The Timing of a Multidisciplinary Approach to the Management of Deep Sternal Wound Infection after Cardiac Surgery

Objective:
Deep sternal wound infection (DSWI) remains a life-threatening complication of median sternotomy after cardiac surgery. Evidence suggests the superiority of a stepwise, staged approach to management including radial debridement, removal of sternal wires, negative pressure wound therapy (NPWT) and myocutaneous flap reconstruction. Additionally, the timing of intervention and collaboration between cardiac, infectious disease (ID) and plastic and reconstructive surgery (PRS) providers, has demonstrated importance in improving of patient outcomes. Here we evaluate the utility and timing of a multidisciplinary stepwise approach in the management of DSWI.

Methods:
We performed a retrospective analysis of 65 patients with DSWI undergoing wound debridement from January 2011 to September 2022. Patients were separated into early (0-7 days) or delayed multidisciplinary consultation (>7 days), from the time of diagnosis of DSWI, to consultation of both PRS and ID teams together. Primary outcome variables included post-operative systemic complications and mortality during admission and 1-year after discharge.

Results:
67.12% of patients were male, with a mean age of 67.12, and had a BMI >30 (67.69%). Most were current or past smokers (67.69%), and had hypertension (95.38%), hyperlipidemia (70.77%), diabetes mellitus (61.54%), coronary artery disease (89.23%), and/or a history of myocardial infarction (56.92%). 47.69% of patients were entirely functionally dependent at their index procedure, with an ASA score of 4 (80%).
Most patients presented with sternal wound discharge and polymicrobial infection (24.62%) within one month after coronary artery bypass graft (73.85%).

Almost all patients underwent our standard stepwise approach of early antibiotic administration (87.69%) and wound debridement within 7 days (83.08%), use of NPWT (75.38%), and myocutaneous flap reconstruction within 30 days of debridement (66.15%). IV antibiotics were administered at discharge in 98.5% of patients.

Early multidisciplinary consultation (n=40), was associated with reduced post-operative complications such as bacteremia (20% vs 45%), wound reoperation (31% vs 45%), sepsis (*p=0.0073), dehiscence, (11.11% vs 30%), and reduced time to reconstructive closure (median of 8 days vs 141 days)(*p=0.0049), when compared to delayed consultation (n=20).
Mortality occurred in 3 patients during admission, 2 of which had delayed multidisciplinary consultation. There were no mortalities within 1-year of discharge.


Conclusion and Implications:
Our data suggest that a stepwise approach is safe and effective when applied to the management of DSWI in a heavily comorbid population. Timely multidisciplinary involvement of both PRS and ID teams together, may contribute to reduced time to reconstructive closure and improved outcomes for patients.

Reconstructive

PSTM 2024