Open chest

Negative impact on haemodynamics and respiratory parameters after median sternotomy was first described in 1975, with emphasis on “compression of the heart and producing a cardiac tamponade”.

Indications for delayed sterna closure and open chest:

• ‘Large’ heart syndrome
• Haemodynamic instability after temporal sternal approximation
• Low cardiac output post CPB
• ECMO or VAD cannulation
• Severe arrhythmia
• Severe bleeding complications
• Severe contamination requiring frequent reexploration

Potential complications due to delayed sterna closure with increased rate of infection, longer PICU stay.

Effects of sternal closure:

• Increase in intrathoracic pressure
• Decrease in total lung compliance
• Decrease in systolic/mean BP
• Decrease in SV, leading to a decrease in CO
• Decrease in cerebral oxygenation

Indication for chest closure:

• When the patient is ready!
• Haemodynamically stable (age appropriate MAP with minimal inotropic support, stable CVP, LA, PAP, stable heart rat and rhythym, appropriate CRT)
• Respiratory stable (acceptable ventilation settings, FiO2 requirements)
• Stable fluid status (oedema, fluid balance over last 12/24 hrs)

Preparation for sterna closure in PICU:

•  Sterile surgical field (gown, mask)
• Standard monitoring (ECG, invasive BP, CVP (LA, PAP, pacemaker, SaO2, etCO2, ventilation parameters)
• Standard setup: standby for inotropic support with adrenaline or dobutamine (noradrenaline infusion), adrenaline 10 mcg/kg bolus, fluid resuscitation with NaCl 0.9%, human albumin and PRBC (minimum 2 units crossmatched), good floating fluid line and separate inotropic line, accessible outside the surgical field
• Cephazolin 25-50 mg/kg IV minimum 30 mins preceding the surgical procedure
• Fentanyl 5 mcg/kg IV bolus and midazolam 100 mcg/kg IV Bolus plus vecuronium 0.1 mg/kg IV bolus to provide adaequate anaesthesia and muscle relaxation

Observe during and post sternal closure: haemodynamic/respiratory/fluid and metabolic stability

References:

[1] J Thorac Cardiovasc Surg. 2010 Apr;139(4):894-900: Horvath et al: Cerebral and somatic oxygen saturation decrease after delayed sternal closure in children after cardiac surgery

[2] Cardiol Young. 2009 Dec;19(6):573-9. Vojtovic P et al: Haemodynamic changes due to delayed sternal closure in newborns after surgery for congenital cardiac malformations

[3] J Thorac Cardiovasc Surg. 1997 May;113(5):886-93: Tabbutt et al: Delayed sternal closure after cardiac operations in a pediatric population

 All Marc’s PICU cardiology FOAM can be found on PICU Doctor and can be downloaded as a handy app for free on iPhone or Android. A list of contributors can be seen here.