Deep Sternal Wound Infection Following OPCAB: Delving Deeper into the Predisposition!

Dear Editor,

Predisposition to deep sternal wound infection (DSWI) following off-pump coronary artery bypass (OPCAB) grafting surgery classifies as an area of particular research interest. Given the fact that a sound evaluation of the risk factors for DSWI mandates a comprehensive approach, we wish to highlight a few important concerns pertaining to the Enginoev et al.[¹] study recently published in the Brazilian Journal of Cardiovascular Surgery.

Interestingly, the index analysis does not outline diabetes mellitus as a preoperative risk factor for DSWI (30.2% in DSWI and 26.2% in non DSWI group, P=0.5)[¹] albeit the lack of data on perioperative glycaemic control deserves attention. Appropriate to the context, the Mayo Clinic research group delineate as high as 30% increase in adverse outcomes, including infective complications for every 20 mg/dL rise in mean intraoperative glucose levels[²]. Moreover, specific literature linking glycaemic fluctuations with infective complications continues to accumulate over the past decade[³,⁴]. Järvelä et al.[³] found a significantly heightened rate of postoperative infections in their cardiac surgical cohort manifesting repeated hyperglycaemia (39.7% incidence) as opposed to normoglycaemic or those with single hyperglycaemic episode (12.1% and 8.2%, respectively, P=0.019).

Furnary et al.[⁴] reveal the independent DSWI predictive ability of post-cardiac surgery hyperglycaemia in the Portland Diabetic Project, wherein the subset with 48-hour mean blood glucose levels >200 mg/dL demonstrated a 2.2 times elevated risk of DSWI. Concomitantly, there is convincing evidence to suggest that perioperative glucose control with insulin infusion management protocols considerably attenuate the DSWI incidence[⁴-⁶]. Alongside the absence of perioperative glucose data, Enginoev et al.[¹] fail to describe the glucose management regime employed in their retrospective study[¹].

In addition, the authors could have elaborated whether or not any of the study participants were receiving preoperative corticosteroids[¹,⁷]. Herein, a comparative account of the preoperative leucocytic counts of the DSWI and non-DSWI groups could also have added incremental value[¹,⁸]. As much as we laud the endeavours of Enginoev et al.[¹], the points of perioperative relevance elucidated by us and the authors’ explanation would probably assist readers to comprehend this dynamic research area in a more holistic manner.

REFERENCES

• ¹
  Enginoev S, Rad AA, Ekimov S, Kondrat’ev D, Magomedov G, et al. Risk Factors for Deep Sternal Wound Infection after Off-Pump Coronary Artery Bypass Grafting: a Case-Control Study [ahead of print] Braz J Cardiovasc Surg 2021 DOI: 10.21470/1678-9741-2020-0444
  » https://doi.org/10.21470/1678-9741-2020-0444
• ²
  Gandhi GY, Nuttall GA, Abel MD, Mullany CJ, Schaff HV, et al. Intraoperative hyperglycemia and perioperative outcomes in cardiac surgery patients. Mayo Clin Proc 2005; 80: 862-866
• ³
  Järvelä KM, Khan NK, Loisa EL, Sutinen JA, Laurikka JO, Khan JA. Hyperglycemic Episodes Are Associated With Postoperative Infections After Cardiac Surgery. Scand J Surg 2018;107:138-144
• ⁴
  Furnary AP, Wu Y, Bookin SO. Effect of hyperglycemia and continuous intravenous insulin infusions on outcomes of cardiac surgical procedures: the Portland Diabetic Project. Endocr Pract 2004;10 Suppl 2:21-33
• ⁵
  Kramer R, Groom R, Weldner D, Gallant P, Heyl B, et al. Glycemic control and reduction of deep sternal wound infection rates: a multidisciplinary approach. Arch Surg 2008; 143:451-456
• ⁶
  Cotogni P, Barbero C, Rinaldi M. Deep sternal wound infection after cardiac surgery: Evidences and controversies. World J Crit Care Med 2015; 4:265-273
• ⁷
  Magoon R, Choudhury A, Sahoo S, Malik V. Steroids for adult cardiac surgery: The debate echoes on. J Anaesthesiol Clin Pharmacol 2019; 35:560-562
• ⁸
  Dey S, Kashav R, Kohli JK, Magoon, R., ItiShri, et al. Systemic Immune-Inflammation Index Predicts Poor Outcome After Elective Off-Pump CABG: A Retrospective, Single-Center Study. J Cardiothorac Vasc Anesth 2021; 35:2397-2404

Publication Dates

• Publication in this collection
  13 June 2022
• Date of issue
  2023