Wound Support Following Thoracic Surgery„Complications
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Wound Support Following Thoracic Surgery„Complications Document Transcript

  • 1. Wound Support Following Thoracic Surgery—ComplicationsA. Be Proactive With ComplicationsB. Pulmonary ComplicationsC. Sternal Wound ComplicationsD. Economic ImplicationsE. Sternal Wound Stability (& the Pillow)F. Patient Compliance & The Clinical PathwayG. Heart Hugger™ & ComplicationsA. Be Proactive With ComplicationsMajor complications following thoracic surgery fall into two categories: respiratory complications andwound infections. Especially at risk are those patients with co morbidities (e.g. diabetes, obesity,emphysema, COPD, etc.) as well as barrel-chested men, large breasted women and patients on the vent for aprolonged period.Respiratory complications are a primary concern in the recovery of the post surgical patient. Stabilizationand return to premorbid levels of respiratory function is a major determinant in the discharge of patients.The use of a sternum support harness provides your patients with the confidence and independence to beaggressive with respiratory therapy, keeping them on your clinical pathway. Following discharge,continuing respiratory therapy exercises are critical to full recovery.Sternal wound infection increases length of hospitalization more consistently than any other major complica-tion 1 and significantly influences readmission. 2 Treatment of sternal wound complications requires amultidisciplinary approach for effective patient care. 3 Use of a sternum support harness to stabilize thesternal wound reduces both pulmonary and wound complications, 4,5 enhancing both quality of care and costcontainment.Providing your patients with Heart Hugger™ gives them the best possible chance at a speedy, uncomplicatedrecovery. Heart Hugger™ is the standard of care at more than 340 hospitals worldwide.B. Pulmonary ComplicationsThe most common respiratory complication is pulmonary collapse. During monotonous tidal ventilation,progressive alveolar atelectasis occurs until a deep breath is taken to apply sufficient pressure to reopen thecollapsed alveoli. These deep breaths occur five to ten times hourly in normal resting adults. 6Normal lung compliance and alveolar aeration is abolished by general anaesthesia, by narcotic drugs, such asmorphine and by the effects of the ventilator, with the result that widespread alveolar collapse and fluid buildup is invariably present following surgery.8,7Deep breathing exercises with emphasis on sustained inspiration to total lung capacity has been consistentlyeffective in inflating alveoli and preventing postoperative pulmonary complications. 8,9 Preoperativeinstruction includes the practice of proper deep breathing and coughing maneuvers. 10 Unfortunately,recovering thoracic surgical patients are frequently non-compliant during their respiratory therapy exercisesbecause of pain or fear of pain. During a recent evaluation at a very busy Heart Hospital in Northern California a Respiratory Therapist informally measured the lung volume of his patient during deep breathing exercises while using a pillow and Heart Hugger™ alternately to splint the 1
  • 2. sternal wound. The result was nothing short of astounding. He first recorded the lung volume levels while the patient used the incentive spirometer while splinting with the pillow. He then showed the patient how to use Heart Hugger™ and again measured lung volume. He recorded an increase of 30% in lung volume immediately. The comfort, support and pain relief Heart Hugger™ offered the patient allowed him to be more aggressive with his deep breathing.Heart Hugger™ can help increase the lung volume of your patients, getting them back to pre-op respiratorylevels quicker, keeping them on your clinical pathway."Over half our patients are released by the fifth post-operative day, and many by the fourth post-operativeday. I believe this is due in a large part to the fact that we have a device available which allows the patient tocontinue aggressive coughing and deep breathing at home, with much less discomfort."David G. Ellertson, M.D., Thoracic and Cardiovascular Surgery, Modesto CA"I am impressed that my patients who use Heart Hugger™ all seem to have a much smoother convalescence... Because of this speeded recovery, I am inclined to allow them to be discharged from the hospital earlier."Michael F. Teodori, M.D., Pediatric and Adult Cardiovascular Surgery, Phoenix AZC. Sternal Wound ComplicationsSternal wound complications fall into three categories: 1) deep subcutaneous infection, 2) sternal infectionand 3) mediastinal infection with sternal dehiscence. 11Mediastinitis can contribute to the development of life threatening illnesses, such as systemic sepsis,respiratory insufficiency, and renal failure. Mediastinitis occurs as a result of sternal instability anddehiscence5 and is usually evident from six days to three weeks following surgery. 12 Most patients areusually discharged by this time. Patients at risk for mediastinitis and dehiscence include: patients older than65 years (the Medicare population), diabetes patients, older women (osteoporosis), obese patients, COPD andthose subjected to prolonged postoperative ventilation.5, 13 , 14The incidence of morbidity and death from sternal wound complications occurs in significant numbers ofpatients. Upwards of 2.3% of patients may suffer these complications with an associated mortality rate of13% to 52%.3, 15 , 16 The incidence of mortality after initial discharge and up to the first postoperative year isnearly as high as hospital mortality.3D. Economic ImplicationsReturn to premorbid levels of respiratory function is a major determinant in the discharge of patients.Recovering open heart patients are frequently non-compliant during their respiratory therapy exercisesbecause of pain or fear of pain. Recent federal studies 17 have shown that inadequately managed pain caninhibit recovery, prolong hospitalization and contribute to higher-than-necessary costs. The Wound Supportand Pain Management provided by Heart Hugger™ helps keep patients on your clinical pathway.The post discharge necessity of respiratory therapy exercises cannot be overemphasized. The use of HeartHugger™ gives patients the confidence and independence to continue these exercises in the unsupervisedpost discharge setting.In addition to a high mortality rate, wound complications can be financially devastating to the hospital,particularly the Medicare and co morbid population. The cost to hospitals for complications and the resulting 2
  • 3. increased length of stay ranges from $13,453 to $109,118 per complication. (To see how much money yourhospital’s heart program can save by using Heart Hugger™ click HERE).E. Sternal Wound Stability (& the Pillow)Aggressive coughing and deep breathing maneuvers, which frequently initiates coughing, are important forpurging the lungs of fluid and inflating the lungs to prevent atelectasis. These maneuvers are initiated in thehospital and are a mandatory part of post discharge respiratory therapy.21 The percussive expansionassociated with coughing puts extreme stress on the sternal wound. Ambulating, getting into and out of bedor chairs, bowel movements and other normal activities also place strain on the sternotomy site. Whilepatients experience this stress on their sternal wound as pain and the feeling that they are "coming apart," theclinical result may in fact be grave: dehiscence and mediastinal infection.Sternal stability is crucial in preventing these severe sternal wound complications. Until recently,prophylactic methods used to achieve sternal stability following a sternotomy has been available only to theextent that folded sheets, towels or a pillow could be used to "splint" the incision.12 This method, whileproviding an inward pressure to the sternum, provides no encircling support to the rib cage and chest wallduring coughing, is unavailable to the patient when ambulating, and provides no lateral support to stabilizethe sternal wound.Without sternal support, the pain of the surgical wound is often extreme. For this reason, patients often lackthe confidence to continue with respiratory therapy exercises and coughing following discharge.There is a trend toward early discharge of open heart surgery patients.5,6,21 The risk to these patients in theunsupervised, post discharge setting is two-fold: 1) the patient may be unaware or unable to diagnose apotential sternal wound complication, (success in treating sternal wound complications depends upon earlyrecognition and management15); and 2) due to pain considerations, patients often lack the confidence tocontinue their respiratory therapy exercises in the outpatient setting. Heart Hugger™ can help manage theirpain by stabilizing and supporting their surgical wound.F. Patient Compliance & The Clinical PathwayHeart Hugger™ Sternum Support Harness is a U.S. FDA classified medical device that provides a clearalternative to the limited methods previously described. It is a simple harness fitting over the shoulders, witha four inch wide belt around the chest, finished with handles on either end. The belt is adjusted to center thehandles over the sternal wound, the patients hand width apart. Squeezing the handles together with one orboth hands tightens the chest belt, supporting the chest wall and stabilizing the sternal wound. Completelyencircling the chest, it remains loose and passive until activated by the patient.Patients are introduced to the device prior to surgery as a part of their preoperative education. Followingsurgery (usually upon transfer from ICU to stepdown) patients are fitted with the device over their gown.Following discharge, patients wear the device at home over their street clothes for approximately three tofour weeks.6,21,22 In this unsupervised setting it is essential that patients be able to stabilize their sternalwound for continuing respiratory therapy exercises and other stress resulting from the resumption of normalactivities.Used in conjunction with contemporary methods of wiring the sternum and suturing tissue layers, maximalsternal wound stability is achieved. The incidence of sternal infection is reduced and sternal dehiscence ispractically eliminated.5,6 Additionally, preoperative respiratory capacity levels are achieved sooner when thedevice is used in conjunction with respiratory therapy exercises.After a short training period, patients operate the Heart Hugger™ themselves when they feel the need tostabilize their wound. It is a turning point in the patients perception of recovery. It returns control to the 3
  • 4. patient. If patients feel that they have some control over the situation that affects them they will perceive thesituation to be less stressful, will be less threatened, and will cooperate and perform better.6, 23 Patientsexperience more confidence and independence, taking control of their own recovery sooner, exemplifyingthe true sense of cardiac rehabilitation and keeping them on your clinical pathway.There is a trend toward earlier discharge of thoracic surgical patients. The potential for respiratorycomplications, and particularly wound complications continues well into the discharge period.3,6 HeartHugger™ enables patients to stabilize their wound, continuing aggressive coughing and deep breathingexercises while resuming normal activities: walking, climbing stairs, getting into and out of automobiles, etc.G. Heart Hugger™ & ComplicationsThe use of Heart Hugger TM sternum support harness provides maximal sternal wound stability, enhancingthe preventive care of recovering patients and keeping them on your clinical pathway. This is particularlyimportant in the outpatient setting, where the incidence of, and mortality from complications is as high as inthe hospital, and where immediate diagnosis and management of complications is absent.Several alternative protocols have been established to minimize the risk of dehiscence and mediastinitis dueto the failure of six small wires to keep the sternum stable. They include: thicker gauged wires, doublewires, the Figure 8 Wiring Method, sternal cable systems and several options for sternal locks.With all the methods and protocols developed over the years to solve the problem of sternal instability andpulmonary complications, Heart Hugger TM remains the only product that sufficiently addresses all thepotentials for both following thoracic surgery. No product can eliminate all of the risks from surgery. Whenit comes to wound support and pain management, Heart Hugger TM does it best.To set up an appointment to evaluate Heart Hugger™ or to get a sample, e-mail me mat@hearthugger.com.Sincerely,Mat PiroVice PresidentSales and Marketing1 . Weintraub, W.S., Jones, E. L., Craver, J., Guyton, R. et al (1989). Determinants of prolonged length ofhospital stay after coronary bypass surgery. Circulation, 80, pp. 276-284.2 . Loop, F.D., Lytle, B.W., Cosgrove, D.M., et al (1990). Sternal wound complications after isolated coronaryartery bypass grafting: Early and late mortality, morbidity, and cost of care. Annals of Thoracic Surgery, 49, pp.179-187.3. Vitello-Cicciu, J. (1989). Sternal wound management: a case study. Nursing grand rounds. Journal ofCardiovascular Nursing, 3(3), pp.66-70.4. Ellertson, D., Zapolanski, A., Moloney, S.T. et al (1991). Management and Prevention of Post-SternotomyMediastinitis. San Francisco Heart Institute, Seton Medical Center, 1900 Sullivan Avenue, Daly City, California.5 . Teodori, Michael F., MD. In a letter dated August 7, 1991. 340 East Palm Lane, Suite 330, Phoenix, Arizona85004.6 . Bendixen, H., Bullwinkle, B., Hedley-Whyte, J. & Laver, M. (1964). Atelectasis and shunting duringspontaneous ventilation in anaesthetized patients. Anaesthesiology, 24, pp. 297-301. 4
  • 5. 7. Hamilton, W., McDonald, J., Fisher, H. & Bettards, R. (1964). Postoperative respiratory complications.Anaesthesiology, 25, pp. 607-612.8 . Bartlett, R. Gazzaniga, A. & Geraghty, T. (1973). Respiratory maneuvers to prevent postoperative pulmonarycomplications: A critical review. Journal of the American Medical Association, 224, pp. 1017-1021.9 . Alexander, G., Schreiner, R. & Smiler, B. (1981). Maximal inspiratory volume and postoperative pulmonarycomplications. Surgery, Gynecology & Obstetrics, 152, pp. 601-603.10 . Sorenson, K. & Luckman, J. (1980). Medical-Surgical Nursing.11 . Boyce, J.M., Potter-Bynoe, Dziobek, L. (1990). Hospital Reimbursement patterns among patients with surgicalwound infections following open heart surgery. Infection Control and Hospital Epidemiology, 11(2), pp. 89-93.12 . Norris, S. O. (1989). Managing postoperative mediastinitis. Journal of Cardiovascular Nursing, 3, pp. 52-65.13 . Lazar, H.L., Wilcox, K., McCormick, J.R., et al (1987). Determinants of Discharge following Coronary ArteryBypass Graft Surgery. Chest, 92(5), pp. 800-802.14 . McDonald, W.S., Brame, M., Sharp, C. et al (1989). Risk factors for median sternotomy dehiscence in cardiacsurgery. Southern Medical Journal, 82(11), pp. 1361-1364.15 . Ottino, G., Depaulis, R., Pansini, S. et al (1987). Major sternal wound infection after open-heart surgery: amultivariate analysis of risk factors in 2,579 consecutive operative procedures. Annals of Thoracic Surgery, 44,173-179.16 . Sarr, M.G., Gott, V.L., Townsend, T.R. (1984). Mediastinal infection after cardiac surgery. Annals ofThoracic Surgery, 38, pp. 415-423.17 . Agency for Health Care Policy Research (1992). New Guidelines for Pain Relief After Surgery. AHCPRPublications Clearinghouse, P.O. Box 8547, Silver Spring, MD 2090721 . Ellertson, D.G., MD. In a letter dated May 28, 1991. 1800 Coffee Road, Suite 101, Modesto, California 95355.22 . Vathayanon, Sathaporn, MD. In a letter dated May 21, 1991. 728 E. Bullard Avenue, Suite 104, Fresno,California 93710.23 . Huckabay, L., Daderian, A.D. (1990). Effect of choices on breathing exercises post open heart surgery.Dimensions of Critical Care Nursing, 9(4), pp. 190-201Selected Published Papers on Complications“A Multimodal approach for reducing wound infections after sternotomy”Interactive Cardiovascular and Thoracic Surgery 3 (2004) 206-210Institutional report – Cardiac General www.icvts.org Lars-Goran Dahlin*, Hans Granfeldt, Henrik HultkvistDivision of Cardiothoracic Surgery, Linkoping Heart Centre, SE-581 85 linkoping, Sweden, Revised 10 June2003; received in revised form 24 November 2003; accepted 25 November 2003“A Better Way to Treat Most Sternal Wound Complications After Cardiac Surgery”E. Charles Douville, MD, James W. Asaph, MD, Ronald J. Dworkin, MD, John R. Handy, Jr, MD, Clifford S.Canepa, MD, Gary L Grunkemeir, PhD, and YingXing Wu, MDAccepted for publication April 27, 2004Address reprint request to Dr. Douville, The Oregon Clinic PC, 507 NE 47th Ave, Portland OR 97213; E-mail:ecdouville@orclinic.com0003-4975/04/$30Doi:10.1016/j.athoracsur.2004.04.082©2004 by The Society of Thoracic SurgeonsPublished be Elsevier Inc. www.elsevier.com 5
  • 6. “Superficial Wound Dehiscence After Median Sternotomy: Surgical Treatment Versus SecondaryWound Healing”Jacob Zeitani, MD, Fabio Bertoldo, MD, Carlo Bassano, MD, PhD, Alfonso Penta de Peppo, MD, AntonioPellergrino, MD, Fadi M. El Fakhri, MD, Luigi Chiariello, MDDivision of Cardiac Surgery, Tor Vergata University, Rome, ItalyAccepted for publication August 6, 2003Address reprint request to Dr. Zeitani, Division of cardiac Surgery,Tor Vergata University, European Hospital, Via Portuense 700, 00149 Rome, Italy; email:zeitani@hotmail.com2004 by The Society of Thoracic SurgeonsPublished be Elsevier Inc. 6