Open Incision Question

[bstew7890]

Hi everyone. I love this site and I expect it will be a great resource for me!

I had my AVR on Sept 14, 2011, just over 4 weeks ago. About 3 weeks post-op a hole formed about an inch below the top of my sternal incision. At first it was just a wider part of the scar, then beneath the scab was a hole about 1 cm wide and 2 cm tall. There was a small amount of puss inside. My surgeon stuck an applicator stick into the hole and was able to tap directly on the sternum. I'm not sure if this is common or how serious it is.

The current treatment is to pack the hole with iodine-soaked gauze (changed 3 times a day), and I am taking cephalexin orally. The gauze is all white when it's removed. After ten days of this there is little or no puss today (hard to tell) but still some white to be seen at the bottom of the hole. The sugeon says when the hole is all red or pink (no white) we will switch to saline soaked gauze and the hole will heal faster.

How does the treatment sound to you all? I know a sternal infection is not to be taken lightly. I saw some had mentioned a topical antibiotic cream when they had similar problems with their incisions. What was the name of the antibiotic? Any other suggestions or questions I can ask my Doctor about?

 

[Lynlw]

Hi, sorry to hear this. I'm afraid I have more questions than answer. It sounds like the hole first showed up about a week ago? When the surgeon stuck the applicator in it did he do any cultures to see what if anything grew? If so how were the results? Did they do any testing like and Echo, MRI or Ct scan to see if there is any infection you can't see inside?

Justin had problems with his incision after 2 of his surgeries, but how he was treated depended on what was going on. The first time when he was a baby, there wasn't any infection when they lanced it open and he was fine with doing the saline packing twice a day. He didn't have any fevers or anything hat time we just took him in because I didn't think it looked "right" that was mainly because he has problems not dissolving dissolving sutures.

The other time he did have bacteria growing, there was drainage coming out that didn't look like puss more a reddish watery fluid. We called and took him to get checked becausewe thought it was sutures again. That time they were also able to stick a probe to the sternum , this was only 10 days post op tho so it shouldn't have been as healed as Id expect 3 weeks post op Anyway since they could stick the prob in far and by that time he started to get a fever they did an echo and MRI, which were fine and just to be safe they also did a CT scan. The CT showed a "pocket" under his sternum, so they took him to the OR the next morning. I can't remember but I think maybe by the morning, before surgery the first cultures they did already showed bacteria growing but that might have been after surgery we knew ther was something growing.

 

[bstew7890]

Hi Lyn. No, they did not do a culture. What did they do in the surgery where they found the "pocket" under the sternum? Was there an alternative to removing the sternum?

 

[Lynlw]

Hi Lyn. No, they did not do a culture. What did they do in the surgery where they found the "pocket" under the sternum? Was there an alternative to removing the sternum?

I'm surprised they didn't culture it, They decided what antibiotics Justin needed from what grew, but that is the best way to see if there is an infection and if so what is causing it.. Maybe since they did put an applicator into the wound, he sent that off for cultures? When Justin had the problem as a baby, that was a "sterile abcess"so he "only" needed it lanced open and packed with the saline guaze for a couple weeks until everything healed.
.
For the one with the "pocket" They started him on very strong antibiotics right away, but were able to switch to bactrim when the bacteria was supseptable to that. The pocket they saw on the CT scan was actually filled with the fluid and infection.
Thankfully, he didn't need his sternum removed, I think that is pretty much for worst case senerios from what we were told, and a couple other people I know whose kids had sternal infecions were told the same thing.. Justin infection was in a few spots of his sternum and the tissue below it surround his heart (the technical names are in my sig below)
Anyway they "debrised" it basically cut away any tissue that looked infected plus a small area around the bad spots to hopefully get rid all. he had some spots of his sternum removed, They actually shoot a blue dye in that tracks they infection and remover any places the blue dye settles in, well a little more involved than that of course. They also removed all the wires, holding his sternum together since they can be a place the bacteria gets on, and then used some of his pec muscle to wrap around his sternum to hold it together while it heals and the muscl carries alot of red cells and oxygen that helps the bone heal, they filled in spaces in his sternum with the muscle.

He "only" needed 1 surgery, Thankfully they got it all, but we were told they often have to go back in a time or 2 if they didn't get everything cleaned out because the tissue looked good and the infection grew again. His surgeons try to be conservative as to the amount of tissue they remove, they rather remove the smallest sections possible, while still trying to get it all. They also cleaned everything with antibiotics. I know a couple kids that had to go bac to the OR a couple times and they also made full recoveries when all was said and done.

Have you hd any fevers or other symptons you might get when you have an infection? If not thats probably a good sign.
Hopefully this will soon behind you and you can get on to recovering doing everything you enjoy.

 

[bstew7890]

No, no fever. I saw the applicator he used go into the trash so I'm sure there was no culture done. I will call and ask about that today. Thanks for sharing!

 

[Mentu]

I would echo Lyn's question about a culture of the substance found. My doctor would have run the culture at once since an infection could not only delay healing but could also pose the threat of endocarditis. It sounds as though your doctor assumed it was a bacterial infection but I am surprised that he didn't care to know the nature of the bacteria. Please watch this closely and report any change. If your surgeon is uninterested, speak with your family doctor who will be caring for you long after the surgical incisions are healed.

Larry

 

[kfay]

I developed an infection when I was about 5 weeks post op. My only symptom was a sudden redness on the lower part of my incision. My cardio put me in the hospital the same day and called in a surgeon and an infectious disease Dr. They did a CAT scan that evening to see if there was any infection that they needed to go in and clean out. They also drew my blood to run cultures on. They put me on 2 IV antibiotics. By the next day, the redness was greatly reduced so they agreed to let me go home on oral antibiotics. Luckily for me, that was all I needed to clear it up. They said I caught it very early.

Obviously, these kind of infections aren't anything to mess with. I'd probably at least want a CAT scan to make sure it isn't anywhere else. As Lyn shared with you, there can be infection hiding somewhere else.

Kim

 

[bstew7890]

I would echo Lyn's question about a culture of the substance found. My doctor would have run the culture at once since an infection could not only delay healing but could also pose the threat of endocarditis. It sounds as though your doctor assumed it was a bacterial infection but I am surprised that he didn't care to know the nature of the bacteria. Please watch this closely and report any change. If your surgeon is uninterested, speak with your family doctor who will be caring for you long after the surgical incisions are healed.

Larry

I have an appointment with a primary care Doctor tomorrow so I will be discussing it. I call the surgeon (his assistant) today and she assured me that if he had thought it was serious he would have done a culture. So I guess we can take it as a good sign that it didn't appear serious to the doctor. That was probably combined with the fact that I had no fever, redness or tenderness.

 

[Greg a]

How is your white cell count and also is there any consideration for a wound vac unit? It is vital that the wound heals from the bottom up and with a wound vac a sterile sponge soaked in benodine is packed in the wound and a vac seal placed over it and suddenly you have a new purse to carry 24/7 .......this was tried and pumping me full of antibiotics before it was determined that removing my sternum was the last resort

 

[bstew7890]

How is your white cell count and also is there any consideration for a wound vac unit? It is vital that the wound heals from the bottom up and with a wound vac a sterile sponge soaked in benodine is packed in the wound and a vac seal placed over it and suddenly you have a new purse to carry 24/7 .......this was tried and pumping me full of antibiotics before it was determined that removing my sternum was the last resort

I've been getting bloodwork done weekly and my white cell count is normal. I am packing the wound with sterile gauze soaked in iodine (betadyne?) and changing it 3 times a day, plus I'm taking cephalexin orally. No mention of a wound vac.

 

[Lynlw]

How is your white cell count and also is there any consideration for a wound vac unit? It is vital that the wound heals from the bottom up and with a wound vac a sterile sponge soaked in benodine is packed in the wound and a vac seal placed over it and suddenly you have a new purse to carry 24/7 .......this was tried and pumping me full of antibiotics before it was determined that removing my sternum was the last resort

Greg, I was wonderring when they knew you had the infection, before they used the wound vac, did they do any surgeries to try and clean up the infected tissue? Or was when they did the surgery to remove your sternum the first surgery for the infection? or i guess I was wonderring did you know going into the OR that your sternum would be removed or did they think before they opened you they might be able to just remove small areas, But too much of your sternum was already infected since it seemed like the infection was going on for a while

FWIW Justin did not need a wound vac, for either of the surgeries he had problems with the incision, just packing the wound like Bstew's is doing or even the wet to dry dressing we had to do when Justin was a baby, helps with the wound healing from the inside up too. Luckily for his infection a couple years ago since they caught Justins infection 10 days post op, it really helped since the infection didn't have more time to spread.

 

[Greg a]

Lynn, I was walking across the driveway when I collapsed almost two and a half weeks later I woke up with a whole "new normal" life for me to live and three weeks ago I was so glad I did
​

 

[Greg a]

They are pricey to use but it seems that most members of our sternectomy support site have had them ......here in Canada it does not cost me if it is used but my understanding is that some insurers there it may not be an option due to cost

 

[bstew7890]

I have an appointment with a primary care Doctor tomorrow so I will be discussing it. I call the surgeon (his assistant) today and she assured me that if he had thought it was serious he would have done a culture. So I guess we can take it as a good sign that it didn't appear serious to the doctor. That was probably combined with the fact that I had no fever, redness or tenderness.

I actually saw my surgeon today and he said that because there was some chest hair present any culture swab would have come back as staph. If there had been a significant amount of drainage it might have been accurate.

 

[Lynlw]

I actually saw my surgeon today and he said that because there was some chest hair present any culture swab would have come back as staph. If there had been a significant amount of drainage it might have been accurate.

Ok, well thats interesting.
Was it looking any better today? Were you able to move to just the saline dressing and not the iodine? If so 1 thing I do remember from when Justin was a baby, it could hurt a little when you are putting aline into the wound, after you just removed the old dressing.
I meant to say earlier, i would take it as a good sign you've been having weekly blood test and your white count is normal. How the rest of your recovery going/ i hope everything else is going well.

 

[hetmarie]

Hi there, I hope this clears up for you soon. The bottom part of my incision didn't close properly and I kept showing it to any doctor or PA who would look but they all said it was fine. Then one morning I woke up and it had opened up again and didn't look right so I went to the surgeon's office. He cleaned it out really good and took a culture to humor me saying "I'm sure this will come back negative but just in case". He ordered a wound vacuum to help close it up and I followed up with his PA the next week. The PA came in and chatted about how the wound looked and was ready to send me home. As an afterthought he called to check on the results of the culture and found out that it showed I had a bacteria that was super-resistant to antibiotics. He spent the next hour on the phone with the wound care team and my physician to see if they should admit me to the hospital or send me home with heavy duty antibiotics. Fortunately they sent me home with lots of pills but it still took the wound vacuum 6 weeks to work. After they took it off, the wound closed only to fill up with liquid two weeks later and open up again.

Stay on top of it!!! You've been through too much to have all that work ruined by a nasty little infection.