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Eur J Cardiothorac Surg 2000;17:482-484
© 2000 Elsevier Science NL

How to do it

Novel application of vacuum assisted closure technique to the treatment of sternotomy wound infection

Department of Cardiac Surgery, Wessex Regional Thoracic & Cardiac Unit, Southampton General Hospital, Tremona Road, Southampton SO16 6YD, UK

Corresponding author. Tel.: +44-1703-777-222; fax: +44-1703-796-614
e-mail: gusTMTang{at}aol.com

	Abstract

Top Abstract 1. Introduction 2. Methods 3. Results 4. Discussion 5. Authors’ declaration References

 
Infection of the sternotomy wound is a potentially devastating and sometimes lethal complication following cardiac surgery. Established treatment may involve a combination of debridement, packing, delayed closure, plastic reconstruction, re-wiring and irrigation dependent on the severity of infection. Vacuum assisted closure, originally adopted for the treatment of non-healing wounds, has recently gained popularity among various surgical specialities in managing complex wound infection. Here we describe this novel technique of managing postoperative sternal wound infection.

Key Words: Negative pressure therapy • Sternal dehiscence • Mediastinitis • Treatment

	1. Introduction

Top Abstract 1. Introduction 2. Methods 3. Results 4. Discussion 5. Authors’ declaration References

 
Sternotomy infection following cardiac surgery may involve superficial wound, sternum and mediastinum. The reported incidence vary from under 1% to about 5% of all sternotomy procedures [1]. Surgical management depends on the severity of infection and may entail debridement, packing, delayed closure, re-wiring, closed irrigation and plastic reconstruction. However, such treatments can be complex, invasive and prolong hospitalization particularly when the primary method fails. Application of negative pressure by controlled suction through a porous dressing has emerged as a simple and effective treatment for a wide spectrum of wounds [2]. We describe below the practical aspects of managing post-sternotomy wound infection using this approach.

	2. Methods

Top Abstract 1. Introduction 2. Methods 3. Results 4. Discussion 5. Authors’ declaration References

 
This method is applicable to both superficial and deep sternal wound infection. Thorough debridement of loose prosthetic material, necrotic tissue and bone is performed. Sterile polyurethane foam dressing (PFD) with an open-pore structure (400- to 600-µm pore size) and available in various sizes (KCI, Oxfordshire, UK) is then trimmed to fit the geometry of each wound. One small PFD may fill a superficial wound whilst a dehisced sternum often requires two apposed PFDs. Contact between the wound base and the PFD is essential particularly where bone or metal is exposed. The open wound is sealed by a transparent adhesive drape which overlaps the wound margin by 5 cm (Fig. 1). A non-collapsible evacuation tube connects the controlled closed wound to a vacuum source and leaves the wound parallel to the surface avoiding pressure-sensitive areas. We have used a purpose-built unit – V.A.C.^® (KCI, Oxfordshire, UK) which delivers either continuous or intermittent suction with a pressure range of -20 to -200 mmHg. Satisfactory performance requires a target pressure of -125 mmHg. Our protocol maintains constant suction for the first 48 h followed by cycles of 5 min on and 2 min off. This particular intermittent regime is known to accelerate wound closure compared to continuous therapy [3]. An in-line canister collects exudate drawn from the wound. Dressings are changed and wound assessed every 48 h under aseptic conditions. Most patients tolerated dressing-change with oral analgesia alone although sedation and parenteral opiate are sometimes used. Injecting local anesthetic down the evacuation tube into the wound also lessens pain associated with dressing-change. Adherent dressing should be soaked with sterile saline before removal to minimize damage to granulation tissue which will cover exposed bone, cartilage and even metalwork. Further debridement may be necessary as is more frequent dressing-change if granulation overgrows into the pores of the PFD. As the wound heals, the PFD must be trimmed to fit a shrinking cavity. After a week of negative pressure therapy (NPT) when granulation usually covers the base of the wound, one may opt for continued VAC closure until healing completes by secondary intention or surgical reconstruction.

View larger version (39K): [in this window] [in a new window]   Fig. 1. View of a dehisced sternal wound packed with polyurethane foam dressing (PFD) and sealed with a self-adhesive drape leaving only the evacuation tube to exit the airtight zone.

	3. Results

Top Abstract 1. Introduction 2. Methods 3. Results 4. Discussion 5. Authors’ declaration References

	4. Discussion

Top Abstract 1. Introduction 2. Methods 3. Results 4. Discussion 5. Authors’ declaration References

 
NPT was described in the early 1990s as a means of accelerating wound healing in postoperative general surgical patients [4,5]. This concept subsequently extended to the treatment of acute traumatic wounds associated with open fracture [6]. Detailed evaluation of the effects of NPT on wounds in animals and man culminated in the development of the V.A.C.^® device [2,3]. Clinical application of this system has since gained popularity with surgeons, principally in reconstructive surgery, to treat a wide spectrum of wounds. A particular strength of V.A.C.^® therapy is to promote healing in difficult wounds with complex aetiology which failed to respond to established treatments [2]. Furthermore, NPT could also downstage surgical reconstruction of a non-healing wound. However, management of sternotomy wound infection using this approach has so far not been reported.

Although fistulation to body cavity was considered a contraindication to NPT, we did not encounter any problem in treating deep sternal wounds where heart or pericardium was exposed. Similarly, bleeding from the wound did not occur even with full anticoagulation after heart valve surgery. An adequate air-tight seal is crucial to the success of this technique but can be difficult to obtain in practice; in addition to ensuring a contour-fit of the adhesive drape around the wound margin, a ‘mesentery’ should be formed around the evacuation tube to complete the seal. Continuous air-leak across the wound dries the tissue which becomes adherent to the PFD. This in turn renders dressing-change painful and traumatic.

With appropriate nursing skills and equipment NPT can be extended to treating wounds in the community thus reducing hospitalization, costs and improve the quality of life in those patients. In summary our initial experience suggests that V.A.C.^® therapy is simple and effective in dealing with sternotomy wound infection of varying severity. Its long-term efficacy and cost-effectiveness should be further evaluated in a controlled setting.

	5. Authors’ declaration

Top Abstract 1. Introduction 2. Methods 3. Results 4. Discussion 5. Authors’ declaration References

 
There is no conflict of interest with the company, KCI (UK) Ltd., the manufacturer of the V.A.C.^® pump and dressings associated with the submitted manuscript. The equipment used to treat the patients described had been purchased from the supplier by the hospital through normal channels and no financial or other interest in the company is derived by reporting our technical experience with negative pressure therapy in this setting.

	References

Top Abstract 1. Introduction 2. Methods 3. Results 4. Discussion 5. Authors’ declaration References

 

1. Raudat C.W., Pagel J., Woodhall D., Wojtanowski M., Van Bergen R. Early intervention and aggressive management of infected median sternotomy incision: a review of 2242 open-heart procedures. Am Surg 1997;63:238-241.[Medline]
2. Argenta L.C., Morykwas M.J. Vacuum-assisted closure: a new method for wound control and treatment: clinical experience. Ann Plast Surg 1997;38:563-576.[Medline]
3. Morykwas M.J., Argenta L.C., Shelton Brown E.I., McGuirt W. Vacuum-assisted closure: a new method for wound control and treatment: animal studies and basic foundation. Ann Plast Surg 1997;38:553-562.[Medline]
4. Davydov Iu A., Larichev A.B., Abramov A. Wound healing after vacuum drainage. Khirurgiia Mosk 1992;7:21-26.
5. Davydov Iu A., Abramov A., Darichev A.B. Regulation of wound process by the method of vacuum therapy in middle-aged and aged patients. Khirurgiia Mosk 1994(9):7-10.
6. Fleischmann W., Strecker W., Bombelli M., Kinzl L. Vacuum sealing as treatment of soft tissue damage in open fractures. Unfallchirurg 1993;96:488-492.[Medline]

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This Article Abstract Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Augustine T.M. Tang Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Tang, A. T.M. Articles by Haw, M. P. Search for Related Content PubMed PubMed Citation Articles by Tang, A. T.M. Articles by Haw, M. P.