04 October 2014: Review Articles
Use of Incisional Negative Pressure Wound Therapy on Closed Median Sternal Incisions after Cardiothoracic Surgery: Clinical Evidence and Consensus Recommendations
Pascal M. Dohmen ABCDEFG , Thanasie Markou ABCDEF , Richard Ingemansson ABCDEF , Heinrich Rotering ABCDEF , Jean M. Hartman ABCDEF , Richard van Valen ABCDEF , Maaike Brunott ABCDEF , Patrique Segers ABCDEF
DOI: 10.12659/MSM.891169
Med Sci Monit 2014; 20:1814-1825
Abstract
ABSTRACT: Negative pressure wound therapy is a concept introduced initially to assist in the treatment of chronic open wounds. Recently, there has been growing interest in using the technique on closed incisions after surgery to prevent potentially severe surgical site infections and other wound complications in high-risk patients. Negative pressure wound therapy uses a negative pressure unit and specific dressings that help to hold the incision edges together, redistribute lateral tension, reduce edema, stimulate perfusion, and protect the surgical site from external infectious sources. Randomized, controlled studies of negative pressure wound therapy for closed incisions in orthopedic settings (which also is a clean surgical procedure in absence of an open fracture) have shown the technology can reduce the risk of wound infection, wound dehiscence, and seroma, and there is accumulating evidence that it also improves wound outcomes after cardiothoracic surgery. Identifying at-risk individuals for whom prophylactic use of negative pressure wound therapy would be most cost-effective remains a challenge; however, several risk-stratification systems have been proposed and should be evaluated more fully. The recent availability of a single-use, closed incision management system offers surgeons a convenient and practical means of delivering negative pressure wound therapy to their high-risk patients, with excellent wound outcomes reported to date. Although larger, randomized, controlled studies will help to clarify the precise role and benefits of such a system in cardiothoracic surgery, limited initial evidence from clinical studies and from the authors’ own experiences appears promising. In light of the growing interest in this technology among cardiothoracic surgeons, a consensus meeting, which was attended by a group of international experts, was held to review existing evidence for negative pressure wound therapy in the prevention of wound complications after surgery and to provide recommendations on the optimal use of negative pressure wound therapy on closed median sternal incisions after cardiothoracic surgery.
Keywords: Evidence-Based Medicine, Consensus, Negative-Pressure Wound Therapy, Sternum - surgery, Thoracic Surgery
Background
Surgical site infections (SSIs) are serious complications after cardiothoracic surgery and contribute significantly to post-operative morbidity, mortality, and healthcare costs [1–3]. Studies have reported that up to 15% of patients develop a wound infection after cardiac surgery [4–7]; with rates of SSIs ranging from 0.5 to 22.2% [8–14]. Incidence rates for deep sternal wound infection (DSWI) have ranged from 0.4 to 2.6%, with mortality rates of between 7 and 35% reported with conventional therapies such as surgical revision with open packing dressing, rewiring over a surgical drain(s), or reconstruction with vascularized soft tissue flaps compared with only 2.7–7.1% in uninfected controls [2,6,11,15–23]. Mortality rates are especially high (up to 74%) in patients with DSWI due to methicillin-resistant
Host factors contributing to the risk of SSIs after cardiothoracic surgery have been well described in the literature and include obesity, renal insufficiency, diabetes mellitus, advanced age, gender, chronic obstructive pulmonary disease, smoking, steroid use, and length of hospitalization (>5 days) [1,19,22,23,26]. Surgical risk factors include the use of 1 or 2 internal mammary artery (IMA) grafts (especially bilaterally and when using the pedicle IMA), duration of surgery and perfusion time, prolonged mechanical ventilation, use of an intra-aortic balloon pump, post-operative bleeding, re-operation, sternal rewiring, extensive electro-cautery, shaving with razors, and use of bone wax [1,23].
Surgical incisional wounds have traditionally been closed by primary intention using sutures, staples, or a combination of these methods. After closure of clean surgical incisions, wound care may include the use of traditional gauze dressings, and more advanced therapies such as hydrocolloids, growth factors, cultured skin, low-energy ultrasound, and negative pressure wound therapy (NPWT) (V.A.C.® Therapy, Kinetic Concepts, Inc., San Antonio, TX, USA).
NPWT is a treatment concept introduced initially to assist in the treatment of acute and chronic open wounds [27,28]. NPWT uses a negative-pressure device and specific dressings to create a negative-pressure environment at the wound site. This helps to hold the incision edges together [29], reduces lateral tension and edema [30,31], stimulates perfusion [27,32–36], enhances the development of granulation tissue [27,37,38], reduces bacterial colonization of wound tissues [27,39], and protects the surgical site from external infectious sources [40].
NPWT has also become a well-established method for improving outcomes after skin grafting, where the technique is used to prepare the wound surface for graft acceptance and to stabilize the graft to prevent shearing and removal [41–43]. In this clinical setting, removal of exudate reduces the risk of hematoma and seroma formation and helps to prevent contamination [44]. Increased granulation facilitates revascularization and attachment of the graft to the wound bed [45]. Numerous clinical studies have shown the successful use of NPWT in the management of both skin and biomatrix grafts (reviewed by Gupta in 2012) [45].
Recently, there has been growing interest in using the technique on closed incisions to prevent potentially severe SSIs and other wound complications in high-risk individuals. This paper aims to review existing evidence for NPWT in the prevention of wound complications after surgery and to provide consensus recommendations on optimizing the use of NPWT after cardiothoracic procedures. The paper has been developed from a consensus meeting held in Amsterdam in November 2011.
NPWT for Prevention of Wound Complications: Clinical Evidence
Modern Approaches to Applying NPWT/CIM
Using NPWT in Cardiothoracic Surgery: Selecting Appropriate Patients
Optimizing the use of NPWT in Cardiothoracic Surgery
The authors of this consensus document have considerable experience in using the CIM for the prevention of wound complications after cardiothoracic surgery and have found the system to be easy to use and well tolerated by patients. The system should be applied immediately after surgery, in a sterile field (while the patient is still in the operating room and before the sterile drapes have been removed), to clean, closed incisions for a period of 5–7 days. When used preventively, the system should ideally be left undisturbed for at least 5 days, unless the patient develops clear signs of wound infection, such as pain. If the dressing is lifted to observe the incision, a new dressing should be applied.
If the wound extends beyond the length of the dressing, the dressing can be applied over part of the incision. It should not be placed over drains or wires, should not be used to treat open or dehisced surgical incisions, and should not be used in patients with sensitivity to silver.
Skin preparation should include the use of chlorhexidine, iodine, or alcohol, with careful drying to prevent foil blistering. Drains should be placed in a lower position when planning to use CIM (see case studies).
The system should be removed carefully with the vacuum turned off. Adequate closure of the wound, no redness at the incision site, and no evidence of edema upon dressing removal suggest that the wound has healed adequately. In our experience, concerns regarding the canister becoming too full of fluid are unfounded. A summary of consensus recommendations for optimizing the use of CIM after cardiothoracic surgery is presented in Table 4.
Case Studies
CASE STUDY 1: URGENT TRIPLE CABG AND MITRAL VALVE REPLACEMENT (MVR) VIA STERNOTOMY:
A 70-year-old male presented with a non-ST elevation myocardial infarction (Figure 4). His medical history included type 2 diabetes, peripheral vascular disease, renal insufficiency, hyperlipidemia, and pulmonary hypertension. The patient was diagnosed with triple vessel coronary artery disease and severe mitral insufficiency. Urgent triple CABG and MVR were performed.
Due to his elevated risk of post-operative incision complications, the CIM system was used, with the dressing applied along the incision (Figure 4A), with special care taken to leave sufficient distance between the inferior aspect of the incision and the chest tubes in order to secure an adequate seal (Figure 4B). On post-operative day 3, the patient experienced a cardiopulmonary arrest requiring immediate resuscitative chest compressions. However, the integrity of CIM dressing was maintained.
On post-operative day 8, the CIM dressing was removed. The incision edges appeared well apposed and were healing appropriately (Figure 4C). In contrast, the chest tube sites, which were not treated with CIM, demonstrated some drainage. The patient was discharged home on post-operative day 18, with his incision continuing to heal well.
CASE STUDY 2: CABG AND MVR VIA STERNOTOMY:
A 65-year-old male presented with progressive angina and a positive exertional stress test (Figure 5). His medical history included diabetes mellitus, obesity (BMI 38 kg/m2), and chronic obstructive pulmonary disease. Cardiac catheterization demonstrated severe 3-vessel coronary artery disease.
Four-vessel CABG was performed using left IMA to left anterior descending coronary artery and reverse saphenous vein grafts to the right coronary artery, ramus intermedius artery, and first diagonal artery, separately. The standard median sternal incision was approximately 10 inches in length. Sternal re-approximation was performed with stainless steel cables and the skin was closed with subcuticular sutures. The CIM dressing was applied in the operating theater and remained in place until it was removed on post-operative day 5. The patient was discharged on post-operative day 6.
CASE STUDY 3: ELECTIVE CABG IN A MORBIDLY OBESE FEMALE:
This 77-year-old morbidly obese (BMI 57.5 kg/m2) female underwent an elective CABG due to angina functional class III/IV (Figure 6). She was at high risk of developing DSWI as a result of her obesity, insulin-dependent diabetes mellitus, and long-term use of systemic prednisolone for chronic obstructive pulmonary disease (Gold [Global initiative for chronic Obstructive Lung Disease] class II).
Revascularization was achieved using bilateral internal mammary grafting, as the saphenous vein and the radial artery were both unusable. Transdermal stitches were used to close the incision. The CIM system was selected prior to surgery, allowing the drains to be placed in a low position in order to accommodate both the dressing and the short stature of the patient. The CIM dressing was applied carefully, under sterile conditions, along the incision and left undisturbed for 5 days.
The dressing was removed on post-operative day 6; there was no edema or infection present, and the wound was healing well. The patient was discharged on post-operative day 10, with no surgical wound infection, even at the 30-day follow-up.
To date, the CIM system has been used successfully on 32 of the contributing author’s (AM) patients with no signs of surgical wound infection during hospitalization or at the 30-day follow-up.
Summary and Conclusions
There is growing interest in the use of NPWT on closed incisions after cardiothoracic surgery to prevent potentially severe SSIs in high-risk individuals. Use of NPWT on closed incisions has been shown to reduce the risk of wound infection, wound dehiscence, and seroma in randomized, controlled studies of patients in orthopedic settings [47,51]. NPWT also enhances graft adherence and survival after skin and biomatrix grafting [43].
Evidence is now accumulating that NPWT improves wound outcomes after cardiothoracic procedures [28,44,45]. Based on published data and clinical evidence, we recommend that NPWT should be considered in at-risk patients with the aim of preventing DSWI after surgery.
Identifying at-risk individuals for whom prophylactic use of NPWT would be most cost-effective remains a challenge. However, several risk-stratification systems have been proposed [13,28], and should be evaluated more fully. In the meantime, we believe that patients with 1 or more major risk factors or multiple intermediate risk factors are strong candidates for prophylactic use of NPWT, and that any patient undergoing heart, lung, or heart/lung transplantation should receive this treatment.
The availability of the peel-and-place, single-use CIM system offers surgeons a convenient and practical solution to overcome SSIs in high-risk patients, and CIM is recommended by the authors based on their own clinical experiences. Larger, randomized studies will help to clarify the precise role and benefits of NPWT on closed incisions after cardiothoracic surgery; however, initial data appear very promising.
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