Open chest
Negative impact on haemodynamics and respiratory parameters after median sternotomy was first described in 1975, with emphasis on “compression of the heart and producing a cardiac tamponade”.
Indications for delayed sterna closure and open chest:
- ‘Large’ heart syndrome
- Haemodynamic instability after temporal sternal approximation
- Low cardiac output post CPB
- ECMO or VAD cannulation
- Severe arrhythmia
- Severe bleeding complications
- Severe contamination requiring frequent reexploration
Potential complications due to delayed sterna closure with increased rate of infection, longer PICU stay.
Effects of sternal closure:
- Increase in intrathoracic pressure
- Decrease in total lung compliance
- Decrease in systolic/mean BP
- Decrease in SV, leading to a decrease in CO
- Decrease in cerebral oxygenation
Indication for chest closure:
- When the patient is ready!
- Haemodynamically stable (age appropriate MAP with minimal inotropic support, stable CVP, LA, PAP, stable heart rat and rhythym, appropriate CRT)
- Respiratory stable (acceptable ventilation settings, FiO2 requirements)
- Stable fluid status (oedema, fluid balance over last 12/24 hrs)
Preparation for sterna closure in PICU:
- Â Sterile surgical field (gown, mask)
- Standard monitoring (ECG, invasive BP, CVP (LA, PAP, pacemaker, SaO2, etCO2, ventilation parameters)
- Standard setup: standby for inotropic support with adrenaline or dobutamine (noradrenaline infusion), adrenaline 10 mcg/kg bolus, fluid resuscitation with NaCl 0.9%, human albumin and PRBC (minimum 2 units crossmatched), good floating fluid line and separate inotropic line, accessible outside the surgical field
- Cephazolin 25-50 mg/kg IV minimum 30 mins preceding the surgical procedure
- Fentanyl 5 mcg/kg IV bolus and midazolam 100 mcg/kg IV Bolus plus vecuronium 0.1 mg/kg IV bolus to provide adaequate anaesthesia and muscle relaxation
Observe during and post sternal closure:Â haemodynamic/respiratory/fluid and metabolic stability
References:
[1] J Thorac Cardiovasc Surg. 2010 Apr;139(4):894-900: Horvath et al: Cerebral and somatic oxygen saturation decrease after delayed sternal closure in children after cardiac surgery
[2] Cardiol Young. 2009 Dec;19(6):573-9. Vojtovic P et al: Haemodynamic changes due to delayed sternal closure in newborns after surgery for congenital cardiac malformations
[3] J Thorac Cardiovasc Surg. 1997 May;113(5):886-93: Tabbutt et al: Delayed sternal closure after cardiac operations in a pediatric population
 All Marc’s PICU cardiology FOAM can be found on PICU Doctor and can be downloaded as a handy app for free on iPhone or Android. A list of contributors can be seen here.
