RESUMO
BACKGROUND: Severe pain occurs after cardiac surgery in the sternum and chest tubes sites. Although analgesia targeting the sternum is often prioritized, the analgesia of the drain site is sometimes overlooked. This study of patients undergoing coronary artery bypass grafting (CABG) aimed to provide optimized analgesia for both the sternum and the chest tubes area by combining parasternal block (PSB) and serratus anterior plane block (SAPB). METHODS: Ethics committee approval (E.Kurul-E2-24-6176, 07/02/2024) was received for the study. Then, the trial was registered on www. CLINICALTRIALS: gov ( https://clinicaltrials.gov/ ) under the identifier NCT05427955 on 17/03/2024. Twenty patients between the ages of 18-80, with ASA physical status classification II-III, undergoing coronary artery bypass grafting CABG with sternotomy, were included. While the patients were under general anesthesia, PSB was performed through the second and fourth intercostal spaces, and SAPB was performed over the sixth rib. The primary outcome was VAS (Visual Analog Scale) during the first 12 h after extubation. The secondary outcomes were intraoperative remifentanil consumption and block-related side effects. RESULTS: The average age of the patients was 64 years. Five patients were female, and 15 were male. For the sternum area, only one patient had resting VAS scores of 4, while the VAS scores for resting for the other patients were below 4. For chest tubes area, only two patients had resting VAS scores of 4 or above, while the resting VAS scores for the other patients were below 4. The patients' intraoperative remifentanil consumption averaged 2.05 mg. No side effects related to analgesic protocol were observed in any of the patients. CONCLUSIONS: In this preliminary study where PSB and SAPB were combined in patients undergoing CABG, effective analgesia was achieved for the sternum and chest tubes area.
Assuntos
Ponte de Artéria Coronária , Bloqueio Nervoso , Dor Pós-Operatória , Humanos , Ponte de Artéria Coronária/métodos , Masculino , Pessoa de Meia-Idade , Bloqueio Nervoso/métodos , Feminino , Idoso , Dor Pós-Operatória/prevenção & controle , Dor Pós-Operatória/tratamento farmacológico , Adulto , Medição da Dor/métodos , Remifentanil/administração & dosagem , Idoso de 80 Anos ou mais , Analgésicos Opioides/administração & dosagem , Esterno/cirurgia , Adulto JovemRESUMO
An orthotopic heart transplant and an aortic operation can be done concomitantly at centres that are experienced in both aortic operations and heart transplants with meticulous surgical strategy.
Assuntos
Transplante de Coração , Humanos , Transplante de Coração/métodos , Masculino , Esterno/cirurgia , Aneurisma Aórtico/cirurgia , Pessoa de Meia-Idade , Aneurisma da Aorta Torácica/cirurgia , Aneurisma da Aorta Torácica/diagnóstico , Implante de Prótese Vascular/métodos , Aorta/cirurgia , Aneurisma da Aorta AscendenteRESUMO
OBJECTIVE: To analyze bone tissue damage at different stages of disease (El Oakley classification), treatment options for each clinical situation and results after each approach. MATERIAL AND METHODS: There were 45 patients with wound complications after cardiac surgery between October 2022 and September 2023. Thirty-eight (84.4%) patients underwent CABG, 7 (15.6%) patients - heart valve or aortic surgery. Mean age of patients was 68.1±10.3 years. There were 35 men (77.8%) and 10 women (22.2%). The first type was found in 11 (24.5%) patients, type 2-3 - 19 (42.2%), type 4 - 4 (8.8%), type 5 - 11 (24.5%) patients. RESULTS: Systemic inflammatory response syndrome was observed in 7 (36.8%) persons of the 1st group, 14 (73.7%) ones of the 2nd group, 4 (100%) patients of the 3rd group and 2 (18.2%) patients of the 4th group. C-reactive protein and procalcitonin increased in all patients with the highest values in groups 2 and 3. Redo soft tissue inflammation occurred in all groups after treatment. Mean incidence was 25%. Two (10.5%) patients died in the 2nd group and 1 (25%) patient in the 3rd group. CONCLUSION: The modern classification of sternomediastinitis does not fully characterize severity of disease in a particular patient. Simultaneous debridement with wound closure demonstrates acceptable mortality (within 10%). The highest mortality rate was observed in patients with diffuse lesions of the sternum. Less aggressive treatment approaches are possible for stable anterior chest wall.
Assuntos
Mediastinite , Complicações Pós-Operatórias , Humanos , Masculino , Feminino , Mediastinite/etiologia , Mediastinite/diagnóstico , Mediastinite/terapia , Idoso , Pessoa de Meia-Idade , Complicações Pós-Operatórias/diagnóstico , Complicações Pós-Operatórias/etiologia , Procedimentos Cirúrgicos Cardíacos/métodos , Procedimentos Cirúrgicos Cardíacos/efeitos adversos , Proteína C-Reativa/análise , Proteína C-Reativa/metabolismo , Esterno/cirurgia , Esterno/patologia , Síndrome de Resposta Inflamatória Sistêmica/etiologia , Síndrome de Resposta Inflamatória Sistêmica/diagnóstico , Infecção da Ferida Cirúrgica/diagnóstico , Desbridamento/métodos , Esternotomia/efeitos adversos , Esternotomia/métodosRESUMO
Although potential risk factors for sternal wound infection (SWI) have been extensively studied, the onset time of SWI and different risk factors for superficial and deep SWI were rarely reported. This nested case-control study aims to compare the onset time and contributors between superficial and deep SWI. Consecutive adult patients who underwent cardiac surgery through median sternotomy in a single center from January 2011 to January 2021 constituted the cohort. The case group was those who developed SWI as defined by CDC and controls were matched 6:1 per case. Kaplan-Meier analysis, LASSO and univariate and multivariate Cox regressions were performed. A simple nomogram was established for clinical prediction of the risk of SWI. The incidence of SWI was 1.1% (61 out of 5471) in our cohort. Totally 366 controls were matched to 61 cases. 26.2% (16 of 61) SWI cases were deep SWI. The median onset time of SWI was 35 days. DSWI had a longer latency than SSWI (median time 46 days vs. 32 days, p = 0.032). Kaplan-Meier analyses showed different time-to-SWI between patients with and without DM (p = 0.0011) or MI (p = 0.0019). Multivariate Cox regression showed that BMI (HR = 1.083, 95% CI: 1.012-1.116, p = 0.022), DM (HR = 2.041, 95% CI: 1.094-3.805, p = 0.025) and MI (HR = 2.332, 95% CI: 1.193-4.557, p = 0.013) were independent risk factors for SWI. Superficial SWI was only associated with BMI (HR = 1.089, 95% CI: 1.01-1.175, p = 0.027), while deep SWI was associated with DM (HR = 3.271, 95% CI: 1.036-10.325, p = 0.043) and surgery time (HR = 1.004, 95% CI: 1.001-1.008, p = 0.027). The nomogram for SWI prediction had an AUC of 0.67, good fitness and clinical effectiveness as shown by the calibration curve and decision curve analyses. BMI, DM and MI were independent risk factors for SWI. DSWI had a longer latency and different risk factors compared to SSWI. The nomogram showed a fair performance and good effectiveness for the clinical prediction of SWI.
Assuntos
Esternotomia , Infecção da Ferida Cirúrgica , Humanos , Masculino , Estudos de Casos e Controles , Esternotomia/efeitos adversos , Feminino , Fatores de Risco , Pessoa de Meia-Idade , Infecção da Ferida Cirúrgica/epidemiologia , Infecção da Ferida Cirúrgica/etiologia , Idoso , Fatores de Tempo , Incidência , Esterno/cirurgia , Procedimentos Cirúrgicos Cardíacos/efeitos adversosRESUMO
Anterior chest wall instability as a result of sternocostal non-union is a rare complication but can give rise to invalidating pain and cardiac arrhythmias. A woman in her 40s was referred to us with anterior chest wall pain and instability after a modified Ravitch procedure. Sternocostal pseudoarthrosis was seen for which multiple operations were performed which were complicated by low-grade infections. A patient-specific three-dimensional modelled and printed prostheses was used in an operation to both lift the sternum for pectus correction and to reconnect the sternum and the sternal costal junction to regain anterior chest wall stability.
Assuntos
Procedimentos de Cirurgia Plástica , Impressão Tridimensional , Esterno , Parede Torácica , Humanos , Feminino , Parede Torácica/cirurgia , Esterno/cirurgia , Adulto , Procedimentos de Cirurgia Plástica/métodos , Pseudoartrose/cirurgia , Pseudoartrose/diagnóstico por imagem , Tórax em Funil/cirurgia , Articulações Esternocostais/cirurgia , Articulações Esternocostais/diagnóstico por imagemRESUMO
This brief report discusses the diagnosis, management and surgical intervention of a man in his 30s presenting with a rare traumatic sternal manubrium dislocation following a motorcycle crash, accompanied by multiple concomitant rib fractures. The severity and complexity of the patient's injuries necessitated an operative approach for his sternomanubrial dislocation, emphasising the importance of multidisciplinary coordination, accurate diagnosis and prompt surgical intervention. The report provides valuable insights into the successful application of open reduction and internal fixation with plating in a real-world setting, which resulted in positive patient outcomes, despite the rarity and severity of this type of trauma. It further underscores the need for additional research to advance best practices for managing traumatic sternal manubrium dislocations in the context of high-impact injuries.
Assuntos
Acidentes de Trânsito , Fixação Interna de Fraturas , Luxações Articulares , Manúbrio , Motocicletas , Fraturas das Costelas , Esterno , Humanos , Masculino , Fraturas das Costelas/cirurgia , Fraturas das Costelas/diagnóstico por imagem , Luxações Articulares/cirurgia , Luxações Articulares/diagnóstico por imagem , Fixação Interna de Fraturas/métodos , Adulto , Manúbrio/lesões , Manúbrio/cirurgia , Esterno/lesões , Esterno/cirurgia , Esterno/diagnóstico por imagemRESUMO
El tumor de células gigantes (TCG) constituye un tumor óseo benigno relativamente frecuente. Se caracteriza por ser localmente agresivo y el lugar de presentación más frecuente es a nivel del esqueleto axial (fémur distal o tibia proximal). Hasta la actualidad, existen escasos informes de presentaciones atípicas, como a nivel del esternón. En este informe, se presenta el caso de una paciente mujer de 24 años que presenta tumoración indurada a nivel de la región esternal de crecimiento progresivo asociado a dolor. Los hallazgos radiológicos revelan tumoración osteolítica que tiene como origen el cuerpo del esternón y lo compromete casi en su totalidad. Este se proyecta hacia las partes blandas y llega al plano superficial. Debido a la extensión de la enfermedad y al compromiso extenso en el cuerpo del esternón, se realiza la resección del cuerpo y manubrio esternal. El defecto es reconstruido con malla de polipropileno, barras de titanio, parche de epiplón y autoinjerto de piel; se obtiene una adecuada estabilidad de la caja torácica y resultados estéticos favorables. El caso tiene un adecuado manejo oncológico puesto que la resección es completa con márgenes microscópicos libres (resección R0).
Giant cell tumor (GCT) constitutes a relatively common benign bone tumor, characteri-zed by its local aggressiveness. The most frequent site of occurrence is in the axial ske-leton (distal femur or proximal tibia). To date, there have been few reports of atypical presentations, such as at the level of the sternum. In this report, we present the case of a 24-year-old female patient who presented with an indurated mass in the sternal region, progressively growing and associated with pain. Radiological findings revealed an osteolytic mass originating from the body of the sternum, involving almost its entire extent and projecting into the soft tissues, reaching the superficial plane. Due to the extent of the disease and the extensive involvement of the sternal body, resection of the body and manubrium of the sternum was performed. The surgical defect was reconstructed with polypropylene mesh, titanium bars, an omental patch and a skin graft, achieving adequate stability of the thoracic cage and favorable cosmetic results.
Assuntos
Humanos , Feminino , Adulto , Polipropilenos , Tumor de Células Gigantes do Osso/cirurgia , Neoplasias/diagnóstico , Peru , Próteses e Implantes , Esterno/cirurgia , Transplante Autólogo , Biópsia , Tomografia , Diagnóstico DiferencialAssuntos
Neoplasias Ósseas , Criocirurgia , Leiomiossarcoma , Cuidados Paliativos , Esterno , Feminino , Humanos , Neoplasias Ósseas/cirurgia , Neoplasias Ósseas/diagnóstico por imagem , Leiomiossarcoma/cirurgia , Leiomiossarcoma/diagnóstico por imagem , Leiomiossarcoma/patologia , Esterno/cirurgia , Esterno/diagnóstico por imagem , Resultado do TratamentoAssuntos
Esterno , Infecção da Ferida Cirúrgica , Humanos , Esterno/cirurgia , Cirurgiões , EsternotomiaRESUMO
INTRODUCTION: Minimally invasive repair of pectus carinatum (MIRPC) has been performed using the Abramson technique in which the bar that compresses the sternum is fixed with steel wires on the ribs. A 14-year-old patient underwent to a MIRPC using a sandwich technique in which two metallic bars fixed with bridges were implanted below the sternum under thoracoscopic vision, and another bar in a subcutaneous tunnel was implanted above. This technique has the potential to avoid specific problems related to the original technique like loosening of support for correction (broken wire), avoidance of induction of pectus excavatum or subcutaneous tissue adhesion.
Assuntos
Pectus Carinatum , Humanos , Pectus Carinatum/cirurgia , Adolescente , Masculino , Procedimentos Cirúrgicos Minimamente Invasivos/métodos , Procedimentos Cirúrgicos Minimamente Invasivos/instrumentação , Toracoscopia/métodos , Toracoscopia/instrumentação , Esterno/cirurgia , Esterno/anormalidades , Fios Ortopédicos , Resultado do TratamentoRESUMO
Thoracic aortic graft infections are infrequent yet grave complications of cardiovascular surgery. Risk factors include prolonged operative time, postoperative wound infections, and patient-specific risk factors like diabetes or malnutrition (Van Hemelrijck et al., Vessel Plus 6:47, 2022). In postoperative vascular scenarios, it is critical to utilize cross-sectional imaging to detect the presence of a complication, followed by describing the morphology, extent, and ancillary features. FDG-PET/CT can help differentiate between expected postoperative changes and worrisome infection by metabolic activity (FDG uptake). We present an extensive case of ascending aortic graft infection in the setting of ongoing sternal osteomyelitis. CT and PET/CT reveal chronic sternal osteomyelitic changes spreading into the retrosternal soft tissues, and a large intraluminal thrombus in the ascending aortic graft. Small mobile strands propagate toward the right brachiocephalic origin, posing a significant stroke risk. PET/CT confirmed postoperative infection by demonstrating increased FDG uptake.
Assuntos
Implante de Prótese Vascular , Prótese Vascular , Fluordesoxiglucose F18 , Osteomielite , Tomografia por Emissão de Pósitrons combinada à Tomografia Computadorizada , Valor Preditivo dos Testes , Infecções Relacionadas à Prótese , Esterno , Humanos , Osteomielite/diagnóstico por imagem , Osteomielite/etiologia , Osteomielite/cirurgia , Implante de Prótese Vascular/efeitos adversos , Implante de Prótese Vascular/instrumentação , Prótese Vascular/efeitos adversos , Doença Crônica , Resultado do Tratamento , Esterno/cirurgia , Esterno/diagnóstico por imagem , Infecções Relacionadas à Prótese/diagnóstico por imagem , Infecções Relacionadas à Prótese/microbiologia , Infecções Relacionadas à Prótese/cirurgia , Infecções Relacionadas à Prótese/etiologia , Masculino , Fluordesoxiglucose F18/administração & dosagem , Fatores de Risco , Idoso , Antibacterianos/uso terapêutico , Compostos Radiofarmacêuticos , Aortografia/métodos , Pessoa de Meia-IdadeRESUMO
AIM: To compare the biomechanical properties of three different sternal closure techniques in a 3D-printed bone model of a sternum from a 30-kg dog. METHODS: Median sternotomy was performed on a total of 90 three-dimensional (3D) copies of a polycarbonate (PC) model of a sternum, generated from the CT images of the sternum of a 30-kg German Shepherd dog. Three different methods were used to repair the sternotomies: polydioxanone suture (group PDS, n = 30), stainless steel bone staples (group SS, n = 30), and nitinol bone staples (group NS, n = 30). Each repair method was tested by applying tensile force in one of three ways (longitudinally, laterally, or torsionally) resulting in a sample size of n = 10 for each repair method-loading combination. In all experiments, the loads at 1-mm and 2-mm gap formation, failure, and the displacement at the failure point were measured. RESULTS: In lateral distraction and longitudinal shear tests, NS and SS staple repairs required application of significantly greater force than PDS across all displacement criteria (1 and 2 mm). NS exhibited significantly greater failure load than PDS. In torsion tests, NS required significantly greater application of force compared to SS or PDS at all displacement criteria (1 and 2 mm) and exhibited a greater failure load than PDS. In terms of displacement at failure point, PDS suture showed more displacement than SS or NS across all experiments (laterally, longitudinally, torsionally). CONCLUSIONS: In this study, bone staples were mechanically superior to PDS suture in median sternotomy closure using 3D-printed bone model in terms of 1-mm, 2-mm displacement loads, and displacement at failure. NS had a higher failure load than PDS under lateral, longitudinal, and torsional distraction. CLINICAL RELEVANCE: These study results imply that bone staples can be considered as an alternative surgical method for median sternotomy closure in dogs.
Assuntos
Impressão Tridimensional , Esternotomia , Suturas , Animais , Suturas/veterinária , Cães , Fenômenos Biomecânicos , Esternotomia/veterinária , Esternotomia/métodos , Grampeamento Cirúrgico/veterinária , Grampeamento Cirúrgico/métodos , Grampeamento Cirúrgico/instrumentação , Esterno/cirurgia , Modelos Anatômicos , Técnicas de Sutura/veterináriaRESUMO
BACKGROUND: Pectus arcuatum, also known as horns of steer anomaly or Currarino-Silverman Syndrome, is a distinct chest wall anomaly characterized by severe manubriosternal angulation, a shortened sternum, and mild pectus excavatum. The anomaly is typically repaired using open techniques, employing orthopedic fixation devices. Here, we report the results of a minimally invasive hybrid procedure to repair pectus arcuatum. METHODS: The procedure combines a standard Nuss procedure to correct the depressed sternum with a short upper chest (in boys) or inter-mammary (in girls) incision for bilateral subperichondrial resection of the upper costal cartilages, osteotomy, and correction of the manubrial angulation. The medical records of all patients who underwent the procedure over the last 10 years were reviewed. RESULTS: Five patients, 3 boys and 2 girls, aged 14 to 17 years, underwent the procedure. Three patients had their pectus bars removed 3-4 years after repair. Follow-up after correction ranged from 6 months to 7 years. Good correction resulted in all patients achieving recovery without complications and recurrence. To date, all patients have been satisfied with their results. CONCLUSIONS: The minimally invasive hybrid procedure adequately corrects pectus arcuatum with minimal scarring and high satisfaction.
Assuntos
Tórax em Funil , Procedimentos Cirúrgicos Minimamente Invasivos , Osteotomia , Humanos , Masculino , Feminino , Adolescente , Procedimentos Cirúrgicos Minimamente Invasivos/métodos , Tórax em Funil/cirurgia , Osteotomia/métodos , Esterno/cirurgia , Esterno/anormalidades , Resultado do Tratamento , Parede Torácica/cirurgia , Parede Torácica/anormalidades , Estudos Retrospectivos , SeguimentosRESUMO
OBJECTIVE: To compare the clinical effects of coronary artery bypass grafting (CABG) between the left anterior small thoracotomy (LAST) and lower-end sternal splitting (LESS) approaches for coronary artery disease. METHODS: In total, 110 patients who underwent LAST from October 2015 to December 2020 in Tianjin Chest Hospital were selected as the observation group. Patients who underwent the LESS approach during the same period were analyzed. The propensity score was calculated by a logistic regression model, and nearest-neighbor matching was used for 1:1 matching. RESULTS: The length of hospital stay and ventilator support time were significantly shorter in the LAST than LESS group. The target vessels in the obtuse marginal branch and posterior left ventricular artery branch grafts were significantly more numerous in the LAST than LESS group, but those in the right coronary artery graft were significantly less numerous in the LAST group. CONCLUSIONS: CABG using either the LAST or LESS approach is safe and effective, especially in low-risk patients. The LAST approach can achieve complete revascularization for multivessel lesions and has the advantages of less trauma and an aesthetic outcome. However, it requires a certain learning curve to master the surgical techniques and has specific surgical indications.
Assuntos
Ponte de Artéria Coronária , Doença da Artéria Coronariana , Toracotomia , Humanos , Ponte de Artéria Coronária/métodos , Masculino , Toracotomia/métodos , Feminino , Pessoa de Meia-Idade , Doença da Artéria Coronariana/cirurgia , Idoso , Tempo de Internação/estatística & dados numéricos , Esterno/cirurgia , Resultado do Tratamento , Pontuação de Propensão , Estudos RetrospectivosRESUMO
INTRODUCTION: Deep sternal wound infection (DSWI) after midline sternotomy of cardiac surgery is a challenging complication that affects the outcome of surgery. This study aims to assess the clinical effectiveness of the antibiotic-loaded bone cement fixation technique combined with bilateral pectoralis major muscle flaps tension-free management in the treatment of DSWI. METHODS: We retrospectively analyzed 5 patients with DSWI who underwent antibiotic-loaded bone cement combined with bilateral pectoralis major muscle flaps for chest wall reconstruction after sternotomy for cardiac surgery in a tertiary hospital in China from January 2020 to December 2021. The clinical and follow-up data were retrospectively analyzed. RESULTS: All patients had no perioperative mortalities, no postoperative complications, 100% wound healing, and an average hospital stay length of 24 days. The follow-up periods were from 6 to 35 months (mean 19.6 months). None of the cases showed wound problems after initial reconstruction using antibiotic-loaded bone cement combined with bilateral pectoralis major muscle flaps. CONCLUSIONS: We report our successful treatment of DSWI, using antibiotic-loaded bone cement fixation technique combined with bilateral pectoralis major muscle flaps tension-free management. The clinical and follow-up results are favorable.
Assuntos
Antibacterianos , Cimentos Ósseos , Músculos Peitorais , Esternotomia , Retalhos Cirúrgicos , Infecção da Ferida Cirúrgica , Humanos , Masculino , Esternotomia/efeitos adversos , Antibacterianos/uso terapêutico , Antibacterianos/administração & dosagem , Estudos Retrospectivos , Cimentos Ósseos/uso terapêutico , Músculos Peitorais/cirurgia , Pessoa de Meia-Idade , Infecção da Ferida Cirúrgica/cirurgia , Infecção da Ferida Cirúrgica/tratamento farmacológico , Feminino , Idoso , Procedimentos Cirúrgicos Cardíacos/métodos , Esterno/cirurgia , Procedimentos de Cirurgia Plástica/métodosRESUMO
BACKGROUND: Rib fixation for traumatic rib fractures is advocated to decrease morbidity and mortality in select patient populations. We intended to investigate the effect of combination osseous thoracic injuries on mortality with the hypothesis that combination injuries will worsen overall mortality and that SSRF will improve outcomes in combination injuries and in high-risk patients. METHODS: Patients with rib fractures were identified from the Trauma Quality Improvement Project registry from 2019. Patients were then divided into rib fracture(s) alone or in combination with sternal, thoracic vertebra, or scapula fracture. Patients were also categorized into those with COPD and smokers. Patients with AIS >3 outside of thorax were excluded. Patients were subcategorized into those who had rib fixation verse nonoperative management for all subgroups. Analysis was performed to evaluate the efficacy of rib fixation. RESULTS: A total of 111,066 patients were included for analysis. The overall mortality was 1.4%. Patients with COPD had over double the mortality risk, with an overall mortality of 3.4%. Combination injuries did not appear to increase mortality. SSRF did not decrease mortality; however, the number of patients in this group was too small to complete statistical analysis. The overall complication rate was 0.43%. There was a trend towards an increase in extrapulmonary complications in the group that underwent surgical fixation. DISCUSSION: Mortality from rib fractures with concomitant osseous thoracic fracture appears to be low. However, mortality is increased in patients with COPD regardless of rib fracture pattern. The number of patients who underwent SSRF was too small to make a statistical comparison.
Assuntos
Doença Pulmonar Obstrutiva Crônica , Fraturas das Costelas , Humanos , Fraturas das Costelas/mortalidade , Fraturas das Costelas/cirurgia , Fraturas das Costelas/complicações , Masculino , Feminino , Pessoa de Meia-Idade , Fatores de Risco , Doença Pulmonar Obstrutiva Crônica/mortalidade , Doença Pulmonar Obstrutiva Crônica/complicações , Idoso , Adulto , Estudos Retrospectivos , Vértebras Torácicas/lesões , Vértebras Torácicas/cirurgia , Escápula/lesões , Escápula/cirurgia , Fixação Interna de Fraturas/métodos , Fixação Interna de Fraturas/mortalidade , Esterno/lesões , Esterno/cirurgia , Sistema de Registros , Complicações Pós-Operatórias/mortalidade , Complicações Pós-Operatórias/epidemiologia , Fraturas da Coluna Vertebral/mortalidade , Fraturas da Coluna Vertebral/cirurgia , Fraturas Múltiplas/cirurgia , Fraturas Múltiplas/mortalidade , Fraturas Múltiplas/complicações , Resultado do TratamentoRESUMO
Despite evidence suggesting the benefit of prophylactic regional antibiotic delivery (RAD) to sternal edges during cardiac surgery, it is seldom performed in clinical practice. The value of topical vancomycin and gentamicin for sternal wound infections (SWI) prophylaxis was further questioned by recent studies including randomized controlled trials (RCTs). The aim of this systematic review and meta-analysis was to comprehensively assess the safety and effectiveness of RAD to reduce the risk of SWI.We screened multiple databases for RCTs assessing the effectiveness of RAD (vancomycin, gentamicin) in SWI prophylaxis. Random effects meta-analysis was performed. The primary endpoint was any SWI; other wound complications were also analysed. Odds Ratios served as the primary statistical analyses. Trial sequential analysis (TSA) was performed.Thirteen RCTs (N = 7,719 patients) were included. The odds of any SWI were significantly reduced by over 50% with any RAD: OR (95%CIs): 0.49 (0.35-0.68); p < 0.001 and consistently reduced in vancomycin (0.34 [0.18-0.64]; p < 0.001) and gentamicin (0.58 [0.39-0.86]; p = 0.007) groups (psubgroup = 0.15). Similarly, RAD reduced the odds of SWI in diabetic and non-diabetic patients (0.46 [0.32-0.65]; p < 0.001 and 0.60 [0.44-0.83]; p = 0.002 respectively). Cumulative Z-curve passed the TSA-adjusted boundary for SWIs suggesting adequate power has been met and no further trials are needed. RAD significantly reduced deep (0.60 [0.43-0.83]; p = 0.003) and superficial SWIs (0.54 [0.32-0.91]; p = 0.02). No differences were seen in mediastinitis and mortality, however, limited number of studies assessed these endpoints. There was no evidence of systemic toxicity, sternal dehiscence and resistant strains emergence. Both vancomycin and gentamicin reduced the odds of cultures outside their respective serum concentrations' activity: vancomycin against gram-negative strains: 0.20 (0.01-4.18) and gentamicin against gram-positive strains: 0.42 (0.28-0.62); P < 0.001. Regional antibiotic delivery is safe and effectively reduces the risk of SWI in cardiac surgery patients.
Assuntos
Antibacterianos , Antibioticoprofilaxia , Gentamicinas , Ensaios Clínicos Controlados Aleatórios como Assunto , Infecção da Ferida Cirúrgica , Vancomicina , Humanos , Infecção da Ferida Cirúrgica/prevenção & controle , Antibacterianos/administração & dosagem , Antibacterianos/uso terapêutico , Antibioticoprofilaxia/métodos , Vancomicina/administração & dosagem , Gentamicinas/administração & dosagem , Gentamicinas/uso terapêutico , Esterno/cirurgia , Esterno/microbiologia , Procedimentos Cirúrgicos Cardíacos/efeitos adversosRESUMO
ABSTRACT: Sternal wound complications following sternotomy need a multidisciplinary approach in high-risk postoperative cardiac surgical patients. Poorly controlled pain during surgical management of such wounds increases cardiovascular stress and respiratory complications. Multimodal analgesia including intravenous opioids, non-opioid analgesics, and regional anesthesia techniques, like central neuraxial blocks and fascial plane blocks, have been described. Pecto-intercostal fascial plane block (PIFB), a novel technique, has been effectively used in patients undergoing cardiac surgery. Under ultrasound (US) guidance PIFB is performed with the aim of depositing local anesthetic between two superficial muscles, namely the pectoralis major muscle and the external intercostal muscle. The authors report a series of five cases where US-guided bilateral PIFB was used in patients undergoing sternal wound debridement. Patients had excellent analgesia intraoperatively as well as postoperatively for 24 hours with minimal requirement of supplemental analgesia. None of the patients experienced complications due to PIFB administration. The authors concluded that bilateral PIFB can be effectively used as an adjunct to multimodal analgesia with general anesthesia and as a sole anesthesia technique in selected cases of sternal wound debridement.