Management of Open Chest After Surgery
For a non-infected open chest after cardiac surgery, negative-pressure wound therapy (NPWT) is the preferred management approach, as it reduces reexplorations for bleeding and improves early survival compared to traditional wound therapy. 1
Immediate Post-Surgical Management
Primary Wound Management Strategy
NPWT should be applied as the first-line therapy for managing non-infected open chests after cardiac surgery, with frequency of use approaching 100% in contemporary practice due to superior outcomes. 1
NPWT is safe and effective, with no reported cardiovascular injuries related to its use, and has become the therapy of choice for open-chest management. 1
The median duration from open-chest to definitive sternal closure is approximately 3.5 days with NPWT. 1
Alternative Traditional Wound Management
If NPWT is unavailable or not tolerated, Esmarch bandages (orthopedic surgical bandages) can be sutured to the open chest wound for temporary management. 2
Traditional wound therapy with appropriate antibiotics can prevent wound infection when NPWT is not feasible. 2
Conversion between therapies may be necessary: approximately 3.3% of patients require conversion from NPWT to traditional therapy due to hemodynamic intolerance. 1
Monitoring and Complications
Bleeding Management
NPWT significantly reduces reexplorations for bleeding (29% vs 44% with traditional therapy, p=0.002), making it particularly valuable in high-risk patients. 1
Continuous monitoring for bleeding is essential, as early chest reexploration is a significant risk factor for subsequent wound infection. 3
Infection Prevention
Appropriate antibiotic prophylaxis must be maintained throughout the open-chest period to prevent infection. 2, 3
The interval between hospital admission and surgery, reoperation status, blood transfusions, and any reintervention are significant risk factors for wound infection that require vigilant monitoring. 3
Definitive Closure Considerations
Timing of Closure
Delayed sternal closure should be performed when hemodynamic stability is achieved and coagulopathy is corrected, typically within 3-4 days. 1
The decision for closure depends on resolution of the primary indication (uncontrolled coagulopathy, hemodynamic compromise, cardiac failure, or primary graft dysfunction). 1, 2
Dressing Selection After Closure
Once the chest is closed, dry absorbent dressings (such as Primapore) are the most comfortable and cost-effective option for sternotomy wounds. 4
Hydrocolloid and hydroactive dressings offer no additional benefit for infection prevention or wound healing and are associated with increased wound exudate, poor dressing integrity, more frequent changes, and higher costs. 4
Common Pitfalls to Avoid
Avoid premature chest closure in patients with ongoing coagulopathy or hemodynamic instability, as this necessitates reexploration and increases infection risk. 1, 3
Do not hesitate to leave the chest open when indicated—NPWT has potentially lowered the threshold for this decision by improving safety and outcomes. 1
Minimize blood transfusions when possible, as they are an independent risk factor for wound infection. 3
Avoid routine use of plastic surgical adhesive drapes and minimize preoperative hospitalization time to reduce infection risk. 5
Do not use hydrocolloid or hydroactive dressings for closed sternotomy wounds, as they provide no benefit and increase cost and patient discomfort. 4