Postoperative management

Postoperative complications

Acute Postoperative Mediastinitis

• Epidemiology & Risk Factors
  • < 14 days post-median sternotomy (CABG/valves).
  • Orgs: S. aureus, S. epidermidis.
  • Risks: DM, obesity, smoking, reoperation.
• Clinical Features
  • Fever, tachycardia, purulent wound drainage.
  • Buzzword: Sternal instability (“clicking” or “rocking” w/ breathing).
• Diagnosis
  • Initial: Blood & wound cx, CBC (↑ WBC).
  • Imaging: CT Chest w/ contrast (mediastinal fluid/gas). Note: Small amt of pneumomediastinum on CXR is normal < 14 days post-op; worsening gas is pathologic.
  • Confirmatory: Surgical exploration w/ positive cx.
• Differential Diagnostics
  • Superficial Skin Infection: Intact sternum (no clicking), no systemic toxicity.
  • Postpericardiotomy Syndrome: Autoimmune, weeks-months later. Pleuritic pain, friction rub. Tx: NSAIDs.
  • Non-infectious Dehiscence: Sternal clicking without fever or purulence (mechanical failure).
• Management
  1. Surgical (Immediate): Urgent exploration, debridement, & sternal fixation (muscle flaps). c
  2. Medical: Empiric IV Abx (Vanco + Cefepime) targeting MRSA/Gram-negatives.
  3. Ongoing: 4-6 wks IV Abx tailored to cx.
• Complications
  • Sepsis / Septic shock (high mortality).
  • Sternal osteomyelitis.