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Ann Thorac Surg 2009;88:707-708. doi:10.1016/j.athoracsur.2009.02.039
© 2009 The Society of Thoracic Surgeons
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Correspondence

Sternal Wound Infection: Prevention Requires More Than a Good Closure

Robert S. Kramer, MD, Robert Groom, CCP, MS

Division of Cardiothoracic Surgery, Maine Medical Center, 22 Bramhall St, Portland, ME 04102

(Email: kramer{at}mmc.org).

To the Editor:

The article by Schimmer and colleagues [1] regarding prevention of deep sternal wound infection (DSWI) and dehiscence emphasizes the importance of stable sternal approximation for prevention of DSWI, with little mention of the management other critical perioperative factors. Although their analysis of high-risk patients is valuable in pointing out the significantly elevated hazard ratios associated with high body mass index, diabetes, renal dysfunction, transfusions, reoperation for bleeding, peripheral vascular disease, closure by assistant, immunosuppression, and delirium, their conclusion puts the emphasis in the wrong place. They concluded, "The key factor in preventing sternal dehiscence and sternal wound infection is a stable sternal approximation," and failed to mention the role glucose and blood management play in decreasing DSWI rates.

Our experience with glucose management [2], as well as others [3], demonstrates how tight glycemic control in the first 48 hours postoperatively is key in decreasing the DSWI rate. Furthermore, the transfusion medicine literature has many examples [4, 5] that suggest a link between red blood cell transfusions and wound infection, possibly related to immunomodulation.

As cardiac surgeons, our focus on technique needs to be coupled with postoperative tight glycemic control and a restrictive transfusion policy, giving patients the best chance to avoid the morbid complication of DWSI.


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  1. Schimmer C, Reents W, Berneder S, et al. Prevention of sternal dehiscence and infection in high-risk patients: a prospective randomized multicenter trial Ann Thorac Surg 2008;86:1897-1904.[Abstract/Free Full Text]
  2. Kramer R, Groom R, Weldner D, et al. Glycemic control and reduction of deep sternal wound infection rates: a multidisciplinary approach Arch Surg 2008;143:451-456.[Abstract/Free Full Text]
  3. Furnary AP, Zerr KJ, Grunkemeier GL, Starr A. Continuous intravenous insulin infusion reduces the incidence of deep sternal wound infection in diabetic patients after cardiac surgical procedures Ann Thorac Surg 1999;67:352-362.[Abstract/Free Full Text]
  4. Leal-Noval SR, Rincón-Ferrari, MD, García-Curiel A. Transfusion of blood components and postoperative infection in patients undergoing cardiac surgery Chest 2001;119:1461-1468.[Abstract/Free Full Text]
  5. Blumberg N. Allogenic transfusion and infection: economic and clinical implications Semin Hematol 1997;34(3 suppl 2):34-40.[Medline]

Related Article

Reply
Christoph Schimmer and Rainer Leyh
Ann. Thorac. Surg. 2009 88: 708. [Extract] [Full Text] [PDF]



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C. Schimmer and R. Leyh
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Ann. Thorac. Surg., August 1, 2009; 88(2): 708 - 708.
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