Emergency resternotomy is a special team skill that is required in a unit that has open heart surgery patients.  It is imperative that this team can work together seamlessly and with precision.  This ICU needs to be trained to assist with this procedure.  Also, due to the fact that the emergency resternotomy is not a frequent procedure, there needs to be scheduled training days to keep this skill fine-tuned.

The open heart unit should have a resternotomy tray always available.  This tray will have only the essential tools needed to open the chest.  There should be a larger set of instruments available once the chest is open; usually for the OR team that will be available by that time.  These trays and carts should be checked each shift just as the crash cart is checked to make sure that everything is present and not outdated.

The open chest tray should have the following items:

• Sterile thoracic drape—large enough to make the entire bed a sterile field
• Scalpel—to cut skin
• Wire cutter
• Heavy needle holder
• Hemostat—to grab wires
• Sternal retractor—to hold chest open

The cart itself should have the following items plus the items needed for the procedure outlined below:

• Internal defibrillator paddles
• External defibrillator pads with long cord
• Documentation sheet

Items Needed for Procedure Itself

1.  Gown and glove
2. Prep the skin
3. Place large sterile drape that makes the entire bed a sterile field
4. Have ioban available if surgeon wants this—an antimicrobial drape that provides continuous antimicrobial activity, thus helping to reduce the risk of infection.
5. Place sterile towels and towel clips on drape
6. Give instrument tray with scalpel taped to top to surgeon
7. Open basin and place on sterile drape
8. Open lap sponges and place on sterile drape
9. Have sterile suction tubing and yankauer available for removal of blood and clots from the chest
10. Warmed normal saline for irrigating the chest (warmed to keep fluid from defibrillating the heart
11. The large instrument tray is available to the surgeon once the chest is open in order for him to use what he needs from there

In less than 5 minutes the chest should be opened, with the retractor in place, so that whatever needs to be done can be accomplished.  Cardiac massage, tie off a bleeder, release pericardial tamponade, etc.

When reviewing a case involving the arrest of a cardiac surgery patient one should assess whether the standard of care would have been to do an emergent resternotomy if one was not done.  If a emergent resternotomy was done one should assess if the staff has been adequately trained (there should be documentation available regarding this issue), if the trays/carts are checked every shift, and if all of the necessary equipment was available.  Was the chest opened in a timely manner.

If you have a case involving an arrest in a Cardiac Surgery patient, Alvin & Associates, Legal Nurse Consultants would be happy to assist you with a review of your case.