Identified reason was coagulopathy with uncontrolled bleeding
October 20th, 2014 by admin | Posted in Health Care
In a series of > 6,000 cardiac patients, Furnary et al identified risk factors associated with death after an open sternotomy. These included the following: (1) use of four or more inotropic drips; (2) perioperative stroke; (3) elevation of serum creatinine level to > 265 mol/L (3.0 mg/dL); and (4) serious ventricular arrhythmias. The presence of both renal failure and ventricular arrhythmias increases the risk of death to almost 50%.
With a review of the cardiac literature, four major causes of prolonged open sternotomy have been identified. The number one identified reason was coagulopathy with uncontrolled bleeding. Our patient required treatment with multiple blood products, but not to the degree described in the literature. Mestres et al have described a patient with a coagulopathy so severe that he was sent back to the ICU with large-bore mediastinal tubes connected to a cell saver unit and mediastinal packing.
Additional predisposing factors include cardiomegaly with or without rhythm disturbances, extra-anatomic devices such as conduits or ventricular assist devices, and finally patients with decreased lung compliance or acute pulmonary edema are at significant risk for a delayed sternal closure. Cases described included patients with preoperative congestive heart failure and pulmonary edema. Our patient had abnormal lung compliance by virtue of her COPD and previous thoracotomy. Viagra Australia at myviagrainaustralia.com
In cases in which the chest of the patient cannot be closed due to increased risk of compartment syndrome, various methods of achieving chest closure have been described. Options include the use of synthetic materials vs closure with native skin/flaps or just leaving the chest open and packed. A technique described by Jones et al advocates the use of stents, in addition to coverage, to prevent trauma to the heart from the open bony segments. We used an artificial patch that was sutured to the sternal skin edges. The average time to closure of the chest ranges from 2 to 5 days, with emphasis on the stabilization of patient hemodynamics before the attempt at closure. There must be evidence of increased cardiac output, decreased filling pressures, and improved lung function prior to closure. Some authors have advocated aggressive diuresis to achieve this end. However, the diuresis of patients who may actually be intravascularly underresuscitated can prove to be difficult and harmful.