Treatment of Sternal Wound Infection with Vacuum-Assisted Closure
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Index: WOUNDS. 2013;25(2):41–50.
Abstract: Introduction. Previous work has demonstrated the efficacy of vacuum-assisted closure (VAC) in the treatment of poststernotomy local wound infections, compared to historical treatment protocol. The negative pressure has been found to protect wounds against contamination, prevent wound fluid retention, increase blood flow, and increase rates of granulation tissue formation. For this study, a retrospective analysis compared patients receiving VAC as definitive treatment versus bridging to delayed flap closure. Methods. Sixteen patients developed sternal wound infections after cardiac surgeries at the authors’ institution from 2006 to 2008. Data was gathered regarding patient comorbidities, treatment method, and outcome. Study objectives included assessment of risk factors that warranted secondary surgical closure and examination of long-term followup where VAC was the definitive treatment modality. Results. Group A (n = 12) had VAC as the final treatment modality. Group B (n = 4) required myocutaneous flap closure. One patient in Group B passed away prior to flap surgery. Both groups had similar risk factors, except Group B had a higher risk of body mass index (BMI) > 35 that was near statistically significant (P = 0.085; odds ratio = 0.0, 95% CI = [0.0 – 1.21]). Group A required a shorter hospital stay on average. Long-term follow-up showed the majority of Group A had completely healed sternal wounds 2-3 years from initial cardiac surgery. Conclusions. Vacuum-assisted closure as definitive treatment modality is a successful, first line therapy for local superficial sternal wound infections. When deep infections occur, however, VAC as bridge-to-flap coverage is recommended over attempted secondary healing with VAC.
Sternal wound infections after cardiac surgery is a concerning complication, increasing morbidity and mortality. Approximately 0.3% - 5.0% of median sternotomy surgical approaches result in infection.1 Mortality rates range in the literature between 14% - 47%.2 Preoperative risk factors for sternal wound infections include diabetes mellitus, chronic obstructive airway disease, obesity, and smoking.3 Postoperative risk factors include blood transfusions, surgical chest exploration, prolonged postoperative ventilation, and longer stay in the intensive care unit.4-6
Microbiology of sternal wound infections is variable. Staphylococcus aureus is the most common pathogen (29%), followed by Staphylococcus epidermidis (22%), with a notable frequency of Pseudomonas aeruginosa, methicillin-resistant staphylococci and streptococci, facultative and aerobic gram-negative rods, and anaerobes.7,8
Since the mid-1950s, when the median sternotomy became a common approach for intracardiac procedures, the poststernotomy wound infection has had few treatment solutions.9 Superficial infections were treated by irrigation, debridement, and open dressing changes. Deep infections were more difficult to treat.