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The Annals of Thoracic Surgery, Vol 40, 214-223, Copyright © 1985 by The Society of Thoracic Surgeons
EA Grossi, AT Culliford, KH Krieger, D Kloth, R Press, FG Baumann and FC Spencer
Sternal wound infections developed following 77 (0.97%) of 7,949 operative
procedures involving median sternotomy at New York University Medical
Center from 1976 to 1984. Risk factors associated with the development of a
sternal wound infection included combined revascularization and valve
replacement, early reexploration for bleeding, prolonged low cardiac output
syndrome, and prolonged ventilatory support (greater than 24 hours).
Concomitant infection at other sites with the same organism as cultured
from the sternum was present in 42% of the patients. Thirty-seven patients
(48%) were treated with radical debridement followed by closed antibiotic
irrigation. In 31 other patients (40%), the wounds were debrided and left
to heal by open granulation. Both initial treatments had equally high
success rates (78.4% and 74.2%, respectively). However, the open
granulation method resulted in a hospital stay that was an average of 10
days longer than the closed antibiotic irrigation method. Muscle flaps were
used to expedite healing of open granulation in 9 patients. Analysis of the
results of different treatment strategies revealed that if debridement was
accomplished within 20 days of the initial cardiac procedure, 76% of the
patients could be successfully treated with closed antibiotic irrigation.
Conversely, if treatment was delayed for longer than 20 days, 81% of the
patients were treated with open granulation (p less than 0.001). Also noted
was an inverse relationship between the serum blood urea nitrogen (BUN)
level and the success rate of initial treatment with closed antibiotic
irrigation. Patients with a serum BUN level of less than 40 mg/dl at the
time of debridement had a 90% success rate as opposed to a success rate of
38% when the BUN level was 40 mg/dl or greater. The data presented suggest
the following conclusions. Early diagnosis is crucial to successful
treatment of sternal wound infection. When diagnosis can be established
within 20 days, 80% of infections can be eradicated by the simple approach
of debridement and closed antibiotic irrigation. When diagnosis is delayed,
however, prompt debridement followed by muscle flaps is the procedure of
choice. Open granulation alone, while successful, unnecessarily prolongs
the hospital course.
ARTICLES
A survey of 77 major infectious complications of median sternotomy: a review of 7,949 consecutive operative procedures
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