Primary delayed sternal closure in adult cardiac surgery: a systematic review of protocols.

Introduction: Primary delayed sternal closure (DSC) is a useful tool in the management of certain critically unstable patients after cardiac surgery, but there is a paucity of consensus management guidelines. This review aimed to identify critical key areas in DSC management.

Evidence acquisition: Systematic literature search was conducted in January 2023 and performed using Embase and PubMed. For original research articles were included that described outcomes and/or protocols for primary adult DSC patients, excluding articles on pediatric patients and secondary DSC.

Evidence synthesis: Eleven retrospective review original articles examined protocols for adult patients undergoing DSC. Hemodynamic instability and uncontrolled bleeding/coagulopathy were the two most common indications. Time to chest closure ranged 22 hours - 8.7 days. A range of dressings were employed, including Esmark and VAC dressings, with about half of authors not disclosing details. VAC was endorsed by several authors specifically for management of uncontrolled hemorrhage/coagulopathy. There was no consensus regarding irrigation solution for mediastinal prepping, with or without antibiotic solution. There was a lack of consensus on antibiotic selection and duration, varying from 2 and 3 multidrug regimens of broad-spectrum antibiotics, with/without antifungals. Mediastinal re-exploration varied from undefined intervals to regimented 24-48-hour interval re-explorations, with final closures in the OR or ICU.

Conclusions: The optimum care for the patient with an open chest is evolving, and although there is a lack of a consensus DSC protocol, this review identifies mediastinal management, antimicrobial prophylaxis, and mediastinal re-exploration schedules/protocols as key areas for study to determine optimal care for DSC patients.