Negative Pressure Wound Therapy for Patient Bleeding Management
All cardiac surgeons have found themselves spending several hours in the operating room for hemostasis, in particular after complex interventions such as aortic dissection and aortic arch replacement with deep hypothermia. Very often the surgeon wonders what should be done: Continue with hemostasis? Try to close the sternum? Leave the sternum open?
The first step is carried out by the anesthesiologist, who proceeds with the evaluation of thromboelastography and coagulation profile tests. Once the alterations have been corrected and satisfied with the surgical hemostasis, the sternum can be closed.
However, re-exploration for bleeding is associated with a prolonged hospital stay, increased complications such as sternal wound infection and renal impairment, and consequently increased hospitalization costs.
Delayed sternal closure was first described in 1975 by Riahi and colleagues (1) to avoid hemodynamic compromise resulting from sternal closure. Indeed, the rationale for leaving the chest open is to treat hemodynamic compromise after cardiac surgery and uncontrolled coagulopathy.
Leaving the sternotomy open turns out to be of paramount importance when cardiac function is reduced and the heart is edematous after a long operation (2). Various methods for maintaining the sternum open have been used, including direct skin approximation, mediastinal packing, and adhesive membrane coverage (3). Direct skin closure is often not possible. Use of adhesive drape film is easily detached by active bleeding with the risks of damaging the skin through repeated reexplorations and loss of sterility. As a result, the event of uncontrollable postoperative bleeding is usually managed by packing the sternum and mediastinal tissues with gauze.
Adding a sump chest tube allows application of negative pressure to the mediastinum. This pressure, together with surgical sponges, creates a homeostatic barrier, which improves hemodynamic stability and the restoration of coagulative balance. To accomplish this, a VAC sponge is added. It has proven effective in removing blood excess, keeping the barrier effect for a long time, and increasing the stability of the divided sternum (4). In fact, in patients with hemodynamic impairment because of sternal closure, it is sufficient to shape the VAC sponge to the required width to achieve the desired degree of sternal approximation and place it between the sternal edges. Once the negative pressure is applied, the vacuum effect makes the sponge rigid, stabilizing the sternum to the desired distance.
Unfortunately, in patients on ECMO, bleeding mostly derives from a mismatch of coagulation and fibrinolysis that makes it impossible to obtain surgical control of the resulting hemorrhagic state. For these reasons, the authors of this article prefer to use a cell saver instead of VAC therapy in such patients, so the drained blood can be reinfused, when necessary, after processing and washing, and blood is not “lost” in the reservoir of the VAC. Particular attention must be taken in the placement of chest drains when using a cell saver because of the possibility of clotting the circuitry.
In the authors’ experience, packing big bleeders reduces complications and intensive care unit time when compared to reexploration. The rationale for starting to use negative mediastinal pressure was to reduce the risk of tamponade and take-backs for bleeding. In fact, this therapy was initially used in patients who continued to bleed after thorough hemostasis and correction of any coagulopathies. Given the excellent results, it was decided to also use this technique for managing patients with hemodynamic compromise evident at sternal closure. Many studies report meaningful survival and low occurrence of mediastinitis. Indeed, the polyurethane sponge microstructure can increase the suction surface and create negative pressure, which is a useful and safe therapy for mediastinitis.
Open chest management and delayed sternal closure with the use of VAC sponge after cardiac surgery reduces reexplorations for bleeding and blood transfusions and it is a very simple and effective therapeutic option. It should be considered in the armamentarium of every cardiac surgeon.
1. Riahi M, Tomatis LA, Schlosser RJ, Bertolozzi E, Johnston DW. Cardiac compression due to closure of the median sternotomy in open heart surgery. Chest. 1975; 67:113-4.
2. Bakaeen FG, Haddad O, Ibrahim M, Paladin SR, Germano E, Mok S, Halbreiner S et al. Advances in managing the noninflected open chest after cardiac surgery: Negative-pressure wound therapy. JTCVS 2019; 157(5): 1891-1903.
3. Furnary AP, Magovern JA, Simpson KA, Magovern GJ. Prolonged open sternotomy and delayed sternal closure after cardiac operations. Ann Thorac Surg. 1992; 54:233-9.
4. Fleck T, Kickinger B, Moidl R, Waldenberger F, Wolner E, Grabenwoger M, Wisse W. Management of open chest and delayed sternal closure with the vacuum assisted closure system: preliminary experience. Interactive CardioVascular and Thoracic surgery. 2008;7(5):801-804.