Are chest compressions safe for the patient reconstructed with sternal plates? Evaluating the safety of cardiopulmonary resuscitation using a human cadaveric model
Douglas R McKay
0
3
Hosam F Fawzy
2
Kathryn M McKay
1
Romy Nitsch
5
James L Mahoney
4
0
Department of Surgery, Queen's University
,
Kingston, Ontario
,
Canada
1
Oceanworks International
,
Burnaby, British Columbia
,
Canada
2
Department of Cardiac Surgery, University of Toronto
,
Toronto, Ontario
,
Canada
3
Department of Surgery, Queen's University
,
Kingston, Ontario
,
Canada
4
Department of Plastic Surgery, University of Toronto
,
Toronto, Ontario
,
Canada
5
Queen's University, Department of Obstetrics and Gynecology
,
Kingston, Ontario
,
Canada
Background: Plate and screw fixation is a recent addition to the sternal wound treatment armamentarium. Patients undergoing cardiac and major vascular surgery have a higher risk of postoperative arrest than other elective patients. Those who undergo sternotomy for either cardiac or major vascular procedures are at a higher risk of postoperative arrest. Sternal plate design allows quick access to the mediastinum facilitating open cardiac massage, but chest compressions are the mainstay of re-establishing cardiac output in the event of arrest. The response of sternal plates and the chest wall to compressions when plated has not been studied. The safety of performing this maneuver is unknown. This study intends to demonstrate compressions are safe after sternal plating. Methods: We investigated the effect of chest compressions on the plated sternum using a human cadaveric model. Cadavers were plated, an arrest was simulated, and an experienced physician performed a simulated resuscitation. Intrathoracic pressure was monitored throughout to ensure the plates encountered an appropriate degree of force. The hardware and viscera were evaluated for failure and trauma respectively. Results: No hardware failure or obvious visceral trauma was observed. Rib fractures beyond the boundaries of the plates were noted but the incidence was comparable to control and to the fracture incidence after resuscitation previously cited in the literature. Conclusions: From this work we believe chest compressions are safe for the patient with sternal plates when proper plating technique is used. We advocate the use of this life-saving maneuver as part of an ACLS resuscitation in the event of an arrest for rapidly re-establishing circulation.
-
Background
Chest compressions are a cornerstone of
cardiopulmonary resuscitation. Recent work confirms the importance
of early compressions to improve survival [1]. Oxygen is
present in the blood up to ten minutes after arrest;
reestablishing circulation of this blood via sternal
compressions is the most important step of the ABCs early
in resuscitation [2].
Sternal wound dehiscence after median sternotomy
can be a devastating complication. The mainstay of
treatment has been aggressive debridement followed by
flap closure. This diminishes mechanical chest wall
integrity. A new advance, sternal repair with plate and
screw fixation, can obviate the complications of
persistent sternal instability. These include chronic pain,
paradoxical chest wall motion, and decreased pulmonary
function [3]. The modality is safe when used
appropriately and confers the advantages of early extubation,
tension-free repair and simple soft tissue advancements
in lieu of more complicated flaps whilst restoring
mechanical stability [4].
Cardiac or major vascular surgery places patients at a
higher risk for perioperative cardiac events, and the
subset whose wounds dehisce are typically at higher risk
on the basis of medical comorbidity [5,6]. Some of this
population will require perioperative resuscitation. The
response of sternal plates and the plated chest wall to
compressions has not been studied. Potential
hypothesized pitfalls include hardware failure or skeletal and
visceral trauma.
To determine the safety of performing this potentially
life-saving maneuver, we designed an experiment to
study the effects of chest compressions on sternal
hardware and the thorax. We studied these outcomes using
a human cadaveric model while monitoring
intrathoracic pressure during a simulated resuscitation.
Methods
Institutional Review Board ethics approval was applied
for and granted for this study by the University of
Toronto Ethics Review Office, protocol reference # 18535.
Compressions were performed on an un-plated
cadaver to serve as control. Intrathoracic pressures were
monitored in the control with the intrathoracic pressure
monitoring system detailed below, placed inferior to the
sternum through an incision in the diaphragm. No
sternotomy was performed on the control experiment. The
anterior thorax was exposed and checked for fracture.
Observations were documented. In the experimental
group, a midline sternotomy was performed on five
fresh frozen cadavers. Bilateral composite myocutaneous
pectoralis major flaps were elevated exposing the
anterior thorax for plating.
A digital manometer that records pressure within a
closed system at appropriate range and intervals was
selecte (...truncated)