More than 2 million people across the world have a sternotomy for heart surgery every year. This invasive surgery is highly successful; however, for about 50% it still carries a high risk of experiencing postoperative complications, particularly surgical site and pulmonary infections, as well as persistent pain. The patients at high risk are primarily those who are obese, elderly, osteoporotic, diabetic, patients with high blood pressure, pulmonary issues, immunosuppressive disorders and conditions of malnutrition.
The rate of deep sternal wound infections (DSWIs) is from 0.3% to 5% while patients are still in the hospital. This complication adds another month or two to the patient’s hospitalization with a significantly increased morbidity rate that ranges between 14% and 47%. The incidence of a DSWI diagnosis increases to 7.3% three months after hospital release. Superficial sternal wound infections (SWIs) are contracted by 0.5% to 8% of patients while in hospital and increases to 9% within three months of surgery.
Complications come with significantly increased costs to the healthcare system and are an additional burden to the patient and family. The highest spending is in the USA where the average cost of a CABG procedure is $75,000.
"Having a DSWI is a devastating condition for the patient"
Having a DSWI is a devastating condition for the patient, it's difficult to tackle for the health care staff and it increases the standard cost threefold. Both pulmonary and pain complications cost less per each patient. However, since these are present in a much higher number of individuals, the cumulated costs of pulmonary and pain complications are significantly higher than those of DSWI, causing a significant additional burden on the health care systems.
With the continuous improvements of modern surgical skills and equipment, it would be reasonable to expect improvements in results. However, postoperative complications have remained at the same level over the last decade. This could certainly explain why there is now an increased focus on the postoperative recovery period while patients are in the hospital, and after they are discharged to a recovery clinic or to their home.
Taking costs of complications into account, it is clear that avoiding postoperative complications after CABG can save huge amounts of money for both health care providers and patients. The attention given to investments in methods to improve postoperative care is therefore more and more an important part of patient care plans.
Reducing Postoperative Complications
Scrupulous sterile techniques are a standard in the surgical units. However, high risk patients are still getting infected. The cause of median sternotomy wound infection and dehiscence is not fully understood. Does it start as sternal osteomyelitis? Which subsequently causes sternal separation? Or, is it sternal instability with subsequent skin breakdown that causes bacteria to seep into deeper layers and to develop into a mediastinal wound infection?
Even if the underlying reasons vary, if a postoperative treatment method appears to prevent an infection or a dehiscence it not only spares the patient a devastating, dangerous experience but saves significant sums of money for healthcare providers.
"Negative Pressure Wound Therapy (NPWT), and external chest supports. The two methods address the postoperative issues from different angles"
Two fairly new methods used in the efforts to reduce the risk of complications after sternotomy procedures are Negative Pressure Wound Therapy (NPWT), and external chest supports. The two methods address the postoperative issues from different angles: NPWT is designed to prevent wound infections, while external chest supports, depending on their design, aim at additional ways to prevent complications in the healing phase. Because of the difference in function, one method cannot substitute the other which makes it intriguing to investigate the preventive effect a combination of the two devices could have.
Negative Pressure Wound Therapy (NPWT)
NPWT consists of a vacuum dressing used to enhance and promote wound healing. A negative pressure of up to -125 mmHg is applied with a specific sealed dressing which helps to hold the incision edges together, redistribute lateral tension on these edges, reduce edema, stimulate perfusion, and to protect the surgical site from external infectious sources. NPWT is applied on the sternotomy wound immediately after surgery and should remain unopened for 5-7 days.
NPWT was originally introduced in the 1990’s to assist in the treatment of chronic open wounds. There is now a growing interest in using the therapy on closed incisions after surgery to prevent surgical site infections and other wound complications in high-risk patients. The therapy is increasingly being used as an adjunctive method to prevent infections in high risk patients undergoing sternotomy procedures, since there is accumulating evidence that it improves wound outcomes after cardiothoracic surgery.
"The therapy is increasingly being used as an adjunctive method to prevent infections in high risk patients"
There are at least 12 different companies producing NPWT systems.
External chest support vests
External chest support vests address different aspects of a patients postoperative recovery.
There are many different types of chest or sternum support vests and binders. (See a comparison chart here)
However, they can be grouped into 3 main categories based on their differences in function:
1. Cough supports: Require a patient’s active engagement to grasp and hold either a pillow shaped device against the sternum or pull handles together that are suspended in a rigid vest type device. These devices do not function unless activated by the patient.
2. Rigid chest surrounding supports: Give a constant compression on the chest without additional cough support. These devices are rigid and may present drawbacks concerning comfort and ease of breathing.
3. Dual function chest surrounding supports: Give a constant compression on the chest and have build-in handles for patients to use during coughing or other painful situations to increase the surrounding chest compression. There is only one such device available: the QualiBreath sternum and thorax support.
QualiBreath combines constant stabilization of the sternum with patient activated handles. Because of the elastic material, this device conforms to the patient’s body contour increasing breathing comfort, muscle and ribcage support, even with a very tight fitting closure which helps to decrease pain in addition to stabilizing the sternum.
What if Both Systems are Used Together?
Prevention of surgical site infections receives the most attention even if both pulmonary and pain complications are a higher burden on health care costs. This is perhaps due to the fact that the latter two are less “visible” to the surgical units.
NPWT lasts 5 to 7 days, and if practicable, patients are sent home or to a rehabilitation center. They, their families or other health care givers, need then to take responsibility for the continued wound healing and recovery over the next couple of months. While NPWT helps soft tissue to heal without infection, the healing of the sternum can take up to 8 weeks or even longer depending on the risk category the patient belongs to. If a healing sternum is not stabilized and supported externally until it has totally grown together, friction between the 2 sternum halves could occur and provoke infection. A successful recovery can very much depend on whether the patient receives the right instructions and the right devices to fully support their recovery at home.
NPWT devices cannot substitute an external chest support, and vice versa. NPWT devices appear to decrease the risk of surgical site infections, however, they do not offer overall support to respiratory muscles and sore ribs, or stabilize the sternum.
If an external chest support, that is designed to keep the patient comfortable in the postoperative period and to promote deeper breathing with more effective management of pain, and to help the patient to be active sooner, is used in combination with NPWT, the two adjunctive treatments could most likely increase the odds for an improved recovery. Perhaps using an external chest support vest, such as QualiBreath, could further secure and prolong the effect of NPWT.
QualiBreath has been proven to decrease pain, ease breathing, decrease the sternal gap and improve activity. Furthermore, the patient can use the handles to achieve extra support around the ribcage when they need it most, and it supports the sternum 24/7 for weeks while the patient recovers from surgery.
The combination of NPWT and the QualiBreath chest support vest could be an effective preventive strategy to combat postoperative complications and it could be a cost-effective adjunctive treatment to further minimize the risk after open heart surgery.
Do you think it makes sense to use these two systems together?
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