Prophylactic Application of Closed Incision Negative Pressure Therapy After High Risk Cardiothoracic Procedures: A Single Center Study

Abstract

Objectives: Sternal wound infections (SWIs) after cardiac surgery are devastating complications and cost loads for healthcare providers and vulnerable patients in the postoperative period after high-risk cardiothoracic operations. Although the prophylactic use of closed incision negative pressure therapy (ciNPT) is still controversial, recent studies report positive outcomes. Our study aims to identify the efficacy of ciNPT in ventricular assist device implantation procedures with focus on the hypothesis that the reduction rate of impaired healing and infection. Materials and Methods: We performed a retrospective study with 18 advanced heart failure patients after ventricular assist devices implantations. Conventional sterile gauze dressings were applied in the control group (n=10), while ciNPT (Prevena™ system) was applied in the study group. Patients demographics, risk factors such as diabetes mellitus, obesity, smoking, chronic obstructive pulmonary disease, Euroscore II and Fowler Risk score were documented. Wounds were examined instantly after removal of Prevena™ system on postoperative 6 to 8 days and on follow-up 45 days. Signs of infections and healing problems, inflammatory biomarkers were noted. Results: The number of ventricular assist device implantations were 18, with 10 in control and 8 in study group. Both groups were similar in all demographical characteristics. Driveline insertion site and superficial SWI rates were higher in control group than the study group (p=0.003 and p=0.018, respectively). One superficial SWI was noted in the control group. No deep wound infections requiring debridement was observed in both groups. Length of hospital stay was longer in control group (p=0.05). Conclusion: We concluded that closed incision ciNPT has an impact on reducing driveline site infections, length of hospitalization and cost load for health care providers. This preliminary results appear to support the advantage of closed incision ciNPT application after ventricular assist device implantation procedures and serve as a basic information for more comprehensive studies.

Keywords

• Closed incisional negative pressure therapy
• sternal driveline site infections
• wound infections
• wound therapy

Yüksek Riskli Kardiyotorasik Cerrahi İşlemler Sonrası Kapalı İnsizyon Negatif Basınç Tedavisinin Profilaktik Uygulaması: Tek Merkezli Çalışma

Abstract

Amaç: Kalp cerrahisi sonrası sternal yara enfeksiyonları, özellikle yüksek riskli kardiyotorasik operasyonlardan sonraki postoperatif dönemde hastalar ve sağlık hizmeti sunucuları için önemli komplikasyonlara ve maliyet yüklerine neden olmaktadır. Profilaktik kapalı insizyon negatif basınç tedavisinin kullanımı halen tartışmalı olsa da, son yıllarda yapılan çalışmalarda olumlu sonuçlar bildirilmektedir. Çalışmamız, ventriküler destek sistemi implantasyonu prosedürleri sonrası kapalı insizyon negatif basınç tedavisinin etkinliğini, iyileşme sorunlarında ve enfeksiyon oranlarında azalma hipotezine odaklanarak sunmayı amaçlamaktadır. Gereç ve Yöntem: Çalışmamız, ileri evre kalp yetmezliği olan ve ventriküler destek cihazı implantasyonu yapılan 18 hastanın takip verilerine retrospektif olarak ulaşılarak gerçekleştirilmiştir. Kontrol grubuna (n=10) geleneksel steril gazlı bez pansumanları uygulanırken, çalışma grubuna kapalı insizyon negatif basınç tedavisi (Prevena™ sistemi) uygulanmıştır. Hastaların demografik özellikleri, diabetes mellitus, obezite, sigara kullanımı, kronik obstrüktif akciğer hastalığı gibi risk faktörleri, Euroscore II ve Fowler risk skorları kaydedilmiştir. İnsizyonlar, Prevena™ sistemininçıkarılmasından hemen sonra postoperatif 6 ila 8. günlerde ve 45. günde değerlendirilmiştir. Enfeksiyon belirtileri ve iyileşme sorunları, enflamatuvar biyobelirteçler kaydedilmiştir. Bulgular: Ventriküler destek cihazı implantasyonu yapılan hasta sayısı 10’u kontrol, 8’i çalışma grubunda olmak üzere 18 idi. Her iki grup da tüm demografik özellikler açısından benzerdi. Driveline hattı ve yüzeysel sternal yara enfeksiyonu oranları kontrol grubunda, çalışma grubuna göre daha yüksek saptandı (sırasıyla p=0,003 ve p=0,018). Kontrol grubunda bir adet yüzeysel sternal yara yeri enfeksiyonu görüldü. Her iki grupta da debridman gerektiren derin yara yeri enfeksiyonu görülmedi. Hastanede kalış süresi kontrol grubunda daha uzundu (p=0,05). Sonuç: Bu çalışma ile kapalı insizyon negatif basınç tedavisinin driveline hattı enfeksiyonlarını, hastanede kalış süresini ve sağlık hizmetlerindeki maliyet yükünü azaltmada etkisi olduğu sonucuna varılmıştır. Bu ön sonuçların, ventriküler destek cihazı implantasyonu prosedürleri sonrasında profilaktik kapalı insizyon negatif basınç tedavisi uygulamasının avantajını desteklediği ve daha kapsamlı çalışmalar için temel bilgi teşkil ettiği görülmektedir.

Keywords

• Kapalı insizyon negatif basınç tedavisi
• driveline hattı enfeksiyonları
• yara enfeksiyonları
• yara tedavisi

References

1. 1. El Oakley RM, Wright JE. Postoperative mediastinitis: classification and management. Ann Thorac Surg. 1996;61:1030-1036.
2. 2. Hollenbeak CS, Murphy DM, Koenig S, et al. The clinical and economic impact of deep chest surgical site infections following coronary artery bypass graft surgery. Chest. 2000;118:397-402.
3. 3. Fowler VG Jr, O’Brien SM, Muhlbaier LH, et al. Clinical predictors of major infections after cardiac surgery. Circulation. 2005;112:I358-I365.
4. 4. Segers P, de Jong AP, Spanjaard L, et al. Randomized clinical trial comparing two options for postoperative incisional care to prevent poststernotomy surgical site infections. Wound Repair Regen. 2007;15:192-196.
5. 5. Ling ML, Apisarnthanarak A, Abbas A, et al. APSIC guidelines for the prevention of surgical site infections. Antimicrob Resist Infect Control. 2019;8:174.
6. 6. Nahas FX, Ferreira LM, Ghelfond C. Does quilting suture prevent seroma in abdominoplasty? Plast Reconstr Surg. 2007;119:1060-1064.
7. 7. Greenblatt DY, Rajamanickam V, Mell MW. Predictors of surgical site infection after open lower extremity revascularization. J Vasc Surg. 2011;54:433-439.
8. 8. Braxton JH, Marrin CA, McGrath PD, et al. Mediastinitis and long-term survival after coronary artery bypass graft surgery. Ann Thorac Surg. 2000;70:2004-2007.

9. 9. Lu JC, Grayson AD, Jha P, et al. Risk factors for sternal wound infection and mid-term survival following coronary artery bypass surgery. Eur J Cardiothorac Surg. 2003;23:943-949.
10. 10. Wilson JA, Clark JJ. Obesity: impediment to postsurgical wound healing. Adv Skin Wound Care. 2004;17:426-435.
11. 11. Riou JP, Cohen JR, Johnson H Jr. Factors influencing wound dehiscence. Am J Surg. 1992;163:324-330.
12. 12. Abbas SM, Hill AG. Smoking is a major risk factor for wound dehiscence after midline abdominal incision; case-control study. ANZ J Surg. 2009;79:247- 250.
13. 13. Towfigh S, Cheadle WG, Lowry SF, et al. Significant reduction in incidence of wound contamination by skin flora through use of microbial sealant. Arch Surg. 2008;143:885-891.
14. 14. Reiss N, Schuett U, Kemper M, et al. New method for sternal closure after vacuum-assisted therapy in deep sternal infections after cardiac surgery. Ann Thorac Surg. 2007;83:2246-2247.
15. 15. Chambers A, Scarci M. Is skin closure with cyanoacrylate glue effective for the prevention of sternal wound infections? Interact Cardiovasc Thorac Surg. 2010;10:793-796.
16. 16. Khalafi RS, Bradford DW, Wilson MG. Topical application of autologous blood products during surgical closure following a coronary artery bypass graft. Eur J Cardiothorac Surg. 2008;34:360-364.
17. 17. Teshima H, Kawano H, Kashikie H, et al. A new hydrocolloid dressing prevents surgical site infection of median sternotomy wounds. Surg Today. 2009;39:848-854.
18. 18. Bollero D, Malvasio V, Catalano F, et al. Negative pressure surgical management after pathological scar surgical excision: a first report. Int Wound J. 2015;12:17-21.
19. 19. Stannard JP, Robinson JT, Anderson ER, et al. Negative pressure wound therapy to treat hematomas and surgical incisions following high-energy trauma. J Trauma. 2006;60:1301-1306.
20. 20. Gomoll AH, Lin A, Harris MB. Incisional vacuum-assisted closure therapy. J Orthop Trauma. 2006;20:705-709.
21. 21. Atkins BZ, Wooten MK, Kistler J, et al. Does negative pressure wound therapy have a role in preventing poststernotomy wound complications? Surg Innov. 2009;16:140-146.
22. 22. Rashed A, Csiszar M, Beledi A, et al. The impact of incisional negative pressure wound therapy on the wound healing process after midline sternotomy. Int Wound J. 2021;18:95-102.
23. 23. Wilkes RP, Kilpad DV, Zhao Y, et al. Closed incision management with negative pressure wound therapy (CIM): biomechanics. Surg Innov. 2012;19:67-75.
24. 24. Kilpadi DV, Cunningham MR. Evaluation of closed incision management with negative pressure wound therapy (CIM): hematoma/seroma and involvement of the lymphatic system. Wound Repair Regen. 2011;19:588- 596.
25. 25. Driver VR. Silver dressings in clinical practice. Ostomy Wound Manage. 2004;50:11S-15S.