protocols reducing the need for evacuation of effusion and restrictive use of fibrin sealant for sternal closure facilitate DSWI reduction. TRIAL REGISTRATION The registered retrospective study was registered at the study centre and approved by the Institutional Review Board of Paracelsus Medical University Nuremberg (IRB-2019-005).
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Affiliation(s)
- Tina Kamensek
- Faculty of Health Sciences, University of Ljubljana, Zdravstvena pot 5, Ljubljana, 1000, Slovenia
| | - Jurij Matija Kalisnik
- Department of Cardiac Surgery, Klinikum Nuremberg, Paracelsus Medical University, Breslauer Str. 201, 90471, Nuremberg, Germany.
- Faculty of Medicine, University of Ljubljana, Vrazov trg 2, Ljubljana, 1000, Slovenia.
- Department of Cardiothoracic and Vascular Surgery, University of Graz affiliated Clinic KABEG, Klagenfurt am Wörthersee, Feschnigstrasse 11, Klagenfurt, 9020, Austria.
| | - Mirek Ledwon
- Department of Cardiac Surgery, Klinikum Nuremberg, Paracelsus Medical University, Breslauer Str. 201, 90471, Nuremberg, Germany
| | - Giuseppe Santarpino
- Paracelsus Medical University, Campus Nuremberg, Ernst Nathan Straße 1, 90419, Nuremberg, Germany
| | - Matthias Fittkau
- Department of Cardiac Surgery, Klinikum Nuremberg, Paracelsus Medical University, Breslauer Str. 201, 90471, Nuremberg, Germany
| | - Ferdinand Aurel Vogt
- Paracelsus Medical University, Campus Nuremberg, Ernst Nathan Straße 1, 90419, Nuremberg, Germany
| | - Janez Zibert
- Faculty of Health Sciences, University of Ljubljana, Zdravstvena pot 5, Ljubljana, 1000, Slovenia
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Traylor LB, Bhatia G, Blackhurst D, Wallenborn G, Ewing A, Bolton W, Davis B. Efficacy of incisional negative pressure therapy in preventing post-sternotomy wound complications. Am J Surg 2023; 226:762-767. [PMID: 37453803 DOI: 10.1016/j.amjsurg.2023.07.016] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2023] [Revised: 07/03/2023] [Accepted: 07/10/2023] [Indexed: 07/18/2023]
Abstract
BACKGROUND Sternal wound infections represent a source of significant morbidity and mortality following median sternotomy. The use of incisional negative pressure wound therapy in prevention has yet to be elucidated. METHODS A retrospective study was conducted before and after a universal wound care protocol was implemented including the prophylactic use of negative pressure wound therapy (NPWT). The primary endpoint was sternal infections within 90 days of the index operation. RESULTS In the control period, there was a 3.0% rate of sternal infection within 90 days compared to 0.8% in the intervention period (p < 0.001). An odds ratio of 0.25 (95% confidence interval 0.11, 0.57; p < 0.001) in the intervention period as compared to the control period was demonstrated. CONCLUSIONS The use of a standardized wound care protocol including the universal application of NPWT for patients undergoing cardiac surgery with median sternotomy was an independent predictor of decreased rates of sternal infection.
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Affiliation(s)
- L B Traylor
- University of South Carolina School of Medicine Greenville, Greenville, SC, 29605, USA
| | - G Bhatia
- Prisma Health - Upstate, Greenville, SC, 29605, USA.
| | - D Blackhurst
- Prisma Health - Upstate, Greenville, SC, 29605, USA
| | - G Wallenborn
- Prisma Health - Upstate, Greenville, SC, 29605, USA
| | - A Ewing
- Prisma Health - Upstate, Greenville, SC, 29605, USA
| | - W Bolton
- Prisma Health - Upstate, Greenville, SC, 29605, USA
| | - B Davis
- Prisma Health - Upstate, Greenville, SC, 29605, USA
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Song Y, Chu W, Zhang M, Liu Z, Li D, Zhao F, Zhang B, Gao M, Yuan H, Shen C. A study on the preoperative risk factors for primary healing failure in the reconstruction of deep sternal wound infection with platelet-rich plasma and negative pressure trauma therapy. Int Wound J 2023; 20:3457-3466. [PMID: 37269235 PMCID: PMC10588312 DOI: 10.1111/iwj.14216] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2023] [Revised: 04/12/2023] [Accepted: 04/17/2023] [Indexed: 06/05/2023] Open
Abstract
Deep sternal wound infection (DSWI) is a relatively complex wound in wound reconstruction surgery. Because plastic surgeons deal with DSWI patients late. The primary healing (healing by first intention) after reconstruction of DSWI is restricted by many preoperative risk factors. The purpose of this study is to explore and analyse the risk factors of primary healing failure in patients with DSWI treated with platelet-rich plasma (PRP) and negative pressure trauma therapy (NPWT). 115 DSWI patients treated with the PRP and NPWT (PRP + NPWT) modality were retrospectively (2013-2021) analysed. They were divided into two groups according to primary healing results after the first PRP + NPWT treatment. Univariate and multivariate analyses were used to compare the data of the two groups to find out the risk factors and their optimal cut-off values were identified by ROC analysis. The primary healing results, debridement history, wound size, sinus, osteomyelitis, renal function, bacterial culture, albumin (ALB), platelet (PLT) between the two groups were significantly different (P < 0.05). Binary logistic regression showed that osteomyelitis, sinus, ALB and PLT were the risk factors affecting primary healing outcomes (P < 0.05). ROC analysis showed that AUC for ALB in the non-primary healing group was 0.743 (95% CI: 0.650-0.836, P < 0.05) and its optimal cutoff value of 31 g/L was associated with primary healing failure with a sensitivity of 96.9% and specificity of 45.1%. AUC for PLT in the non-primary healing group was 0.670 (95% CI: 0.571 ~ 0.770, P < 0.05) its optimal cutoff value of 293 × 109 /L was associated with primary healing failure with a sensitivity of 72.5% and specificity of 56.3%. In the cases included in this study, the success rate of primary healing of DSWI treated with PRP + NPWT was not affected by the most common preoperative risk factors for wound non-union. It is indirectly confirmed that PRP + NPWT is an ideal treatment. However, it should be noted that it will still be adversely affected by sinus osteomyelitis, ALB and PLT. The patients need to be carefully evaluated and corrected before reconstruction.
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Affiliation(s)
- Yaoyao Song
- Department of Burns and Plastic SurgeryFourth Medical Center of Chinese PLA General Hospital, (PLA:People's Liberation Army)BeijingChina
| | - Wanli Chu
- Department of Burns and Plastic SurgeryFourth Medical Center of Chinese PLA General Hospital, (PLA:People's Liberation Army)BeijingChina
| | - Ming Zhang
- Department of Burns and Plastic SurgeryFourth Medical Center of Chinese PLA General Hospital, (PLA:People's Liberation Army)BeijingChina
| | - Zhaoxing Liu
- Department of Burns and Plastic SurgeryFourth Medical Center of Chinese PLA General Hospital, (PLA:People's Liberation Army)BeijingChina
| | - Dawei Li
- Department of Burns and Plastic SurgeryFourth Medical Center of Chinese PLA General Hospital, (PLA:People's Liberation Army)BeijingChina
| | - Fan Zhao
- Department of Burns and Plastic SurgeryFourth Medical Center of Chinese PLA General Hospital, (PLA:People's Liberation Army)BeijingChina
| | - Bohan Zhang
- Department of Burns and Plastic SurgeryFourth Medical Center of Chinese PLA General Hospital, (PLA:People's Liberation Army)BeijingChina
| | - Mengmeng Gao
- Department of Burns and Plastic SurgeryFourth Medical Center of Chinese PLA General Hospital, (PLA:People's Liberation Army)BeijingChina
| | - Huageng Yuan
- Department of Burns and Plastic SurgeryFourth Medical Center of Chinese PLA General Hospital, (PLA:People's Liberation Army)BeijingChina
| | - Chuanan Shen
- Department of Burns and Plastic SurgeryFourth Medical Center of Chinese PLA General Hospital, (PLA:People's Liberation Army)BeijingChina
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Song Y, Chu W, Sun J, Liu X, Zhu H, Yu H, Shen C. Review on risk factors, classification, and treatment of sternal wound infection. J Cardiothorac Surg 2023; 18:184. [PMID: 37208736 DOI: 10.1186/s13019-023-02228-y] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2022] [Accepted: 04/02/2023] [Indexed: 05/21/2023] Open
Abstract
Sternal wound infection (SWI) is the most common complication of the median sternal incision. The treatment time is long, and the reconstruction is difficult, which causes challenges for surgeons. Plastic surgeons were often involved too late in such clinical scenarios when previous empirical treatments failed and the wound damage was relatively serious. Accurate diagnosis and risk factors against sternal wound infection need to be in focus. Classification of different types of sternotomy complications post-cardiac surgery is important for specific categorization and management. Not familiar with this kind of special and complex wound, objectively increasing the difficulty of wound reconstruction. The purpose of this comprehensive review is to review the literature, introduce various SWI risk factors related to wound nonunion, various classification characteristics, advantages and disadvantages of various wound reconstruction strategies, to help clinicians understand the pathophysiological characteristics of the disease and choose a better treatment method.
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Affiliation(s)
- Yaoyao Song
- Senior Department of Burns and Plastic Surgery, Fourth Medical Center of Chinese PLA General Hospital, No. 51, Fucheng Road, Haidian District, Beijing, 100048, China
| | - Wanli Chu
- Senior Department of Burns and Plastic Surgery, Fourth Medical Center of Chinese PLA General Hospital, No. 51, Fucheng Road, Haidian District, Beijing, 100048, China
| | - Jiachen Sun
- Senior Department of Burns and Plastic Surgery, Fourth Medical Center of Chinese PLA General Hospital, No. 51, Fucheng Road, Haidian District, Beijing, 100048, China
| | - Xinzhu Liu
- Senior Department of Burns and Plastic Surgery, Fourth Medical Center of Chinese PLA General Hospital, No. 51, Fucheng Road, Haidian District, Beijing, 100048, China
| | - Hongjuan Zhu
- Senior Department of Burns and Plastic Surgery, Fourth Medical Center of Chinese PLA General Hospital, No. 51, Fucheng Road, Haidian District, Beijing, 100048, China
| | - Hongli Yu
- Senior Department of Burns and Plastic Surgery, Fourth Medical Center of Chinese PLA General Hospital, No. 51, Fucheng Road, Haidian District, Beijing, 100048, China
| | - Chuan'an Shen
- Senior Department of Burns and Plastic Surgery, Fourth Medical Center of Chinese PLA General Hospital, No. 51, Fucheng Road, Haidian District, Beijing, 100048, China.
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Perezgrovas-Olaria R, Audisio K, Cancelli G, Rahouma M, Ibrahim M, Soletti GJ, Chadow D, Demetres M, Girardi LN, Gaudino M. Deep Sternal Wound Infection and Mortality in Cardiac Surgery: A Meta-analysis. Ann Thorac Surg 2023; 115:272-280. [PMID: 35618048 DOI: 10.1016/j.athoracsur.2022.04.054] [Citation(s) in RCA: 13] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/07/2022] [Revised: 04/20/2022] [Accepted: 04/23/2022] [Indexed: 12/31/2022]
Abstract
BACKGROUND Deep sternal wound infection (DSWI) is a rare but severe complication after cardiac surgical procedures and has been associated with increased early morbidity and mortality. Studies reporting long-term outcomes in patients with DSWI have shown contradictory results. We performed a study-level meta-analysis evaluating the impact of DSWI on short- and long-term clinical outcomes. METHODS A systematic literature search was conducted to identify studies comparing short- and long-term outcomes of patients submitted to cardiac surgical procedures who developed DSWI and patients who did not. The primary outcome was overall mortality. Secondary outcomes were in-hospital mortality, follow-up mortality, major adverse cardiovascular events, myocardial infarction, and repeat revascularization. Postoperative outcomes were also investigated. RESULTS Twenty-four studies totaling 407 829 patients were included. Overall, 6437 (1.6%) patients developed DSWI. Mean follow-up was 3.5 years. DSWI was associated with higher overall mortality (incidence rate ratio [IRR], 1.99; 95% CI, 1.66-2.38; P < .001), in-hospital mortality (odds ratio, 3.30; 95% CI, 1.88-5.81; P < .001), follow-up mortality (IRR, 2.02; 95% CI, 1.39-2.94; P = .001), and major adverse cardiovascular events (IRR, 2.04; 95% CI, 1.60-2.59; P < .001). No differences in myocardial infarction and repeat revascularization were found, but limited studies reported those outcomes. DSWI was associated with longer postoperative hospitalization, stroke, myocardial infarction, and respiratory and renal failure. Sensitivity analyses on isolated coronary artery bypass grafting studies and by adjustment method were consistent with the main analysis. CONCLUSIONS Compared with patients who did not develop DSWI, patients with DSWI after cardiac surgical procedures had increased risk of death as well as short- and long-term adverse clinical outcomes.
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Affiliation(s)
| | - Katia Audisio
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York, New York
| | - Gianmarco Cancelli
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York, New York
| | - Mohamed Rahouma
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York, New York
| | - Mudathir Ibrahim
- Department of General Surgery, Maimonides Medical Center, Brooklyn, New York
| | - Giovanni Jr Soletti
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York, New York
| | - David Chadow
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York, New York
| | - Michelle Demetres
- Samuel J. Wood Library and C.V. Starr Biomedical Information Centre, Weill Cornell Medicine, New York, New York
| | - Leonard N Girardi
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York, New York
| | - Mario Gaudino
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York, New York.
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6
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Gaudino M, Audisio K, Rahouma M, Robinson NB, Soletti GJ, Cancelli G, Masterson Creber RM, Gray A, Lees B, Gerry S, Benedetto U, Flather M, Taggart DP. Association between sternal wound complications and 10-year mortality following coronary artery bypass grafting. J Thorac Cardiovasc Surg 2021:S0022-5223(21)01812-2. [PMID: 35063171 DOI: 10.1016/j.jtcvs.2021.10.067] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/24/2021] [Revised: 10/12/2021] [Accepted: 10/15/2021] [Indexed: 01/11/2023]
Abstract
OBJECTIVE To evaluate the association between sternal wound complications (SWC) and long-term mortality in the Arterial Revascularization Trial. METHODS Participants in the Arterial Revascularization Trial were stratified according to the occurrence of postoperative SWC. The primary outcome was all-cause mortality at long-term follow-up. The secondary outcome was major adverse cardiovascular events. RESULTS Three thousand one hundred two patients were included in the analysis; the median follow-up was 10 years. 115 patients (3.7%) had postoperative SWC: 85 (73.9%) deep sternal wound infections and 30 (26.1%) sterile SWC that required sternal reconstruction. Independent predictors of SWC included diabetes (odds ratio [OR], 2.77; 95% CI, 1.79-4.30; P < .001), female sex (OR, 2.73; 95% CI, 1.71-4.38; P < .001), prior stroke (OR, 2.59; 95% CI, 1.12-5.98; P = .03), chronic obstructive pulmonary disease (OR, 2.44; 95% CI, 1.60-3.71; P < .001), and use of bilateral internal thoracic artery (OR, 1.70; 95% CI, 1.12-2.59; P = .01). Postoperative SWC was significantly associated with long-term mortality. The Kaplan-Meier survival estimate was 91.3% at 5 years and 79.4% at 10 years in patients without SWC, and 86.1% and 64.3% in patients with SWC (log rank P < .001). The rate of major adverse cardiovascular events was also higher among patients who had SWC (n = 51 [44.3%] vs 758 [25.4%]; P < .001). Using multivariable analysis, the occurrence of SWC was independently associated with long-term mortality (hazard ratio, 1.81; 95% CI, 1.30-2.54; P < .001). CONCLUSIONS In the Arterial Revascularization Trial, postoperative SWC although uncommon were significantly associated with long-term mortality.
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Affiliation(s)
- Mario Gaudino
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York City, NY.
| | - Katia Audisio
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York City, NY
| | - Mohamed Rahouma
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York City, NY
| | - N Bryce Robinson
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York City, NY
| | - Giovanni J Soletti
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York City, NY
| | - Gianmarco Cancelli
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York City, NY
| | - Ruth M Masterson Creber
- Division of Health Informatics, Department of Population Health Sciences, Weill Cornell Medicine, New York City, NY
| | - Alastair Gray
- Nuffield Department of Population Health, Health Economics Research Centre, University of Oxford, Oxford, United Kingdom
| | - Belinda Lees
- Nuffield Department of Surgical Sciences, John Radcliffe Hospital, University of Oxford, Oxford, United Kingdom
| | - Stephen Gerry
- Centre for Statistics in Medicine, Nuffield Department of Orthopaedics, Rheumatology & Musculoskeletal Sciences, University of Oxford, Oxford, United Kingdom
| | - Umberto Benedetto
- Bristol Heart Institute, School of Clinical Sciences, University of Bristol, Bristol, United Kingdom
| | - Marcus Flather
- Norwich Medical School, University of East Anglia, Norwich, United Kingdom
| | - David P Taggart
- Nuffield Department of Surgical Sciences, John Radcliffe Hospital, University of Oxford, Oxford, United Kingdom
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Gutsche JT, Grant MC, Kiefer JJ, Ghadimi K, Lane-Fall MB, Mazzeffi MA. The Year in Cardiothoracic Critical Care: Selected Highlights from 2019. J Cardiothorac Vasc Anesth 2020; 36:45-57. [PMID: 33051148 DOI: 10.1053/j.jvca.2020.09.114] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/15/2020] [Accepted: 09/16/2020] [Indexed: 11/11/2022]
Abstract
In 2019, cardiothoracic and vascular critical care remained an important focus and subspecialty. This article continues the annual series to review relevant contributions in postoperative critical care that may affect the cardiac anesthesiologist. Herein, the pertinent literature published in 2019 is explored and organized by organ system.
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Affiliation(s)
- J T Gutsche
- Department of Anesthesiology and Critical Care, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA.
| | - M C Grant
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
| | - J J Kiefer
- Department of Anesthesiology and Critical Care, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - K Ghadimi
- Department of Anesthesiology and Critical Care, Duke University, Durham, NC
| | - M B Lane-Fall
- Department of Anesthesiology and Critical Care, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - M A Mazzeffi
- Department of Anesthesiology, University of Maryland School of Medicine, Baltimore, MD
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