**13. Can mediastinitis be prevented?**

298 Special Topics in Cardiac Surgery

sternal reapproximation include multiple transverse sternal fractures, poor bone stock, costosternal separation, or the requirement for such extensive sternal debridement that reapproximation of the sternal halves is not feasible. Gustafsson en et al have advocated use of serum C-reactive protein levels to guide wound closure timing [95, Figure 6]. C-reactive protein levels less than 70 mg/L corresponded with successful sternal reapproximation [95]. Successes have also been reported with sternal plating as a treatment for the fractured sternum [11, 96], but our approach has been conservative in this regard since any residual

Numerous clinical advantages for DSWI management protocols incorporating NPT have been observed, many centered upon the sternal stabilization achieved when vacuumassisted clousure is engaged [70]. The sternal stability afforded by NPT improves pain compared with open packing or other approaches for addressing the infected mediastinum [88]. In addition, the stabilized sternum yields several pulmonary benefits, the first of which is the ability to successfully separate from mechanical ventilation. This promotes earlier and more effective patient mobilization and prevents the patient from being confined to bed, where other complications common to DSWI therapy are often incurred [70]. Negative pressure therapy also improves ventilation and overall pulmonary function and leads to more effective chest physiotherapy [70, 97]. Importantly, no deleterious hemodynamic

It has been estimated that approximately 15% of patients develop recurrent infection [98]. In the experience of Bapat et al, this has included recurrent infection with the same organism associated with the original sternal infection [99], and we speculate that if the polyurethane foam required for NPT is not adequately inserted with each dressing change, small, isolated spaces may arise within the wound that can become superinfected. We recently reported rates of recurrent wound complications associated with various mediastinal flap coverages. For example, muscle flap repair of the treated mediastinum, consisting predominantly of pectoralis muscle flaps, was associated with increased rates of recurrent wound complications such as hematoma, seromas, and recurrent infection [14]. Conversely, use of NPT prior to definitive repair of the sternal wound defect was associated with increased rates of successful secondary sternal closure without the need for any flap transfer, and with shortened length of hospital stay after definitive repair. Excellent results have been reported elsewhere when NPT is incorporated into

Petzina et al recently reported a 7.2% rate of "major complications" associated with NPT for DSWI in a cohort of 69 patients. Most complications were bleeding-related [100]. On the other hand, cardiac function and hemodynamics appear to be stable during NPT to the open

When NPT is used, caution should be exercised with regard to the length of therapy. In our own experience, prolonged use of NPT leads to a "frozen" mediastinum, making subsequent closure by vascularized flaps or other technique difficult to perform and places the cardiac structures at risk for injury during subsequent sternal repair. Others have noted the similar difficultiess [99]. In such cases, continued application of NPT to closure by secondary intent may be the best therapeutic option rather than to place the mediastinal

infectious process could contaminate the implanted hardware [91].

effects of NPT have been documented although this has been speculated [70].

**12. Complications of treating mediastinitis** 

management protocols for DSWI [65].

structures at risk for injury during attempted flap repair.

mediastinal wound [101, 102].

Loop has stated: "prevention and better treatment of sternal wound complications must be a major goal in assuring the highest quality of cardiovascular care…[5]. Although most efforts towards DSWI have focused on the treatment of DSWI, several methods to reduce rates of mediastinitis have been proposed and validated recently. As a result, efforts to prevent mediastinal infection may already be working. For instance, investigators from Boston recently reported on their experience with DSWI between 1992 and 2006, separating analysis into early and late time periods. They noted that DSWI had decreased from 1.57% to 0.88% over the last 5 years of their analysis and attributed the positive findings to adoption of strict glucose control algorithms [40]. Tight glycemic control appears to be effective in significantly reducing rates of DSWI. [30, 103]. In addition, Lazar et al demonstrated improved coronary surgery outcomes with a strategy for strict glucose control (125 – 200 mg/dL) using glucose-insulin-potassium solution, including reduced ischemic events and improved rates of wound infection in a cohort of diabetic patients undergoing CABG [31].

Antimicrobial therapy has also positively impacted rates of DSWI. Most notably, appropriate timing and selection of preoperative antibiotics has been associated with reduced rates of sugical site infection [6, 104]. Furthermore, use of nasal mupirocin in patients undergoing cardiac surgery via median sternotomy eradicates 95 – 100% of *S. aureus* for up to one year postoperatively [105], and sternal wound infections are also reduced by nearly 2/3 in some series with the use of mupirocin in patients colonized with *S. aureus* [106, 107].

Technical details of the median sternotomy incision and closure almost certainly impact the likelihood for DSWI postoperatively. Baskett et al have argued that assiduously following technical details and proper surgical and aseptic techniques can also dramatically reduce rates of poststernotomy infection [42]. They emphasize the importance of accurate reapproximation of the sternal halves and caution against the use of bone wax to gain sternal hemostasis [42]. Since sternal instability is often evoked as one mechanism contributing to the development of sternal infection, evaluation of the most effective sternal closure methods has been undertaken. For example, Schimmer et al compared standard closure techniques by transsternal or peristernal wiring with techniques using additional lateral wire reinforcement in the method described by Robicsek in a cohort of 815 high-risk patients [108]. There were no differences observed in the rates of sternal dehiscence or superficial or deep sternal wound infections, but they did show that more sternal wires placed for closure was associated with significantly reduced rates of DSWI [108]. Others have emphasized that rigid sternal closure techniques are preferred, particularly in those considered at high risk for sternal wound complications such as dehiscence and infection. These techniques are widely used in most surgical practices that incorporate osteotomy incisions. In fact, cardiac surgery is now the only discipline not routinely repairing osteotomies with rigid plating techniques [109]. Lee et al recently reported their experience with titanium plate fixation of the sternum in 750 patients at high risk for sternal wound complications, noting 97.6% freedom from sternal infection or dehiscence [110]. Levin et al have also introduced another form of rigid sternal closure as an alterntive to wire circlage and highlighted advantages to this approach [111]. Although rigid sternal closure techniques have not been compared prospectively with wire circlage, cadaveric studies have shown rigid plate fixation techniques to be superior to wire circlage by providing increased stiffness to the wound closure and less lateral displacement of the sternal halves [112].

Sternal Wound Complications Following Cardiac Surgery 301

Deep sternal wound infections remain dreaded and deadly complications associated with cardiac surgery. However, incremental improvements have been made recently with regard to lowering rates of observed infections due to a variety of measures. In addition, it appears that management of DSWI with negative pressure therapy alleviates the impact of this condition on short- and long-term survival. Further investigation is needed to determine the potential impact of negative pressure therapy on closed incisions as a novel method to

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**14. Conclusions** 

**15. References** 

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Other suggested techniques for reducing the incidence of DSWI include ensuring true midline sternotomy as this is thought to preserve periosteal blood flow and limits transverse sternal fractures which contribute to sternal nonunionn and instability [42, 44]. Since sternal ischemia is thought to play an important role in most cases of DSWI, limiting the length of internal mammary artery harvested for use as a coronary artery bypass conduit or avoiding its use altogether in prohibitively high risk patients may help to reduce DSWI [44]. Harvesting the internal mammary artery as a skeletonized conduit is also preferable to harvesting the graft as a pedicle since this preserves more peristernal blood flow [113]. Finally, sternal foreign bodies that may impede bony union, especially bone wax, should be avoided [42, 44]. In contrast, vancomycin paste or gentamicin-soaked absorbable sponges applied to the sternum upon closure have been shown to reduce rates of sternal bacterial contamination [114, 115]. However a more recent randomized controlled trial evaluating the impact of gentamicin-soaked collagen sponge on poststernotomy wound infection did not show an advantage of this approach over controls [116].

Based on the aforementioned successes with NPT in the treatment of documented DSWI we and others have recently evaluated the application of NPT to clean, closed incisions as a method to prevent complications in high-risk wounds [117, 118]. We initially applied this form of "well wound therapy" in a cohort of 57 adult cardiac surgery patients known to be at increased risk for DSWI based on a validated risk stratification model [13]. No cases of superficial or deep sternal wound infections were noted although the group had an estimated 6% risk for DSWI [118]. This form of NPT was noted to be easy to apply, welltolerated by the patients, and was also judged to be cost-effective when utilized in patients with increased demonstrated risk for DSWI [117]. Since the time of the original report, we have used this novel wound treatment system in over 200 high risk patients and continue to observe reduce rates of sternal wound complications (unpublished data). However, residual problems have been encountered with gross technical errors including off-center sternal incisions, sternal fractures, and costo-sternal separation.

The mechanisms underlying such positive clinical findings are not well understood, but based on well described mechanisms of vacuum-assisted therapy in open incisions, it is hypothesized that applying NPT to the closed incision also favorably affects wound perfusion. Therefore, we assessed peristernal perfusion after median sternotomy and under various degrees of reduced native sternal perfusion as a result of mammary artery harvesting using laser Doppler flowmetry, demonstrating that after median sternotomy and IMA harvesting, peristernal perfusion is significantly reduced and recovers little in the first 4 postoperative days [119]. However, NPT applied to the closed incision increases peristernal perfusion compared with controls regardless of the status of the ipsilateral IMA, providing a rare piece of physiologic evidence for the efficacy of NPT and supports use of NPT as a form of "well wound therapy," particularly in patients at high-risk for sternotomy complications [119] These findings are clinically important and relevant, implying that NPT can augment peristernal soft tissue perfusion made relatively ischemic by IMA harvesting. Although this study does not address bony perfusion, per se, Fokin et al proposed that substrate diffusion through peristernal tissues may be an important mechanism to maintain perfusion in sternal wounds rendered ischemic by mammary artery harvesting until collateral blood supply to the sternum is well-established [120, 121]. If so, NPT may indeed augment sternal and/or periosteal perfusion via improved peristernal "diffusion" through improved soft tissue perfusion.

### **14. Conclusions**

300 Special Topics in Cardiac Surgery

Other suggested techniques for reducing the incidence of DSWI include ensuring true midline sternotomy as this is thought to preserve periosteal blood flow and limits transverse sternal fractures which contribute to sternal nonunionn and instability [42, 44]. Since sternal ischemia is thought to play an important role in most cases of DSWI, limiting the length of internal mammary artery harvested for use as a coronary artery bypass conduit or avoiding its use altogether in prohibitively high risk patients may help to reduce DSWI [44]. Harvesting the internal mammary artery as a skeletonized conduit is also preferable to harvesting the graft as a pedicle since this preserves more peristernal blood flow [113]. Finally, sternal foreign bodies that may impede bony union, especially bone wax, should be avoided [42, 44]. In contrast, vancomycin paste or gentamicin-soaked absorbable sponges applied to the sternum upon closure have been shown to reduce rates of sternal bacterial contamination [114, 115]. However a more recent randomized controlled trial evaluating the impact of gentamicin-soaked collagen sponge on poststernotomy wound infection did not show an advantage of this approach over

Based on the aforementioned successes with NPT in the treatment of documented DSWI we and others have recently evaluated the application of NPT to clean, closed incisions as a method to prevent complications in high-risk wounds [117, 118]. We initially applied this form of "well wound therapy" in a cohort of 57 adult cardiac surgery patients known to be at increased risk for DSWI based on a validated risk stratification model [13]. No cases of superficial or deep sternal wound infections were noted although the group had an estimated 6% risk for DSWI [118]. This form of NPT was noted to be easy to apply, welltolerated by the patients, and was also judged to be cost-effective when utilized in patients with increased demonstrated risk for DSWI [117]. Since the time of the original report, we have used this novel wound treatment system in over 200 high risk patients and continue to observe reduce rates of sternal wound complications (unpublished data). However, residual problems have been encountered with gross technical errors including off-center sternal

The mechanisms underlying such positive clinical findings are not well understood, but based on well described mechanisms of vacuum-assisted therapy in open incisions, it is hypothesized that applying NPT to the closed incision also favorably affects wound perfusion. Therefore, we assessed peristernal perfusion after median sternotomy and under various degrees of reduced native sternal perfusion as a result of mammary artery harvesting using laser Doppler flowmetry, demonstrating that after median sternotomy and IMA harvesting, peristernal perfusion is significantly reduced and recovers little in the first 4 postoperative days [119]. However, NPT applied to the closed incision increases peristernal perfusion compared with controls regardless of the status of the ipsilateral IMA, providing a rare piece of physiologic evidence for the efficacy of NPT and supports use of NPT as a form of "well wound therapy," particularly in patients at high-risk for sternotomy complications [119] These findings are clinically important and relevant, implying that NPT can augment peristernal soft tissue perfusion made relatively ischemic by IMA harvesting. Although this study does not address bony perfusion, per se, Fokin et al proposed that substrate diffusion through peristernal tissues may be an important mechanism to maintain perfusion in sternal wounds rendered ischemic by mammary artery harvesting until collateral blood supply to the sternum is well-established [120, 121]. If so, NPT may indeed augment sternal and/or periosteal perfusion via improved peristernal "diffusion" through

incisions, sternal fractures, and costo-sternal separation.

improved soft tissue perfusion.

controls [116].

Deep sternal wound infections remain dreaded and deadly complications associated with cardiac surgery. However, incremental improvements have been made recently with regard to lowering rates of observed infections due to a variety of measures. In addition, it appears that management of DSWI with negative pressure therapy alleviates the impact of this condition on short- and long-term survival. Further investigation is needed to determine the potential impact of negative pressure therapy on closed incisions as a novel method to prevent sternal wound complications.

### **15. References**


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