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Ann Thorac Surg 2000;69:1152-1154
© 2000 The Society of Thoracic Surgeons

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ORIGINAL ARTICLES: CARDIOVASCULAR

Is early tracheostomy safe in cardiac patients with median sternotomy incisions?

^a Department of Cardiothoracic Surgery, Royal Infirmary of Edinburgh, Edinburgh, Scotland, United Kingdom

Address reprint requests to Dr Campanella, Department of Cardiothoracic Surgery, Edinburgh Royal Infirmary, Lauriston Pl, Edinburgh EH3 9YW, Scotland

	Abstract

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Background. Tracheostomy after cardiac operation through a median sternotomy is believed to increase the risk of mediastinitis, leading to debate as to whether early tracheostomy is safe in these patients.

Methods. A record search of patients undergoing cardiac operation through median sternotomy was done. Day and duration of tracheostomy were correlated to day of positive bacteriological evidence and clinical outcome for the patient. The method of tracheostomy was also recorded.

Results. Of 174 cases, 4 patients had mediastinitis, 3 before tracheostomy was performed. Of these three patients, 2 survived and the third died of multiorgan failure 46 days after the procedure. The fourth patient, on immunosuppressive therapy for severe rheumatoid arthritis and pulmonary fibrosis, had tracheostomy performed at primary operation, developed fatal mediastinitis after 6 days, and died 18 days postoperatively of multiorgan failure. Of the tracheostomies performed, 24 (14%) were percutaneous, and 110 (63%) were achieved using standard surgical techniques (in 40 cases type was unrecorded). In 72 cases (41%), tracheostomy was performed on or before day 7, 11 (6%) being performed before 48 hours. Mortality occurred in 38 (22%).

Conclusions. There is no demonstrable relationship between early tracheostomy and mediastinitis in median sternotomy patients.

	Introduction

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Much has been written about different types of tracheostomy and their short and long-term complications [1–4], but there has been little described in the context of cardiac operation patients.

A commonly held belief, propagated in textbooks [5, 6] is that tracheostomy, especially early tracheostomy, increases the risk of mediastinitis in patients who have had median sternotomies. In addition, Marshall and colleagues suggested bilateral incisions for a cardiac bypass patient with a tracheostomy in situ preoperatively [7]. Hubner and others [8] reported the results of 45 percutaneous tracheostomies (median postoperative day of tracheostomy, day 6) citing no cases of mediastinitis. Similarly, a series from Northwestern University [9] analyzed the postoperative outcomes of patients undergoing prolonged ventilation and reported no cases of mediastinitis. Prolonged ventilation postcardiac operation is a recognized risk factor for mediastinal infection [10–12]. Our study aims, by reviewing case notes in our institution over a 13-year period, to determine the incidence of mediastinitis in patients with tracheostomies who have had cardiac operation performed through a median sternotomy.

	Material and methods

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Using the patient data held on the hospital mainframe computer, we searched for key words, median sternotomy or tracheostomy, to isolate case note numbers. These key words were taken from the computerized discharge summaries, which included detailed operation and procedure notes.

Apart from procedural details, five parameters were extracted from the notes: (1) postoperative day that tracheostomy was sited; (2) duration of tracheostomy in situ; (3) bacteriological isolates from the median sternotomy wound and the day of isolation; (4) bacteriological isolates from the tracheostomy wound and the day of isolation; and (5) clinical outcome of patient (based on the diagnosis of mediastinitis by clinical evidence of deep-seated mediastinal pus requiring evacuation and resulting in hemodynamic derangement and septicemia).

	Results

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A 13-year period from 1986 to 1997 yielded 9,900 patients who had median sternotomies, and of these, 179 (1.8%) had tracheostomies during the same admission period.

Nine case notes were unavailable to us, and in these the information was obtained from the detailed discharge summaries. No information was available for 5. Of the resultant 174 patients, 108 underwent coronary artery bypass operations (62%), 73 valvular operations (42%), and 18 emergency aneurysm or postinfarct ventricular septal defect operations (10%). Twenty-four patients underwent more than one procedure.

Prophylactic doses of cephalosporin were given perioperatively (cefuroxime 1.5 g at induction, with two additional 750 mg doses at 6 and 12 hours postoperatively), and also when the chest was left open or a ventricular assistance device or intraaortic balloon device was in place.

After the initial cardiac operation, 119 patients had no further procedure performed before or after tracheostomy, but 8 required left ventricular assist device and 4 right ventricular assist device. Twenty-seven patients returned to the operating theatre because of suspected cardiac tamponade. Twenty-eight patients had intraaortic balloon device inserted.

Three patients of the 174 cases had mediastinitis, according to our definition, diagnosed before tracheostomy. Two of these survived, but the third died of multiorgan failure 46 days after the procedure. There was a mean incidence of mediastinitis of 0.4% in the total median sternotomy population over the 13-year period.

Of the remaining 171, 1 developed mediastinitis after tracheostomy. The tracheostomy was carried out as a formal procedure at the same time as the primary operation, pericardiectomy, because the patient had severe pulmonary fibrosis and it was considered that she would need a prolonged period of postoperative ventilation. She also had chronic rheumatoid arthritis, and was on high-dose steroid therapy at the time of her admission. Subsequently, her sternotomy broke down 6 days after the tracheostomy and Staphylococcus aureus was cultured from the wound. The sternotomy was resutured, but the patient became septic. Although antistaphylococcal antibiotics were administered, she developed multiorgan failure. Her tracheostomy dehisced, and it became impossible to ventilate her. She died 18 days after the initial procedure.

In 72 (41%) cases, tracheostomy was performed on or before the 7th postoperative day (Fig 1). Eleven (6%) were performed within 48 hours of initial operation. Thirty-four patients had microbiological evidence of superficial sternal wound bacterial colonization, without signs of mediastinitis, and were therefore not treated with specific antibiotics. In 18 of these, the bacteria cultured were identical to that tracheostomy wound isolate at the same time (Fig 2).

View larger version (6K): [in this window] [in a new window]   Fig 1. Day of tracheostomy formation. (Y-axis: %; X-axis: days).

View larger version (22K): [in this window] [in a new window]   Fig 2. Tracheostomy bacterial isolates (pie chart). (Coagulase-negative Staphylococcus [black]); Staphylococcus aureus [thick black oblique lines]; Pseudomonas aeruginosa [white]; Enterococcus [thin black oblique lines]; other [horizontal lines]).

	Comment

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Our aim from this retrospective study was to determine if there was any association between early tracheostomy and mediastinitis.

The great majority of patients after a cardiac surgical procedure are extubated within 24 to 72 hours. A small proportion require tracheostomy for prolonged ventilation. Type and duration of tracheostomy vary (Figs 3, 4) with more patients undergoing a percutaneous approach in recent months. In our institution, 179 out of 9,900 patients were found to have had a tracheostomy performed in a 13-year period. This represents 1.8% of these patients, in keeping with standard tracheostomy rates in cardiac operation in the United Kingdom.

View larger version (5K): [in this window] [in a new window]   Fig 3. Type of stoma. (Y-axis: %; X-axis: formal/percutaneously/ unknown).

View larger version (6K): [in this window] [in a new window]   Fig 4. Duration of tracheostomy. (Y-axis: %; X-axis: days).

This patient had severe rheumatoid arthritis, and was being treated with high doses of steroids at the time of admission to hospital. She had suffered from recurrent pericardial effusions requiring pericardial fenestration, and had subsequently developed a fibrinous pericarditis. An elective tracheostomy was performed at her primary pericardiectomy, as she had severe pulmonary fibrosis. Subsequent to this, both the mediastinotomy and tracheostomy wounds broke down and she developed a fatal mediastinitis within 2 weeks.

Of the 24 other patients who died of sepsis and multiorgan failure, none had a positive mediastinal bacterial culture.

Some authors consider that early tracheostomy may allow us to decrease the amount of sedation required to maintain efficient mechanical ventilation [13]. This in part, is due to the increased comfort of a tracheostomy tube in comparison to an endotracheal tube, and is considered beneficial in general intensive care patients.

In 72 patients (41%), tracheostomy was performed within the first week, and 11 (6%) within 48 hours after cardiac operation. In the remaining patients, tracheostomy was performed in the 2 to 3 postoperative weeks. Apart from the case described, no other patient developed mediastinitis after tracheostomy. Concerns for the spread of infection by early tracheostomy appear to be unfounded.

And so, we concluded that there is no demonstrable relationship between early tracheostomy and mediastinitis in median sternotomy patients.

	References

Top Abstract Introduction Material and methods Results Comment References

 

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This Article Abstract Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Ian S. Morgan Ciro Campanella Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Stamenkovic, S. A. Articles by Campanella, C. Search for Related Content PubMed PubMed Citation Articles by Stamenkovic, S. A. Articles by Campanella, C.