Management and outcomes of delayed sternal closure after cardiac surgery in neonates and infants

Abstract

Objectives: To investigate the efficacy, safety, and patterns of management of open sternotomy and delayed sternal closure in infants who were left with an open sternum after cardiac surgery and to assess these patterns for possible correlation with outcome. Design: Retrospective chart review with statistical analysis. Setting: Pediatric cardiac surgery service at a regional referral center based in an urban university teaching hospital. Patients: All 128 patients <1 yr of age who were left with an open sternum after cardiac surgery with cardiopulmonary bypass during the 4-yr period from July, 1992 to June, 1996. Interventions: Procedures for managing open sternotomy and delayed sternal closure were analyzed retrospectively. No interventions were undertaken for the study. Measurements and Results: Of the 128 patients, 14 (11%) died before sternal closure; delayed sternal closure was performed in the remaining 114. Of these 114, 13 died in the early postoperative period. During sternal closure, significant increases were noted in pulmonary arterial (from 21.1 ± 7.6 mm Hg to 26.1 ± 6.5 mm Hg; p = .006), left atrial (from 8.4 ± 3.4 mm Hg to 11.5 ± 3.7 mm Hg; p < .001), and right atrial pressures (from 7.3 ± 2.5 mm Hg to 9.8 ± 2.5 mm Hg; p < .001). In addition, mean airway pressure (from 7.4 ± 2.0 mm Hg to 8.6 ± 2.4 mm Hg; p < .001) and peak inspiratory pressure (from 29.3 ± 5.4 mm Hg to 31.3 ± 5.6 mm Hg; p = .004) increased. Sternal wound infection occurred in one patient. Conclusions: Delayed sternal closure is an effective approach to the management of neonates and infants at risk for hemodynamic, respiratory, or hemostatic instability early after cardiac surgery. Significant changes in hemodynamics and respiratory variables occur during sternal closure, often requiring adjustment of inotropic and ventilatory management.