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)
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.
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Open chest
Tags: open chest
Marc Anders. Open chest, Don't Forget the Bubbles, 2013. Available at:
https://doi.org/10.31440/DFTB.3705
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:
Potential complications due to delayed sterna closure with increased rate of infection, longer PICU stay.
Effects of sternal closure:
Indication for chest closure:
Preparation for sterna closure in PICU:
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 populationAll 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.
About Marc Anders
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