What is the protocol for incision care following Coronary Artery Bypass Grafting (CABG) in a patient with a history of coronary artery disease?

Protocol for Incision Care Following CABG

Preoperative antibiotic prophylaxis with a first- or second-generation cephalosporin is mandatory for all patients, and postoperative incision care should focus on preventing deep sternal wound infection through aggressive glycemic control (target ≤180 mg/dL), supervised chlorhexidine gluconate showers, and avoidance of shaving the surgical site. 1, 2, 3, 4

Preoperative Preparation

• Administer first- or second-generation cephalosporin prophylaxis to all patients without methicillin-resistant Staphylococcus aureus (MRSA) colonization 1
• Use vancomycin alone or in combination with other antibiotics for patients with proven or suspected MRSA colonization 1
• Implement supervised chlorhexidine gluconate (CHG) showers preoperatively, which reduces surgical site infection rates from 13.56% to 1.69% 4
• Remove hair with clippers only—never use razors for shaving, as this significantly increases infection risk 3

Intraoperative Considerations

• Administer peri-incisional antibiotics at the time of incision to reduce surgical site infection rates 3
• Maintain blood glucose ≤180 mg/dL using continuous intravenous insulin infusion throughout the procedure to prevent deep sternal wound infection 2, 3
• Avoid excessive fluid removal during cardiopulmonary bypass, as hyperosmotic dehydration contributes to wound complications 2

Postoperative Incision Management

Immediate Postoperative Period (First 48-72 Hours)

• Continue aggressive glycemic control with continuous IV insulin targeting blood glucose ≤180 mg/dL—this is the single most important modifiable factor for preventing deep sternal wound infection 1, 2, 3
• Maintain tight glucose control at 80-110 mg/dL throughout the ICU stay when feasible 3
• Monitor for signs of sternal wound infection including erythema, drainage, sternal instability, or fever 5
• Avoid excessive diuresis that could lead to dehydration and impaired wound healing 2

Risk Factors Requiring Enhanced Surveillance

Monitor patients with the following high-risk features more closely for wound complications:

• Diabetes mellitus (odds ratio 4.71 for infection) 3
• Female gender (odds ratio 2.83 for infection) 3
• Transfer from outside hospital 4
• Emergency operation 4
• Redo sternotomy 4
• Higher American Society of Anesthesiologists score 4
• Prolonged duration of surgery 4

Management of Deep Sternal Wound Infection

If deep sternal wound infection develops, treat with aggressive surgical debridement followed by primary or secondary closure with muscle or omental flap reconstruction. 1

• Perform aggressive surgical debridement in the absence of complicating circumstances 1
• Use vacuum-assisted closure therapy in conjunction with early and aggressive debridement as effective adjunctive therapy 1
• Consider muscle flap (pectoralis major) or omental flap for definitive closure 1

Special Considerations

Patients with Permanent Tracheostomy

• Consider alternative surgical approaches such as low midline skin incision with transverse skin flaps and manubrium-sparing sternotomy to reduce risk of tracheal injury and mediastinitis 6
• These patients are at significantly increased risk for wound infection and require enhanced monitoring 6

Monitoring Timeline

• Continue close wound surveillance for at least 30 days postoperatively, as up to 14% of patients present to the emergency department within this timeframe with complications 5
• The early risk interval extends for 3 months after CABG, with 1-2% morbidity rate for wound infection 1

Common Pitfalls to Avoid

• Never use razors for hair removal—clippers only, as shaving increases infection rates 3
• Do not allow hyperglycemia to persist—postoperative blood glucose level is a significant independent risk factor for surgical site infection 4
• Avoid delaying surgical consultation if wound infection is suspected—early intervention with aggressive debridement improves outcomes 1, 5
• Do not underestimate the importance of preoperative CHG showers—this simple intervention dramatically reduces infection rates 4