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Eur J Cardiothorac Surg 2008;34:931. doi:10.1016/j.ejcts.2008.07.021
Copyright © 2008, European Association for Cardio-thoracic Surgery. Published by Elsevier. All rights reserved.
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Letters to the Editor

Reply to Friberg and Svedjeholm

Dumbor L. Ngaage*

Department of Cardiothoracic Surgery, Castle Hill Hospital, Kingston-Upon-Hull, East Yorkshire HU16 5JQ, United Kingdom

Received 15 July 2008; accepted 16 July 2008.

* Corresponding author. Tel.: +44 1482 623256; fax: +44 1482 623257. (Email: dngaage{at}yahoo.com).

Key Words: Early tracheostomy • Percutaneous dilatational tracheostomy • Deep sternal wound infection

We note with interest, the comments of Friberg and Svedjeholm [1] about our paper [2]. The interpretation of published data, including our report, needs to be put in the proper perspective.

While we agree that postoperative surgical wound infections continue to manifest post-hospital discharge [3], we maintain that (as the study of Avato and Lai [3] which they referenced showed) the incidence of this postoperative complication, like all others, occur at a much reduced rate after hospital discharge and probably more so in the at-risk group. This, therefore, does not invalidate in-hospital morbidity rates.

There is controversy about the relationship between tracheostomy and deep sternal wound infection, and we acknowledge the seemingly contradictory report of Rahmanian et al. [4]. In that study, open tracheostomy was performed in patients with respiratory failure at a mean interval of 13 ± 6 days following coronary artery bypass grafting, whereas our patients received early percutaneous dilatational tracheostomy at a median interval of 7 days post-sternotomy for cardiac surgery, in patients with anticipated prolonged mechanical ventilation. These cardinal differences in patient characteristics may explain why respiratory failure which was common to all tracheostomy patients was a risk factor in the study of Rahmanian et al. [4] and tracheostomy was not. Put in perspective, these studies are not conflicting: tracheostomy does not have an incremental influence on the risk of deep sternal wound infection (DSWI) when performed late in the setting of respiratory failure. When performed early, as our series have shown, tracheostomy increases the risk of DSWI.

Retrospective data like the two discussed above, have inherent drawbacks but well-constructed multivariate models compensate for some of these limitations. The multivariate analysis of our large study was comprehensive and robust. Nevertheless, we agree that a prospective randomised trial is warranted to study the various aspects of the association between tracheostomy and DSWI.

References

  1. Friberg O, Svedjeholm R. Post-sternotomy percutaneous tracheostomy and risky multivariable analyses. Eur J Cardiothorac Surg 2008;34:930-931.[Free Full Text]
  2. Ngaage DL, Cale AR, Griffin S, Guvendik L, Cowen ME. Is post-sternotomy percutaneous dilatational tracheostomy a predictor for sternal wound infections?. Eur J Cardiothorac Surg 2008;33(6):1076-1079discussion 80-1.[Abstract/Free Full Text]
  3. Avato JL, Lai KK. Impact of postdischarge surveillance on surgical-site infection rates for coronary artery bypass procedures. Infect Control Hosp Epidemiol 2002;23(7):364-367.[CrossRef][Medline]
  4. Rahmanian PB, Adams DH, Castillo JG, Chikwe J, Filsoufi F. Tracheostomy is not a risk factor for deep sternal wound infection after cardiac surgery. Ann Thorac Surg 2007;84(6):1984-1991.[Abstract/Free Full Text]




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