Should additional antibiotics or an iodine washout be given to all patients who suffer an emergency re-sternotomy on the cardiothoracic intensive care unit?

May 29, 2009

June 5, 2009

ElaineYee Ling Yapa, Adrian Levine, Tim Strang , Specialist Registrars in Cardiothoracic Surgery (James Cook University Hospital, Middlesbrough, North Staffordshire Royal Infirmary, Stoke-on-Trent and Wythenshawe Hospital, Manchester)

Joel Dunning, James Cook University Hospital, Middlesbrough, North Staffordshire Royal Infirmary, Stoke-on-Trent and Wythenshawe Hospital, Manchester

In [patients suffering emergency re-sternotomy after cardiac surgery on the ICU] do [Antibiotics or iodine washouts] results in a lower incidence of [sternal wound infections]?

A patient two hours after a double valve and grafts suddenly goes into ventricular fibrillation as you are passing by his bed in the intensive care unit. Three rapid attempts at defibrillation fail and the nurse who was looking after him said that he had been very unstable with a high CVP prior to the arrest. You elect to perform an emergency re-sternotomy, which relieves a tamponade and the heart spontaneously cardioverts into sinus rhythm. A vein proximal anastomosis was bleeding and you repair this and you are eventually happy to re-close the chest. The anaesthetist asks you if you want any more antibiotics and the scrub nurse asks you if you want a betadine washout. You do this as you are not sure how sterile one of your scrubbed colleagues were, but you are not sure if this is necessary.

Medline 1950–Oct 2007 using the OVID interface.
EMBASE 1980–Oct 2007 using the OVID interface.

Medline:[open chest.mp OR internal cardiac.mp OR resuscitative thoracotomy.mp OR open heart.mp] AND [CPR.mp OR exp Cardiopulmonary resuscitation/or massage.mp]

Embase:[open chest.mp OR internal cardiac.mp OR resuscitative thoracotomy.mp OR open heart.mp] AND [CPR.mp OR exp resuscitation/or massage.mp]

The Cochrane database for systematic reviews and central register of controlled trials was searched using the term ‘open chest’, or ‘internal cardiac’ or CPR. NICE, SIGN, STS, AHA and ESC guidelines were searched.

Two hundred and sixty-three papers were found in Medline, 256 in EMBASE and eight articles in the Cochrane library. Of these nine were felt to be relevant

In 2007, The Society of Thoracic Surgeons published a guideline on antibiotic prophylaxis for elective cardiac surgery [Engleman]. They recommend that a first generation cephalosporin (usually cefazolin) should be the antibiotic of choice for elective cardiac surgery with the addition of vancomycin for patients with increased risk of Staphylococcal infection. Mupirocin ointment is recommended as an additional routine prophylactic measure. The SIGN guidelines recommend antibiotic prophylaxis for patients undergoing cardiac surgery. However, no specific antibiotics were recommended<br><br>In these two guidelines some recommendations for high-risk patients are given but neither address emergency re-sternotomy in patients who have recently received these prophylactic antibiotics and may not necessarily have had a sterile reopening.<br><br>Kriaras et al. published the only paper on patients after cardiac surgery who had open chest CPR on the day of surgery specifically in order to look at the issue of antimicrobial protection. Twelve patients had 10% iodine spread around the peri-sternotomy skin and vancomycin 500 mg intravenously was given peri-procedure. Mediastinal iodine and then saline washout were given at the end of the procedure. There were no wound infections, and they concluded that this protocol might be a useful intervention in emergency situations.<br><br>McKowen et al. reported the outcomes from resuscitation of 64 cardiac surgical patients after emergency re-sternotomy. Their practice was to use povodine-iodine preparation of the skin. Intravenous antibiotics were given simultaneously and bacitracin washout prior to closure. Only 2 out of 49 patients had a wound infection after this (4%).<br><br>Charalambos et al. conducted a study on patients who had chest reopening for bleeding or tamponade on the intensive care unit. Patients who arrested were excluded. The sternum was prepared using povodine-iodine solution and prophylactic antibiotic was usually flucloxacillin or an equivalent antibiotic. There was a variation in the duration of antibiotic administered. The incidence of sternal wound infection was 3%. <br><br>Anthi et al. reported the outcomes of 16 emergency chest reopenings after a cardiac arrest. They only reported that betadine was applied to the skin and full sterile technique was used. No patients suffered a wound nfection.<br><br>Fairman and Edmunds reported 64 patients who had an emergency re-sternotomy after cardiac surgery for inadequate circulation. These patients had iodine skin preparation and sterile towel drapes. Re-irrigation was performed prior to closure. Following that, patients had three days of a cephalosporin and aminoglycoside. Wound infection rate was 5% in survivors.<br><br>El Banyosy et al. reported the outcomes of 113 patients who arrested within 7 days of cardiac surgery . They found that 7 of the 79 surviving patients had at least one episode of sepsis after the resuscitation (9%). No mention of antibiotic use was given<br><br>Ramen et al. reported the outcomes of 39 patients who arrested after cardiac surgery in 1989. Twenty-one patients had an emergency re-sternotomy with povodine-iodine skin preparation, aseptic reopening on the intensive care unit and perioperative antibiotics for 48 h if successful. In addition, if successful the patient was returned to theatre for povodine-iodine washout and closure. <br><br>Of note a few of these papers documented ‘full-aseptic technique’ but no more detail than this was given. Thus, we would propose that a gown and gloves with full patient draping would constitute ‘full-asepsis’ in this setting. We also propose that it is not necessary to wash your hands prior to putting the gown and gloves on due to the difficulty of putting gloves on with wet hands and the necessity for rapid emergency re-sternotomy.

For patients who require an emergency re-sternotomy on the intensive care unit, the incidence of sternal wound infection or sepsis after this emergency treatment is around 5%. We found only seven papers that documented the incidence of infection after emergency re-sternotomy. Of these seven papers five documented that they routinely gave additional intravenous antibiotics and an iodine washout. The other two papers did not report whether this was done. We conclude that even though the incidence of subsequent infection is low in the cardiac arrest situation, full aseptic technique including gown and gloves might be regarded as best practice. It is common practice also to give additional antibiotics and a povodine-iodine washout although we could identify no studies other than uncontrolled cohort studies in support of this.

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