Discriminate use of electrocautery on the median sternotomy incision. A 0.16% wound infection rate
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H Nishida1, R K Grooters, H Soltanzadeh
1Department of Surgery, Iowa Methodist Medical Center, Des Moines.
Abstract:
Between June 1978 and June 1989, superficial or deep mediastinitis (or both) developed in only five (0.16%) of 3118 consecutive patients. All patients studied underwent cardiac procedures through a median sternotomy and survived more than 7 postoperative days. The surgical team disciplined itself to divide presternal soft tissues with a scalpel and used electrocautery for pinpoint hemostasis only. This 0.16% infection rate was statistically significantly lower than those in 28 previously published studies (Pearson's chi 2 test, p less than 0.05). Twenty-four predisposing factors were evaluated by Fisher's exact test. Among these only an operating time longer than 3 hours is related to sternotomy infections (p = 0.0208), and this effect was not a strong one. Statistical evidence strongly suggests that discriminate use of electrocautery is a major reason for the lowest median sternotomy infection rate reported to date.
Insights
Minimizing electrocautery use during median sternotomy significantly reduced mediastinitis infection rates to 0.16%. This surgical technique proved superior to previous studies, highlighting careful hemostasis as key to preventing sternotomy infections.
Area of Science:
- Cardiovascular Surgery
- Infectious Disease Prevention
- Surgical Techniques
Background:
- Mediastinitis is a serious complication following cardiac surgery via median sternotomy.
- Previous infection rates in similar patient cohorts have been significantly higher.
- Identifying modifiable risk factors for mediastinitis is crucial for improving patient outcomes.
Purpose of the Study:
- To report an exceptionally low mediastinitis infection rate in patients undergoing cardiac procedures.
- To identify factors contributing to this low infection rate, specifically focusing on surgical technique.
- To compare the observed infection rate with historical data from similar studies.
Main Methods:
- A retrospective analysis of 3118 consecutive patients undergoing median sternotomy between 1978 and 1989.
- Detailed review of surgical techniques, focusing on soft tissue dissection and hemostasis.
- Statistical comparison of the observed infection rate (0.16%) with 28 previous studies using Pearson's chi-squared test.
- Evaluation of 24 predisposing factors for sternotomy infections using Fisher's exact test.
Main Results:
- An infection rate of only 0.16% (5 out of 3118 patients) for superficial or deep mediastinitis was observed.
- This rate was statistically significantly lower than those reported in 28 prior studies (p < 0.05).
- Operating time longer than 3 hours was the only statistically significant (p=0.0208), though weak, predisposing factor identified.
- The discriminate use of electrocautery for pinpoint hemostasis was strongly suggested as the primary reason for the low infection rate.
Conclusions:
- A meticulous surgical approach, particularly the discriminate use of electrocautery, can achieve exceptionally low rates of mediastinitis following median sternotomy.
- This technique significantly reduces the risk of infection compared to historical benchmarks.
- Careful surgical technique, rather than prolonged operating time, appears to be the most critical factor in preventing sternotomy-related infections.