A clinical audit—cost effective way of managing superficial chest wound infections post sternotomy

Karthik Raman

Consultant cardiac surgeon, Department of CTVS, Kauvery heart city, Trichy

Abstract

Sternal wound infection in post cardiac surgery leads to worrisome complication. This recorded Incidence of 1–5% and Mortality as high as 30% if left untreated (mediastinitis). This audit was conducted to study the cost effective way of managing superficial chest wound infections post sternotomy.

Background

  • Lower end sternal wound discharge.
  • Post operatively- from 5th pod onwards.

Causes

  • Inadequate rectus sheath closure.
  • Too much use of cautery.
  • Uncontrolled diabetes.
  • Para median sternotomy
  • Bilateral mammary harvest
  • COPD, bronchial asthma pts- chronic steroid therapy.

Conventional treatment (CON)

  • Antibiotics IV
  • Admission in ward and hospital stay
  • Opening the wound.
  • Wound is dry and healthy.
  • Secondary suturing .

Deep Sutures (DS)

  • Mostly around 5–7th
  • No obvious purulent discharge.
  • Lower end chest wound
  • DEEP interrupted mattress sutures with 2-0 ethylon under LA in aseptic sterile conditions.
  • Suture removal after 2 weeks
  • Empirical oral antibiotics.

Demography study details

  • January 2023–March 2024
  • Divided into two study arms
  • January 2023–Aug 2023- first arm- conventional treatment (CON)
  • September 2023–march 2024- second arm- Deep Suturing (DS) treatment

Inclusion criteria:

All post sternotomy cardiac surgery patients operated in the above time line with sternal wound infection (definition in further slides)

Results and Discussion

Sternal wound infection

  • Presence of atleast 2 or more than 2 criteria
  • Chest wound discharge-bloody/ serous post sternotomy.
  • Presence of microbiological organisms -growth from the culture.
  • Fever (>100 °F) with all other causes ruled out.
  • Clinically stable sternum. (unstable sternum would be classified to sternal dehiscence needing rewiring treatment )
  • Intact skin (skin gaping at presentation – would be classified to different treatment protocol).

First arm data

January–August 2023
No of patients20 /343 (5.8%)
Mean hospital stay7±3 days
Most common organismCoagulase negative staphylococcus.
IV antibiotics: Inj clindamycin .mean no of doses(14±4)
Inj magnex forteMean no of doses (10±5)

Second arm data

September 2023–March 2024.
No of patients17/ 324 (5.2%)
Mean time to suturing7±3 days.
Hospital stay0 days.
Most common organismCoagulase negative staphylococcus.
Oral antibiotics: Tab linezolid mean no of doses10±5.
Treatment failure and cross over to first arm 3 patients
Parameter CON armDS armP value
Total cases20/343(5.8%)17/324 (5.2%)0.07
Hba1c10.2±1.311.3±2.40.08
COPD340.09
BMI25±1.824±1.60.08
LV ejection fraction (%)45±1048±90.07
Lima harvest 20170.08
Hospital stay (days)7±30-
Mean cost incurred /pt/day (INR)5433±25 1623±30 0.03

Lessons learnt (3 cross over cases)

  • Things common in those three cases:
  • Hba1c ≥ Hb (uncontrolled diabetes)
  • MRSA the organism
  • Statistically cant be proven as the no of cases -less.

DS method not in cases of

  • Hba1c ≥ Hb (uncontrolled diabetes)
  • MRSA the organism
  • Purulent discharge

Limitations

  • Need more numbers statistically to prove.
  • Control arm -not exactly a control arm
  • Base line differences between the 2 arms
  • Retrospective study

Conclusion

  • DS methods – safe effective.
  • Choosing the right subset of patients.
  • Saves a huge cost.
  • Saves hospital stay.
  • Easy compliance for patients.

 

Dr. Karthik Raman
Consultant cardiac surgeon

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