Sternum Instability in Clinical Practice
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1 in Clinical Practice Hans Jonsson M.D Ph.D. Department of Cardiothoracic Surgery and Anesthesiology Karolinska University Hospital
2 Is that a problem in open heart surgery? Yes!!
3 We must stabilize sternum much better!
4 -There are different ways in stabilizing the sternum perioperativly -steelwires -plastic bundles -osteoplates
5 -We must treat our sternumfracture in the same way as the ortopedic surgeon treat their fractures. -Reposition -Stabilisation -Rehabilitation
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7 Steelwires- different kinds of steelwires Does it stabilise the sternum? How many wires?
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11 -Sternal dehiscence is a major cause of morbidity and mortality in open heart surgery. -A feared complication is mediastinitis, more then 2/3 of the patients have sternal dehiscence. -Coagulase negative Staphylococci were isolated in 55% of those with S. dehiscence compared to 26% with stable sternum. -High BMI (>30) and COPD were associated with CNS
12 Sternal Instability -Sternal dehiscence. The blue arrows point to one group of sternal wires that are displaced to the right of the midline while the red arrow points to a lower wire that has traveled with the left half of the dehisced sternum -American Journal of Roentgenology, Vol 173,
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14 Sternal Instability -Staphylococcus aureus were isolated in 26% of the patients with S. dehiscence. -It is more frequent among patients with stable sternum. -Patients who had been reoperated before onset of mediastinitis tended to have an increased risk for a gramnegative etiology
15 -Median time from operation to development of mediastinitis was 7 days in our material. -Sternal dehiscence was seen in 68 % -Coagulase negative Staphylococci (CNS) in 46 % -Staphylococcus aureus in 26 % -Gramnegative bacteria in 18 % -CNS more frequent in patients with unstable sternum and S. aureus more frequent in patients with stable sternum. Eur J Cardiothoraci Surg May:21(5): Gårdlund B, Bitkover CY, Vaage J
16 -The overall 90-day mortality was 19 % -Three different types of postoperative mediastinitis -Mediastinitis associated with obesity, COPD, sternal dehiscence are mainly caused by CNS -Mediastinitis caused by perioperative contamination are mainly caused by S. aureus. -M. mainly spread from concomittant infections during the postoperative period are mainly caused by gram negative rods. Eur J Cardiothoraci Surg May:21(5): Gårdlund B, Bitkover CY, Vaage J
17 -Mediastinitis leads to a significant suffering for the patients. -It prolongs the hospital stay 5 to 6 times, from 7 days to around 40 days. -The cost increased from Euro to Euro. -That means we have to do something about it. -It is a win-win situation The most important thing is, reduce the suffering for the patient. And as a result of that we also decrease the cost.
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20 -After the operation comes a very importent period. It takes approximately 6-8 weeks for the sternum to heal. -During this time the sternum must also be stabilized, like all other fractures. We have, sorry to say, not been good in the period after operation. -One very importent factor that differ sternum fractures from other fractures is, it moves all the time due to breathing. -In our clinic the frequence of mediastinitis varied from 1,6 to 2,5 % in the last 6 year.
21 Sternal Instability Important: The vest is fitted with the back part to rest below the shoulder blades and the two cushions high up in front, to the left and right of the sternum. Breath in before closing the 2 side straps. Now exhale. Before closing the shoulder straps, pull the vest below the shoulder blades. Now the two cushions should stabilize the sternum without too much pressure, to allow normal breathing and acceptable comfort. Use correct sizing
22 -We started to use the Posthorax vest October From the 1st of January to the 31st of December in 2012 we performed a midline sternotomy in 978 patient. -6 patients got mediastinitis -3 of them wore the west according to the protocol -It is too good to be true
23 Posthorax vest What we have seen with the west -Our mediastinitis frequence decreased from 2,2 % in 2011 to 0,6 % in 2012! -The frequence of atelectasis is signifacant lower then before -The physioterapist says that the patients are much easier to mobilise. They do not have so much pain -Hospital stay decreased with 1 day among women.
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