Year : 2012 | Volume
: 15 | Issue : 1 | Page : 92--93
Prophylactic percutaneous minitracheostomy after omentoplasty for sternal wound infection
Dheeraj Arora, Yatin Mehta
Medanta Institute of Critical Care and Anaesthesiology, Medanta The Medicity, Gurgaon, Haryana, India
Medanta Institute of Critical Care and Anaesthesiology, Medanta The Medicity, Gurgaon, Haryana
|How to cite this article:|
Arora D, Mehta Y. Prophylactic percutaneous minitracheostomy after omentoplasty for sternal wound infection.Ann Card Anaesth 2012;15:92-93
|How to cite this URL:|
Arora D, Mehta Y. Prophylactic percutaneous minitracheostomy after omentoplasty for sternal wound infection. Ann Card Anaesth [serial online] 2012 [cited 2020 Jun 5 ];15:92-93
Available from: http://www.annals.in/text.asp?2012/15/1/92/91478
Sternal wound infection or mediastinitis is a fatal complication after cardiac surgery. It has a reported mortality of over 50%.  Conservative treatments with local debridement, irrigating suction systems, hyperbaric oxygen and specific antibiotic therapy are sometimes inadequate. However, the poor course of certain patients (those with poorly controlled diabetes, immunosuppression, advanced age, vasculopathy, etc.) requires the creation of flaps using muscle, the greater omentum, or both, in an effort to achieve better infection control by obliterating the cavity and providing richly vascularized viable tissue thus lowering the rates of mortality, reoperation, major complications and recurrence, as well as shortening the hospital stay and prolonging long-term survival.  The greater omentum is used in these conditions because of its rich vascularization, versatility and angiogenic and immunogenic properties, keeping it viable even in highly infected fields, and has been used successfully. 
Postoperatively, these patients require optimal respiratory care to prevent retention of secretions and respiratory complications like pneumonitis. Moreover, chest physiotherapy should be gentle without causing any traction on the sternal wound that may lead to dislodgement of the omentum.
A 50-year-old obese diabetic female underwent coronary artery bypass grafting, left ventricular (LV) clot removal and repair of LV aneurysm. She was shifted to the recovery room with moderate dose on inotropes and intraaortic balloon counterpulsation. She was mechanically ventilated for 72 h in view of poor respiratory effort and poor oxygenation and shifted to the ward on the 8 th postoperative day (POD). She developed sternal wound gaping and dehiscence on the 10 th POD. She was treated with broad-spectrum antibiotics, chest wound drainage and vacuum-assisted closure without satisfactory result. The plastic surgeons' opinion was sought, and they advised wound debridement and omentoplsty.
Omentoplasty was performed on the 23 rd POD. The surgery was uneventful. However, she was not able to cough out secretions and aggressive chest physiotherapy would have dislodged the omentum. Her oxygenation was poor and she required intermittent bilevel positive end expiratory pressure, had bilateral infiltrates in both lung fields on X-ray and coarse crepitations on auscultation. Therefore, it was decided to perform percutaneous minitracheostomy, which involves insertion of a flanged, reclosable cannula 4.0 mm in internal diameter (Portex® Mini-Trach II Kit, Smiths Medical International Ltd., Hythe, Kent, UK) through the cricothyroid membrane into the trachea. Secretions can be sucked with the help of suction without compromising the chest wound, and high-frequency ventilation can be given in case of emergency. This technique is used routinely in our institution in patients with poor respiratory effort, excessive postoperative secretions and in patients with sternal dehiscence.  In this patient, minitracheostomy helped in periodic drainage of secretions without compromising the chest wound and omentum. The patient gradually showed signs of recovery with healthy wound and was discharged on the 35 th POD. In conclusion, percutaneous minitraheostomy in patients with omentoplasty after sternal wound infection may improve outcome by preventing respiratory complications.
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