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Should additional antibiotics or an iodine washout be given to all patients who suffer an emergency re-sternotomy on the cardiothoracic intensive care unit?

Three Part Question

In [patients suffering emergency re-sternotomy after cardiac surgery on the ICU] do [Antibiotics or iodine washouts] results in a lower incidence of [sternal wound infections]?

Clinical Scenario

A patient two hours after a double valve and grafts suddenly goes into ventricular fibrillation as you are passing by his bed in the intensive care unit. Three rapid attempts at defibrillation fail and the nurse who was looking after him said that he had been very unstable with a high CVP prior to the arrest. You elect to perform an emergency re-sternotomy, which relieves a tamponade and the heart spontaneously cardioverts into sinus rhythm. A vein proximal anastomosis was bleeding and you repair this and you are eventually happy to re-close the chest. The anaesthetist asks you if you want any more antibiotics and the scrub nurse asks you if you want a betadine washout. You do this as you are not sure how sterile one of your scrubbed colleagues were, but you are not sure if this is necessary.

Search Strategy

Medline 1950–Oct 2007 using the OVID interface.
EMBASE 1980–Oct 2007 using the OVID interface.
Medline:[open OR internal OR resuscitative OR open] AND [ OR exp Cardiopulmonary resuscitation/or]

Embase:[open OR internal OR resuscitative OR open] AND [ OR exp resuscitation/or]

The Cochrane database for systematic reviews and central register of controlled trials was searched using the term ‘open chest’, or ‘internal cardiac’ or CPR. NICE, SIGN, STS, AHA and ESC guidelines were searched.

Search Outcome

Two hundred and sixty-three papers were found in Medline, 256 in EMBASE and eight articles in the Cochrane library. Of these nine were felt to be relevant

Relevant Paper(s)

Author, date and country Patient group Study type (level of evidence) Outcomes Key results Study Weaknesses
Engleman et al,
Practice Guideline from the Society of Thoracic Surgery (No recommendations directly for patients who suffer a cardiac arrest requiring emergency re-sternotomy)Guideline (level 1, excellent)Guideline recommendationPrimary prophylactic antibiotic for elective cardiac surgery is a first generation cephalosporin which is usually cefazolin. (Class IIA) Mupirocin is recommended as a routine prophylactic measure

For patients who are considered B-lactam or penicillin allergic, vancomycin is recommended as the primary prophylactic antibiotic with additional gram-negative coverage
High risk patients For patients at high risk of Staphylococcal infection, vancomycin may be reasonable. (Class IIB, level of evidence C)
SIGN Publication,
Guideline from the Scottish Intercollegiate Guidelines NetworkGuideline (level 1, excellent)RecommendationAntibiotics are recommended for all patients undergoing cardiac surgery (Grade B recommendation based on level II evidence)No specific antibiotics are recommended

No specific recommendations for patients requiring emergency re-sternotomy
Kriaras et al,
All patients (12) who underwent open chest CPR on the day of surgery were included in this study

Dates:Dec 1993–Mar 1995

10% iodine spread around the peri-sternotomy skin.

Vancomycin 500 mg iv given peri-procedure. Mediastinal iodine and then saline washout at the end of the procedure
Case series (level 5,unsatisfactory)Cardiac arrest on first postoperative day in ICU12/2140 patients (0.6%)The hypothesis that their protocol protects against infection is not sufficiently supported by the evidence presented here in 10 patients

Abstract only, full paper not published
Arrest survival 10/12 patients (83%)
Survival to discharge8/12 patients (67%)
Wound infectionsNone
McKowen et al,
2 year retrospective audit of 88 resuscitations in 64 patients

Dates: Jul, 1982-May 1984

Patients group: Patients undergoing open resuscitation through a midline sternotomy

Single centre, Pittsburgh USA

Povodine-Iodine preparation of the skin and sterile dressing pack.IV antibiotics are given simultaneously. Bacitracin washout prior to closure also a seperate chest reopening set is used

2 groups, Group 1: primary closure, (n=31). Group 2: secondary closure (n=18)
Retrospective cohort study (level 4, fair)Wound complications in 49 survivorsGroup 1 (primary closure) 2 wound infections

Group 2 (secondary closure) , No wound infections. Total 4% wound infection rate.
Only 2 patients actually had a chest wound infection. The antibiotic given was not specified in this paper.
Wound organismPatient 1: Staph epidermidis. Patient 2: Escherichia coli
Cause of chest reopeningCardiac arrest 15%, pernicious ventricular arrhythmia 14%, shock 30%, tamponade 35%, exsanguinating haemorrhage 7%
Arrest survival49/64(77%)
Survival to discharge60%
Charalambos et al,
9 year retrospective study of 240 patients


Patient group: Patients who had chest reopening for bleeding or tamponade on the ICU. Patients who arrested were excluded. Majority reopened in the ICU rather than theatres

Chest prepared using provodine-iodine antibiotic was usually Flucloxacillin or equivalent antibiotic, duration varied.

Single centre: Manchester Royal Infirmary, UK
Retrospective cohort study (level 4, fair)Complications7 sternal wound infections (2.9%)This paper considered all chest re-openings in the ICU rather than in theatres but specifically excluded patients who had a cardiac arrest
Cause of reopening20/240 (86%) bleeding. 22/240 (9%) tamponade. 11/240 (5%) both.
Cause of reopening125/240 (55%) focal bleeding. 74/240 (33%) diffuse bleeding. 11/240 (5%) both. 25/240 (12%) packed and not closed. 13/240 (10%) further chest reopening
Reopening survival224/240 (84%) survived
Incidence requiring reopening240 patients (3.4%)
Anthi et al,
30 month audit of 29 patients who suffered an unexpected cardiac arrest

Dates: Dec 1993-Mar 1996

Patient group: Patients in the ICU suffering a cardiac arrest within 24 h of surgery

Protocol: CPR and if no restoration of output after 3-5 min then proceed to chest reopening

Betadine to skin. No mention of antibiotics

Single centre: Onassis Cardiac Surgery Centre, Athens
Prospective cohort study (level 3, good)Cause of arrest13/29 (45%) VF/VT

11/29 (38%) Brady arrhythmia

5/29 (17%) EMD
No antibiotics or iodine washout mentioned in the paper
Interventions during arrest, or cause of arrest14/29 (48%) MI

5/29 (17%) Tamponade

3/29 (10%) Graft malfunction

7/29 (24%) Unknown
Arrest survivalClosed chest CPR successful in 13/29 (45%)

14/16 having open chest. CPR recovered an output
Out of hospital survival23/29 (79%) survived to discharge
Resuscitation not in ICUExcluded in this study
Incidence requiring CPR29/3982 (0.7%) required CPR in the first 24 h
Wound infectionsNone
Fairman et al,
42 month retrospective audit of 64 patients who had 74 re-thoracotomies

Dates: Jan 1977- July 1980

Patient group: Patients who had an emergency re-thoracotomy after cardiac surgery for inadequate circulation

University of Pennsylvania

Iodine skin preparation, and sterile towel drapes. Re-irrigated prior to closure

3 days of a cephalosporin and aminoglycoside afterwards
Retrospective cohort study (level 4, good)Cause of arrest13/64 arrhythmia

15/64 massive bleeding

6/64 suspected tamponade

10/64 unexplained

20/64 progressive deterioration
5% medistinal wound infection rate (2 patients)

If the first year surgical resident did the thoracotomy, survival was 29%. Thoracic fellow survival was 41%

Of the 20 patients with progressive deterioration, 7 had initially resuscitated and 2 had a tamponade

Fairman call for training of nurses in advance of emergency chest reopening
Arrest survival37 of 74 (50%) re-thoracotomies
Out of hospital survival19/64 discharged (30%)

Best survival with tamponade or bleeding. No survivors in the progressive deterioration group
Incidence requiring CPR64/2112 (3%) had emergency re-thoractomy in ICU (not necessarily arrested)
Longest time to reopening resulting in survival to discharge12 h, 12-24 h - 4, 24-48 h - 7, more than 2 days - 10 patients. Survival by time not documented
El-Banayosy et al,
2 year retrospective audit of 113 patients

Dates: Jan 1993-Dec 1994

Patient group: All patients with circulatory collapse requiring CPR within 7 days of surgery

Adults but transplants and paediatric patients excluded

Single centre:North Rhine heart Centre, Bad Oeynhausen, Germany

Protocol: After 20-30 min of CPR IABP performed. If unsuccessful and operation <48 h - chest reopening. Unsuccessful and operation >48 h - Fem Fem Bypass
Retrospective cohort study (level 4, good)Complications in the 79 survivors10 sepsis (8.9%)

11 Renal failure (14%)

10 GI failure (13%)

8 Neurologic (10%)

2 Limb ischaemia

1 Pneumothorax
Duration of CPR 2 to 230 min (mean 30 min)

No mention of antibiotic protocols usage mentioned in the paper
Cause of arrest58/113 (51%) VF

22/113 (19.5%) EMD

6/113 (5.3%) Asystole
Interventions during arrest, or cause of arrest47 MI

9 bleeding

4 heart failure

5 patients had Fem Fem bypass - all died

49/113 had IABP (24-49% survived)

24/113 had resternotomy (13 or 54% survived)

6 patients had a VAD (7 of 47% survived)
Raman et al,
39 patients who arrested within 72 h of a cardiac surgical operation between 1984 and 1988.

25 CABG, 2 transplants, 12 valves, 1 aneurysmectomy

Divided into 2 groups retrospectively

Group A (24 patients): Open cardiac massage and resternotomy

Group B (15 patients): External cardiac massage only

Mean time to reopening 5.6±2 min. After successful chest reopening patient always taken to theatre for closure after povodine-iodine washout. Periresusitative antibiotics were 'recommended' for 48 h
Retrospective cohort study (level 4, good)Cause of arrestGroup A (after resternotomy)

Tamponade 5 (21%)

Bleeding 8 (33%)

Dissection 1

Graft thrombosis 1

Ruptured ventricle 1

RV failure 1

Arrhythmia 1

Group B (autopsy)
Of note no damage to the heart was noted from any external cardiac compression

No sternal wound infection

They provided a protocol indicating emergency re-sternotomy after 5 min of unsuccessful resuscitation. Reopening by a cardiac surgeon, return to theatre for closure, IV antibiotics, povodine-iodine washout
Interventions during arrest, or cause of arrestGroup A

Evacuation of clot 4

Regraft or repair 7 (29%)

CPB 7 (29%)



Pacing 5
Arrest survivalGroup A 21/24 (87%)

Group B 5/15 (33%)
Infective complicationsNo wound infections reported


In 2007, The Society of Thoracic Surgeons published a guideline on antibiotic prophylaxis for elective cardiac surgery [Engleman]. They recommend that a first generation cephalosporin (usually cefazolin) should be the antibiotic of choice for elective cardiac surgery with the addition of vancomycin for patients with increased risk of Staphylococcal infection. Mupirocin ointment is recommended as an additional routine prophylactic measure. The SIGN guidelines recommend antibiotic prophylaxis for patients undergoing cardiac surgery. However, no specific antibiotics were recommended

In these two guidelines some recommendations for high-risk patients are given but neither address emergency re-sternotomy in patients who have recently received these prophylactic antibiotics and may not necessarily have had a sterile reopening.

Kriaras et al. published the only paper on patients after cardiac surgery who had open chest CPR on the day of surgery specifically in order to look at the issue of antimicrobial protection. Twelve patients had 10% iodine spread around the peri-sternotomy skin and vancomycin 500 mg intravenously was given peri-procedure. Mediastinal iodine and then saline washout were given at the end of the procedure. There were no wound infections, and they concluded that this protocol might be a useful intervention in emergency situations.

McKowen et al. reported the outcomes from resuscitation of 64 cardiac surgical patients after emergency re-sternotomy. Their practice was to use povodine-iodine preparation of the skin. Intravenous antibiotics were given simultaneously and bacitracin washout prior to closure. Only 2 out of 49 patients had a wound infection after this (4%).

Charalambos et al. conducted a study on patients who had chest reopening for bleeding or tamponade on the intensive care unit. Patients who arrested were excluded. The sternum was prepared using povodine-iodine solution and prophylactic antibiotic was usually flucloxacillin or an equivalent antibiotic. There was a variation in the duration of antibiotic administered. The incidence of sternal wound infection was 3%.

Anthi et al. reported the outcomes of 16 emergency chest reopenings after a cardiac arrest. They only reported that betadine was applied to the skin and full sterile technique was used. No patients suffered a wound nfection.

Fairman and Edmunds reported 64 patients who had an emergency re-sternotomy after cardiac surgery for inadequate circulation. These patients had iodine skin preparation and sterile towel drapes. Re-irrigation was performed prior to closure. Following that, patients had three days of a cephalosporin and aminoglycoside. Wound infection rate was 5% in survivors.

El Banyosy et al. reported the outcomes of 113 patients who arrested within 7 days of cardiac surgery . They found that 7 of the 79 surviving patients had at least one episode of sepsis after the resuscitation (9%). No mention of antibiotic use was given

Ramen et al. reported the outcomes of 39 patients who arrested after cardiac surgery in 1989. Twenty-one patients had an emergency re-sternotomy with povodine-iodine skin preparation, aseptic reopening on the intensive care unit and perioperative antibiotics for 48 h if successful. In addition, if successful the patient was returned to theatre for povodine-iodine washout and closure.

Of note a few of these papers documented ‘full-aseptic technique’ but no more detail than this was given. Thus, we would propose that a gown and gloves with full patient draping would constitute ‘full-asepsis’ in this setting. We also propose that it is not necessary to wash your hands prior to putting the gown and gloves on due to the difficulty of putting gloves on with wet hands and the necessity for rapid emergency re-sternotomy.

Clinical Bottom Line

For patients who require an emergency re-sternotomy on the intensive care unit, the incidence of sternal wound infection or sepsis after this emergency treatment is around 5%. We found only seven papers that documented the incidence of infection after emergency re-sternotomy. Of these seven papers five documented that they routinely gave additional intravenous antibiotics and an iodine washout. The other two papers did not report whether this was done. We conclude that even though the incidence of subsequent infection is low in the cardiac arrest situation, full aseptic technique including gown and gloves might be regarded as best practice. It is common practice also to give additional antibiotics and a povodine-iodine washout although we could identify no studies other than uncontrolled cohort studies in support of this.


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