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Multiple opportunities exist for infection risk neutralization in coronary bypass patients.Skin and nasopharyngeal gram positive organisms are the leading cause of the most threatening complication, deep sternal wound infection or mediastinitis. Skin preparation with topical antiseptics, clipping rather than shaving the skin, avoidance of hair removal, reduction in traffic, laminar flow ventilation, shorter operations, minimal electrocautery, avoidance of bone wax, use of double gloving barrier techniques for the operating team, and routine use of easily constructed pleuropericardial flap, have all shown to be of value in reducing postoperative infection.
Preoperative antibiotic administration reduces the risk of postoperative infection five fold. Prophylactic antimicrobial efficacy is dependent on adequate drug tissue levels before microbial exposure. The cephalosporin class of antimicrobials is currently the agent of choice for prophylaxis of infection for coronary operation.
Strict control of blood glucose levels two hundred mg/dL by continuous intravenous infusion of insulin has been shown to significantly reduce the incidence of sternal infection in diabetic patients. To further avoid mediastinitis, meticulous aseptic technique, and minimal perfusion times, use of one IMA, avoidance of unnecessary electrocautery, appropriate use of perioperative antibiotics , and strict control of blood glucose levels during and after operation are suggested. If preventive strategies fail, prompt recognition of deep sternal wound infection or mediastinitis is critical. Aggressive surgical debridement and early vascularizied muscle flap coverage are keys to reducing the cost, LOS, and death. Treatment by wound exploration, sternal rewriting and drainage failed in 88 % of patients compared with high success in patients treated initially with muscle flap closure.
Pre-hospitalization autologous blood donation can be effective. If a patient has no exclusionary criteria heart failure, unstable angina left main disease or symptoms on the proposed day of donation and can give 3 units of blood over 30 days before the operation, the risk of homologous transfusion is significantly lowered in a non-preadmission donor control group. An alternative or additional method of pre CPB blood donation is the removal of blood from the patient in the OR immediately before CPB. This blood is then set aside not exposed to the CPB circuitry, and then reinfused into the patient after the patient is disconnected from CPB.
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