A vest used to stabilize the chest following cardiac surgery has slashed the rate of deep sternal wound infections by 50% in a large, prospective, multicenter, randomized trial [1]. Dr Michael Gorlitzer (Hospital Hietzing, Vienna, Austria) reported the results during a late-breaking clinical trial session here today at the European Association for Cardio-Thoracic Surgery (EACTS) 2012 Annual Meeting.
"Sternal wound infections are a major cause of morbidity and mortality following cardiac surgery, and a problem all over the world, affecting up to 3%--or even 5%--of patients undergoing this type of operation," Gorlitzer told heartwire . Although antibiotics are used, other approaches are needed to try and reduce this complication. Approaches that have already been tried include the adoption of different techniques for closure of the sternum and wiring of the sternum, he explained. But "surgeons tend to focus on the pre- and intraoperative periods, when in fact they also need to pay attention postoperatively," he noted.
The support vest reduces the number of reoperations needed due to instabiltity and deep sternal wound infections (DSWI) as well as the length of postoperative stay in hospital, and is therefore "cost-effective due to reduction of major events," Gorlitzer said.
Vest Must Be Worn for Six Weeks Postop
Gorlitzer explained that the Posthorax sternum vest (Epple Inc, Vienna, Austria) is designed to stabilize the sternum after cardiac surgery--it allows normal breathing but acts as a shock absorber when the patient coughs. It is fitted with the help of a nurse after the patient leaves the intensive care unit, and is most effective if worn for around six weeks after surgery. The patient may remove the vest to wash it, and the vest itself can be laundered twice before it starts to lose its effectiveness. The vest costs around €120, although this will differ depending on where it is sold, Gorlitzer said.
In the study, 2539 patients who underwent cardiac surgery were randomized to wear the sternum support vest (n=1351) or not (n=1188). Patients were excluded if they underwent a heart transplant, were aged <20 years, had a congenital heart defect, or underwent mechanical reanimation or irradiation of the chest.
Although 933 patients were randomized to wear the vest, 202 patients did not receive it for varying reasons and 216 patients refused it. This tended to happen more often in the early days of the study when patients were unsure about the vest, Gorlitzer said, and he stressed that it is very important to educate patients. "We need to inform them before the operation what is going to happen afterwards--that they have to wear this vest and that it is a little uncomfortable," he explained.
Of the 1188 patients randomized not to receive the vest, 12 patients did get it, Gorlitzer said.
In an intention-to-treat analysis, the rate of the primary end point--deep sternal wound infection--was 1.04% in those who wore the vest compared with 2.27% in those who did not, a relative risk reduction of 56% (p<0.05).
Organic brain syndrome can increase the risk [of DSWI] 2.5-fold, something that was not previously appreciated. It is important that the vest is worn for six weeks after the operation if possible, said Gorlitzer, noting that in this study, 34% of patients developed DSWI after leaving the hospital.
He noted that the vest can be uncomfortable, particularly when patients are lying down, and it can slip up and irritate the neck. The company is now working on a new design, which should improve the comfort and be available in a few months.
Organic Brain Syndrome Also Identified as Predictor of DSWI
Another important study finding was the identification of a new risk factor for DSWI: organic brain syndrome.
Organic brain syndrome occurs in some patients "who have a kind of psychotic episode after deep anesthesia," Gorlitzer explained. "They thrash around a lot and get agitated."
"We already know that diabetes and long duration of surgery can increase the risk of DSWI, but in this study we saw that organic brain syndrome can increase this risk 2.5-fold, something that was not previously appreciated. This is a very important message," said Gorlitzer.
Gorlitzer reports no conflicts of interest.
"Sternal wound infections are a major cause of morbidity and mortality following cardiac surgery, and a problem all over the world, affecting up to 3%--or even 5%--of patients undergoing this type of operation," Gorlitzer told heartwire . Although antibiotics are used, other approaches are needed to try and reduce this complication. Approaches that have already been tried include the adoption of different techniques for closure of the sternum and wiring of the sternum, he explained. But "surgeons tend to focus on the pre- and intraoperative periods, when in fact they also need to pay attention postoperatively," he noted.
The support vest reduces the number of reoperations needed due to instabiltity and deep sternal wound infections (DSWI) as well as the length of postoperative stay in hospital, and is therefore "cost-effective due to reduction of major events," Gorlitzer said.
Vest Must Be Worn for Six Weeks Postop
Gorlitzer explained that the Posthorax sternum vest (Epple Inc, Vienna, Austria) is designed to stabilize the sternum after cardiac surgery--it allows normal breathing but acts as a shock absorber when the patient coughs. It is fitted with the help of a nurse after the patient leaves the intensive care unit, and is most effective if worn for around six weeks after surgery. The patient may remove the vest to wash it, and the vest itself can be laundered twice before it starts to lose its effectiveness. The vest costs around €120, although this will differ depending on where it is sold, Gorlitzer said.
In the study, 2539 patients who underwent cardiac surgery were randomized to wear the sternum support vest (n=1351) or not (n=1188). Patients were excluded if they underwent a heart transplant, were aged <20 years, had a congenital heart defect, or underwent mechanical reanimation or irradiation of the chest.
Although 933 patients were randomized to wear the vest, 202 patients did not receive it for varying reasons and 216 patients refused it. This tended to happen more often in the early days of the study when patients were unsure about the vest, Gorlitzer said, and he stressed that it is very important to educate patients. "We need to inform them before the operation what is going to happen afterwards--that they have to wear this vest and that it is a little uncomfortable," he explained.
Of the 1188 patients randomized not to receive the vest, 12 patients did get it, Gorlitzer said.
In an intention-to-treat analysis, the rate of the primary end point--deep sternal wound infection--was 1.04% in those who wore the vest compared with 2.27% in those who did not, a relative risk reduction of 56% (p<0.05).
He noted that the vest can be uncomfortable, particularly when patients are lying down, and it can slip up and irritate the neck. The company is now working on a new design, which should improve the comfort and be available in a few months.
Organic Brain Syndrome Also Identified as Predictor of DSWI
Another important study finding was the identification of a new risk factor for DSWI: organic brain syndrome.
Organic brain syndrome occurs in some patients "who have a kind of psychotic episode after deep anesthesia," Gorlitzer explained. "They thrash around a lot and get agitated."
"We already know that diabetes and long duration of surgery can increase the risk of DSWI, but in this study we saw that organic brain syndrome can increase this risk 2.5-fold, something that was not previously appreciated. This is a very important message," said Gorlitzer.
Gorlitzer reports no conflicts of interest.
