sternal dehiscence 10.5
TRANSCRIPT
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GoalGoal
One of the complications of a Median SternotomyAnd how to Prevent and Manage it
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IndicationsIndications
1. Coronary Artery Bypass Grafting2. Valve Surgeries3. Aortic Surgeries ‘Bentalls’4. Cardiac & Mediastinal Tumours5. ASD VSD Closures6. Re Sernotomy
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Sternotomies done in SKMCSternotomies done in SKMC
161161 1515 33 22 11 66
1. Coronary Artery Bypass Grafting
2. Valve Surgeries
3. Aortic Surgeries ‘Bentalls’
4. Cardiac & Mediastinal Tumours
5. ASD VSD Closures
6. Re Sernotomy
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Complications of Sternal WoundsComplications of Sternal Wounds
Superficial InfectionSuperficial Infection Deep InfectionDeep Infection
1.1. Sternal OsteomyelitisSternal Osteomyelitis2.2. Sternal DehiscenceSternal Dehiscence
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Incidence of Sternal Wound Incidence of Sternal Wound ComplicationsComplications
Sternal wound complications--incidence, microbiology and risk factorsDepartment of Thoracic and Cardiovascular SurgeryUniversity Hospital, Uppsala, SwedenFrom 1980 through 1995 open heart surgery, was performed on 13,285 adult patients
5 out of 195 that is 2.6 %
1-4%
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Some Positive Pointers
None of the Valve replacements,Aortic dissections or other
Semi-elective or post emergent surgeries got sternal dehiscence
All the five patients had severe pre morbid factors (Euroscore > 8)
None of the Re Sternotomies got infected
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Patho etiologyPatho etiology
Localized area of Sternal OsteomyelitisLocalized area of Sternal Osteomyelitis with minimal external signs with minimal external signs followed by Sternal separation followed by Sternal separation
Sternal instabilitySternal instability, followed by skin breakdown with seepage of , followed by skin breakdown with seepage of bacteriabacteria
Inadequate mediastinal drainageInadequate mediastinal drainage, leading to a large retrosternal , leading to a large retrosternal collectioncollection
Staphylococcus aureus or S epidermidis are identified in 70% to 80% of cases . .Coagulase negativeCoagulase negative
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Patho etiologyPatho etiology
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So the most important etiological factor So the most important etiological factor which is in our hands iswhich is in our hands is
Sternal StabilitySternal Stability
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What are the other etiological factorsWhat are the other etiological factors
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EuroscoreEuroscore
Patient-related factorsPatient-related factors Age Age SexSex Chronic pulmonary diseaseChronic pulmonary disease Extracardiac arteriopathyExtracardiac arteriopathy Neurological dysfunction disease Neurological dysfunction disease Previous cardiac surgeryPrevious cardiac surgery Serum creatinineSerum creatinine Active endocarditisActive endocarditis Critical preoperative stateCritical preoperative state
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EuroscoreEuroscore
Cardiac-related factorsCardiac-related factors Unstable angina Unstable angina LV dysfunctionLV dysfunction Recent myocardial infarct Recent myocardial infarct Pulmonary hypertensionPulmonary hypertension
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EuroscoreEuroscore
Operation-related factorsOperation-related factors Emergency Emergency Any other surgery than isolated CABGAny other surgery than isolated CABG Surgery on thoracic aortaSurgery on thoracic aorta Post infarct septal rupturePost infarct septal rupture
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Our Our Four Four Sternal Dehiscence PatientsSternal Dehiscence Patients
ThreeThree are are chronic smokerschronic smokers All All fourfour are are diabeticsdiabetics TwoTwo of them are of them are nephropathsnephropaths All All Four Four had severehad severe triple vessel disease triple vessel disease Two had severe comlications on admisson Two had severe comlications on admisson
Myocardial infractMyocardial infract
PneumoniaPneumonia
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Operative FactorsOperative Factors
Sternal StabilitySternal Stability
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Operative FactorsOperative Factors
Paramedian SternotomyParamedian Sternotomy
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To what lengths the discussion goes…To what lengths the discussion goes…
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ManagementManagement
How early you recognize the problemHow early you recognize the problem
3.3. AcuteAcute
4.4. Sub acuteSub acute
5.5. ChronicChronic
2 Wks2-5 Wks>5 Wks
Postoperative Mediastinitis : Classification and Management Reida M. El Oakley, FRCS, John E. Wright, FRCS Ann Thorac Surg 1996;61:1030-1036
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ManagementManagement
Close Close examinationexamination to confirm problems with to confirm problems with sternal stability sternal stability
Early and adequateEarly and adequate debridement debridement Prompt application of Prompt application of VAC VAC Sternal debridementSternal debridement if necessary if necessary Tissue cover with local flapTissue cover with local flap..
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How to make an early diagnosisHow to make an early diagnosis
The The Classic symptomsClassic symptoms and signs of acute infection are and signs of acute infection are infrequentlyinfrequently encounteredencountered
Fever and LeukocytosisFever and Leukocytosis in the absence of local symptoms or signs may be in the absence of local symptoms or signs may be the only presenting clinical features in a small percentage of patients the only presenting clinical features in a small percentage of patients
Wound dischargeWound discharge is the most common presentation and occurs in 70% to is the most common presentation and occurs in 70% to 90% 90%
Local symptoms include wound pain, tenderness, and sternal instability Local symptoms include wound pain, tenderness, and sternal instability
Chest roentgenogramsChest roentgenograms are rarely helpful in the early diagnosis are rarely helpful in the early diagnosis
Chest computed tomography scanning with mediastinal aspirationChest computed tomography scanning with mediastinal aspiration
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CT vs MRI
Retrosternal ShadowRetrosternal Shadow
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Osteomyelitic Sternum
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Look in your ‘minds eye’Look in your ‘minds eye’
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Radical and prompt debridement Radical and prompt debridement with VAC applicationwith VAC application
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We We graftedgrafted this sternum to our loss this sternum to our loss
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Pectoralis Flap with graftingPectoralis Flap with grafting
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Pectoralis major flap as the work Pectoralis major flap as the work horsehorse
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OmentoplastyOmentoplasty
Because of the relative degree of skeletal muscle ischemia after its mobilization and because omental lipid extract has been shown to have a powerful angiogenic effect an omentoplasty may be the procedure of choice
El Oakley RM, Jarvis J, Barman D, et al. Factors affecting the integrity of latissimus dorsi muscle grafts: implicationsfor cardiac assistance from skeletal muscle. J Heart Lung Transplant 1995;14:359–65
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OmentoplastyOmentoplasty
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If your getting any If your getting any freshfresh ideas….. ideas…..
Sternal wound infections in patients undergoing Sternal wound infections in patients undergoing open heart surgery: randomized study comparing open heart surgery: randomized study comparing intracutaneousintracutaneous and and transcutaneoustranscutaneous suture suture techniquestechniques
Risnes, M. Abdelnoor, S. Tore Baksaas, R. Lundblad, and J. L. SvennevigRisnes, M. Abdelnoor, S. Tore Baksaas, R. Lundblad, and J. L. Svennevig
Ann. Thorac. Surg ,November 1, 2001; 72(5): 1587 - 1591. Ann. Thorac. Surg ,November 1, 2001; 72(5): 1587 - 1591.
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