Negative pressure wound therapy with instillation on sternal wound: is it really worrisome?

Negative pressure wound therapy is being used for treatment of sternal wound infections for a long time [1]. It reduces the reinfection rate, the overall hospital stay, and mortality [2]. Negative pressure wound therapy with instillation (NPWTi) is also in use for a couple of years (for different parts of the body) [3]. NPWTi has been proven to have better results than the standard NPWT [4]. There is reluctance in the use of NPWTi on sternal wounds, both by the manufacturer and the surgeons. Manufacturers recommend this as off-label use for sternal wounds. The reasons sighted are (1) risk of bleeding and (2) possible leakage of the fluid in the thoracic cavity [5]. For the same reasons, there are hardly any publications on the use of NPWTi on sternal wounds.

We have been using NPWTi over sternal wounds for over a year now. Our method of managing sternal wound is as follows:

1. Preoperative contrast computerized tomography (CT) scan to localize and access the depth of the wound.

2. The cavity is laid open all around in the operating room, so that there is no dead space and all the dead bone, cartilages, and the exposed wires are removed.

3. Normal dressing is done at the time of surgery.

4. Next-day NPWTi is applied and dressings are changed every 72 h. Normal saline is the instillation fluid used. The soak time is 10 min every 3 h. Pressure used is 125 mmHg.

5. Final reconstruction is done on optimization of wound.

The advantages of applying NPWTi on the next day are as follows: (1) confirmation of hemostasis and (2) any leak in the thoracic cavity during surgery would have presented itself clinically by this time. This protocol takes care of both the reasons for reluctance of use of NPWTi on sternal wounds. Once the wound is optimized, the final reconstruction is done depending upon the requirement of the depth and location of the defect- secondary suturing, transfer of pectoralis major flap and omental flap.

In the last 1 year, we have managed 32 cases of sternal wound infection with the abovementioned protocol and having good results (Figs. 1 and 2). Appropriate antibiotics, according to cultures, and supportive care were given. There was better control of wound infection and early granulation tissue formation in patients treated with NPWTi. The size of the wound also reduces, leading to simpler reconstruction. There were no complications associated with the NPWTi over sternal wounds, as was feared before. It also stabilizes the thoracic cage and improves hemodynamics and pulmonary function. We recommend NPWTi as an effective method to optimize the sternal wounds for definitive closure.

Fig. 1.

Sternal wound with infection

Fig. 2.

Sternal wound having healthy granulations after 2 sittings of NPWTi