A technique for the treatment of sternal infections using the Vacuum Assisted Closure (TM) device

Background: Sternal infections after median sternotomy remain a serious cau se of postoperative morbidity and mortality. The treatment of sternal infec tions has evolved over the past few decades, and now aggressive surgical de bridement with rotational muscle flap closure has provided an acceptable me ans of managing this complication. However, there are several disadvantages with this approach, mainly related to the morbidity associated with serial debridements with dressing changes and open packing until the wound is clo sed. Other disadvantages include potential morbidity and mortality associat ed with the shearing forces between the beating heart and the debrided ster nal edges, and the need to paralyze the patient during the period after deb ridement. Methods: Our method of managing sternal infections is based on the triad of prompt surgical debridement, serial quantitative wound cultures, and the u se of the Vacuum Assisted Closure(TM) (VAC) device (KCI International, San Antonio, TX). Following debridement and irrigation, a biopsy of the healthy appearing bone is sent for quantitative culture. If culture results are fa vorable, the wound is then fitted with the VAC(TM) device, which consists o f a non-collapsible, open-cell, polyurethane sponge with embedded vacuum tu bing, a vacuum pump, and transparent adhesive dressing. When systemic signs of infection and quantitative cultures indicate the resolution of the loca l infection, regional muscle flap or primary wound closure is performed. Conclusions: The VAC(TM) serves as a bridge to sternal wound closure and is a safe and effective therapeutic strategy for patients with impaired physi ologic reserve and/or highly contaminated wounds. We feel that it is also r easonable to consider the VAC(TM) as a preventive strategy against right ve ntricular rupture. Furthermore, because the firmness of the vacuum sponge a pparatus acts as an impressive sternal stabilizer, post-debridement extubat ion is possible, reducing the need for prolonged paralysis and mechanical v entilation. This stabilization also allows early postoperative ambulation w ith the VAC(TM) in place. In summary, we believe that the VAC(TM) device of fers an effective means of managing patients with sternal infections.