Background: 33.6% of all deaths in America are caused by cardiovascular disease. An estimated 82.6 million adults (>1 in 3) in America have some form of cardiovascular disease. There were over 400,000 bypass surgeries requiring open-heart surgery. Sternal dehiscence is associated with a morbidity rate of over 47% if mediastinitis supervenes. A rigid closure is required to avoid healing complications, and wire, plates, and bands are all used in an attempt to make a better closure. The purpose of this study it to compare multiple closures and validate a new testing method. Methods: Polyurethane foam blocks will be used, as an alternative to cadavers, to provide homogeneous samples to test and compare multiple closure techniques. Each closure was performed by an engineer after instruction from a cardiothoracic surgeon and the SternaLock plate manufacturers. Seven different closure techniques (single suture, double suture, figure-eight suture, Robicsek weave, Sternalock Silver, Sternalock Blu, and Sternalock Wide Ladder) were compared in both lateral distraction and longitudinal shear. Statistical analysis was used to show the differences in stiffness, yield force, failure force, and yield displacement of each closure method. Results: Under lateral distraction, double wire closure showed the greatest stiffness followed by the Sternalock plates. The Sternalock plates had the greatest failure and yield forces, whereas the double wire performed significantly poorer. The longitudinal testing revealed that the wires provide no resistance to the shearing forces on the sternum, but the screws for plates can allow for multidirectional loading. Conclusions: Overall Sternalock plates are less likely to fail in all directions compared to wired closures. Even though double wire closures displayed a higher average lateral stiffness, the high stress concentrations created by wires allowed for easy foam cutting and much lower yield force and failure force. Testing using foam blocks as sternal analogues produces highly reproducible results, with less variance than cadaveric tests.

Bakgrund: På Akademiska sjukhuset i Uppsala genomförs ungefär 700 hjärtoperationer varje år. Efter en hjärtoperation är det av stor vikt att patienterna är fysiskt aktiva för att minska risken för postoperativa komplikationer. Det finns ett flertal faktorer som kan påverka den fysiska aktivitetsnivån, så som tidigare fysisk aktivitetsnivå, rörelserädsla och bröstsnittsmärta.    Syfte: Syftet med studien var att undersöka hur patienter som genomgått hjärtkirurgi via sternotomi skattade tidigare fysisk aktivitetsnivå, rörelserädsla och bröstsnittssmärta, och utifrån dessa variabler undersöktes sambandet till den fysiska aktivitetsnivån, mätt med antal steg, under sjukhusvistelsen.   Metod: Studien var en tvärsnittsstudie med en deskriptiv design, som bestod av formulär, skattningsskala och stegräknare. Den innefattade även en korrelerande design där samband mellan variablerna analyserades.   Resultat: Det var totalt 20 deltagare som medverkade, varav 15 som slutförde hela studien. Sambandet mellan antal steg och tidigare fysisk aktivitetsnivå visade en korrelationskoefficient r = 0,60 (p = 0,04) och mellan antal steg och rörelserädsla r = 0,69 (p = 0,02). Sambandet mellan antal steg och bröstsnittsmärta var r = - 0,25 (p = 0,38), det vill säga ej signifikant.   Konklusion: Positiv korrelation fanns mellan tidigare fysisk aktivitetsnivå och antal steg samt mellan rörelserädsla och antal steg. Det var dock svårt att generalisera till målpopulationen på grund av för lågt deltagarantal. Ingen korrelation fanns mellan bröstsnittsmärta och antal steg.

Bakgrund: I sjuksköterskans ansvarsområde ingår det att använda omvårdnadsåtgärder för att förebygga komplikationer efter operation. På thoraxkirurgiska vårdavdelningar skiljer sig rutinerna vid postoperativ vård och på vissa avdelningar används Posthorax-västen för att förhindra instabilitet i sternum efter sternotomi. Syfte: Syftet var att undersöka vilka postoperativa omvårdnadsåtgärder sjuksköterskor använder sig av på sternotomerade patienter för att förebygga mediastinit samt hur sjuksköterskor upplever att omvårdnadsåtgärderna påverkar patienterna. Metod: Data samlades in via en enkätundersökning på tre thoraxkirurgiska vårdavdelningar på tre olika sjukhus i Sverige. Resultat: Enkätundersökningen lyfte fram vilka omvårdnadsåtgärder som vanligtvis används på olika avdelningar, vilka omvårdnadsåtgärder som sjuksköterskor ansåg var viktigast samt faktorer som sjuksköterskor uppger främjar och hämmar omvårdnadsåtgärder. Slutsats: Sjuksköterskor uppgav att den viktigaste postoperativa omvårdnadsåtgärden efter sternotomi var Mobiliseringsrestriktioner. De största hindren var postoperativ förvirring, smärta och illamående samt organisatoriska faktorer som hög arbetsbelastning, stress och bristande rutiner. Klinisk betydelse: Denna studie har visat på behovet av vidare forskning genom att ha lyft fram vilka postoperativa omvårdnadsåtgärder som sjuksköterskor uppger att de använder i klinisk praxis på thoraxkirurgiska vårdavdelningar. / Background: Nurses have a responsibility to use nursing interventions to prevent complications after surgery. There is a difference in which procedures are used in thoracic surgical wards for postoperative prevention and some hospitals use the Posthorax vest to prevent sternal instability. Aims: The aim of this study was to investigate nursing interventions used to prevent mediastinitis on patients who have undergone sternotomy and how nursing interventions affect patients according to nurses. Methods: A survey was used to procure data from three different thoracic surgical wards in hospitals in Sweden. Results: The survey has shown the most commonly used nursing interventions in different thoracic surgical wards and what nursing interventions nurses’ state are most important. The survey also found promoting and inhibiting factors for nursing interventions according to nurses. Conclusion: According to nurses the most important nursing intervention was restricting the use of upper body extremities. The most inhibiting factors for nursing interventions were postoperative confusion, pain, nausea and organizational factors as high workload, stress and inadequate procedures. Clinical implications: This study has shown the need for further research by determining the postoperative nursing interventions used in clinical practice in thoracic surgical wards.

ABSTRAKT Bakgrund: Mediastinit är en allvarlig komplikation efter öppen hjärtkirurgi. Syftet med post- thorax västen är att förebygga och förhindra mediastinit genom att stötta upp instabilitet och minska friktion i sternum efter operation. Uttalade osäkerheter och brister i erfarenheter av att jobba med västen väckte författarnas intresse för att intervjua intensivvårdssjuksköterskor och sjuksköterskor om deras erfarenheter med att arbeta med post-thorax västen. Syfte: Syftet med studien var att belysa sjuksköterskors erfarenheter av att vårda patienter som bar Post-thorax väst. Design: En kvalitativ intervjustudie Metod: Semistrukturerade intervjuer av 14 stycken grundutbildade och intensivvårdsutbildade sjuksköterskor som arbetade vid två enheter på ett sjukhus i Norra Sverige och hade mer än 6 månaders erfarenhet av att arbeta med västen. Intervjuerna analyserades genom en kvalitativ innehållsanalys. Resultat: Sjuksköterskors erfarenheter av att vårda patienter som burit Post-thorax väst resulterade i 4 kategorier och 13 subkategorier. Följande kategorier finns representerade: Ambivanlens, Säkerhet, Svårigheter, Motivation. Konklusion: Resultatet i studien visade att deltagarna hade varierande erfarenheter av att arbeta med patienter som bär väst. Deltagare utryckte svårigheter och fördelar med västen samt sin egen osäkerhet kring den. Deltagare ville ha utbildning och en utvärdering av västen och de beskrev motivationsarbetet och varför det är viktigt. Deltagarnas erfarenheter av patienternas upplevelser var något som genomsyrade alla kategorier. Resultatet kan tala för att implementeringen av västen på berörda enheter inte genomförts på ett optimalt sätt. / ABSTRACT Background: Mediastinitis is an infection in the mediastinum which can be a serious complication after open heart surgery. The purpose of the Post-thorax vest is to prevent mediastinitis by providing the required support to and minimize any friction within the sternum after heart surgery. There are outspoken uncertainties and gaps in the experience of working with the vest which aroused the interest of the authors to interview nurses and intensive care nurses about their experiences of working with the Post-thorax vest. Aim: The aim of this study was to investigate nurses’ experiences of working with patients who wear a Post-thorax vest. Design: A qualitative interview study Method: Semi-structured qualitative interview study of 14 nurses and intensive care nurses who worked at two units in the north of Sweden who had at least 6 months of experience working with the vest. The interviews were analyzed using content analysis. Results: Nurses’ experiences of working with patients who wore Post-thorax vests resulted in 4 categories and 13 sub-categories. The following categories are represented: Ambivalence, Security, Difficulties, Motivation. Conclusion: The result of the study showed that the participants had various experiences of working with patients wearing the vest. Participants expressed difficulties and benefits of the vest, and their own uncertainty about it. Participants wanted education and an evaluation of the vest and they described why motivational work was important. The participants described patients' experiences of the vest in almost every category. The result may indicate that the implementation of the vest at the units in question where not completed in an optimal way.

Orientador: Antonio José Maria Cataneo / Resumo: Introdução: A técnica de fechamento convencional, após esternotomia mediana, para unir as duas partes do esterno, é realizada com fios de aço aplicando-se sutura simples ou sutura em forma de oito, no entanto, esta técnica tem sido associada a várias complicações pós-operatórias graves, tais como: deiscência da ferida, infecção esternal profunda, instabilidade esternal e mediastinite, principalmente em pacientes com fatores de risco, tais como portadores de osteoporose, diabetes, obesidade, entre outros. Novas estratégias para o fechamento de esternotomias medianas estão sendo propostas para tentar minimizar a incidência dessas complicações. Objetivos: Avaliar a eficácia de técnicas de fechamento esternal não convencional para a prevenção de complicações da ferida esternal após esternotomia mediana, comparando com o fechamento convencional. Métodos: A última pesquisa foi realizada nodia 15 de Setembro de 2015. Não houve restrições de linguagem. Os trabalhos foram obtidos a partir das seguintes fontes: Wounds Cochrane Grupo Especializada Register, Cochrane Central Register de Ensaios Controlados (CENTRAL), Ovid MEDLINE (1946 até o dia 15 de Setembro de 2015), Ovid EMBASE (1974 até o dia 15 de Setembro de 2015), EBSCO CINAHL (1982 até o dia 15 de Setembro de 2015) e LILACS (1982 até o dia 15 de Setembro de 2015). Foram pesquisados os registros de ensaios clínicos. Foram também rastreadas as listas de referências e contactados os autores necessários. Critério de seleção: dois re... (Resumo completo, clicar acesso eletrônico abaixo) / Doutor

Background: Over 700,000 patients per year undergo open-heart surgery. Healing complication rates can be up to 5% of patients who undergo this procedure, with a morbidity rate of 50% if mediastinitis supervenes. A secure and rigid fixation of surgically divided sternum is critical to avoid healing complications. The purpose of this study was to compare the yield load, construct stiffness, ultimate load, displacement at ultimate load, and post-yield behavior of three sternotomy closure methods (Peristernal wires or Sternalock titanium plates) when stressed in each of three directions: lateral distraction, rostro-caudal (longitudinal) shear distraction, and anterior-posterior (transverse) shear in a cadaveric model. Methods: Forty-two fresh cadaver models were divided into three test groups: group A, B, and C. A cardiothoracic surgeon divided each cadaveric sternum longitudinally and repaired peristernal wires or one of two Sternalock configurations. Tests were performed using a materials testing system that applied force at a constant displacement rate in a uniaxial direction until the construct catastrophically failed. Mechanical behavior was monitored using a 3D texture correlation system to create a real-time three-dimensional representation of strain directions. The resulting displacement pattern is analogous to a finite element contour plot of displacements, Lagrange Strain, or velocity. Statistical analysis was used to show the different mechanical properties of each closure method. Results: When loaded in lateral distraction, both Sternalock configurations surpassed the rigidity of peristernal wires by 600%. Some evidence was also found linking Sternalock with stiffer behavior in the rostro-caudal direction. Though not statistically significant, a trend was observed showing that constructs using the Sternalock also had higher yield loads, as well as, less post-yield displacement when compared to peristernal wires. Conclusions: Data gathered showed the superior performance of the Sternalock system in stiffness in both longitudinal distraction and rostro-caudal shear. Implications for use of the Sternalock system are faster healing times, lower complication rates, and success of the procedure.

京都大学 / 新制・論文博士 / 博士(医学) / 乙第13587号 / 論医博第2307号 / 新制||医||1070(附属図書館) / 京都大学大学院医学研究科医学専攻 / (主査)教授 安達 泰治, 教授 森本 尚樹, 教授 伊達 洋至 / 学位規則第4条第2項該当 / Doctor of Medical Science / Kyoto University / DFAM

Le traitement de la douleur après chirurgie cardiaque avec sternotomie reste à ce jour un défi pour le clinicien. Chez ces patients à risque, une prise en charge non adaptée de la douleur peut altérer la réhabilitation postopératoire et majorer les complications métaboliques, immunologiques, cardiovasculaires, respiratoires, ou psychiques de la chirurgie. L’objectif de ce travail de recherche clinique en chirurgie cardiaque était : 1) d’évaluer les effets analgésiques d’une anesthésie locorégionale continue par un bloc bi-latéro-sternal (bloc BLS) par perfusion continue de ropivacaïne,2) d’évaluer l’effet du bloc BLS sur la durée de séjour en réanimation et morbidité postopératoire, chez les patients présentant un risque respiratoire accru, 3) d’évaluer l’effet analgésique d’un antiinflammatoire non stéroïdien (AINS) de référence, le kétoprofène, à une posologie conventionnelle et des posologies réduites. Les deux techniques étaient appliquées pendant les 48 heures suivant la chirurgie cardiaque.Testé (contre placebo) sur une population standard, le bloc BLS continu diminue de 41% la douleur à la mobilisation (dynamique), diminue la douleur au repos et la consommation de morphine (d’environ 40%). Il permet une reprise plus précoce de l’alimentation et du traitement per os, une mobilisation plus précoce et une plus grande satisfaction des patients. En revanche, il ne permet pas une amélioration des paramètres respiratoires (spirométrie et gaz du sang artériel). Testé (contre une prise en charge standard) sur une population à risque respiratoire accru, contrairement aux attentes, il ne réduit pas la durée de séjour en réanimation et à l’hôpital, mais il a des effets bénéfiques sur la douleur dynamique, la satisfaction des patients, l’incidence de nausées/vomissements et de troubles neurologiques de type confusionnel. Un bénéfice en termes médico-économique est suggéré par une analyse secondaire. Testé (contre placebo) sur une population à faible risque, l’utilisation du kétoprofène en plein dose permet de réduire la douleur dynamique et au repos, sans augmentation des effets indésirables rénaux et hémorragiques, habituellement craints avec les AINS. Bien que les arguments manquent pour pouvoir utiliser des posologies réduites, le kétoprofène peut néanmoins être conseillé chez ce type de patients, alors qu’il est à ce jour insuffisamment prescrit. L’étude de protocoles d’administration utilisant des posologies réduites potentialisées par une dose de charge est suggérée. / The treatment of pain after cardiac surgery with sternotomy remains to this day a challenge for the clinician. In these frail patients, non-appropriated pain treatment can alter the postoperative rehabilitation and increase metabolic, immunologic, cardiovascular, respiratory, and psychological postoperative complications. The goal of this clinical research was to evaluate:- the analgesic effects of bi-latero-sternal (BLS) block by a continuous infusion of ropivacaine, - the effect of the BLS block on the length of stay in intensive care and postoperative morbidity in patients with increased respiratory risk,- evaluate the analgesic effect of ketoprofen, the standard non-steroidal anti-inflammatory drug (NSAID), at a conventional and reduced dosages.The two techniques were applied during the 48 hours following cardiac surgery.Tested (against placebo) on a standard population, the BLS continuous block decreased pain at mobilisation (dynamic pain) by 41%, decreased pain at rest, and morphine consumption (by 40%). It allowed an earlier postoperative first dietary and oral medication intake, earlier mobilisation and a greater patients’ satisfaction. On the other hand, it did not show any significant improvement of respiratory parameters (spirometry and arterial blood gases).Tested against a standard treatment in patients with increased respiratory risk, the BLS block did not reduce the length of stay in intensive care and in hospital, but it had beneficial effects on dynamic pain, patients’ satisfaction, the incidence of nausea/vomiting and of postoperative delirium. A benefit in economics terms is suggested by a secondary analysis.Tested against placebo in a low-risk population, the use of ketoprofen in full dose regimen, reduced pain at mobilisation and at rest, without increasing renal adverse effects or bleeding (as it could be feared with NSAIDs). We missed to demonstrate the ketoprofen efficacy at reduced doses. Ketoprofen may be recommended on a low-risk population, while it is insufficiently prescribed so far. The study of protocols using a reduced dosage potentiated by a loading dose is suggested.

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No. of bitstreams: 1 pinotti_kf_dr_bot.pdf: 7020764 bytes, checksum: fa87243e46f8244edc33c33d3eea6530 (MD5) Previous issue date: 2016-08-08 / Introdução: A técnica de fechamento convencional, após esternotomia mediana, para unir as duas partes do esterno, é realizada com fios de aço aplicando-se sutura simples ou sutura em forma de oito, no entanto, esta técnica tem sido associada a várias complicações pós-operatórias graves, tais como: deiscência da ferida, infecção esternal profunda, instabilidade esternal e mediastinite, principalmente em pacientes com fatores de risco, tais como portadores de osteoporose, diabetes, obesidade, entre outros. Novas estratégias para o fechamento de esternotomias medianas estão sendo propostas para tentar minimizar a incidência dessas complicações. Objetivos: Avaliar a eficácia de técnicas de fechamento esternal não convencional para a prevenção de complicações da ferida esternal após esternotomia mediana, comparando com o fechamento convencional. Métodos: A última pesquisa foi realizada nodia 15 de Setembro de 2015. Não houve restrições de linguagem. Os trabalhos foram obtidos a partir das seguintes fontes: Wounds Cochrane Grupo Especializada Register, Cochrane Central Register de Ensaios Controlados (CENTRAL), Ovid MEDLINE (1946 até o dia 15 de Setembro de 2015), Ovid EMBASE (1974 até o dia 15 de Setembro de 2015), EBSCO CINAHL (1982 até o dia 15 de Setembro de 2015) e LILACS (1982 até o dia 15 de Setembro de 2015). Foram pesquisados os registros de ensaios clínicos. Foram também rastreadas as listas de referências e contactados os autores necessários. Critério de seleção: dois revisores independentes identificaram os estudos para a inclusão. Foram incluídos estudos randomizados controlados de técnicas de fixação esternal após esternotomias, comparando métodos convencionais com métodos alternativos realizados com pessoas de qualquer idade, sexo e raça. Coleta e análise de dados: dois revisores extraíram independentemente os dados, avaliaram seu risco de viés e os desfechos para cada artigo. Para desfechos dicotômicos foi utilizada a razão de risco (RR) com intervalos de confiança (IC) de 95%. Para desfechos contínuos foram apresentados os resultados como diferenças de médias (MD) com intervalo de confiança (IC) de 95%. Resultados: Foram incluídos 23 estudos que envolveram 8741 pacientes. O maior risco de viés foi do mascaramento de participantes e pessoal, devido à natureza cirúrgica da intervenção. Houve uma diferença estatisticamente significativa favorecendo o fechamento não convencional, mas com uma baixa qualidade de evidência, quando analisados os desfechos: infecção profunda da ferida esternal (RR 0,24, IC95% 0,06-0,93; 16 estudos, 7559 participantes); instabilidade do esterno (RR 0,20, IC95% 0,07-0,56; 15 estudos, 5467 participantes); e tempo de ventilação mecânica (diferença média de -1,93 dias, IC 95% -3,77 a -0,10; 5 estudos, 1800 participantes). Não houve diferença nos desfechos: deiscência da ferida (RR 1,07, IC95% 0,60-1,89; 12 estudos, 6758 participantes); morte (RR 0,96, IC95% 0,64 a 1,45; 13 estudos, 4506 participantes); tempo de internação hospitalar (diferença média - 1,16 dias, IC 95% -3,15 a 0,83; 11 estudos, 4859 participantes); re-operação (RR 0,60, IC95% 0,23-1,60; 9 estudos, 5124 participantes); permanência na UTI (diferença média - 0,15 dias, IC 95% -0,37 a 0,07; 8 estudos, 5240 participantes); e mediastinite (RR 0,65, IC95% 0,18 a 2,39; 7 estudos, 3011 participantes). Houve diferença estatisticamente significante favorecendo a utilização de colete torácico pós-operatório, mas também com baixa qualidade de evidência, quando analisados os desfechos: infecção profunda da ferida esternal (RR 0,44, IC95% 0,25- 0,77; 3 estudos, 3510 participantes); tempo de internação hospitalar (diferença média - 5,16 dias, IC 95% -6,65 a -3,67; 2 estudos, 971 participantes); e reoperação (RR 0,43, IC95% 0,23 a 0,80; 2 estudos, 3289 participantes). Não houve diferença nos desfechos: deiscência da ferida (RR 1,07, IC95% 0,59-1,91; 3 estudos, 3510 participantes); instabilidade do esterno (RR 0,13, IC95% 0,01-1,22; 2 estudos, 971 participantes); e morte (RR 0,14, IC95% 0,02 a 1,16; 2 estudos, 971 participantes). Conclusões: Há alguma evidência, de baixa qualidade, de que o uso de métodos não convencionais, em pacientes de alto risco, pode reduzir a infecção profunda da ferida esternal, a instabilidade esternal e o tempo de ventilação mecânica no pós-operatório de esternotomia mediana, mas não há diferença quando se comparam as taxas de: morte, deiscência da ferida, mediastinite, reoperação, tempo de internação hospitalar ou internação em UTI. Existe uma baixa evidência de que o uso de colete torácico no pós-operatório pode reduzir a infecção profunda da ferida esternal, a reoperação e o tempo de internação hospitalar, mas não há diferença quando comparamos deiscência, instabilidade esternal e mortalidade. / Background: The standard closure technique after median sternotomy is to join the two parts of the sternum using steel wires with simple suture or figure-of-eight fashion wiring, however this tecnique has been associated with several serious postoperative complications, such as: wound dehiscence, deep sternal wound infection, sternal instability, mediastinitis, specially in patients with risk factors such as osteoporosis, diabetis, obesity, and others. New strategies for the closure of median sternotomies are being sought to try minimize the incidence of these complications. Objectives: Evaluate the efficacy and safety of non-conventional sternal closure techniques for preventing sternal wound complications following sternotomy, compared to the conventional closure. Methods: We ran the search on the 15 September 2015. There were no language restrictions. Trials were obtained from the following sources: the Cochrane Wounds Group Specialized Register, the Cochrane Central Register of Controlled Trials (CENTRAL), Ovid MEDLINE (1946 to present), Ovid EMBASE (1974 to present), EBSCO CINAHL (1982 to present) and LILACS (1982 to present). We searched clinical trials registers. We also screened reference lists and contacted experts. Selection criteria: Two review authors independently identified studies for inclusion. We included randomized controlled trials of sternal fixation techniques following sternotomies, comparing standard methods with alternative methods conducted with people of any age, gender and race. Data collection and analysis: Two review authors, independently extracted data, assessed their risk of bias in the trials and outcomes for each trial. For dichotomous data we used the risk ratio (RR) with 95% confidence intervals (CI). For continuous data we presented the results as mean differences (MD) with 95% confidence intervals (CI). Results: We included 23 studies that involved 8741 people. The increased risk of bias was the blinding of participants and personnel, due to the surgical nature of the intervention. There were low quality of the evidence favoring non standard closure, when we analised the outcomes: deep sternal wound infection (DSWI) (RR 0.14, 95% CI 0.04 to 0.43; 16 studies, 7559 participants); sternal instability (RR 0.20, 95% CI 0.07 to 0.56; 15 studies, 5467 participants); and mechanical ventilation time (Mean difference 1.93 fewer days, 95% CI -3.77 to -0.10; 5 studies, 1800 participants). There was no difference in outcomes: wound dehiscence (RR 1.07, 95% CI 0.60 to 1.89; 12 studies, 6758 participants); death (RR 0.96, 95% CI 0.64 to 1.45; 13 studies, 4506 participants); hospital stay (Mean difference - 1.16 days, 95% CI -3.15 to 0.83; 11 studies, 4859 participants); reoperation (RR 0.60, 95% CI 0.23 to 1.60; 9 studies, 5124 participants); ICU stay (Mean difference - 0.15 days, 95% CI -0.37 to 0.07; 8 studies, 5240 participants); and mediastinitis (RR 0.65, 95% CI 0.18 to 2.39; 7 studies, 3011 participants). There were low quality of evidence favoring the use of post operative thoracic vest (corset), when we analised the outcomes: deep sternal wound infection (DSWI) (RR 0.44, 95% CI 0.25 to 0.77; 3 studies, 3510 participants); hospital stay (Mean difference 5.16 fewer days, 95% CI -6.65 to -3.67; 2 studies, 971 participants); and reoperation (RR 0.43, 95% CI 0.23 to 0.80; 2 studies, 3289 participants). There was no difference in outcomes: wound dehiscence (RR 1.07, 95% CI 0.59 to 1.91; 3 studies, 3510 participants); sternal instability (RR 0.13, 95% CI 0.01 to 1.22; 2 studies, 971 participants); and death (RR 0.14, 95% CI 0.02 to 1.16; 2 studies, 971 participants). Conclusions: There is low quality of the evidence that the use of non standard methods, in high risk patients, can reduce deep sternal wond infection, sternal instability and mechanical ventilation time on post operative median sternotomy, but there is no difference when we compare rates of: death, wound dehiscence, mediastinites, reoperation, hospital stay or ICU stay. There is low quality of the evidence that the use of post operative Thorax Vest (Corset) can reduce deep sternal wound infection, reoperation and hospital stay, but there is no difference when we compare wound dehiscence, sternal instability and death.

Introduction: The procedure of longitudinal median sternotomy is the most commonly used approach in cardiac surgery with the necessary complex postoperative treatment. A multifactorial approach is particularly important to prevent later complications, which can be very serious or fatal. The theoretical part of the thesis is not just about the risk factors that may interfere with the healing process but also about nutritional measures that could reduce the risk or completely prevent the profound dehiscence of the sternotomic wound. Methodology: The research method consisted of a retrospective analysis of the risk factors of deep sternal dehiscence in 22 patients who underwent cardiac surgery using the technique of longitudinal median sternotomy over a ten-year interval. 11 patients with sternal healing disorder were selected and included in group 1. Subsequently, an additional 11 patients were selected without sternal dehiscence. These patients were selected in such a way that their characteristics corresponded to the characteristics of patients of the first group in terms of statistical evaluation and comparison of both groups (type of exercise, length of operation, use of extracorporeal circulation, LIMA / BIMA, etc.). In the selection of patients in the control group 2, the laboratory nutrition...