Delayed Sternal Closure?

Editorial Team / Admin · Feb 25, 2013

Not sure how other facilities do it, but we most certainly do not leave the retractor in there (we need it for the next day, plus it would equate to a wrong count- sentinel event report required). What we do is protect the edges of the incision (material varies from surgeon to surgeon but must be x-ray detectable), splint the sternum open, and cover it with x-ray detectable towels and a sterile, impervious adhesive drape that fully seals the incision from the outside world. Between the chest tubes to suction and the full seal, it's almost like a VAC dressing without actually being a VAC dressing. Signs are posted above the bed that state no compressions. We only do this for patients who become hemodynamically unstable when we try to close their chest and we can't in any way get them stabilized without reopening (mostly our trauma patients).

ndsrn · Feb 25, 2013

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 knowledge?

That last patient I had with delayed sternal closing did not have the retractor in place or a binder. There was an ioban dressing with another dry dressing on top of that. The patient ended up tamponading, but was asymptomatic because the ioban had some give to it. The dressing started expanding a little and the patient was brought back to the OR to fix the bleed. The patient ended up with a pressure ulcer because turning was an issue, so a specialty bed is something to consider. Other than the bleed, my experience was pretty uneventful and the management was very similar to a normal post open heart. sorry I do not have much else to offer.

TX911 · Feb 25, 2013

Adhesive drape? Is there a (manufacturer) name for these or are they just something that's put together? Someone has mentioned something called an I-Band? Have you ever heard of this? Thanks for the response

edit* I bet the "I-Band" is actually the ioban that ndsrn just mentioned. Thanks!

meanmaryjean, DNP, RN · Feb 25, 2013

This is common in the PICU esp. with hypoplasic left heart initial Norwood procedure. The only thing covering the heart is an occlusive transparent dressing. It FREAKS the parents out, so we cover it with a cloth diaper while they are at bedside. It is not uncommon to have a chest left open for 2-4 days.

We also sometimes have open chests on our ECMO kids who are centrally cannulated.

TX911 · Feb 25, 2013

Lol, I can definitely see how walking in and seeing your kid's chest open after surgery might be a little off-putting. Also, that Norwood procedure is pretty wild. Well, all three (Glenn, Fontan) are actually, my goodness....

meanmaryjean, DNP, RN · Feb 25, 2013

Lol, I can definitely see how walking in and seeing your kid's chest open after surgery might be a little off-putting. Also, that Norwood procedure is pretty wild. Well, all three (Glenn, Fontan) are actually, my goodness....

Just another reason why PICU rocks! (PLUS, you need a background in plumbing to figure out the many hundreds of ways a baby can be born with a jacked up heart!)

TX911 · Feb 25, 2013

PLUS, you need a background in plumbing to figure out the many hundreds of ways a baby can be born with a jacked up heart!)

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

meanmaryjean, DNP, RN · Feb 25, 2013

I've done everything from gero-psych, to adult CCU to NICU - and this job is BY FAR the most clinically interesting.

The great thing about kids is this: NONE of them WANT to be sick or takes any enjoyment in the 'sick role'.

umcRN, BSN, RN · Feb 25, 2013

I also work in a peds cardiac ICU so we have many open chests, and usually if the kids code after surgery (and their chest is closed) the surgeons will come open it right at the bedside to put them on ecmo.

As far as the "no compressions" rule that someone mentioned previously we do not have that...well we don't do compressions per say but cardiac massage. I can distinctly remember asking when I was on orientation what to do if my open chest patient coded and my instructor told us "you do compressions, preferably with gloves!". In other words some circulation is better than no circulation, you better believe it though that the nurse is hitting that code button for a doc because most of us would rather a doc do cardiac massage, and of course we're all holding our breath for the surgeons to get there because really, that's their territory!

dah doh, BSN, RN · Feb 25, 2013

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.

imaginations · Feb 25, 2013

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.