A 72-year-old man undergoes coronary artery bypass graft (CABG) for severe coronary artery disease. He is extubated on the second postoperative day. His temperature is 36.6° C (97.9° F), blood pressure is 120/70 mm Hg, pulse is 80/min, and respirations are 12/min. On the third postoperative day, he complains of dyspnea and worsening retrosternal pain despite continuous analgesia with morphine. His temperature is 38.6° C (101.5° F), blood pressure is 112/52 mm Hg, pulse is 125/min and irregularly irregular, and respirations are 28/min. Examination shows normal heart sounds. A small amount of cloudy fluid is present in the sternal wound drain. His ECG shows atrial fibrillation with rapid ventricular response. An x-ray film of the chest shows widening of the mediastinum. Echocardiography reveals a small amount of pericardial fluid. Laboratory studies show: Which of the following will this patient most likely require?

Question

A 72-year-old man undergoes coronary artery bypass graft (CABG) for severe coronary artery disease.  He is extubated on the second postoperative day.  His temperature is 36.6° C (97.9° F), blood pressure is 120/70 mm Hg, pulse is 80/min, and respirations are 12/min.  On the third postoperative day, he complains of dyspnea and worsening retrosternal pain despite continuous analgesia with morphine.  His temperature is 38.6° C (101.5° F), blood pressure is 112/52 mm Hg, pulse is 125/min and irregularly irregular, and respirations are 28/min.  Examination shows normal heart sounds.  A small amount of cloudy fluid is present in the sternal wound drain.  His ECG shows atrial fibrillation with rapid ventricular response.  An x-ray film of the chest shows widening of the mediastinum.  Echocardiography reveals a small amount of pericardial fluid.  Laboratory studies show:  Which of the following will this patient most likely require?

Quizplus · Accepted Answer

This patient presents with findings consistent with likely acute mediastinitis, a possible complication of cardiac surgery that is usually due to intraoperative wound contamination. Mediastinitis can complicate up to 5% of sternotomies. Patients typically present post-operatively (usually within 14 days) with fever, tachycardia, chest pain, leukocytosis, and sternal wound drainage or purulent discharge (as in this patient). Chest x-ray usually shows a widened mediastinum in non-postoperative mediastinitis, but this can also be seen in postoperative mediastinitis after cardiac surgery. The diagnosis is usually clinically made and confirmed during surgery when pus is noted in the mediastinum. Postoperative mediastinitis requires drainage, surgical debridement with immediate closure, and prolonged antibiotic therapy. Antibiotics alone do not appropriately treat mediastinitis (Choice B). Acute mediastinitis has a mortality rate of 10%-50%, even with appropriate treatment. (Choice A) Atrial fibrillation commonly (up to 15%-40%) occurs within a few days after CABG and is usually self-limited, with resolution in <24 hours. Rate control with beta-blockers or amiodarone is best. Anticoagulation and/or cardioversion is reserved for patients with atrial fibrillation lasting >24 hours after CABG. Since this patient requires immediate surgery anticoagulation should not be given. (Choice C) Nonsteroidal antiinflammatory agents have limited efficacy in treating mediastinitis and are more effective in pericarditis, which is less likely in this patient. (Choice D) Postpericardiotomy syndrome can present with fever, leukocytosis, tachycardia, and chest pain. However, it is usually autoimmune and occurs a few weeks following a procedure with a pericardium incision. Nonsteroidal antiinflammatory agents or steroids treat the inflammation, and pericardial puncture is indicated if tamponade occurs. Educational objective: Acute mediastinitis can occur following cardiac surgery and present with fever, chest pain, leukocytosis, and mediastinal widening on chest x-ray. It is a serious condition that requires drainage, surgical debridement, and prolonged antibiotic therapy. References: Postoperative mediastinitis: classification and management (http://www.ncbi.nlm.nih.gov/pubmed/8619682)

A 72-Year-Old Man Undergoes Coronary Artery Bypass Graft (CABG) for Severe