1
|
Iguidbashian J, Feng Z, Colborn KL, Barrett CS, Newman SR, Harris M, Campbell DN, Mitchell MB, Jaggers J, Stone ML. Open Chest Duration Following Congenital Cardiac Surgery Increases Risk for Surgical Site Infection. Pediatr Cardiol 2022:10.1007/s00246-022-03088-4. [PMID: 36583758 DOI: 10.1007/s00246-022-03088-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/16/2022] [Accepted: 12/21/2022] [Indexed: 12/31/2022]
Abstract
Surgical site infections (SSI) following congenital heart surgery (CHS) remain a significant source of morbidity. Delayed sternal closure (DSC) is often required to minimize the potential for hemodynamic instability. The purpose of this study was to determine the incidence of SSI among patients undergoing DSC versus primary chest closure (PCC) and to define a potential inflection point for increased risk of SSI as a function of open chest duration (OCD).A retrospective review of our institutional Society of Thoracic Surgeons dataset is to identify patients undergoing CHS at our institution between 2015 and 2020. Incidences of SSI were compared between DSC and PCC patients. DSC patients were evaluated to determine the association of OCD and the incidence of SSI.2582 operations were performed at our institution between 2015 and 2020, including 195 DSC and 2387 PCC cases. The incidence of SSI within the cohort was 1.8% (47/2,582). DSC patients had significantly higher incidences of SSI (17/195, 8.7%) than PCC patients (30/2387, 1.3%, p < 0.001). Further, patients with an OCD of four or more days had a significantly higher incidence of SSI (11/62, 17.7%, p = 0.006) than patients with an OCD less than 4 days (6/115, 5.3%).The incidence of SSI following CHS is higher in DSC patients compared to PCC patients. Prolonged OCD of 4 days or more significantly increases the risk of SSI and represents a potentially modifiable risk factor for SSI predisposition. These data support dedicated, daily post-operative assessment of candidacy for chest closure to minimize the risk of SSI.
Collapse
Affiliation(s)
- John Iguidbashian
- Department of Surgery, University of Colorado School of Medicine, 12605 E 16th Ave, Aurora, CO, 80045, USA.
| | - Zihan Feng
- Department of Surgery, University of Colorado School of Medicine, 12605 E 16th Ave, Aurora, CO, 80045, USA
| | - Kathryn L Colborn
- Department of Surgery, University of Colorado School of Medicine, 12605 E 16th Ave, Aurora, CO, 80045, USA
| | - Cindy S Barrett
- Department of Cardiology and Cardiothoracic Surgery, Children's Hospital of Colorado, Aurora, CO, USA
| | - Shanna R Newman
- Department of Cardiology and Cardiothoracic Surgery, Children's Hospital of Colorado, Aurora, CO, USA
| | - Marisa Harris
- Department of Cardiology and Cardiothoracic Surgery, Children's Hospital of Colorado, Aurora, CO, USA
| | - David N Campbell
- Department of Cardiology and Cardiothoracic Surgery, Children's Hospital of Colorado, Aurora, CO, USA
| | - Max B Mitchell
- Department of Cardiology and Cardiothoracic Surgery, Children's Hospital of Colorado, Aurora, CO, USA
| | - James Jaggers
- Department of Cardiology and Cardiothoracic Surgery, Children's Hospital of Colorado, Aurora, CO, USA
| | - Matthew L Stone
- Department of Cardiology and Cardiothoracic Surgery, Children's Hospital of Colorado, Aurora, CO, USA
| |
Collapse
|
2
|
Akay MH, Jezovnik MK, Salas De Armas IA, Ilic M, Karabulut MN, Alagoz M, Patel M, Radovancevic R, Kar B, Gregoric ID. Delayed versus primary sternal closure for left ventricular assist device implantation: Impact on mechanical circulatory support infections. J Heart Lung Transplant 2022; 42:645-650. [PMID: 36641296 DOI: 10.1016/j.healun.2022.12.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2021] [Revised: 10/31/2022] [Accepted: 12/06/2022] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND Delayed sternal closure may be required after left ventricular assist device (LVAD) implantation due to coagulopathy or hemodynamic instability. There is conflicting data regarding infection risk. METHODS We performed a single-center, retrospective analysis of patients who received their first LVAD between May 2012 and January 2021. Patients were divided into delayed sternal closure (DSC) and primary sternal closure (PSC) groups. We used chi-squared or Fisher Exact tests, as appropriate, to compare the incidence of postoperative LVAD-related infections (mediastinal/sternal wound) and LVAD-specific infections (driveline and pump pocket) after definitive chest closure between these two groups. RESULTS A total of 327 patients met eligibility criteria, including 127 (39%) patients that underwent DSC and 200 (61%) patients that had a PSC. Demographic and clinical characteristics were similar except for an overrepresentation of men (87% vs. 75%, p = .016), Interagency Registry of Mechanically Assisted Circulatory Support class I-II patients (89% vs 66%, p < .001), patients with a previous sternotomy (43% vs 13%, p < .001), and patients with chronic kidney disease (55% vs 43%, p = .030) in the DSC group. The median DSC time was 24 (IQR: 24-48) hours. The incidence of LVAD-related mediastinal/sternal wound infection was similar between the DSC and PSC groups (4.7% vs 3.0%, p = .419). There was no difference between DSC and PSC groups in the incidence of driveline infection (6.3% vs 9%, p = .411) and pump pocket infection (1.6% vs 1.5%, p =.901), respectively. CONCLUSIONS DSC does not seem to increase the incidence of LVAD-related or LVAD-specific infection rates in heart failure patients undergoing device implantation surgery.
Collapse
Affiliation(s)
- Mehmet H Akay
- Department of Advanced Cardiopulmonary Therapies and Transplantation, Center for Advanced Heart Failure, The University of Texas Health Science Center-Houston/Memorial Hermann Hospital-Texas Medical Center, Houston, TX
| | - Mateja K Jezovnik
- Department of Advanced Cardiopulmonary Therapies and Transplantation, Center for Advanced Heart Failure, The University of Texas Health Science Center-Houston/Memorial Hermann Hospital-Texas Medical Center, Houston, TX
| | - Ismael A Salas De Armas
- Department of Advanced Cardiopulmonary Therapies and Transplantation, Center for Advanced Heart Failure, The University of Texas Health Science Center-Houston/Memorial Hermann Hospital-Texas Medical Center, Houston, TX
| | - Milica Ilic
- Department of Advanced Cardiopulmonary Therapies and Transplantation, Center for Advanced Heart Failure, The University of Texas Health Science Center-Houston/Memorial Hermann Hospital-Texas Medical Center, Houston, TX
| | - Mehmet N Karabulut
- Department of Advanced Cardiopulmonary Therapies and Transplantation, Center for Advanced Heart Failure, The University of Texas Health Science Center-Houston/Memorial Hermann Hospital-Texas Medical Center, Houston, TX
| | - Mehmet Alagoz
- Department of Advanced Cardiopulmonary Therapies and Transplantation, Center for Advanced Heart Failure, The University of Texas Health Science Center-Houston/Memorial Hermann Hospital-Texas Medical Center, Houston, TX
| | - Manish Patel
- Department of Advanced Cardiopulmonary Therapies and Transplantation, Center for Advanced Heart Failure, The University of Texas Health Science Center-Houston/Memorial Hermann Hospital-Texas Medical Center, Houston, TX
| | - Rajko Radovancevic
- Department of Advanced Cardiopulmonary Therapies and Transplantation, Center for Advanced Heart Failure, The University of Texas Health Science Center-Houston/Memorial Hermann Hospital-Texas Medical Center, Houston, TX
| | - Biswajit Kar
- Department of Advanced Cardiopulmonary Therapies and Transplantation, Center for Advanced Heart Failure, The University of Texas Health Science Center-Houston/Memorial Hermann Hospital-Texas Medical Center, Houston, TX
| | - Igor D Gregoric
- Department of Advanced Cardiopulmonary Therapies and Transplantation, Center for Advanced Heart Failure, The University of Texas Health Science Center-Houston/Memorial Hermann Hospital-Texas Medical Center, Houston, TX.
| |
Collapse
|
3
|
Rodríguez-Holguín F, González Hadad A, Mejia D, García A, Cevallos C, Himmler AN, Caicedo Y, Salcedo A, Serna JJ, Herrera MA, Pino LF, Parra MW, Ordoñez CA. Abdominal and thoracic wall closure: damage control surgery's cinderella. Colomb Med (Cali) 2021; 52:e4144777. [PMID: 34908622 PMCID: PMC8634273 DOI: 10.25100/cm.v52i2.4777] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2021] [Revised: 04/18/2021] [Accepted: 06/30/2021] [Indexed: 11/11/2022] Open
Abstract
Damage control surgery principles allow delayed management of traumatic lesions and early metabolic resuscitation by performing abbreviated procedures and prompt resuscitation maneuvers in severely injured trauma patients. However, the initial physiological response to trauma and surgery, along with the hemostatic resuscitation efforts, causes important side effects on intracavitary organs such as tissue edema, increased cavity pressure, and hemodynamic collapse. Consequently, different techniques have been developed over the years for a delayed cavity closure. Nonetheless, the optimal management of abdominal and thoracic surgical closure remains controversial. This article aims to describe the indications and surgical techniques for delayed abdominal or thoracic closure following damage control surgery in severely injured trauma patients, based on the experience obtained by the Trauma and Emergency Surgery Group (CTE) of Cali, Colombia. We recommend negative pressure dressing as the gold standard technique for delayed cavity closure, associated with higher wall closure success rates and lower complication and mortality rates.
Collapse
Affiliation(s)
- Fernando Rodríguez-Holguín
- Fundación Valle del Lili. Department of Surgery. Division of Trauma and Acute Care Surgery, Cali, Colombia
| | - Adolfo González Hadad
- Universidad del Valle, Facultad de Salud, Escuela de Medicina, Department of Surgery. Division of Trauma and Acute Care Surgery, Cali, Colombia.,Hospital Universitario del Valle, Department of Surgery. Division of Trauma and Acute Care Surgery, Cali, Colombia.,Centro Médico Imbanaco, Cali, Colombia
| | - David Mejia
- Hospital Pablo Tobon Uribe, Department of Surgery, Medellín, Colombia.,Universidad de Antioquia, Department of Surgery, Medellín, Colombia
| | - Alberto García
- Fundación Valle del Lili. Department of Surgery. Division of Trauma and Acute Care Surgery, Cali, Colombia.,Universidad del Valle, Facultad de Salud, Escuela de Medicina, Department of Surgery. Division of Trauma and Acute Care Surgery, Cali, Colombia.,Universidad Icesi, Cali, Colombia
| | - Cecibel Cevallos
- Hospital Vicente Corral Moscoso. Department of Surgery. Division of Trauma and Acute Care Surgery, Cuenca, Ecuador.,Universidad de Cuenca. Cuenca, Ecuador
| | - Amber Nicole Himmler
- Medstar Georgetown University Hospital and Washington Hospital Center. Department of Surgery, Washington, D.C., USA
| | - Yaset Caicedo
- , Fundación Valle del Lili, Centro de Investigaciones Clínicas (CIC)Cali, Colombia
| | - Alexander Salcedo
- Fundación Valle del Lili. Department of Surgery. Division of Trauma and Acute Care Surgery, Cali, Colombia.,Universidad del Valle, Facultad de Salud, Escuela de Medicina, Department of Surgery. Division of Trauma and Acute Care Surgery, Cali, Colombia.,Hospital Universitario del Valle, Department of Surgery. Division of Trauma and Acute Care Surgery, Cali, Colombia.,Universidad Icesi, Cali, Colombia
| | - José Julián Serna
- Fundación Valle del Lili. Department of Surgery. Division of Trauma and Acute Care Surgery, Cali, Colombia.,Universidad del Valle, Facultad de Salud, Escuela de Medicina, Department of Surgery. Division of Trauma and Acute Care Surgery, Cali, Colombia.,Hospital Universitario del Valle, Department of Surgery. Division of Trauma and Acute Care Surgery, Cali, Colombia.,Universidad Icesi, Cali, Colombia
| | - Mario Alain Herrera
- Universidad del Valle, Facultad de Salud, Escuela de Medicina, Department of Surgery. Division of Trauma and Acute Care Surgery, Cali, Colombia.,Hospital Universitario del Valle, Department of Surgery. Division of Trauma and Acute Care Surgery, Cali, Colombia
| | - Luis Fernando Pino
- Universidad del Valle, Facultad de Salud, Escuela de Medicina, Department of Surgery. Division of Trauma and Acute Care Surgery, Cali, Colombia.,Hospital Universitario del Valle, Department of Surgery. Division of Trauma and Acute Care Surgery, Cali, Colombia
| | - Michael W Parra
- Broward General Level I Trauma Center, Department of Trauma Critical Care, Fort Lauderdale, FL - USA
| | - Carlos A Ordoñez
- Fundación Valle del Lili. Department of Surgery. Division of Trauma and Acute Care Surgery, Cali, Colombia.,Universidad del Valle, Facultad de Salud, Escuela de Medicina, Department of Surgery. Division of Trauma and Acute Care Surgery, Cali, Colombia.,, Fundación Valle del Lili, Centro de Investigaciones Clínicas (CIC)Cali, Colombia
| |
Collapse
|
4
|
Pan Y, Li P, Liang F, Zhang J, Yuan J, Yin M. A Nano-Silver Loaded PVA/Keratin Hydrogel With Strong Mechanical Properties Provides Excellent Antibacterial Effect for Delayed Sternal Closure. Front Bioeng Biotechnol 2021; 9:733980. [PMID: 34692656 PMCID: PMC8534296 DOI: 10.3389/fbioe.2021.733980] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2021] [Accepted: 09/22/2021] [Indexed: 12/13/2022] Open
Abstract
Delayed chest closure (DSC) is widely performed during the treatment of congenital heart diseases. However, the high prevalence of surgical site infection (SSI) in patients undergoing DSC affects prognosis negatively. Herein, we designed a suturable poly (vinyl alcohol)/keratin film loaded with silver nanoparticles (AgNPs) as an alternative material for DSC, which was named PVA/Keratin/AgNPs. The PVA/Keratin/AgNPs films exhibited significantly enhanced mechanical strength after crosslinking by sodium trimetaphosphate (STMP). These films were non-toxic, and cells proliferated with good morphology after 1 week of culture. In addition, PVA/Keratin/AgNPs films provided superior antibacterial ability, as evidenced by the eradication and lower growth rate of Staphylococcus aureus and Escherichia coli. Finally, the PVA/Keratin/AgNPs films were demonstrated to successfully cover the chest cavity temporarily and protect the chest cavity from bacterial infection. These results indicated that the PVA/Keratin/AgNPs films have great prospects to be further exploited for clinical applications in DSC.
Collapse
Affiliation(s)
- Yanjun Pan
- Department of Cardiothoracic Surgery, Shanghai Children's Medical Center, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Pengfei Li
- Jiangsu Key Laboratory of Biofunctional Materials, School of Chemistry and Materials Science, Nanjing Normal University, Nanjing, China
| | - Fubang Liang
- Department of Cardiothoracic Surgery, Shanghai Children's Medical Center, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Jingyi Zhang
- Department of Cardiothoracic Surgery, Shanghai Children's Medical Center, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Jiang Yuan
- Jiangsu Key Laboratory of Biofunctional Materials, School of Chemistry and Materials Science, Nanjing Normal University, Nanjing, China
| | - Meng Yin
- Department of Cardiothoracic Surgery, Shanghai Children's Medical Center, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| |
Collapse
|
5
|
Elsisy MF, Dearani JA, Crestanello JA, Ashikhmina EA, Van Dorn CS, Stephens EH. Outcomes of Primary vs Secondary Delayed Sternal Closure in Pediatric Cardiac Surgery. Ann Thorac Surg 2021; 113:1231-1237. [PMID: 33662305 DOI: 10.1016/j.athoracsur.2021.02.029] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/09/2020] [Revised: 02/11/2021] [Accepted: 02/16/2021] [Indexed: 11/01/2022]
Abstract
BACKGROUND Delayed sternal closure (DSC) is a management strategy for hemodynamic instability and severe coagulopathy after complex congenital heart surgery. We hypothesized that DSC results in better outcomes than perioperative sternal reopening. METHODS We reviewed patients aged <18 years old undergoing cardiac surgery 2007-2017 at our institution. A total of 179 patients (3.8%) had primary DSC (PDSC, sternum left open after initial operation) and 45 patients (0.9%) had secondary DSC (SDSC, sternum closed primarily and reopened perioperatively). Perioperative characteristics and outcomes among PDSC ≤2 days (98 patients), PDSC >2 days (81 patients), and SDSC (45 patients) were analyzed. RESULTS Median age was 120 days (range, 3-6553 days) and median DSC duration was 2 days (range, 1-60 days). The PDSC >2 days group was the youngest group, and the distribution of procedures was different between groups. Indications for DSC were hemodynamic instability in 152 patients (67.9%) and severe coagulopathy in 33 patients (14.7%), with no difference between groups (P = .141). Extracorporeal membrane oxygenation use was higher in the PDSC >2 days group than the other groups (47.5% vs 7.1%, P < .01 and 47.5% vs 28.9%, P = .02), respectively. Operative mortality was higher in SDSC compared to the other groups (17.8% vs 0% for PDSC ≤2 and 6.2% for PDSC >2 days, P < .01). Hospital stay was longer in SDSC (57 ± 7 days) than PDSC ≤2 days (22 ± 5 days) and PDSC >2 days (44 ± 6, P = .01). Survival was better in PDSC regardless of duration than SDSC. CONCLUSIONS PDSC demonstrated better outcomes than SDSC. Sternal reopening can be life-saving, but, when anticipated, PDSC can yield better outcomes.
Collapse
Affiliation(s)
- Mohamed F Elsisy
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, Minnesota
| | - Joseph A Dearani
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, Minnesota
| | | | - Elena A Ashikhmina
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, Minnesota
| | - Charlotte S Van Dorn
- Department of Pediatric and Adolescent Medicine, Division of Pediatric Critical Care Medicine, Mayo Clinic, Rochester, Minnesota; Department of Pediatric and Adolescent Medicine, Division of Pediatric Cardiology, Mayo Clinic, Rochester, Minnesota
| | | |
Collapse
|
6
|
Vaswani P, Sahu MK, Bipin C, Singh SP, Rajashekar P, Devagourou V, Talwar S. Outcomes of Delayed Sternal Closure in Paediatric Cardiac Surgical Patients–A Prospective Single Centre Study. JOURNAL OF CARDIAC CRITICAL CARE TSS 2020. [DOI: 10.1055/s-0040-1721229] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022] Open
Abstract
Abstract
Background Delayed sternal closure (DSC) is being increasingly used as an interim support to help the dysfunctional heart in the road to recovery after complex pediatric cardiac surgeries. The purpose of this study was to assess the conduct of DSC at a tertiary care center.
Methods Between 2018 and 2019, 185 consecutive pediatric patients (below 12 years of age) underwent cardiac surgery at a tertiary care center. The incidence and causes of DSC were noted. The various pre, intra and postoperative factors till discharge or demise were noted and analyzed.
Results In this study, DSC was done in 63 patients (34.05%) with a median age and weight of 29 days (18–100 days) and 4 kg (2–12.3 kg), respectively. Transposition of great arteries (TGA) (41.27%) constituted the majority, followed by total anomalous pulmonary venous connection (TAPVC) (26.98%). Myocardial edema (49.21%) was the most common indication for DSC. Mean duration of open chest was 40.75 ± 18.58 hours. All-cause mortality was 19.05% (12/63). On multivariate analysis by logistic regression, the independent predictors of mortality were needed for preoperative mechanical ventilation (OR 42.82, 95% CI = 4.52–406.03, p < 0.001) and development of postoperative sepsis (OR 20.07, 95% CI = 2.12–189.80, p = 0.002).
Conclusions DSC is a safe and effective technique in the management of complex pediatric cardiac surgeries. It provides assistance to the severely dysfunctional myocardium soon after the surgery and helps in stabilization of hemodynamics with avoidance of postoperative mediastinal compression. Early sternal closure should be considered on the basis of cardiovascular function and/or resolution of primary indication for DSC.
Collapse
Affiliation(s)
- Prateek Vaswani
- Department of Cardiothoracic and Vascular Surgery, Cardiothoracic and Neurosciences Centre, All India Institute of Medical Sciences, New Delhi, India
| | - Manoj Kumar Sahu
- Intensive Care for CTVS, CT Centre, Cardiothoracic and Neurosciences Centre, All India Institute of Medical Sciences, New Delhi, India
| | - Challatil Bipin
- Intensive Care for CTVS, CT Centre, Cardiothoracic and Neurosciences Centre, All India Institute of Medical Sciences, New Delhi, India
| | - Sarvesh Pal Singh
- Intensive Care for CTVS, CT Centre, Cardiothoracic and Neurosciences Centre, All India Institute of Medical Sciences, New Delhi, India
| | - Palleti Rajashekar
- Department of Cardiothoracic and Vascular Surgery, Cardiothoracic and Neurosciences Centre, All India Institute of Medical Sciences, New Delhi, India
| | - Velayoudam Devagourou
- Department of Cardiothoracic and Vascular Surgery, Cardiothoracic and Neurosciences Centre, All India Institute of Medical Sciences, New Delhi, India
| | - Sachin Talwar
- Department of Cardiothoracic and Vascular Surgery, Cardiothoracic and Neurosciences Centre, All India Institute of Medical Sciences, New Delhi, India
| |
Collapse
|
7
|
Coccolini F, Improta M, Picetti E, Vergano LB, Catena F, de ’Angelis N, Bertolucci A, Kirkpatrick AW, Sartelli M, Fugazzola P, Tartaglia D, Chiarugi M. Timing of surgical intervention for compartment syndrome in different body region: systematic review of the literature. World J Emerg Surg 2020; 15:60. [PMID: 33087153 PMCID: PMC7579897 DOI: 10.1186/s13017-020-00339-8] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2020] [Accepted: 10/07/2020] [Indexed: 12/28/2022] Open
Abstract
Compartment syndrome can occur in many body regions and may range from homeostasis asymptomatic alterations to severe, life-threatening conditions. Surgical intervention to decompress affected organs or area of the body is often the only effective treatment, although evidences to assess the best timing of intervention are lacking. Present paper systematically reviewed the literature stratifying timings according to the compartmental syndromes which may beneficiate from immediate, early, delayed, or prophylactic surgical decompression. Timing of decompression have been stratified into four categories: (1) immediate decompression for those compartmental syndromes whose missed therapy would rapidly lead to patient death or extreme disability, (2) early decompression with the time burden of 3-12 h and in any case before clinical signs of irreversible deterioration, (3) delayed decompression identified with decompression performed after 12 h or after signs of clinical deterioration has occurred, and (4) prophylactic decompression in those situations where high incidence of compartment syndrome is expected after a specific causative event.
Collapse
Affiliation(s)
- Federico Coccolini
- General, Emergency and Trauma Surgery Department, Pisa University Hospital, Via Paradisia 1, 56100 Pisa, Italy
| | - Mario Improta
- General, Emergency and Trauma Surgery Department, Bufalini Hospital, Cesena, Italy
| | - Edoardo Picetti
- Department of Anesthesia and Intensive Care, Parma University Hospital, Parma, Italy
| | | | - Fausto Catena
- Emergency Surgery Department, Parma University Hospital, Parma, Italy
| | - Nicola de ’Angelis
- Unit of Digestive and Hepato-biliary-pancreatic Surgery, Henri Mondor Hospital and University Paris-Est Créteil (UPEC), Créteil, France
| | - Andrea Bertolucci
- General, Emergency and Trauma Surgery Department, Pisa University Hospital, Via Paradisia 1, 56100 Pisa, Italy
| | - Andrew W. Kirkpatrick
- Departments of Surgery and Critical Care Medicine, Foothills Medical Centre, Calgary, Canada
| | | | - Paola Fugazzola
- General, Emergency and Trauma Surgery Department, Bufalini Hospital, Cesena, Italy
| | - Dario Tartaglia
- General, Emergency and Trauma Surgery Department, Pisa University Hospital, Via Paradisia 1, 56100 Pisa, Italy
| | - Massimo Chiarugi
- General, Emergency and Trauma Surgery Department, Pisa University Hospital, Via Paradisia 1, 56100 Pisa, Italy
| |
Collapse
|
8
|
Kundan S, Tailor K, Radhakrishnan HB, Mohanty SR, Bhavsar K, Kadam S, Joshi P, Joshi V, Karande T, Bobhate P, Kulkarni S, Rao SG. Elective delayed sternal closure portends better outcomes in congenital heart surgery: a retrospective observational study. Indian J Thorac Cardiovasc Surg 2020; 35:530-538. [PMID: 33061048 DOI: 10.1007/s12055-019-00830-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2018] [Revised: 03/07/2019] [Accepted: 05/02/2019] [Indexed: 11/28/2022] Open
Abstract
Introduction Delayed sternal closure is used in paediatric cardiac surgery as a management strategy for patients with unstable hemodynamics or postoperative bleeding routinely. We hypothesise that planned postponement of sternal closure leads to better outcomes than emergent reopening in the intensive care unit (ICU) in patients exhibiting some hemodynamic indication for the same. Methods We retrospectively analysed the outcomes of delayed sternal closure 220/2111 (10.42%) out of which 14 sternums were opened in the ICU after shifting the patients. Results A total of 220/2111 (10.42%) sternums were left open postoperatively, out of which 14 were opened after shifting to the ICU. Total mortality of the delayed sternal closure was 33/220, i.e. 15%. The patients whose sternums were left open from the theatre had a mortality of 23/206, i.e. 11.16%, whereas those patients whose sternums were opened in the ICU had a mortality of 10/14, i.e. 71.42%. Conclusion In doubtful postoperatively hemodynamic, the choice of leaving the sternum open electively has better outcomes, rather than opening the sternum as a terminal bail out procedure.
Collapse
Affiliation(s)
- Simran Kundan
- Pediatric and Congenital Heart Surgery, Kokilaben Dhirubai Ambani Hospital, Mumbai, India
| | - Kamlesh Tailor
- Pediatric Cardiac Anesthesiologist and Intensivist, Kokilaben Dhirubai Ambani Hospital, Mumbai, India
| | | | - Smruti Ranjan Mohanty
- Pediatric and Congenital Heart Surgery, Kokilaben Dhirubai Ambani Hospital, Mumbai, India
| | - Keyur Bhavsar
- Pediatric Cardiac Anesthesiologist and Intensivist, Kokilaben Dhirubai Ambani Hospital, Mumbai, India
| | - Shankar Kadam
- Pediatric Cardiac Anesthesiologist and Intensivist, Kokilaben Dhirubai Ambani Hospital, Mumbai, India
| | - Preetha Joshi
- Pediatric and Neonatal Intensivist, Kokilaben Dhirubai Ambani Hospital, Mumbai, India
| | - Vinay Joshi
- Pediatric and Neonatal Intensivist, Kokilaben Dhirubai Ambani Hospital, Mumbai, India
| | - Tanuja Karande
- Pediatric Cardiologist, Kokilaben Dhirubai Ambani Hospital, Mumbai, India
| | - Prashant Bobhate
- Pediatric Cardiologist, Kokilaben Dhirubai Ambani Hospital, Mumbai, India
| | - Snehal Kulkarni
- Pediatric Cardiologist, Kokilaben Dhirubai Ambani Hospital, Mumbai, India
| | - Suresh Gururaja Rao
- Pediatric and Congenital Heart Surgery, Kokilaben Dhirubai Ambani Hospital, Mumbai, India
| |
Collapse
|
9
|
Kennedy JT, DiLeonardo O, Hurtado CG, Nelson JS. A Systematic Review of Antibiotic Prophylaxis for Delayed Sternal Closure in Children. World J Pediatr Congenit Heart Surg 2020; 12:93-102. [PMID: 32783516 DOI: 10.1177/2150135120947685] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Antibiotic prophylaxis following delayed sternal closure in pediatric cardiac surgery is not standardized. We systematically reviewed relevant literature published between 1990 and 2019 to aid future trial design. Patient characteristics, antimicrobial prophylaxis regimens, and postoperative incidence of infection were collected. Twenty-eight studies described 36 different regimens in over 3,000 patients. There were 11 single-drug regimens and 25 multidrug regimens. Cefazolin-only was the most common regimen (9/36, 25%). The overall incidence of surgical site infection was 7.5% (217/2,910 patients) and bloodstream infection was 7.4% (123/1,667 patients). In the 2010s, multidrug regimens were associated with a significantly lower incidence of both surgical site infections (4.6% vs. 20%, P < .001) and bloodstream infections (6.0% vs. 50%, P < .001) compared to single-drug regimens.
Collapse
Affiliation(s)
- John T Kennedy
- 124506University of Central Florida College of Medicine, Orlando, FL, USA
- Department of Surgery, 124506University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Olivia DiLeonardo
- Department of Medical Education, Nemours Children's Hospital, Orlando, FL, USA
- Nemours Children's Hospital Medical Library, Orlando, FL, USA
| | | | - Jennifer S Nelson
- 124506University of Central Florida College of Medicine, Orlando, FL, USA
- Department of Cardiovascular Services, Nemours Children's Hospital, Orlando, FL, USA
| |
Collapse
|
10
|
Li M, Mazzeffi MA, Gammie JS, Banoub M, Pazhani Y, Herr D, Madathil R, Pousatis S, Bathula A. Characterization of Postoperative Infection Risk in Cardiac Surgery Patients With Delayed Sternal Closure. J Cardiothorac Vasc Anesth 2020; 34:1238-1243. [PMID: 32127277 DOI: 10.1053/j.jvca.2020.01.010] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/27/2019] [Revised: 01/07/2020] [Accepted: 01/08/2020] [Indexed: 11/11/2022]
Abstract
OBJECTIVES To compare the incidence of postoperative infection in cardiac surgery patients who had delayed sternal closure (DSC) with those who had primary sternal closure (PSC) and evaluate the effectiveness of antibiotic prophylaxis in DSC patients. DESIGN Retrospective, observational cohort study with propensity score matching. SETTING Single academic medical center. PARTICIPANTS Cardiothoracic surgery patients, excluding transplantation patients, from a single academic medical center who had DSC or PSC between November 2015 and November 2018. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Of 2,685 patients who had cardiac surgery with cardiopulmonary bypass, 99 had DSC. Fifty-nine DSC patients met study inclusion criteria, and the final propensity score matched cohort included 57 patients with DSC and 57 patients with PSC. Propensity score matching reduced bias but was unable to balance all covariates. The most common indication for DSC was coagulopathy in 32 of the 57 patients. All patients in the PSC group received routine antibiotic prophylaxis for 48 hours after surgery. Patients in the DSC group received prolonged broadened prophylaxis until 48 hours after sternal closure. Despite prolonged broadened antibiotic prophylaxis, the DSC group had a higher rate of postoperative infection (31.6% v 3.5%; p < 0.005), mainly pneumonia (19.3% v 1.8%; p < 0.005), in the first 30 days after surgery. There was no difference in the incidence of sepsis (5.3% v 0%; p = 0.24), superficial skin and soft tissue infection (1.8% v 1.8%; p = 1), or mediastinitis/deep tissue infection (5.3% v 0%; p = 0.24) in patients with DSC. Seventy-seven percent of causative organisms for infection were Gram-negative bacteria in the matched cohort. CONCLUSION The incidence of postoperative infection, particularly pneumonia, is high in cardiothoracic surgery patients with DSC, even with prolonged broadened antibiotic prophylaxis, but the rate of mediastinitis/deep tissue infection did not appear to be greater with DSC. Additional research is needed into optimal antibiotic prophylaxis in this high-risk group of patients.
Collapse
Affiliation(s)
- Matthew Li
- Department of Pharmacy, University of Maryland Medical Center, Baltimore, MD.
| | - Michael A Mazzeffi
- Department of Anesthesiology, University of Maryland School of Medicine, Baltimore, MD
| | - James S Gammie
- Division of Cardiac Surgery, University of Maryland School of Medicine, Baltimore, MD
| | - Mary Banoub
- Department of Pharmacy, University of Maryland Medical Center, Baltimore, MD
| | | | - Daniel Herr
- Department of Medicine, University of Maryland School of Medicine, Baltimore, MD
| | - Ronson Madathil
- Division of Cardiac Surgery, University of Maryland School of Medicine, Baltimore, MD
| | - Sheelagh Pousatis
- Division of Cardiac Surgery, University of Maryland School of Medicine, Baltimore, MD
| | - Allison Bathula
- Department of Pharmacy, University of Maryland Medical Center, Baltimore, MD
| |
Collapse
|
11
|
Commentary: Delayed sternal closure-an open and not-so-shut case. JTCVS Tech 2020; 2:80-81. [PMID: 34317760 PMCID: PMC8298877 DOI: 10.1016/j.xjtc.2020.02.024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2020] [Revised: 02/14/2020] [Accepted: 02/20/2020] [Indexed: 11/17/2022] Open
|
12
|
Abstract
OBJECTIVES Capillary leak syndrome can be severe in children after open-heart surgery which may hinder sternum closure and described as mediastinal tamponade. Reopening the sternum postoperatively may help maintaining hemodynamics and respiratory function. We looked for predictors that indicate the need for reopening the sternum. DESIGN A retrospective cohort study. SETTING A single cardiac center experience from 2009 to end of 2015. PATIENTS All children who required emergent reopening the sternum in the pediatric cardiac ICU after cardiac surgery were grouped as index cases and matched to a control group for age, body weight, cardiac diagnosis, and type of repair (single vs biventricular). INTERVENTIONS Emergent reopening the sternum. MEASUREMENTS AND MAIN RESULTS With a ratio of two control cases for each index case, variables related to cardiac output (predictors) were collected in a time line of 12, 6 hours, and just before reopening the sternum. Morbidities and mortality were also reviewed. Thirty-three index cases were compared with 63 control cases. Hospital stay and hospital-acquired infections were the same between the groups. Ventilation hours were longer in the index cases. Temperature gap more than 3°C, inotropic score more than 14, and acute kidney injury indicated by doubled blood urea nitrogen and creatinine were higher in the index group 6 hours before reopening the sternum. Mortality was more in the reopening sternum group with higher risk when extracorporeal membrane oxygenation was needed. CONCLUSIONS Low cardiac output after cardiac surgery in children in form of temperature gap more than 3°C, inotropic score more than 14, and acute kidney injury may predict the need of reopening the sternum. Rate of mortality was higher in the reopening sternum group when extracorporeal membrane oxygenation was needed.
Collapse
|
13
|
Yabrodi M, Hermann JL, Brown JW, Rodefeld MD, Turrentine MW, Mastropietro CW. Minimization of Surgical Site Infections in Patients With Delayed Sternal Closure After Pediatric Cardiac Surgery. World J Pediatr Congenit Heart Surg 2019; 10:400-406. [PMID: 31307311 DOI: 10.1177/2150135119846040] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Delayed sternal closure (DSC) following pediatric cardiac surgery is commonly implemented at many centers. Infectious complications occur in 18.7% of these patients based on recent multicenter data. We aimed to describe our experience with DSC, hypothesizing that our practices surrounding the implementation and maintenance of the open sternum during DSC minimize the risk of infectious complications. METHODS We reviewed patients less than 365 days who underwent DSC between 2012 and 2016 at our institution. Infectious complications as defined by the Society of Thoracic Surgeons Congenital Heart Surgery Database were recorded. Patients with and without infectious complications were compared using Wilcoxon rank sum tests or Fisher exact tests as appropriate. RESULTS We identified 165 patients less than 365 days old who underwent DSC, 135 (82%) of whom had their skin closed over their open sternum. Median duration of open sternum was 3 days (range: 1-32 days). Infectious complications occurred in 15 (9.1%) patients-13 developed clinical sepsis with positive blood cultures, one patient developed ventilator-associated pneumonia, and one patient developed wound infection (0.6%). No cases of mediastinitis occurred. No statistical differences in characteristics between patients with and without infectious complications could be identified. CONCLUSION Infectious complications after DSC at our institution were notably less than reported in recent literature, primarily due to minimization of surgical site infections. Practices described in the article, including closing skin over the open sternum whenever possible, could potentially aid other institutions aiming to reduce infectious complications associated with DSC.
Collapse
Affiliation(s)
- Mouhammad Yabrodi
- 1 Division of Critical Care, Department of Pediatrics, Riley Hospital for Children at Indiana University Health, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Jeremy L Hermann
- 2 Division of Cardiothoracic Surgery, Department of Surgery, Riley Hospital for Children at Indiana University Health, Indiana University School of Medicine, Indianapolis, IN, USA
| | - John W Brown
- 2 Division of Cardiothoracic Surgery, Department of Surgery, Riley Hospital for Children at Indiana University Health, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Mark D Rodefeld
- 2 Division of Cardiothoracic Surgery, Department of Surgery, Riley Hospital for Children at Indiana University Health, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Mark W Turrentine
- 2 Division of Cardiothoracic Surgery, Department of Surgery, Riley Hospital for Children at Indiana University Health, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Christopher W Mastropietro
- 1 Division of Critical Care, Department of Pediatrics, Riley Hospital for Children at Indiana University Health, Indiana University School of Medicine, Indianapolis, IN, USA
| |
Collapse
|
14
|
Silvetti S, Landoni G, Castagnola E, Nuri H, Pomé G, Moscatelli A. Antibiotic Management for Delayed Sternal Closure Following Pediatric Cardiac Surgery: A Systematic Review of Recent Literature. J Cardiothorac Vasc Anesth 2019; 34:1333-1340. [PMID: 31420313 DOI: 10.1053/j.jvca.2019.07.134] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/13/2019] [Revised: 07/02/2019] [Accepted: 07/16/2019] [Indexed: 12/21/2022]
Abstract
Delayed sternal closure after pediatric cardiac surgery is a management option for the treatment of patients with severely impaired heart function. The optimal antimicrobial treatment strategy for this condition is unknown. The aim of this systematic review was to evaluate the current antibiotic administration attitudes in pediatric cardiac surgery patients needing an open chest in terms of infection with a focus on surgical site infection rate. The authors performed a systematic review and meta-analysis of all articles, which described the antibiotic administration strategy and surgical site infection rate in pediatric patients with an open chest after cardiac surgery. The authors performed a subgroup analysis on "standard" versus "non-standard" (defined as any antimicrobial drugs different from the adult guidelines recommendations) therapy for one-proportion meta-analysis with a random effect model. The authors identified 12 studies published from January 1, 2000 to July 1, 2019 including a total of 2,203 patients requiring an open chest after cardiac surgery, 350 of whom (15.9%) developed infections and 182 (8.3%) developed a surgical site infection. The surgical site infection rate in patients with "non-standard" strategy was higher than in patients with "standard" strategy: 8.8% (140 reported infections/1,582 patients) versus 6.8% (42 reported infections/621 patients), p = 0.001. The "standard" antibiotic management proposed by guidelines for adult cardiac surgery patients could be used an acceptable strategy to treat pediatric patients with an open chest after cardiac surgery.
Collapse
Affiliation(s)
- Simona Silvetti
- Neonatal and Pediatric Intensive Care Unit, Department of Surgery and Critical Care, IRCCS Istituto Giannina Gaslini, Genova, Italy
| | - Giovanni Landoni
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, University Vita-Salute San Raffaele, Milano, Italy.
| | - Elio Castagnola
- Infectious Disease Unit, Department of Pediatrics, IRCCS Istituto Giannina Gaslini, Genova, Italy
| | - Halkawt Nuri
- Cardiac Surgery Unit, Department of Surgery and Critical Care, IRCCS Istituto Giannina Gaslini, Genova, Italy
| | - Giuseppe Pomé
- Cardiac Surgery Unit, Department of Surgery and Critical Care, IRCCS Istituto Giannina Gaslini, Genova, Italy
| | - Andrea Moscatelli
- Neonatal and Pediatric Intensive Care Unit, Department of Surgery and Critical Care, IRCCS Istituto Giannina Gaslini, Genova, Italy
| |
Collapse
|
15
|
Advances in managing the noninfected open chest after cardiac surgery: Negative-pressure wound therapy. J Thorac Cardiovasc Surg 2018; 157:1891-1903.e9. [PMID: 30709676 DOI: 10.1016/j.jtcvs.2018.10.152] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/23/2018] [Revised: 08/31/2018] [Accepted: 10/09/2018] [Indexed: 01/13/2023]
Abstract
OBJECTIVE The objective of this study was to compare safety and clinical effectiveness of negative-pressure wound therapy (NPWT) with traditional wound therapy for managing noninfected open chests with delayed sternal closure after cardiac surgery. METHODS From January 2000 to July 2015, 452 of 47,325 patients who underwent full sternotomy left the operating room with a noninfected open chest (0.96%), managed using NPWT in 214-with frequency of use rapidly increasing to near 100%-and traditionally in 238. Predominant indications for open-chest management were uncontrolled coagulopathy or hemodynamic compromise on attempted chest closure. Weighted propensity-score matching was used to assess in-hospital complications and time-related survival. RESULTS NPWT and traditionally managed patients had similar high-risk preoperative profiles. Most underwent reoperations (63% of the NPWT group and 57% of the traditional group), and 21% versus 25% were emergency procedures. Reexplorations for bleeding were less common with NPWT versus traditional wound therapy (n = 63 [29%] vs 104 [44%], P = .002). Median duration of open-chest to definitive sternal closure was 3.5 days for NPWT versus 3.1 for traditionally managed patients (P[log rank] = .07). Seven patients (3.3%) were converted from NPWT to traditional therapy because of hemodynamic intolerance and 6 (2.5%) from traditional to NPWT. No NPWT-related cardiovascular injuries occurred. Among matched patients, NPWT was associated with better early survival (61% vs 44% at 6 months; P = .02). CONCLUSIONS NPWT is safe and effective for managing noninfected open chests after cardiac surgery. By facilitating open-chest management and potentially improving outcomes, it has become our therapy of choice and perhaps has lowered our threshold for leaving the chest open after cardiac surgery.
Collapse
|
16
|
Outcomes of Delayed Sternal Closure in Pediatric Heart Surgery: Single-Center Experience. BIOMED RESEARCH INTERNATIONAL 2018; 2018:3742362. [PMID: 29850507 PMCID: PMC5933025 DOI: 10.1155/2018/3742362] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/17/2017] [Accepted: 03/14/2018] [Indexed: 11/18/2022]
Abstract
Background Delayed sternal closure (DSC) after cardiac surgery is a therapeutic option in the treatment of the severely impaired heart in pediatric cardiac surgery. Methods A single-center retrospective review of all bypass surgeries performed over a 10-year period (2003–2012). Results Of a total of 2325 patients registered in our database, the DSC group included 259 cases (11%), and the remaining 2066 cases (89%) constituted the control group (PSC). RACHS-1 risk was higher for the DSC group (74% had a score of 3 or 4) than for the PSC group (82% had a score of 2 or 3). The most frequent diagnosis for the DSC group was transposition of the great arteries (28%). We found out that hemodynamic instability was the main indication observed in patients aged ≤ 8 years (63%), while bleeding was the principal indication for patients aged ≥ 8 years (94%) (p ≤ 0.001). The average time between surgery and sternal closure was 2.3 ± 1.4 days. Overall mortality rates were higher for patients of the DSC group (22%) than for the PSC group (8.7%) (OR: 0.4 (95% CI: 0.4 to 0.5), p < 0.05). There were six patients with DSC who developed mediastinitis (2.3%). The risk of mediastinitis was significantly higher when DSC was performed 4 days after the primary surgery. Conclusions DSC is an important management strategy for congenital cardiac surgery in infants and children. The prolonged sternal closure time is associated with an increased rate of postoperative mediastinitis.
Collapse
|
17
|
Wong JK, Joshi DJ, Melvin AL, Aquina CT, Archibald WJ, Lidder AK, Probst CP, Massey HT, Hicks GL, Knight PA. Early and late outcomes with prolonged open chest management after cardiac surgery. J Thorac Cardiovasc Surg 2017; 154:915-924. [DOI: 10.1016/j.jtcvs.2017.03.143] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/25/2016] [Revised: 02/16/2017] [Accepted: 03/20/2017] [Indexed: 11/26/2022]
|
18
|
Aguilar PR, Bemiss BC, Witt C, Byers DE, Kreisel D, Puri V, Meyers B, Patterson GA, Krupnick AS, Yusen RD, Trulock EP, Hachem RR. Impact of Delayed Chest Closure on Surgical Site Infection After Lung Transplantation. Ann Thorac Surg 2017; 104:1208-1214. [PMID: 28821338 DOI: 10.1016/j.athoracsur.2017.05.023] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/31/2016] [Revised: 04/23/2017] [Accepted: 05/07/2017] [Indexed: 10/19/2022]
Abstract
BACKGROUND Delayed chest closure is an increasingly used approach in the management of bleeding and hemodynamic instability after lung transplantation. We sought to evaluate the impact of delayed chest closure on surgical site infection. METHODS We performed a single-center retrospective cohort study and included adult patients who received a lung transplant at our center between January 1, 2010, and July 31, 2014. We defined surgical site infection as a thoracotomy incision wound or pleural space infection. Follow-up was complete through 6 months after transplantation. We used logistic regression models to examine the impact of delayed chest closure on surgical site infection and to identify other potential risk factors. RESULTS During the study period, 67 of the 232 transplant procedures (29%) required delayed chest closure, and surgical site infection developed in 22 recipients (9%). Among the patients with surgical site infection, 18 experienced a wound infection, and 8 experienced a pleural space infection; 4 experienced concomitant wound and pleural space infection. Among the 67 who underwent delayed chest closure, 13 patients (19%) experienced a surgical site infection compared with 9 of the 165 patients (5%) who underwent primary closure (p = 0.001). In multivariate analysis, delayed chest closure was an independent risk factor for surgical site infection. CONCLUSIONS Although delayed chest closure may have an important role in the immediate management of recipients of a lung transplant, it is an independent risk factor for surgical site infection, and this is associated with increased morbidity.
Collapse
Affiliation(s)
| | - Bradford C Bemiss
- Division of Pulmonary and Critical Care, Loyola University Stritch School of Medicine, Maywood, Illinois
| | - Chad Witt
- Division of Pulmonary and Critical Care, Washington University School of Medicine, St. Louis, Missouri
| | - Derek E Byers
- Division of Pulmonary and Critical Care, Washington University School of Medicine, St. Louis, Missouri
| | - Daniel Kreisel
- Division of Cardiothoracic Surgery, Washington University School of Medicine, St. Louis, Missouri
| | - Varun Puri
- Division of Cardiothoracic Surgery, Washington University School of Medicine, St. Louis, Missouri
| | - Bryan Meyers
- Division of Cardiothoracic Surgery, Washington University School of Medicine, St. Louis, Missouri
| | - G Alexander Patterson
- Division of Cardiothoracic Surgery, Washington University School of Medicine, St. Louis, Missouri
| | - Alexander S Krupnick
- Division of Thoracic Surgery, University of Virginia School of Medicine, Charlottesville, Virginia
| | - Roger D Yusen
- Division of Pulmonary and Critical Care, Washington University School of Medicine, St. Louis, Missouri
| | - Elbert P Trulock
- Division of Pulmonary and Critical Care, Washington University School of Medicine, St. Louis, Missouri
| | - Ramsey R Hachem
- Division of Pulmonary and Critical Care, Washington University School of Medicine, St. Louis, Missouri.
| |
Collapse
|
19
|
Delayed Sternal Closure After Continuous Flow Left Ventricle Assist Device Implantation: Analysis of Risk Factors and Impact on Outcomes and Costs. ASAIO J 2016; 62:432-7. [DOI: 10.1097/mat.0000000000000384] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
|
20
|
Haughey N, Booth K, Parissis H. Post-cardiotomy open chest management. A single-unit experience. Asian Cardiovasc Thorac Ann 2016; 24:530-4. [PMID: 27273233 DOI: 10.1177/0218492316655033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
OBJECTIVE Post-cardiotomy open chest management is used either for salvage or as a planned therapeutic option in patients with low cardiac output, hemorrhage, or intractable arrhythmias. We reviewed our experience with these patients. METHODS Over a 3-year period, 2534 adult cardiac patients were operated on and 35 (1.4%) had delayed sternal closure. The median age was 72 years (range 46-86 years) and mean logistic EuroSCORE I was 11.29 (range 1.33-84.99). The patients were divided into two groups: group A (22/35, 62.9%) left the operating room without sternal closure due to hemodynamic instability after coming off cardiopulmonary bypass; group B (13/35, 37.1%) had a resternotomy and sternal closure was delayed due to acute deterioration in the cardiac intensive care unit. RESULTS The median intensive care unit stay was 17 days (range 2-70 days). Mortality was 25.7% (9 patients). All survivors were followed-up for at least 2 years, with a 2-year survival rate of 57.1%. Overall mortality was broadly similar in both groups. There was a high rate of postoperative complications in both groups, including chest sepsis (77%), liver failure (14.3), renal failure requiring renal replacement therapy (42.9%), sternal wound infection (28.6%), gut ischemia (2.9%), cerebrovascular accident (11.4), and multiorgan failure (31.4%). CONCLUSIONS Some may argue that open chest management is an acceptable salvage procedure, however, follow-up demonstrated significant adverse cardiac or cerebrovascular events in a short period following discharge, thus delayed sternal closure is really a salvage procedure but useful in centers without access to extracorporeal membrane oxygenation.
Collapse
Affiliation(s)
- Niamh Haughey
- Department of Cardiac Surgery, Royal Victoria Hospital, Belfast, UK
| | - Karen Booth
- Department of Cardiac Surgery, Royal Victoria Hospital, Belfast, UK
| | | |
Collapse
|
21
|
Bastero P, DiNardo JA, Pratap JN, Schwartz JM, Sivarajan VB. Early Perioperative Management After Pediatric Cardiac Surgery: Review at PCICS 2014. World J Pediatr Congenit Heart Surg 2016; 6:565-74. [PMID: 26467871 DOI: 10.1177/2150135115601830] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
The sessions of the symposium held in December 2014 allow us to capitalize on the shared knowledge and experience that arise from both cardiac anesthesia and cardiac intensive care. During this session, topics that crossed traditional boundaries of pediatric cardiac intensive care and pediatric cardiac anesthesia were presented and discussed. This article summarizes the five topics presented at the symposium.
Collapse
Affiliation(s)
- Patricia Bastero
- Baylor College of Medicine, Texas Children's Hospital, Houston, TX, USA
| | - James A DiNardo
- Harvard Medical School, Boston Children's Hospital, Boston, MA, USA
| | - J Nick Pratap
- Cincinnati Children's Hospital Medical Center, University of Cincinnati, Cincinnati, OH, USA
| | - Jamie M Schwartz
- Children's National Health System, The George Washington School of Medicine, Washington DC, WA, USA
| | - V Ben Sivarajan
- Critical Care Medicine, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| |
Collapse
|
22
|
Yuh DD. Delayed sternal closure after assist device implantation: Not all bleeding stops. J Thorac Cardiovasc Surg 2015; 150:418-20. [PMID: 26071970 DOI: 10.1016/j.jtcvs.2015.05.037] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/11/2015] [Accepted: 05/12/2015] [Indexed: 11/28/2022]
Affiliation(s)
- David D Yuh
- Section of Cardiac Surgery, Yale University School of Medicine, New Haven, Conn.
| |
Collapse
|
23
|
Pressure, perfusion, and compartments: challenges for the acute care surgeon. J Trauma Acute Care Surg 2014; 76:1341-8. [PMID: 24854298 DOI: 10.1097/ta.0000000000000240] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
|
24
|
Erek E, Yalcinbas YK, Turkekul Y, Saygili A, Ulukol A, Sarioglu A, Sarioglu CT. Indications and risks of delayed sternal closure after open heart surgery in neonates and early infants. World J Pediatr Congenit Heart Surg 2013; 3:229-35. [PMID: 23804779 DOI: 10.1177/2150135111432771] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND Delayed sternal closure (DSC) has been an essential part of neonatal and infant heart surgery. Here, we report our single institution experience of DSC for eight years. METHODS The successive 188 patients were analyzed retrospectively. Sternum was closed at the end of the operation in 97 (51.6%) patients (primary sternal closure [PSC] group). Sternum was left open in 91 (48.4%) patients. Among them, 45 (23.9%) had only skin closure (DSCs group) and 46 (24.4%) had membrane patch closure (DSC membrane [DSCm] group). Median age was higher in PSC group (90 days) than DSCs (11 days) and DSCm groups (9.5 days). RESULTS Mortality was 1%, 11.1%, and 28.2% in PSC, DSCs, and DSCm groups, respectively (P < .05). Univariate analysis recognized the neonatal age (odds ratio [OR] = 4.2), preoperative critical condition (OR = 5.3), cardiopulmonary bypass time >180 minutes (OR = 4), and cross clamp time >99 minutes (OR = 3.9) as risk factors for mortality. Total morbidity rate was higher in DSCm group (73.9%) than DSCs group (51.1%) and PSC group (23.7%; P < .001). Mechanical ventilation time, intensive care unit stay, and hospital stay were longer in DSCs and DSCm groups than PSC group (P < .001). The incidence of hospital infection was also higher in DSCs (43.5%) and DSCm (33.3%) groups than PSC group (20.6%; P < .05). But there was no difference in the incidence of sternal wound complications, including both deep and superficial (4.1%, 8.8%, and 4.4%, respectively). CONCLUSION Although the risk of sternal wound complications is not different, patients who necessitate DSC (using both skin and membrane closure techniques) have more complicated postoperative course than patients with PSC.
Collapse
Affiliation(s)
- Ersin Erek
- Istanbul Mehmet Akif Ersoy Thoracic and Cardiovascular Surgery Training and Research Hospital, Cardiovascular Surgery Department, Istanbul, Turkey
| | | | | | | | | | | | | |
Collapse
|
25
|
Kandakure PR, Ramodass N, Rani U, Chakravarthy S, Rao IM, Kona SM. Sternal traction: simple technique to prevent tamponade/compression of the heart. Asian Cardiovasc Thorac Ann 2013; 20:751-3. [PMID: 23284135 DOI: 10.1177/0218492312458569] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Routine closure of the sternum after cardiovascular surgery sometimes causes severe cardiac depression because of tamponade, leading to cardiogenic shock. We describe a full-thickness chest wall traction suture taken parasternally and tied to an intravenous fluid stand. Upward (outward) traction is applied to the anterior chest while the sternum is primarily closed, which allows physiologic improvement equivalent to delayed sternal closure. It is a safe and easily reproducible technique.
Collapse
|
26
|
Özker E, Saritaş B, Vuran C, Yörüker U, Ulugöl H, Türköz R. Delayed sternal closure after pediatric cardiac operations; single center experience: a retrospective study. J Cardiothorac Surg 2012; 7:102. [PMID: 23031425 PMCID: PMC3514162 DOI: 10.1186/1749-8090-7-102] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2012] [Accepted: 09/25/2012] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Delayed sternal closure (DSC) after cardiac surgery is a therapeutic option in the treatment of the severely impaired heart in pediatric cardiac surgery. The results with the technique of DSC over a 4-year period are examined with regard to mortality and morbidity. METHODS We retrospectively reviewed records of 38 patients who had undergone DSC among 1100 congenital cardiac operations. Indication of DSC, time to sternal closure, pre and post closure cardiopulmonary and metabolic status, mortality, rate of wound and bloodstream infections were recorded. RESULTS The mean sternal closure time was 2.9 days. The mortality rate was 34.2% (n = 13). Twenty (52.6%) patients required prolonged antibiotic use due to postoperative infection. There was gram negative microorganism predominance. There were 4 (10.5%) patients with postoperative mediastinitis. Postoperative infection rate statistically increased with cardiopulmonary bypass time (CPBT), sternal closure time (SCT) and intensive care unit (ICU) stay time (p = 0.039;p = 0.01;p = 0.012). On the other hand, the mortality rate significantly increased with increased cross clamp time (CCT), SCT, and extracorporeal membrane oxygenation (ECMO) use (p = 0.017; p = 0.026; p = 0.03). Single ventricular physiology was found to be risk factor for mortality in delayed sternal closure (p < 0.007). CONCLUSIONS Elective DSC does not reduce the morbidity. The prolonged sternal closure time is associated with increased rate of postoperative infection rate; therefore early closure is strongly advocated.
Collapse
Affiliation(s)
- Emre Özker
- Baskent University, Istanbul medical trainning and research hospital, department of Cardiovascular Surgery, Istanbul, Turkey.
| | | | | | | | | | | |
Collapse
|
27
|
Preliminary experience with a new device for delayed sternal closure strategy in cardiac surgery. Int J Artif Organs 2012; 35:471-6. [PMID: 22466992 DOI: 10.5301/ijao.5000095] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/05/2012] [Indexed: 11/20/2022]
Abstract
PURPOSE Open chest management with delayed sternal closure (DSC) is a valuable strategy in the management of patients with postcardiotomy hemodynamic instability or severe coagulopathy. The conventional extemporized material available for off-label sternal stenting however may limit its efficacy. We evaluated outcomes of patients with refractory severe postcardiotomy cardiogenic shock (SPCCS) treated with DSC using a novel temporary sternal spreader (NTSS) which allows myocardial recovery by progressive controlled approximation of the sternal edges. METHODS Seven patients (4 male, mean age 66.5 ± 5 years) with refractory SPCCS showing acute hemodynamic instability at sternal closure, were implanted with the NTSS, consisting of stainless-steel branches linked to 2 diverging plates of polyether-ether ketone, whose progressive opening/closing mechanism can be controlled from outside the chest with a rotating steel wire. The sternal wound was closed by an elastic membrane to achieve a sterile field. Swan-Ganz monitoring was employed, and clinical outcomes evaluated. RESULTS The device was successfully implanted in all patients without device-related complications or failures. Progressive approximation of sternal edges, titrated on cardiac index values, was successfully completed allowing subsequent uneventful sternal closure in all. Mean time from SPCCS to sternal closure was 70 ± 21 hours. No patient developed infective complications or late hemodynamic instability after device removal and sternal closure. One patient (14%) died of multiorgan failure on postoperative day 9. CONCLUSIONS Despite the limited number of patients enrolled, the NTSS proved safe and effective in allowing complete myocardial recovery after SPCCS, avoiding hemodynamic instability related to abrupt sternal closure, with no occurrence of infective complications.
Collapse
|
28
|
Abstract
Thoracic compartment syndrome has been observed after trauma and after mediastinal and cardiac procedures; however, an adult respiratory distress syndrome (ARDS)-like presentation has not been described as a part of thoracic compartment syndrome. We describe the case of an obese patient who underwent coronary artery bypass (his third such procedure) and hiatal hernia reduction during the same operation, followed by transmyocardial laser revascularization and full chest closure the next day. The patient was hypoxic after chest closure. Two days later, his peak airway pressure increased, and his cardiac and urine outputs decreased. Chest radiography findings suggested ARDS without hemodynamic instability. After we reopened the sternal incisions, the patient's symptoms reversed. Although our patient initially appeared to have ARDS, we believe the organ-volume displacement that occurred during the lengthy dual operation produced a thoracic and abdominal compartment syndrome that responded to decompression of the chest.
Collapse
Affiliation(s)
- Mehmet H Akay
- Department of Cardiopulmonary Transplantation and the Center for Cardiac Support, Texas Heart Institute at St. Luke's Episcopal Hospital, Houston, Texas, USA
| | | |
Collapse
|
29
|
Santini F, Onorati F, Faggian G, Mazzucco A. Safety and efficacy of a novel temporary sternal spreader in the management of severe postcardiotomy cardiogenic shock: A preliminary report study. J Thorac Cardiovasc Surg 2011; 142:1276-8. [DOI: 10.1016/j.jtcvs.2011.03.024] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2011] [Accepted: 03/24/2011] [Indexed: 10/18/2022]
|
30
|
Shin HJ, Jhang WK, Park JJ, Yun TJ. Impact of Delayed Sternal Closure on Postoperative Infection or Wound Dehiscence in Patients With Congenital Heart Disease. Ann Thorac Surg 2011; 92:705-9. [DOI: 10.1016/j.athoracsur.2011.03.040] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/16/2011] [Revised: 03/10/2011] [Accepted: 03/15/2011] [Indexed: 10/17/2022]
|
31
|
Boeken U, Assmann A, Mehdiani A, Akhyari P, Lichtenberg A. Open chest management after cardiac operations: outcome and timing of delayed sternal closure. Eur J Cardiothorac Surg 2011; 40:1146-50. [PMID: 21458291 DOI: 10.1016/j.ejcts.2011.02.047] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/28/2010] [Revised: 02/17/2011] [Accepted: 02/21/2011] [Indexed: 10/18/2022] Open
Abstract
OBJECTIVE Open chest management (OCM) after cardiac surgery is a therapeutic option in the treatment of the severely impaired heart. The aim of this study was the evaluation of the incidence, survival and predictors of poor outcome for OCM with delayed sternal closure (DSC), particularly with regard to parameters to determine the time of closure. METHODS Prolonged open chest was used in 212 of 6041 cardiac surgery patients between 2004 and 2009 (3.5%). We wanted to determine indications, mortality, morbidity, predictors of outcome, and parameters for timing of sternal closure. RESULTS The incidence of open chest (OC) was 3.5%, with 1.4% for isolated coronary artery bypass grafting (CABG), 2.9% for isolated valve, and 7.1% for combined procedures. Indications for OC were: hemodynamic compromise (180), intractable bleeding (14), arrhythmia (12), and cardiac edema or tamponade (six). A total of 153 of the 212 patients with DSC (72%) survived. Fifty-nine patients died: 23 before DSC and 36 after this procedure. Mortality could be related to the indication for OC: With the indication 'low cardiac output syndrome' (LCOS), the mortality was 36%, for bleeding it was 25.5%, for arrhythmias 20.5%, and for tamponade on closure it was 18%. After DSC, deep sternal wound infection (DSWI) occurred in 10 patients (5.3%) and superficial infection in 4.8% of patients. There were 18 patients with postoperative stroke (8.5%) and 27 patients with need for dialysis (12.7%). By univariate analysis, ventricular assist device (VAD) insertion, new onset of hemodialysis, re-operation for bleeding, mean length of duration of OC (survivors 3.2 days, non-survivors 6.4 days), and longer duration of high-dose inotropic therapy could be determined as predictors of mortality. CONCLUSION With our results, we could demonstrate OCM to be a beneficial, therapeutic option in patients with postoperative LCOS, massive hemorrhage or significant arrhythmias with hemodynamic compromise. However, patients with re-operation for bleeding, need for VAD and particularly a prolonged delay before sternal closure continued to have a poor outcome.
Collapse
Affiliation(s)
- Udo Boeken
- Department of Cardiovascular Surgery, Heinrich-Heine-University Medical School, Moorenstrasse 5, D-40225 Duesseldorf, Germany.
| | | | | | | | | |
Collapse
|
32
|
Boeken U, Feindt P, Schurr P, Assmann A, Akhyari P, Lichtenberg A. Delayed Sternal Closure (DSC) After Cardiac Surgery: Outcome and Prognostic Markers. J Card Surg 2010; 26:22-7. [DOI: 10.1111/j.1540-8191.2010.01159.x] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
|
33
|
Abstract
Compartment syndrome is defined as the dysfunction of organs/tissues within the compartment due to limited blood supply caused by increased pressure within the compartment. The aim of this article is to introduce and discuss acute compartment syndromes that are essential for critical care physicians to recognize and manage. Various pathophysiological mechanisms (ischemia-reperfusion syndrome, direct trauma, localized bleeding) could lead to increased compartmental pressure and decreased blood flow through the intracompartmental capillaries. Although compartment syndromes are described in virtually all body regions, the etiology, diagnosis, treatment, and prevention are best characterized for three key body regions (extremity, abdominal, and thoracic compartment syndromes). Compartment syndromes can be classified as either primary (pathology/injury is within the compartment) or secondary (no primary pathology or injury within the compartment), and based on the etiology (e.g., trauma, burn, sepsis). A recently described phenomenon is the "multiple" compartment syndrome or "poly"-compartment syndrome, which is usually a complication of a severe shock and massive resuscitation. The prevention of compartment syndromes is based on preemptive open management of compartments (primary syndromes) in high-risk patients and/or careful fluid resuscitation (both primary and secondary syndromes) to limit interstitial swelling.
Collapse
|
34
|
Pye S, McDonnell M. Nursing considerations for children undergoing delayed sternal closure after surgery for congenital heart disease. Crit Care Nurse 2010; 30:50-62; quiz 63. [PMID: 20515883 DOI: 10.4037/ccn2010712] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Affiliation(s)
- Sherry Pye
- University of Arkansas for Medical Sciences, Arkansas Children's Hospital, Department of Pediatric Cardiology, 800 Marshall Street, Little Rock, AR 72202, USA.
| | | |
Collapse
|
35
|
Wandling MW, An GC. A case report of thoracic compartment syndrome in the setting of penetrating chest trauma and review of the literature. World J Emerg Surg 2010; 5:22. [PMID: 20673346 PMCID: PMC2917402 DOI: 10.1186/1749-7922-5-22] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2010] [Accepted: 07/30/2010] [Indexed: 11/10/2022] Open
Abstract
Trauma-related thoracic compartment syndrome (TCS) is a rare, life threatening condition that develops secondary to elevated intra-thoracic pressure and manifests itself clinically as significantly elevated airway pressures, inability to provide adequate ventilation and hemodynamic instability temporally related to closure of a thoracic surgical incision. TCS is exceedingly rare in the trauma population. We present a case of TCS following surgical repair of a stab wound injury that necessitated decompressive thoracotomy and peri-operative open-chest management.
Collapse
Affiliation(s)
- Michael W Wandling
- Department of Surgery, Section of General Surgery, University of Chicago Pritzker School of Medicine, 5841 South Maryland, S-032 MC5031, Chicago, IL, 60637, USA.
| | | |
Collapse
|
36
|
Hashemzadeh K, Hashemzadeh S. In-hospital outcomes of delayed sternal closure after open cardiac surgery. J Card Surg 2009; 24:30-3. [PMID: 19120673 DOI: 10.1111/j.1540-8191.2008.00745.x] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
BACKGROUND The purpose of this prospective study was to evaluate the current incidence, survival, morbidity, and predictors of mortality for open sternotomy at our center. METHODS Prolonged open chest was used in 126 of 2485 cardiac operations (5.0%) between June 2006 and January 2008. The indications were hemodynamic instability (98), bleeding (14), arrhythmia (five), cardiac edema (three), tamponade (three), and cardiac arrest (three). Delayed sternal closure (DSC) was performed in 81 of 126 patients at a mean of 2.35+/-1.73 days (range: 0.5 to 10 days). RESULTS Sixty-five of the 81 who had DSC (81.4%) survived. Forty-five patients (35.7%) died before DSC and 16 after this method. The 65 survivors (51.6%) were discharged from the hospital at a mean of 15.6+/-8.4 days (range: 7 to 50 days). The most common causes of death included low cardiac output (67.2%) and multiorgan failure (26.2%). Superficial sternal wound infection occurred in one of 81 (1.2%) patients after DSC, mediastinitis in four (4.9%), and sternal dehiscence in two (2.4%) patients. New onset of acute renal failure and the presence of intraaortic balloon pump (IABP) were predictive of in-hospital death. CONCLUSIONS This study shows that open chest with DSC is useful in the treatment of postoperatively impaired cardiac function, intractable bleeding, and persistent arrhythmias. It can be carried out with a relatively low incidence of sternal complications. Patients with new onset acute renal failure and who require IABP continue to have a high mortality rate.
Collapse
Affiliation(s)
- Khosrow Hashemzadeh
- Department of Cardiovascular Surgery, Tabriz University of Medical Sciences, Tabriz, Iran.
| | | |
Collapse
|
37
|
Hassanzade M. New Approach for the Incidence of Ascites Syndrome in Broiler Chickens and Management Control the Metabolic Disorders. ACTA ACUST UNITED AC 2008. [DOI: 10.3923/ijps.2009.90.98] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
|
38
|
Fleck T, Kickinger B, Moidl R, Waldenberger F, Wolner E, Grabenwoger M, Wisser W. Management of open chest and delayed sternal closure with the vacuum assisted closure system: preliminary experience. Interact Cardiovasc Thorac Surg 2008; 7:801-4. [PMID: 18541606 DOI: 10.1510/icvts.2008.177527] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023] Open
Abstract
The management of open chest with the vacuum assisted closure (VAC) system was evaluated in terms of impact on cardiac hemodynamics, respiratory parameters, complications, incidence of wound infection, overall handling and outcome in 22 patients during 2005 and 2008 after cardiac surgery. The decision to leave the sternum open was made electively in all patients at the time of primary operation or reexploration. In four patients the VAC was implanted during the primary operation. In the remainder the VAC was implanted after a mean of five days after the primary operation. The overall mortality rate was 45% (10/22). None of the patients developed a sternal wound infection, nor were there any VAC related complications. Management of open chest with the VAC system can be considered as an alternative to sterile draping. The VAC has no negative impact on cardiac hemodynamics as well as respiratory mechanics. The feared complication of right ventricular rupture and massive bleeding can be effectively prevented. Through the stabilizing of the thoracic cage, the patient can be easily moved and mobilized for nursing reasons and pneumonia prevention. Furthermore, the VAC effectively prevents the contamination of the wound and the mediastinum with potential subsequent infection.
Collapse
Affiliation(s)
- Tatjana Fleck
- Department of Cardiothoracic Surgery, Medical University of Vienna, AKH Vienna, Währinger Gürtel, Vienna, Austria.
| | | | | | | | | | | | | |
Collapse
|
39
|
Kuroczynski W, Muench M, Kampmann C, Parker J, Peivandi AA, Heinemann M, Pruefer D, Vahl CF. Risikofaktoren bei Patienten mit zweizeitigem Thoraxverschluss nach Korrektur eines angeborenen Herzfehlers. ZEITSCHRIFT FUR HERZ THORAX UND GEFASSCHIRURGIE 2008. [DOI: 10.1007/s00398-008-0619-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
|
40
|
Force SD, Miller DL, Pelaez A, Ramirez AM, Vega D, Barden B, Lawrence EC. Outcomes of Delayed Chest Closure After Bilateral Lung Transplantation. Ann Thorac Surg 2006; 81:2020-4; discussion 2024-5. [PMID: 16731123 DOI: 10.1016/j.athoracsur.2006.01.050] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/16/2005] [Revised: 01/09/2006] [Accepted: 01/10/2006] [Indexed: 10/24/2022]
Abstract
BACKGROUND Delayed chest closure (DCC) may be used after bilateral lung transplantation when significant bleeding/coagulopathy or severe pulmonary edema exists. Primary chest closure (PCC) in these patients can lead to heart and lung compression causing cardiopulmonary instability. The purpose of this study is to describe factors associated with DCC and evaluate outcomes after DCC. METHODS We performed a retrospective review of all patients undergoing bilateral lung transplantation between September 2003 and March 2005. Statistical significance was determined by two-tailed t test or Fisher's exact test. RESULTS Twenty-eight bilateral lung transplantations were performed. Indication for transplant was chronic obstructive pulmonary disease (13), pulmonary fibrosis (5), cystic fibrosis (5), sarcoidosis (3), and pulmonary hypertension (1). Seven patients (25%) required DCC. Mean time to DCC was 5.3 days. Six patients (86%) with DCC required tracheostomy versus 4 patients (20%) with PCC (p = 0.003). Mean days to discharge was 44 in the DCC group and 21 in the PCC group (p = 0.03). Thirty-day survival was 100% in the DCC group and 95% in the PCC group (p = 1.0). There were no wound infections in either group, and 1 patient in the PCC group had sternal nonunion. Delayed chest closure was associated with cardiopulmonary bypass use (p = 0.006), cardiopulmonary bypass time longer than mean cardiopulmonary bypass time (mean, 224 minutes; p = 0.04), PaO2/FiO2 less than mean + 1 SD (value = 4.63, p = 0.0002), evidence of moderate/severe reperfusion injury on chest radiograph (p = 0.0002), and PaO2/FiO2 less than mean plus moderate/severe reperfusion injury on chest radiograph (p = 0.002). CONCLUSIONS Cardiopulmonary bypass use, prolonged cardiopulmonary bypass time, and significant reperfusion injury, as determined by chest radiograph and a low PaO2/FiO2 ratio were all associated with an increased incidence of DCC in our bilateral lung transplantation patients. These patients had no wound infections or sternal complications, and although they had longer hospital stays than PCC patients, DCC did not affect operative survival. Delayed chest closure can be employed safely, when necessary, after bilateral lung transplantation with outcomes similar to patients with PCC.
Collapse
Affiliation(s)
- Seth D Force
- Division of Cardiothoracic Surgery, Emory University Hospital and Clinic, Atlanta, Georgia, USA.
| | | | | | | | | | | | | |
Collapse
|
41
|
Riphagen S, McDougall M, Tibby SM, Alphonso N, Anderson D, Austin C, Durward A, Murdoch IA. “Early” Delayed Sternal Closure Following Pediatric Cardiac Surgery. Ann Thorac Surg 2005; 80:678-84. [PMID: 16039227 DOI: 10.1016/j.athoracsur.2005.02.040] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/21/2004] [Revised: 02/01/2005] [Accepted: 02/09/2005] [Indexed: 11/26/2022]
Abstract
BACKGROUND Delayed sternal closure is commonly used following pediatric cardiopulmonary bypass surgery for many reasons including support of the failing myocardium. We hypothesized that, as a result of improvements in perioperative care, sternal closure could be achieved at an earlier postoperative time than the 3 to 5 days typically reported in the literature. METHODS Retrospective chart review of all bypass surgery (n = 585) performed in a single center over a 3-year period (2000-2002). RESULTS We identified 66 children (11.3%), median age 5 days old, who underwent delayed sternal closure. In 60 of these patients, sternal closure was achieved at a median (interquartile) postoperative time of 21 hours (18 to 40 hours). The most common indication was inadequate hemostasis, although early sternal closure was also achieved in the subgroup with poor myocardial function as the primary indication at a median of 36 hours (21 to 44 hours). There was no noticeable hemodynamic, respiratory or metabolic compromise following sternal closure, although patients with poor myocardial function tended to have a lower mean blood pressure than those with inadequate hemostasis (ANOVA, p = 0.02). The overall mortality was 19.7% (13 of 66), with a median duration of ventilation and intensive care stay among survivors of 3.8 days (2.4 to 6.3 days) and 4.8 days (3.7 to 7.9 days), respectively. CONCLUSIONS Delayed sternal closure is possible at an earlier stage than previously reported.
Collapse
Affiliation(s)
- Shelley Riphagen
- Department of Pediatric Intensive Care, Guy's Hospital, London, United Kingdom.
| | | | | | | | | | | | | | | |
Collapse
|
42
|
Rizzo AG, Sample GA. Thoracic compartment syndrome secondary to a thoracic procedure: a case report. Chest 2003; 124:1164-8. [PMID: 12970052 DOI: 10.1378/chest.124.3.1164] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Abstract
Prolonged open sternotomy is a well-known phenomenon in the pediatric and adult cardiac surgery literature. It is usually an adjuvant in the treatment of a severely compromised heart. We present a case of thoracic compartment syndrome that developed postoperatively from a noncardiac thoracic procedure. Management, diagnosis, and literature review are presented.
Collapse
Affiliation(s)
- Anne G Rizzo
- Washington Hospital Center, 110 Irving Street NW, 4B-39, Washington, DC 20010, USA.
| | | |
Collapse
|
43
|
Anderson CA, Filsoufi F, Aklog L, Farivar RS, Byrne JG, Adams DH. Liberal use of delayed sternal closure for postcardiotomy hemodynamic instability. Ann Thorac Surg 2002; 73:1484-8. [PMID: 12022537 DOI: 10.1016/s0003-4975(01)03601-3] [Citation(s) in RCA: 36] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
BACKGROUND The purpose of this retrospective study was to evaluate the current incidence, survival, and predictors of mortality for open chest management at our center. METHODS Our database was analyzed to identify adult postcardiotomy patients who left the operating room without primary sternal closure. Medical records were reviewed to determine mortality, postoperative complications, and pertinent hemodynamic data. RESULTS From November 1997 to June 2000, 5,177 adults underwent cardiac procedures at our center. The incidence of open chest management was 1.7% (87 of 5,177), including 0.7% (16 of 2,254) for isolated coronary artery bypass grafting, 1.6% (15 of 912) for isolated valve, and 5.6% (47 of 839) for combined valve/coronary bypass. Hospital survival was 76% (66 of 87). Major complications included deep sternal infection (n = 4), stroke (n = 8), and dialysis (n = 13). Predictors of mortality by univariate analysis included ventricular assist device insertion (p = 0.003), new onset hemodialysis (p < 0.0005), reoperation for bleeding (p = 0.002), sternal infection (p = 0.042), mean length of delay before sternal closure (survivors = 3.2 days, nonsurvivors = 6.2 days; p = 0.031), higher mean dose of epinephrine at the time of chest closure (2.5 microg versus 0.9 microg, p = 0.011), and longer duration of high dose inotropic therapy (110 hours versus 43 hours, p = 0.002). Multivariate analysis showed ventricular assistance and reoperation for bleeding as independent predictors of in-hospital death with odds ratios of 3.8 and 3.4, respectively. CONCLUSIONS Liberal use of open chest management is useful in patients with postcardiotomy shock, and can be carried out with a relatively low incidence of sternal complications. Patients who require ventricular assistance or exploration for ongoing mediastinal bleeding continue to have a high mortality rate.
Collapse
Affiliation(s)
- Curtis A Anderson
- Division of Cardiac Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | | | | | | | | | | |
Collapse
|
44
|
McElhinney DB, Reddy VM, Parry AJ, Johnson L, Fineman JR, Hanley FL. Management and outcomes of delayed sternal closure after cardiac surgery in neonates and infants. Crit Care Med 2000; 28:1180-4. [PMID: 10809302 DOI: 10.1097/00003246-200004000-00044] [Citation(s) in RCA: 64] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVES To investigate the efficacy, safety, and patterns of management of open sternotomy and delayed sternal closure in infants who were left with an open sternum after cardiac surgery and to assess these patterns for possible correlation with outcome. DESIGN Retrospective chart review with statistical analysis. SETTING Pediatric cardiac surgery service at a regional referral center based in an urban university teaching hospital. PATIENTS All 128 patients <1 yr of age who were left with an open sternum after cardiac surgery with cardiopulmonary bypass during the 4-yr period from July, 1992 to June, 1996. INTERVENTIONS Procedures for managing open sternotomy and delayed sternal closure were analyzed retrospectively. No interventions were undertaken for the study. MEASUREMENTS AND RESULTS Of the 128 patients, 14 (11%) died before sternal closure; delayed sternal closure was performed in the remaining 114. Of these 114, 13 died in the early postoperative period. During sternal closure, significant increases were noted in pulmonary arterial (from 21.1+/-7.6 mm Hg to 26.1+/-6.5 mm Hg; p = .006), left atrial (from 8.4+/-3.4 mm Hg to 11.5+/-3.7 mm Hg; p < .001), and right atrial pressures (from 7.3+/-2.5 mm Hg to 9.8+/-2.5 mm Hg; p < .001). In addition, mean airway pressure (from 7.4+/-2.0 mm Hg to 8.6+/-2.4 mm Hg; p < .001) and peak inspiratory pressure (from 29.3+/-5.4 mm Hg to 31.3+/-5.6 mm Hg; p = .004) increased. Sternal wound infection occurred in one patient. CONCLUSIONS Delayed sternal closure is an effective approach to the management of neonates and infants at risk for hemodynamic, respiratory, or hemostatic instability early after cardiac surgery. Significant changes in hemodynamics and respiratory variables occur during sternal closure, often requiring adjustment of inotropic and ventilatory management. (Crit Care Med 2000; 28: 1180-1184)
Collapse
Affiliation(s)
- D B McElhinney
- Division of Cardiothoracic Surgery, University of California, San Francisco, USA
| | | | | | | | | | | |
Collapse
|
45
|
Tabbutt S, Duncan BW, McLaughlin D, Wessel DL, Jonas RA, Laussen PC. Delayed sternal closure after cardiac operations in a pediatric population. J Thorac Cardiovasc Surg 1997; 113:886-93. [PMID: 9159622 DOI: 10.1016/s0022-5223(97)70261-7] [Citation(s) in RCA: 90] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
OBJECTIVE The purpose of this study was to assess morbidity and mortality associated with delayed sternal closure after pediatric cardiac operations. METHODS Hospital records were reviewed of all patients with an open sternum after a cardiac operation at Children's Hospital, Boston, from January 1992 to December 1995. RESULTS A total of 178 patients had delayed sternal closure with an overall mortality rate of 19%. The most common diagnosis of patients with delayed sternal closure was hypoplastic left heart syndrome (29%). Although myocardial distention or chest wall edema (n = 47) was a common indication to delay sternal closure, in many patients (n = 47) the sternum was left open electively to avoid postoperative cardiac or respiratory compromise. Successful sternal closure was achieved in 158 patients (89%) at a mean of 3.4 +/- 1.8 days after opening. There were significant increases in left atrial pressure (7.7 +/- 3.4 to 9.8 +/- 4.1 mm Hg, p = 0.00001) and right atrial pressure (8 +/- 3.2 to 10.1 +/- 3.3 mm Hg, p = 0.00001) with sternal closure. There was a small but statistically significant drop in pH (7.44 +/- 0.05 to 7.41 +/- 0.08, p < 0.0001) during sternal closure. The peak inspiratory pressure, delivered breaths per minute, and fraction of inspired oxygen all significantly increased during sternal closure. Clinical evidence of surgical site infection occurred in 12 (6.7%) of the patients with delayed sternal closure; mediastinitis developed in 7 (3.9%) patients. CONCLUSIONS Although delayed sternal closure after complex operations for congenital heart disease is often necessary in the operating room because of edema, unstable hemodynamic conditions, or bleeding, it can also be used electively to aid in hemodynamic and respiratory stability in the initial postoperative period. Our review supports a low morbidity associated with delayed sternal closure in a pediatric population.
Collapse
Affiliation(s)
- S Tabbutt
- Department of Medicine, Harvard Medical School, Children's Hospital, Boston, Mass 02115, USA
| | | | | | | | | | | |
Collapse
|
46
|
Donatelli F, Triggiani M, Benussi S, Grossi A. Advantages of delayed sternal closure in cardiac-compromised adult patients. J Card Surg 1995; 10:632-6. [PMID: 8574021 DOI: 10.1111/j.1540-8191.1995.tb00653.x] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
Severe hemodynamic dysfunction may follow closure of the median sternotomy in patients with myocardial edema, cardiac dilatation, postcardiotomy shock, or raised end-expiratory alveolar pressure. Open sternotomy and delayed sternal closure (DSC) is a well described adjunct in complicated cardiac operations, which is more widely applied in neonates. In this article we report our results in using open sternotomy in eight adult patients from January 1994 to February 1995 (excluding patients who needed ventricular assistance devices [VADs]). Three patients died in hospital: 1 case of multiorgan failure; 1 cases of refractory low cardiac output syndrome; and 1 case of respiratory distress syndrome. Our experience confirms that DSC is an effective means of dealing with postoperative hemodynamic impairment. Furthermore, this technique may represent an intermediate step between intraaortic balloon counterpulsation and VADs and should be given a role in the prophylaxis of low postoperative cardiac output and multiorgan failure, particularly when contraindications to VAD exist.
Collapse
Affiliation(s)
- F Donatelli
- Institute for Cardiovascular and Respiratory Diseases, University of Milan, IRCCS H.S. Raffaele, Italy
| | | | | | | |
Collapse
|
47
|
Abstract
BACKGROUND Routine closure of the sternum after cardiovascular surgical procedures sometimes causes severe cardiac depression because of a tamponade-like reduction in ventricular filling, leading to cardiogenic shock. Leaving the sternal halves apart, sealing the mediastinum by simply approximating the skin or using a prosthetic patch, and then performing delayed sternal closure in several days is a widely practiced life-saving maneuver. METHODS Described herein is an experience with 5 patients with severe cardiac output depression of the type usually treated by delayed sternal closure. Instead, upward (outward) traction was applied to the anterior chest while the sternum was primarily closed. Traction was maintained with full-thickness chest wall sutures. RESULTS The traction sutures were removed successfully in the intensive care unit between 1 and 4 days postoperatively, after appropriate vigorous treatment of postbypass myocardial enlargement and pulmonary distention and edema. CONCLUSIONS This method of sternal traction allows physiologic improvement equivalent to delayed sternal closure in some patients and obviates the need for returning to the operating room to close the sternum in the early postoperative period.
Collapse
Affiliation(s)
- M T McEnany
- Department of Cardiovascular Surgery, Kaiser-Permanente Medical Center, San Francisco, California, USA
| |
Collapse
|
48
|
Alexi-Meskishvili V, Weng Y, Uhlemann F, Lange PE, Hetzer R. Prolonged open sternotomy after pediatric open heart operation: experience with 113 patients. Ann Thorac Surg 1995; 59:379-83. [PMID: 7847952 DOI: 10.1016/0003-4975(94)00840-4] [Citation(s) in RCA: 39] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
Between April 1990 and November 1993, 1,252 open heart operations were performed in infants and children with congenital heart defects. Prolonged open sternotomy was used in 113 patients (9%) in 10 surgical categories. Thirty-six of these children (32%) were infants and 43 (38%) were newborns. Twenty-four patients (21%) had undergone operation previously; 3 newborns had been treated with extracorporeal membrane oxygenation before the operation. The patients were grouped according to indications for prolonged open sternotomy as follows: group I, 31 patients with squeezed (large) heart syndrome (1 death); group II, 14 patients with hemodynamic instability after sternal approximation (2 deaths/14.2%); group III, 35 patients with low output state after bypass (17 deaths/48.5%); group IV, 21 patients with extracorporeal circulatory assist devices (15 deaths/71.4%); group V, 3 patients with severe arrhythmias (no deaths); and group VI, 9 patients with atypical tamponade that necessitated reopening the sternum in the intensive care unit (6 deaths/66.6%). Overall mortality was 36.2% (41 patients). Four group IV patients were weaned successfully from extracorporeal membrane oxygenation and heart transplantation was performed successfully on two others. All but one of the deaths occurred before delayed sternal closure. After hemodynamic stabilization was achieved, the sternum was closed in all 72 surviving patients with absorbable sutures (in 86% within the first 6 days after operation). In 50 patients (69% of survivors) pericardial substitution with a polytetrafluoroethylene membrane was performed. One newborn with mediastinal infection after extracorporeal membrane oxygenation was treated successfully with retrosternal drain and suction lavage.(ABSTRACT TRUNCATED AT 250 WORDS)
Collapse
Affiliation(s)
- V Alexi-Meskishvili
- Department of Cardiothoracic and Vascular Surgery, German Heart Institute Berlin
| | | | | | | | | |
Collapse
|
49
|
Hakimi M, Walters HL, Pinsky WW, Gallagher MJ, Lyons JM. Delayed sternal closure after neonatal cardiac operations. J Thorac Cardiovasc Surg 1994. [DOI: 10.1016/s0022-5223(94)70351-5] [Citation(s) in RCA: 40] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
|
50
|
Hanley FL. Invited letter concerning: The influence of paracardiac structures and conditions on cardiac performance in the postcardiotomy period. J Thorac Cardiovasc Surg 1992. [DOI: 10.1016/s0022-5223(19)34706-3] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
|