The document discusses median sternotomy and preventing/managing complications. It notes that complications include superficial and deep infection, osteomyelitis, and dehiscence. Risk factors include patient comorbidities, smoking, diabetes, and technical factors like stability. Management involves early recognition, debridement, vacuum-assisted closure, tissue coverage with flaps, and grafting if needed.

2. Goal One of the complications of a Median Sternotomy And how to Prevent and Manage it

3. Indications Coronary Artery Bypass Grafting Valve Surgeries Aortic Surgeries ‘Bentalls’ Cardiac & Mediastinal Tumours ASD VSD Closures Re Sernotomy

4. Sternotomies done in SKMC 161 15 3 2 1 6 Coronary Artery Bypass Grafting Valve Surgeries Aortic Surgeries ‘Bentalls’ Cardiac & Mediastinal Tumours ASD VSD Closures Re Sernotomy

5. Complications of Sternal Wounds Superficial Infection Deep Infection Sternal Osteomyelitis Sternal Dehiscence

6. Incidence of Sternal Wound Complications Sternal wound complications--incidence, microbiology and risk factors Department of Thoracic and Cardiovascular Surgery University Hospital, Uppsala, Sweden From 1980 through 1995 open heart surgery, was performed on 13,285 adult patients 5 out of 195 that is 2.6 % 1-4%

7. 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

8. Patho etiology Localized area of Sternal Osteomyelitis with minimal external signs followed by Sternal separation Sternal instability , followed by skin breakdown with seepage of bacteria Inadequate mediastinal drainage , leading to a large retrosternal collection Staphylococcus aureus or S epidermidis are identified in 70% to 80% of cases . Coagulase negative

9. Patho etiology

10. So the most important etiological factor which is in our hands is Sternal Stability

11. What are the other etiological factors

12. Euroscore Patient-related factors Age Sex Chronic pulmonary disease Extracardiac arteriopathy Neurological dysfunction disease Previous cardiac surgery Serum creatinine Active endocarditis Critical preoperative state

13. Euroscore Cardiac-related factors Unstable angina LV dysfunction Recent myocardial infarct Pulmonary hypertension

14. Euroscore Operation-related factors Emergency Any other surgery than isolated CABG Surgery on thoracic aorta Post infarct septal rupture

15. Our Four Sternal Dehiscence Patients Three are chronic smokers All four are diabetics Two of them are nephropaths All Four had severe triple vessel disease Two had severe comlications on admisson Myocardial infract Pneumonia

16. Operative Factors Sternal Stability

17. Operative Factors Paramedian Sternotomy

18. To what lengths the discussion goes…

19. Management How early you recognize the problem Acute Sub acute Chronic 2 Wks 2-5 Wks >5 Wks Postoperative Mediastinitis : Classification and Management Reida M. El Oakley, FRCS, John E. Wright, FRCS Ann Thorac Surg 1996;61:1030-1036

20. Management Close examination to confirm problems with sternal stability Early and adequate debridement Prompt application of VAC Sternal debridement if necessary Tissue cover with local flap .

21. How to make an early diagnosis The Classic symptoms and signs of acute infection are infrequently encountered Fever and Leukocytosis in the absence of local symptoms or signs may be the only presenting clinical features in a small percentage of patients Wound discharge is the most common presentation and occurs in 70% to 90% Local symptoms include wound pain, tenderness, and sternal instability Chest roentgenograms are rarely helpful in the early diagnosis Chest computed tomography scanning with mediastinal aspiration

22. CT vs MRI Retrosternal Shadow Retrosternal Shadow

24. Osteomyelitic Sternum

25. Look in your ‘minds eye’

26. Radical and prompt debridement with VAC application

27. We grafted this sternum to our loss

28. Pectoralis Flap with grafting

32. Pectoralis major flap as the work horse

33. Omentoplasty 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: implications for cardiac assistance from skeletal muscle. J Heart Lung Transplant 1995;14:359–65

34. Omentoplasty

35. If your getting any fresh ideas….. Sternal wound infections in patients undergoing open heart surgery: randomized study comparing intracutaneous and transcutaneous suture techniques Risnes, M. Abdelnoor, S. Tore Baksaas, R. Lundblad, and J. L. Svennevig Ann. Thorac. Surg ,November 1, 2001; 72(5): 1587 - 1591.