Nursing Care of the Patient With an Open Sternum

Q What is involved in the general nursing care of the patient with an open sternum?A Brandi L. Holcomb, DNP, APRN, AGACNP-BC, CCRN, replies:In caring for a patient with an open chest after cardiotomy, the nurse must consider the various perioperative conditions that may require the sternum to be kept open. The literature contains few evidence-based articles or guidelines specifically addressing nursing care of the patient with an open chest after cardiotomy. However, more evidence-based guidance is available for the cardiac transplant and pediatric surgical populations.1 It is reasonable to incorporate these recommended practices into the care of the adult cardiac surgical patient with an open chest.Open-chest management and delayed sternal closure are implemented after 1% to 4% of surgical procedures involving cardiotomy in the adult population and more frequently in the pediatric population.2 In order to care for these patients effectively, the intensive care unit (ICU) nurse must have comprehensive knowledge of the anatomical structures in the thoracic cavity, especially the heart, and understand the indications for an open sternum after cardiac surgery.The attending surgeon makes the decision of whether to maintain an open sternum after any type of cardiotomy, primarily on the basis of the patient’s hemodynamic stability and overall clinical condition. Open-chest management after cardiac surgery may be indicated as part of treatment for severely impaired heart function. In addition, open-chest management and delayed sternal closure have been found to be helpful in patients with uncontrollable hemorrhage, intractable arrhythmias, reperfusion myocardial edema, or the need for a left ventricular assist device or a transthoracic intra-aortic balloon pump with central cannulation after cardiac surgery.3Low cardiac output is a primary concern following cardiac surgery. Patients who do not respond to fluids and intravenous inotropic and vasoactive drugs often require mechanical assistance with an intra-aortic balloon pump or a left ventricular assist device, extracorporeal membrane oxygenation (ECMO), or nitric oxide administration. Closure of the sternal wound may further reduce cardiac function, so open-chest management with delayed sternal closure may be beneficial for the patient with an already weakened heart.4 Open-chest management provides an edematous central circulatory system with additional space after cardiopulmonary bypass, reducing the chances of detrimental tamponade on chest closure.The thoracic cavity is subdivided into 3 compartments: the mediastinum and 2 pleural cavities, 1 on each side. The mediastinum is the median compartment and contains the heart and great vessels, whereas the pleural cavities house the lungs. The thoracic cage protects the lungs and the heart and provides attachments for the thorax muscles, upper extremities, back, and abdomen.2 The thoracic cage connects superiorly with the neck via the thoracic outlet and inferiorly is separated from the abdomen from the respiratory diaphragm.Maintaining an open chest after cardiotomy has advantages and disadvantages. Advantages include allowing surgeon access for control of bleeding, evacuation of mediastinal clots or hematoma, access to central cannulation sites, and initiation of internal cardiac massage. In addition, thoracic compartment syndrome due to myocardial edema caused by massive volume resuscitation or blood product transfusion may be mitigated.3 Disadvantages include an increased risk of infection due to the open nature of the wound and the need for frequent irrigation and dressing changes, as well as possible injury to the cardiac structure.The risk of mortality from sternal wound infection in patients with open-chest management is 10%, which increases to 14% if the infection progresses to mediastinitis.3 The risk of sternal wound infection in patients with delayed sternal closure is 50% greater than that in patients with primary chest closure. Surgical techniques, dressing modalities, and prophylactic antibiotic regimens may affect infection risk in patients with delayed sternal closure.3 Ongoing nursing care must include consideration of barriers to patient positioning, assessment of wound dressing integrity, and prompt recognition of increased vasopressor and ventilatory requirements.Nurses caring for these patients must be familiar with the various combinations of treatments, particular institutional policies, and general best practices. Effective assessment and documentation of wound dressings are crucial for the provision of high-quality care.5 Traditional open-chest management consists of packing the mediastinum with sterile gauze sponges, inserting a sternal bridge, suturing or stapling a synthetic membrane to skin edges, and applying a sealing adhesive dressing on top. A widely used technique is to prop open the sternal bone with syringes and cover the wound with an Esmarch patch followed by an iodine-impregnated incision drape.Recent randomized clinical trials have yielded evidence supporting an association between the application of a negative-pressure dressing system to an open sternum and a reduced risk of sternal wound infection.6 Nurses should be trained to recognize and report signs of increased bleeding or drainage to wound dressings or collection receptacles and identify compromised integrity of the surgical site or dressing. Sterile surgical supplies and equipment such as towels, dressings, antiseptic solutions, and appropriate sterile personal protective equipment should always be readily available to staff members.Antibiotic use in patients with delayed sternal closure is at the physician’s discretion and based on best practices and ranges from standard surgical prophylaxis for the first 48 hours to the use of broad-spectrum antibiotics for several days after sternal closure. Timely administration of intravenous antibiotics and other ordered therapies is a key component of nursing care delivery.Great care should be taken in patient positioning, with special attention paid to position changes, to ensure stability of the surgical site. Movements should be gradual, calculated, and effectively communicated among members of the care team. During the COVID-19 pandemic, ICU nurses became creative with the available personnel and resources for prone positioning of patients receiving mechanical ventilation.7 Considerable evidence-based research supported team-based positioning during the pandemic, specifically for patients requiring ECMO.8,9 Development of a nurse-led, unit-based “turn or rotation team” for the open-chest surgical population encourages teamwork and ensures patient safety, preventing iatrogenic injury.Regardless of wound dressing strategy, great care must be taken to ensure that the heart, particularly the right ventricle, is not injured by the sharp edges of the sternum or by the bridge used to separate sternal edges. The tissue of the right ventricle is thinner than that of the left ventricle because of differing pressure variants between the cardiac chambers, and injury to it from sternal edges can be serious and even fatal. The patient is especially vulnerable to such injury during rapid movement or positioning for hygienic purposes or abrupt position changes to alleviate pressure on bony prominences. Adjustments in patient position during patient care procedures and transportation to and from the operating suite should be minimal. When position changes are necessary, close attention should be given to the patient’s overall hemodynamic condition and level of sedation.A high priority for open-chest patients is maintaining hemodynamic and cardiac rhythm stability as well as correcting coagulopathies. As mentioned previously, hemodynamic stability is likely to be compromised in these patients, and they may require supportive modalities, including intravenous inotropic and vasoconstrictive medications, large-bore central venous access, arterial catheters, balloon counterpulsation, ECMO, or mechanical circulatory support devices. The critical care nurses caring for the patient should have expertise in managing and titrating such therapies and be able to recognize and report clinical deterioration.Critically ill patients often require mechanical ventilation, sedation, and paralytic agents to ensure safe gas exchange. Because of their thoracic and hemodynamic instability, open-chest patients often need additional ventilatory support along with a variety of ventilatory delivery mechanisms. The choices of ventilator mode and settings depend on the patient’s underlying condition. Although in these cases mechanical ventilatory support can be lifesaving as well as life-sustaining, barotraumatic complications can occur if such support is incorrectly managed. The goal is always to minimize iatrogenic injury; however, avoiding such complications is not always possible. Involvement of an interprofessional team including cardiothoracic surgeons, anesthesiologists, critical care physicians, advanced practice providers, nurses, pharmacy personnel, and respiratory therapists is key in the effective and efficient provision of clinical care as well as prompt recognition and management of complications as they arise.To provide safe care for patients requiring open-chest management, critical care nurses must have comprehensive knowledge of the anatomical components, hemodynamic response, and all elements of clinical nursing care. A solid understanding of hemodynamics is essential to ensure accurate assessment and rapid intervention should there be subtle or unexpected changes in patient status. Nurses should understand the correct application and placement of open-chest dressings and be able to promptly recognize compromised dressing integrity. Protecting the patient from infection with timely administration of antibiotics and from injury through nurse-led repositioning strategies are also vital elements of nursing care. It is crucial to involve a collaborative, and communicative interprofessional team approach and ensure everyone is comfortable with the delivery of the plan of care and clinical management.