A 72-year-old man is evaluated on day 2 after a coronary artery bypass graft surgery for severe coronary artery disease. He has no new symptoms except for mild sternal wound discomfort exacerbated by deep breathing. The patient's surgery was uncomplicated; he was extubated on postoperative day 1. Medical history is significant for type 2 diabetes mellitus and hyperlipidemia. He is afebrile. Blood pressure is 122/75 mm Hg, pulse is 75/min and regular, and respirations are 16/min. Oxygen saturation is 98% on room air. The sternal wound appears to be healing normally. Breath sounds are decreased at the left base. There is no abdominal distension or peripheral edema. Chest x-ray reveals a small, left-sided pleural effusion. Leukocyte count is 9,200/mm³ and serum creatinine is 1.1 mg/dL. Which of the following is the best next step in management of this patient?

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Explanation: Pleural effusions occur in almost half of patients who undergo coronary artery bypass graft surgery. Most are small, asymptomatic, and benign effusions that usually develop on the left side and are the result of the body's reaction to surgical incision of the pleura, disruption of mediastinal lymphatic channels, cardiac cooling, or postoperative pericarditis. Post-cardiac surgery effusions that meet the following criteria (as in this patient) can be managed conservatively with observation only: Small to moderate in size and not enlarging Early onset (postoperative day 1 or 2) Not associated with respiratory symptoms Effusions that do not meet the above criteria should be actively investigated and treated because they may be due to serious post-cardiac surgery complications, including hemothorax, central line erosion into the pleural space, mediastinitis, chylothorax, and myocardial infarction with heart failure. (Choices A and C) The initial management of large, progressively expansive, or symptomatic pleural effusions should involve diagnostic thoracentesis and fluid analysis. Chest tube placement may be necessary for large effusions or some effusions of infectious etiology; tube placement is also sometimes used in the management of hemothorax or pneumothorax. large (Choices D and E) Antibiotics and intravenous diuretics are appropriate in patients with pleural effusions due to pneumonia (ie, uncomplicated parapneumonic effusion) or heart failure, respectively. However, these effusions are likely to present with other signs and symptoms (eg, shortness of breath, peripheral edema, fever, cough), which this patient lacks. Educational objective: Pleural effusions occur in almost half of patients who undergo coronary artery bypass graft surgery. The majority of these effusions are small, asymptomatic, and benign. When the effusion is small to moderate in size, begins within 1 or 2 days of surgery, and does not cause respiratory symptoms, it can be managed conservatively with observation. References: Prevalence and clinical course of pleural effusions at 30 days after coronary artery and cardiac surgery. (http://www.ncbi.nlm.nih.gov/pubmed/12406850)

A 72-Year-Old Man Is Evaluated on Day 2 After a Coronary