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Difficulty: HardCardiothoracic and Vascular Surgery

An obese 61-year-old man with poorly controlled type 2 diabetes mellitus is evaluated in the emergency department for worsening anterior chest pain, shortness of breath, and chills. He underwent elective four-vessel coronary artery bypass grafting 12 days ago. His temperature is 39.2∘C39.2^\circ\text{C} (102.6∘F102.6^\circ\text{F}), blood pressure is 86/54 mmHg86/54\text{ mmHg}, and pulse is 122/min122/\text{min}. On physical examination, the patient appears toxic and diaphoretic. The sternal incision is erythematous, warm, and draining foul-smelling, purulent fluid. Palpation of the anterior chest wall reveals a palpable click during deep inspiration, and the sternal edges are independently mobile. Laboratory evaluation is notable for a leukocyte count of 24,500/mm324,500/\text{mm}^3 with 20%20\% bands, and a serum lactate of 4.1 mmol/L4.1\text{ mmol/L}. Which of the following is the most appropriate next step in management?

  1. A
    Intravenous vancomycin and application of negative pressure wound therapy
  2. B
    Administration of intravenous furosemide and noninvasive positive pressure ventilation
  3. Emergent surgical exploration and mediastinal debridementAnswer
  4. D
    Computed tomography of the chest with intravenous contrast
  5. E
    Sputum culture, chest radiography, and empiric piperacillin-tazobactam

Answer

The correct answer is emergent surgical exploration and mediastinal debridement.
The correct action is emergent surgical exploration and mediastinal debridement. This patient presents with acute postoperative mediastinitis, a life-threatening complication of a median sternotomy that typically manifests 1 to 2 weeks after surgery. The classic presentation includes fever, tachycardia, chest pain, and a sternal wound draining purulent material. The presence of sternal instability (a palpable click or shifting edges) confirms deep involvement. Because the patient is in septic shock (evidenced by hypotension, tachycardia, and elevated lactate), immediate surgical source control with exploration, debridement, and subsequent rewiring or tissue flap closure is mandatory to prevent mortality.

Step-by-Step Solution

1
Analyze the patient's vital signs and physical exam findings.
The patient is in septic shock (blood pressure 86/54 mmHg86/54\text{ mmHg}, pulse 122/min122/\text{min}, lactate 4.1 mmol/L4.1\text{ mmol/L}) and has a clinically obvious sternal wound infection characterized by purulent drainage and sternal instability (clicking).
Identifying the presence of hemodynamic instability and localizing the severe infection dictates the urgency of intervention.
2
Formulate a diagnosis based on the clinical presentation.
The constellation of fever, marked leukocytosis, purulent drainage, and sternal dehiscence occurring typically 1 to 2 weeks post-cardiac surgery is diagnostic for acute postoperative mediastinitis.
Accurate diagnosis is required to select the correct management pathway for post-cardiac surgery complications.
3
Determine the definitive next step in management.
Immediate surgical exploration, aggressive debridement of necrotic tissue, and broad-spectrum antibiotics are required. Imaging or conservative management should not delay surgery.
Medical management alone is uniformly fatal for deep space necrotic infections, and delaying for a CT scan is contraindicated in unstable patients.

Key Concept

Management of acute postoperative mediastinitis
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Topics

Cardiothoracic and Vascular Surgery

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