Date Presented 4/9/2016
Sternal precautions (SPs) are variable among pediatric heart centers surveyed. Results indicate institutions determine SP protocol based on culture and preferences rather than evidence-based research. Prolonged physical restrictions may negatively affect motor and sensory development.
Primary Author and Speaker: Leslie Rodman Uher
Additional Author and Speaker: Nguyenvu Nguyen
Contributing Author: Michael Monge
PURPOSE: The practice of sternal precautions (SPs) after pediatric cardiac surgery is variable among pediatric institutions. SP practice is more influenced by institutional preferences than evidence-based information.
BACKGROUND: SPs are implemented after cardiac surgery requiring thoracotomy or median sternotomies. Precautions are intended to reduce complications associated with wound dehiscence, infection, and poor sternal healing. Research data and practice consensus are lacking in the pediatric population. A survey was conducted to further understand current SP practice among pediatric heart centers.
METHOD: A survey was administered using a web-based survey tool, SurveyMonkey.com. The survey, comprised of 10 questions, was distributed to members of PediHeart.com, attendees at the Third Annual Neurodevelopmental Symposium, and a collaborative website for directors of rehabilitation therapy departments at children’s hospitals in the United States. Eligible participants included clinical specialists who care for children with cardiac disease.
RESULTS: There were 58 responses, representing different groups of specialists: cardiovascular surgeons (8/58), pediatric cardiologists (34/58), physical therapists (10/58), and occupational therapists (6/58). The majority (96%) of respondents report their institution has restrictions on lifting under arms after sternotomy and thoracotomy. When asked about prone positioning, nearly half (56%) of respondents indicated prone position is prohibited after sternotomy and less commonly after thoracotomy (30%). The duration of SPs was variable, with the majority of institutions adhering to SPs between 2 to 8 wk after surgery.
Utilization of rehabilitation evaluation and treatment was high. Respondents reported referrals to physical therapy (100%), occupational therapy (88%), and speech therapy (56%). When asked to indicate key factors that influence the respondent’s institutional practice, SPs are determined by cardiovascular surgeon (77%), followed by institution culture (54%) and literature (12%). Education regarding SP within daily activities was introduced by cardiovascular surgeon (15%), cardiologist (15%), bedside nurse (55%), occupational therapist (OT; 27%), physical therapist (PT; 24%), ST (5%), and advanced practice nurse (69%).
DISCUSSION: SP practice is inconsistent among pediatric heart centers in the United States and Canada. Currently, institutional culture and preferences, instead of evidence-based research, play key roles in shaping SP practice. Protracted or excessive physical restriction may have a negative impact on motor and sensory development of the infant after cardiac surgery.
Further studies are needed to determine the optimal duration and level of SP. This study highlighted the important roles of nursing and OTs/PTs as primary educators for patients and family about SPs, as well as providing early interventions to optimize neurodevelopmental outcome after cardiac surgery.
IMPACT STATEMENT: This is the first survey to demonstrate the need for standardization of SP practice in children in the United States and Canada. Education and supports for families and availability of occupational and physical therapy are critical during and after a period of SPs to optimize developmental outcomes.
