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Ann Thorac Surg 2001;71:1888-1893
© 2001 The Society of Thoracic Surgeons
a Department of Thoracic and Cardiovascular Surgery, University of Virginia Health Sciences Center, Charlottesville, Virginia, USA
Address reprint requests to Dr Kron, Department of Thoracic and Cardiovascular Surgery, University of Virginia Health Sciences Center, Lee St, Rm 2753, Charlottesville, VA 22908
e-mail: ikron{at}virginia.edu
Presented at the Forty-seventh Annual Meeting of the Southern Thoracic Surgical Association Meeting, Marco Island, FL, Nov 9–11, 2000.
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Abstract |
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Methods. A retrospective analysis was performed on 6,908 adult patients undergoing cardiac operation over a 9-year period. Excluding those in cardiac arrest, 340 (4.9%) patients underwent reoperation in the cardiac intensive care unit, of which 289 survived (85%).
Results. Of the 289 patients who survived reoperation in the intensive care unit, 6 developed wound infections that required operative debridement (2.1%), which was not significantly different from those patients not requiring reoperation (1.9%, 121 of 6,497, p = 0.70). Hospital charges for a 2-hour reoperation in the intensive care unit and operating room are approximately $1,972/patient and $5,832/patient, respectively.
Conclusions. Reoperation in the intensive care unit does not increase wound infection rate compared to those without reoperation. Decreased charges, avoiding transport of potentially unstable patients, quicker time to intervention, and convenience are advantages of reoperation in an intensive care unit.
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Introduction |
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For the past 9 years, our institution has routinely performed open chest reoperations in the cardiac intensive care unit (ICU), as opposed to taking these patients back to the operating room. Our hypothesis was that reoperation in a cardiac ICU does not increase wound infection rate and results in decreased hospital charges and other advantages. To test this hypothesis, we performed a retrospective review of our cardiac surgery patients requiring reoperation in the cardiac ICU.
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Material and methods |
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18 years of age) who had open heart procedures requiring cardiopulmonary bypass. Data for this study was collected from the Thoracic and Cardiovascular Surgery ICU special procedures log book, patient’s hospital charts, and a sternal wound infection database. Sternal wound infection was defined as any infection that required at least open debridement of the sternal wound. This includes patients who had either a superficial sternal wound infection or deep sternal wound infection (mediastinitis). Patients treated for minor skin cellulitis without having their incision opened were not counted in the sternal infection group. 
2 Tests were performed to compare variables. Data are expressed as mean ± standard error of the mean. A p value of 0.05 or less was considered significant.
Intensive care unit reoperation
For reoperation in the ICU, staff varies depending on the availability of operating room nurses. In some instances, reoperations are carried out using only the nurses present in the ICU. If available, an operating room nurse or a cardiac surgery physician assistant is requested to help in the reoperation. However, all of our cardiac ICU nurses are trained in reoperation protocols and given yearly in-services on instruments in the reoperation set-up. The ICU rooms in which the majority of these procedures have taken place are private and do not have reverse ventilation. Anesthesiology support is not requested for our ICU reoperations, with patient anesthesia being administered by the ICU staff. Drugs typically used include morphine, lorazepam, and cisatricurium. Patients who underwent delayed sternal closure were kept sedated and paralyzed until their sternal wound was closed.
After their original operation, our patients typically receive 48 hours of cefazolin unless they have a penicillin allergy, in which case they receive vancomycin. If not already on appropriate antibiotic coverage, patients undergoing reoperation are given cefazolin at least 30 minutes before the reoperation if time permits. Antibiotics are then continued for at least 72 hours.
Reoperations in the ICU are performed in a similar manner as operations in the operating room. Room is made at the head of the patient’s bed to allow access to the endotracheal tube and the pulmonary artery catheter at the time of operation. Care is taken to ensure easy access to the ventilator as well. Patients are placed on 100% oxygen during the procedure. Electrocardiographic leads are repositioned to allow access to the chest. The chest is prepared with a triple scrub that includes betadine and chlorohexadine. Following this, sterile drapes are placed over the patient and the entire bed. These drapes are raised at the head of the bed to uncover the patient’s endotracheal tube and pulmonary artery catheter. The surgeons and assistants involved in the actual reoperation all wear masks, caps, sterile gowns, and sterile gloves. All other support personnel wear caps and masks while in the room. During the reoperation, the door to the room is closed to the rest of the cardiac unit. Two sets of suction devices are set up on either side of the bed using standard wall suctioning devices. Two sets of headlamps and cautery units are available in the ICU for reoperation purposes. A full complement of surgical instruments is provided in the operating room pack including surgical clips and sutures.
ECMO placement
For patients requiring ECMO, the system used at our institution is comprised of a heparin bonded Carmeda BioActive Surface circuit, a Maxima Plus PRF (plasma resistant fiber) hollow membrane oxygenator with integral heat exchanger, a Biopump centrifugal blood pump (circuit, oxygenator, and pump from Medtronic Cardio-pulmonary, Anaheim, CA), an oxygen/air blender (Sechrist, Anaheim, CA), and a Blanketrol II Hyperhypothermia heater/cooler (Cincinnati, OH). For patients requiring delayed transthoracic ECMO after successfully weaning from cardiopulmonary bypass, the right atrium was cannulated with a 36/46F dual drainage cannula (Terumo/Sarns; Ann Arbor, MI). A 24F Aortic Arch cannula (Terumo/Sarns; Ann Arbor, MI) was used for aortic cannulation.
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Results |
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Wound infection
Wound infection requiring operative debridement occurred in 7 patients who survived reoperation, including 1 patient in the cardiac arrest group (1 of 11, 9%) and 6 patients in the noncardiac arrest group (6 of 289, 2.1%). Of those 7 patients who developed sternal wound infections, 3 had deep sternal wound infections that required muscle/omental flaps. Two of those patients survived until time of hospital discharge. Four other patients had superficial sternal wound infections that required only local debridement. All of those patients survived to hospital discharge. The infection rate for the noncardiac arrest group was not significantly different from the infection rate for patients not requiring reexploration (121 of 6,497, 1.9%, p = 0.70). A power analysis was performed and the observed power was 0.064. The infection rate of patients undergoing reexploration for bleeding or tamponade (5 of 251, 2.0%) was not significantly different from those undergoing reoperation for other noncardiac arrest indications (ECMO, delayed sternal closure, or graft occlusion; 1 of 68, 1.5%, p = 0.51). There was no consistent correlation between infection rate and cardiac ICU reoperation rate over the 9-year study period (Fig 1).
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Of the 272 patients who underwent reoperation for bleeding complications, 177 had isolated coronary artery bypass grafting procedures, of which 132 had bleeding that was not associated with any hemodynamic compromise. Mortality rate in that group was 1.5% (2 of 132) and wound infection rate was also 1.5% (2 of 130).
ECMO
In the reoperation for ECMO group (n = 35), mean age was 61.2 ± 0.31 years, 19 (54%) were men, and 3 patients (8.6%) had undergone a previous median sternotomy. Of the patients in the ECMO group, 24 had institution of ECMO in the operating room. All of those patients had ECMO discontinued in the ICU. Eleven other patients had ECMO placement in the ICU. All of those patients had ECMO discontinued in the ICU as well. Eighteen other patients who had institution of ECMO after cardiac arrest were counted in the cardiac arrest group. Of the 35 noncardiac arrest patients who required ICU reoperation for institution or removal of ECMO support, 27 died. Primary cause of death was cardiac failure in 20 patients (74%), whereas 3 patients (11%) died from multisystem organ failure, 3 patients (11%) died from stroke, and 1 other patient (4%) died from respiratory failure. Of the 8 patients who survived after ECMO support, none developed wound infections.
Delayed sternal closure
For the delayed sternal closure group (n = 31), mean age was 67.2 ± 0.52 years, 17 (55%) were men, and 3 patients (10%) had undergone a previous median sternotomy. Patients in this group had delayed sternal wiring as a result of cardiac instability with sternal closure at the time of the original operation. Of the 31 patients in this group, 5 did not survive. Primary cause of death for the majority of these patients was cardiac failure (4 of 5, 80%), whereas 1 patient (20%) died from multisystem organ failure. Of the 26 patients that survived after reoperation for sternal closure, 1 developed a wound infection that required debridement (1 of 26, 3.2%).
Graft occlusion
Two patients who had coronary bypass graft occlusion had reoperation and repair of the occluded vessel in the ICU. Both of these patients were placed on cardiopulmonary bypass while in the ICU. Both of these patients had occluded vein grafts that led to cardiac instability. Both of these patients required vein harvest and regrafting while in the ICU as a result of their instability. Ages for these patients were 61 and 64 years, neither had had a previous median sternotomy, and 1 was a man. Both of these patients survived without wound infection.
Cardiac arrest
For the cardiac arrest group (n = 81), mean age was 70.0 ± 0.2 years, 44 (54%) were men, and 7 patients (8.3%) had undergone a previous median sternotomy. Of the 81 patients who had reexploration for cardiac arrest, 18 had institution of ECMO following arrest. None of those patients survived. Nine of those patients died of cardiac failure and 9 died of stroke complications. Another 52 patients with reoperation for cardiac arrest without ECMO support died. All of the patients in that group died of cardiac failure. Of the 11 patients who survived after cardiac arrest, 1 developed a wound infection (1 of 11, 9%).
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Comment |
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The large majority of reoperations after cardiac operation are for bleeding complications. In the present study, 4.9% of all patients required reoperation for bleeding complications. This rate has remained relatively consistent through each of the academic years with one notable exception. In the academic years 1994 to 1995 and 1995 to 1996, the anesthesia department at our institution began using hetastarch as an alternative to albumin for volume replacement in the operating room. This led to an increase in reexploration for bleeding complications from 4.7% to 6.3%. With discontinuation of hespan for volume replacement in the operating room, reexploration for bleeding complications decreased to 4.0% in academic year 1996 to 1997 [6]. The overall rate of reexploration for bleeding complications in the present study, however, is still similar to that found in other investigations. Moulton and colleagues [2] found a 4.2% reexploration rate for postoperative hemorrhage in 6,015 patients requiring cardiopulmonary bypass. Dacey and associates [3] reported a reexploration rate of 3.6% for bleeding complications in 8,586 patients having cardiac procedures. Sellman and colleagues [4] reported a reexploration rate of 4.4% for bleeding complications following 8,563 coronary artery bypass procedures. Kaiser and associates [5] reported a reexploration rate of 3.1% for postoperative hemorrhage complications in 1,300 cardiac surgery patients.
Mortality for our patients undergoing reoperation in the ICU for bleeding complications (8%) was similar to that found in other studies as well, although reported results vary. Moulton and colleagues [2] reported a mortality rate of 11% after reexploration for bleeding complications. Dacey and associates [3] reported a mortality rate of 10% for patients having undergone coronary artery bypass grafting and needing reoperation for bleeding complications. Kaiser and colleagues [5] reported a mortality rate of 26% for patients reexplored for bleeding complications. Sellman and associates [4], however, reported a mortality rate of only 5.8%.
One of the major concerns with reoperating in an ICU is the issue of sterility and the risk of mediastinal infection. Sternal infection can be a significant cause of morbidity and mortality after cardiac operation [7–9]. Wound infection rates for patients who survived after reoperation was 2.0%. This rate has remained relatively constant during most academic years with a notable exception in the academic year 1994 to 1995. A thorough investigation during that year revealed that the method in which patients were being prepared for operation, in addition to several other factors, led to this increase in infection rate. Modification of these factors led to a decrease in sternal infection rate from 3.7% in academic year 1994 to 1995 to 1.3% in academic year 1995 to 1996. The overall infection rate in our population, however, was similar to or less than that found in other studies. Kaiser and colleagues [5] demonstrated a sternal wound infection rate of 6.1% in patients undergoing reoperation. Sellman and associates [4] revealed a 1.9% sternal wound infection rate for patients undergoing reoperation. Moulton and colleagues [2] reported a 2.4% sternal wound infection rate for patients undergoing reoperation.
This study also demonstrates that several types of open chest procedures, in addition to reexploration for postoperative hemorrhage or tamponade, can be safely accomplished in the ICU. Although most of our reoperations have been for bleeding complications, we have also both placed and discontinued ECMO in numerous patients in the ICU. We have also performed delayed sternal closure for many patients while in our ICU. Furthermore, in 2 unstable patients, we have safely accomplished saphenous vein coronary artery bypass in the ICU without any complications.
Reoperation in the ICU can have distinct advantages over reoperating in the operating room. Many patients who undergo reoperation are unstable and require emergent intervention. Reoperation in the ICU avoids the extra time required to transport the patient to the operating room, which at our institution takes about 15 minutes. This also does not include the time required to get the patient’s bed, lines, drips and possible other support equipment, such as ECMO devices, ready for travel. Another issue is that for unstable patients, such as those with bleeding complications and possible cardiac tamponade, movement can further exacerbate instability problems. Moving patients, especially under hurried conditions, can also result in endotracheal tube dislodgment, loss of intravenous access, and other complications. Furthermore, as shown in the present study, reoperating in the operating room can add considerably to patient charges.
Although a number of reoperative procedures can be accomplished in the ICU, for technical and infectious reasons, some procedures are best reserved for the operating room. For instance, routine use of cardiopulmonary bypass should probably occur in the operating room. Patients requiring valve operations, implantable ventricular assist devices, or aortic graft placement should have their operations performed in the operating room as well.
In summary, reoperation in the ICU can be done for a number for procedures. This is accomplished without an increase in infection rate and at considerably less expense compared to reoperating in the operating room. Some procedures, however, that involve the routine use of cardiopulmonary bypass or insertion of artificial mechanical devices are probably best performed in the operating room.
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Discussion |
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We have seen another demonstration of the effectiveness of this technique. Their experience mirrors ours that we presented to this association years ago. The most significant observations were the ease of performance and savings in time and cost while avoiding increased mortality and morbidity, such as wound infection. As they indicate, reexploration in this manner requires properly trained personnel, adequate supplies, and appropriate equipment. Once these are available, reluctance to use this technique disappears and allows one to promptly reexplore a patient to assist in making a correct diagnosis even when one may be uncertain as to the cause of the patient’s deterioration. Nothing is lost and much may be gained by its prompt use. Although the findings at reexploration may be those chiefly of myocardial depression, this often can be reversed with appropriately applied treatment, including the use of cardiac assistance, which they have also demonstrated.
I have two questions for you, Dr Fiser. There were two patients that had revision of their vein grafts. In view of today’s knowledge about coronary bypass, were these done with or without cardiac assistance? The second is a question about the use of hetastarch. You have indicated there was increased postoperative bleeding with its use, which decreased with its discontinuation. What is your current philosophy of hetastarch use?
I want to thank you for providing me a copy of their manuscript for review. I commend you on a fine report and Dr Fiser for an excellent presentation. Thank you.
DR FISER: First, I will comment on the hetastarch question. We do not use hetastarch during cardiopulmonary bypass. We will use hetastarch postoperatively in patients who show no evidence of bleeding, are in the intensive care unit, and need volume replacement, and then we use only a liter of hetastarch, and we won’t go over that.
As far as your second question, we usually do revision of the vein grafts off-pump while in the ICU.
DR LYNN H. HARRISON (New Orleans, LA): I too would like to compliment Dr Fiser on a very nice presentation and say that we agree with you in principle about the desirability of approaching the majority of patients requiring early reexploration in the intensive care unit. We began as you have in terms of staffing, using the patient’s intensive care unit nurse basically as a scrub tech and the charge nurse as a circulator, but have quickly gotten away from that. The patients that we were reexploring in the unit tended to be more unstable and we believe that they required a nurse who was attendant to their intravenous infusion and their ventilation during the procedure, and those little rooms get awfully crowded if we get many more people in there. So what we have evolved is bringing a heart team of techs and a supervisor from the operating room with the instrument and drape packs, but we perform the procedure in the intensive care unit, and this has seemed in our institution, where perhaps our staffing is a little thinner than yours in the intensive care unit, to work better for us.
DR FISER: One comment about that. I would say in about 60% of the cases that we do, we do involve an operating room nurse that comes up and assists. Obviously they are going to have more experience with these types of procedures.
As far as space concerns, occasionally it can get pretty tight in our intensive care rooms, and I think one of the big things that we try to do is limit the number of people in the room. We really try to take caution and try to keep people out just to keep more room in the area.
DR BEN R. BARTON (Nashville, TN): I enjoyed very much your presentation and found the concept intriguing. I have had a growing suspicion during the past 4 to 5 years that the role of the anesthesiologist was superfluous anyway in the operating room and wondered how you handled anesthesia at reexploration in the intensive care unit or anesthesiologists in attendance.
And then a couple of other just technical questions. When you speak of graft revision, was that putting in a stitch for bleeding or actual reconstruction of a stenotic anastomosis? And then, how did this alter the length of stay? If you are saving money in the intensive care unit by not returning them to the operating room, are you losing money down the line by a prolonged length of stay or an increased risk of complications?
Again, thank you. It is a very fine paper.
DR FISER: Typically for our reoperations we do not involve anesthesiology support. All of the anesthesia for these reoperations were done just with the intensive care unit nurses.
As far as the clotted graft question, the 2 patients who were presented had clotted grafts that were unclotted and then reanastomosed on bypass. All other patients who required graft revision were done off-bypass.
In terms of length of stay after graft revision in the intensive care unit, we have not discovered any changes in time until discharge.
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References |
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