What are the causes of bleeding from a sternotomy (sternal incision) wound?

From the Guidelines

Bleeding from a sternotomy wound can result from inadequate hemostasis during closure, coagulation disorders, or mechanical factors like sternal wire cutting through bone, and addressing the underlying cause is essential for definitive management. The causes of bleeding from a sternotomy wound are multifactorial and can be attributed to various factors, including:

• Inadequate hemostasis during closure, which can lead to persistent bleeding from the wound site 1
• Coagulation disorders, such as coagulopathy, which can increase the risk of bleeding and make it more difficult to control 1
• Mechanical factors, such as sternal wire cutting through bone, which can cause bleeding from the wound site 1
• Trauma, which can cause bleeding from the wound site due to injury to surrounding tissues and blood vessels 1

In order to manage bleeding from a sternotomy wound, it is essential to:

• Apply direct pressure to the wound using sterile gauze or dressings
• Use hemostatic agents, such as topical thrombin or absorbable hemostatic materials, to control bleeding
• Monitor the patient for signs of hemodynamic instability, such as tachycardia, hypotension, or decreasing hemoglobin levels
• Consider surgical re-exploration to identify and address the source of bleeding
• Maintain normothermia and correct any coagulopathy with appropriate blood products as needed
• Consider using tranexamic acid to stabilize clot formation, as recommended by the European guideline for the management of bleeding following major trauma 1

From the Research

Causes of Bleeding from a Sternotomy Wound

• Deep sternal wound infection (DSWI) is a life-threatening complication that can lead to major bleeding, associated with up to 50% mortality 2
• Risk factors for developing sternal wound infections, which can cause bleeding, include diabetes mellitus, rethoracotomy, duration of operation, and the time of operation (morning versus afternoon) 3
• Sternal wound infections can be caused by a variety of factors, including surgical site infections, and can lead to bleeding and other complications 4, 3, 5, 6
• The use of certain treatments, such as vacuum-assisted closure therapy, can help to reduce the risk of bleeding and other complications associated with sternal wound infections 3, 5

Risk Factors for Sternal Wound Infections

• Diabetes mellitus is a significant risk factor for developing sternal wound infections, which can lead to bleeding 3
• Rethoracotomy, or the need for additional surgery, can increase the risk of sternal wound infections and bleeding 3
• The duration of the operation and the time of day (morning versus afternoon) can also impact the risk of sternal wound infections and bleeding 3

Treatment and Management

• Early detection and treatment of sternal wound infections is critical to preventing bleeding and other complications 4, 3, 5, 6
• The use of negative pressure incision management systems, such as Prevena, can help to reduce the incidence of complications, including bleeding, in high-risk patients 5
• Surgical repair, including the use of muscle flaps, may be necessary to treat deep sternal wound infections and prevent bleeding 2, 3, 5, 6