Delayed Sternal Closure? - page 2

by TX911

4,162 Views | 21 Comments

Does anyone have sort of experience with delayed closure following open chest procedures? I just have a few questions. Is the retractor from surgery still left in place? Is there some sort of chest binder used? Can I get some... Read More


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    I do adults only. Yes they can leave the retractor in the chest, but it's rare. They do leave chests open sometimes, usually if the bleeding was horrible or they had to over fluid resuscitate so the want to prevent tamponade. They will cover the open chest with sterile towels and an IV bag sewed in or just covered with iodaban (it's like brown-orange heavy duty Saran Wrap). It is quite interesting the first time you see the heart beating against your hand. CPR...yes please! Usually done one handed and with less force otherwise the patient is dead! Sedate or paralyze the patient. No turning per doctors orders = skin breakdown. Back to surgery for closure of wound once hemodynamically stable and less swollen status. We also use would vacuum for dehiscence of sternal wounds after debridement.
    Biffbradford likes this.
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    We had a complicated TOF repair (I work in paeds ICU) who returned post op with his chest open. Cardiac surgeons tried to close it on day 3 however returned about three hours later to reopen (wound packed with gauze and covered with tegaderm). The cardiac surgeons ended up needing to splint bub's chest open even further the following day. When I looked over his chest the splint they'd used looked like an ET tube that had been cut down to size. & indeed it was. They'd splinted his chest open with an ET tube and then covered with duoderm.
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    Our pediatric open chests are closed at bedside - thought I'd add that.
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    Quote from marycarney
    Our pediatric open chests are closed at bedside - thought I'd add that.

    ours too.

    Now the next question. Whose seen a SUSPENDED chest? Almost fell over first time I saw that on orientation! (luckily it's rare!)
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    Yes some very critical patients will come out with retractors in place. Seen this in OH peds as well as adults. Depends on what was/is going on with the particular patient. Often a surgical set-up for these patients is next to them, like a cabinet with sterile internal paddles for defibrillation, etc.

    My rule of thumb for any of these situations, even times when certain irrigations were order, "I am not a surgeon or a physician; therefore, I will not touch anything that is directly inside that cavity; b/c I am not covered to do so. Now is certain EDs, some docs may be cool with other people, such as nurses, doing internal message or internal paddle defibrillation; but CT surgeons. . .LOL. No, the are very protective and controlling with their patients. So, it's usually not an issue. Some of them are reticent to allow CT surgical fellows do these things. They worry about outcomes and M&Ms, and the effect anything could have upon the work for which THEY are directly responsible.

    In many places with top-not CT, touching what's inside that cavity directly--it's pretty much a non-issue for direct surgical recovery nurses.

    If I am not sufficiently educated and trained in something, it is beyond my scope of practice. Being careful with maintaining and protecting the boundary lines of practice has allowed me to stay out of court rooms over the decades. I mean you can be called or names or even sued and not have done a darn thing wrong. So for me, I will say it's been a combination of good sense and good luck. Job #1 is the patient, and Job #2 is protecting your practice.


    Also OP, Straight up tets may or may not be simpler; it all depends. Have worked adult and kids open heart surgery, in general, kids by far have their own presentations/combos of defects. I mean, a CABG X 3 often enough is pretty straightforward. But one kids tet will look completely different from another kids tet. You can never know what is going on with any of these kids until you get the best picture of their true anatomy-defect. I have recovered some terribly problematic tets; but they each had their own strange twists. A big part of pediatric heart is that often a few defects are straight up what is in the books--and you learn each defect in order to have some idea, b/c even that is nothing like a typical heart with some occlusions, valvular dysfunctions, VSD 2ndary to infarct, etc. So learn the kiddie defects, but after that, for most kids, I have had to look at each child's individual mapping; b/c very easily no two defects will necessarily look alike, and often they don't.
    TX911 likes this.
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    Quote from marycarney
    Our pediatric open chests are closed at bedside - thought I'd add that.
    That too will depend on what's going on and the particular surgeon's preference.
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    Thanks for all the knowledge everyone. Filed away and looking forward to using it
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    Our kids usually have their chests closed bedside, too. All heart kids have defib etc on the end of their bed and kids with open chests have internal paddles ready to go. We also have a cardiac trolley for emergent CT surgery on the unit however the CT theatres staff bring several trolleys of sterile equipment, too
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    Quote from TX911
    Yeah, I got to write a paper on ToF which I know is one of the simpler "plumbing issues" that a kid can have. I wish I had the patience for children, it all seems pretty interesting
    TOF wasn't always considered a "simple plumbing issue." I was born with it in 1954 and every day Ithank Drs Blalock and Tussig ( and God ) for the life saving procedure they developed.
    Psychtrish39 and Poopsiebublnose like this.
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    Quote from CapeCodMermaid
    TOF wasn't always considered a "simple plumbing issue." I was born with it in 1954 and every day Ithank Drs Blalock and Tussig ( and God ) for the life saving procedure they developed.
    That is amazing!

    I participated in the clinical trials for prostaglandinE1 (and am just a year behind you!) and remember when the only treatment for a hypoplastic left was to wrap the baby in a blanket and let parents hold hem. Just the progress I've seen in my career is absolutely astounding.


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