Mediastinitis. Jonathan Parks, MD Kings County Medical Center December 3, 2015
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1 Mediastinitis Jonathan Parks, MD Kings County Medical Center December 3, 2015
2 Case Presentation 69 year-old male from nursing home PMHx: COPD, asthma, HTN, Afib on pradaxa, PTSD, BPH c/o pulled pork stuck in throat s/p EGD one week prior for UGIB
3 Physical Exam 125/ % Mild distress, unable to manage saliva Severe crepitus at base of neck b/l breath sounds
4 Labs WBC 17.9 HGB 12.5 HCT 38.5 PLT 215 Na 140 Cl 97 BUN 12 Glu 151 K 5.0 CO2 29 Cr 0.87 Prot 6.8 Alb 3.9 Lactate 4.6
5 Imagingwww.downstatesurgery.org
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8 EGD Impacted food bolus at 20 cm Mucosa erythematous, edematous, friable No visible perforation Normal stomach still w/ dysphagia, unable to tolerate esophagram
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14 Overnight... Transferred to SICU, Unasyn Hypotension, fever and respiratory distress in early AM, intubated NG tube placed, esophagram in AM
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18 Course HD1 - remained intubated, WBC 20. TPN started. HD3 - extubated, WBC 10 HD5 - clears HD6 - regular diet HD7 - discharged
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20 Questions?
21 Mediastinitis
22 Outline Anatomy Mediastinitis Descending Necrotizing Mediastinitis Mediastinitis from Esophageal Perforation Poststernotomy Mediastinitis Chronic Mediastinitis
23 Mediastinum Thoracic outlet to diaphragm, between the lungs
24 Anterior Thymus Fat Lymph nodes Connective tissue
25 Middle Heart Great vessels Vagus Thoracic duct Lymph nodes Esophagus*
26 Posterior Paravertebral sulci Intercostal NVB Thoracic spinal ganglion Sympathetic trunk More lymph nodes...
27 (Superior) Sternomanubrial joint to 4th thoracic vertebra
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31 Mediastinitis - Definition (CDC) Diagnosis requires one of the following: 1. Organisms cultured from mediastinal tissue or fluid 2. Evidence of mediastinitis during operation 3. Fever, chest pain, or sternal instability with one of the following a. purulent drainage from mediastinal area b. organisms from discharge from mediastinal area c. mediastinal widening on CXR DUH
32 Mediastinitis - Epidemiology Most common cause = iatrogenic (90% of cases) Mortality 5-40%! Post-op from sternotomy = 0.5-1%
33 Mediastinitis - Etiology Four possible sources: 1. Direct contamination (sternotomy, esophageal perforation, trauma) 2. Hematogenous / lymphatic spread 3. Extension from above (neck) or below (retroperitoneum) 4. Extension from lung, pleura, or chest wall
34 Acute Mediastinitis Esophageal perforation (posterior) Cardiac surgery (anterior, discussed separately later) Penetrating trauma Oropharyngeal abscess Neck surgery - thyroidectomy, tracheostomy, lymph node biopsy!
35 Descending Necrotizing Mediastinitis Four criteria: 1. Oropharyngeal infection 2. Mediastinitis on imaging 3. evidence during operation 4. relationship between oropharyngeal and mediastinal processes
36 Microbiology Anaerobes, gram-negative aerobes most common are Strep, Bacteroides Most infections are polymicrobial Debilitated pts - candida and aspergillus
37 Clinical Features ACUTE onset fever, leukocytosis, chest pain Neck Esophagus Pleura dysphagia, odynophagia dysphagia respiratory distress
38 Imaging CXR Mediastinal widening gas, air/fluid level Pneumomediastinum/Pneumothorax Esophagram Gastrografin (10-25% false negative) vs. Barium (inflammation) CT scan 1st Choice!
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45 Treatment Principles Expedient diagnosis and treatment IVF & broad-spectrum Abx Surgical drainage - varies by etiology Multidisciplinary approach Frequent reimaging and redebridement
46 Treatment - Descending Necrotizing Mediastinitis Remember cervical fascial planes Agressive cervical debridement Upper mediastinum accessible blunt dissection of pretracheal space dissection of retropharyngeal space
47 Thorax, 1997 Infection extending below carina -> thoracic approach meta-analysis of 12 series Compared mortality between neck drainage alone (47%) vs. neck and thoracic drainage (19%)
48 Other approaches... Posterolateral thoracotomy Median sternotomy Clamshell Subxiphoid VATS
49 Journal of Thoracic and Cardiovascular Surgery, 2000 Retrospective review, 10 cases Algorithm for DNM w/ serial debridement and reimaging q48 hours
50 Treatment - Esophageal Perforation Nutrition, abx, NGT, PPI, pleural drainage Early surgery w/ repair of perforation Muscle/omental/pericardial/pleural flap Covered stents complications - migration, ischemia, bleeding, retrieval
51 Poststernotomy Mediastinitis Risk Factors: Obesity, DM, COPD, PVD, s/p CABG w/ b/l IMA Incidence remains constant despite advances ( %) Mortality 16-47%
52 Poststernotomy - Microbiology Broad spectrum Gram +/- and fungal Most common S. Aureus others: Aerobic Strep, coag- Staph, Pseudomonas, Enterococcus Dx w/ sternal puncture
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54 Poststernotomy - Treatment Sternal dehiscence - closed irrigation/vac Deep sternal wound infection - flap reconstruction Pec major, rectus, free lat dorsi, omentum
55 Chronic Mediastinitis Secondary to acute mediastinitis or granulomatous process Histoplasmosis, syphilis, tuberculosis, coccidiomycosis, sarcoidosis, foreign bodies Usually asymptomatic unless compression Surgery only for biopsy and palliation
56 Treatment Principles Expedient diagnosis and treatment IVF & broad-spectrum Abx Surgical drainage - varies by etiology Multidisciplinary approach Frequent reimaging and redebridement
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