Managing mediastinitis after cardiac surgery

Learn what causes this deep infection, how to recognize and manage it,
and what you can do to prevent it.
By Diane M. Bosen, RN, APRN,BC, CCRN, MSN, and Soundra D. Mackavich, RN, CVSFE, BSN

M
ore than 600,000 patients un-
dergo cardiac procedures each
year. Those who have a me- Apex of left lung
dian sternotomy, or midline chest inci-
sion, are at risk for mediastinitis, an
uncommon but potentially fatal deep
wound infection.
Occurring in about 5% of patients Sternum
who undergo sternotomy, mediastinitis
increases morbidity and lengthens hos- Heart
4th rib
pital stays. Also called deep sternal
wound infection, mediastinitis may
progress to osteomyelitis, sternal dehis- Apex of heart
Xiphoid
cence, sepsis, or right ventricular rupture. process
Up to 47% of patients who develop it die. Diaphragm
Here’s what you need to know about
the causes of mediastinitis, signs and
symptoms, prevention, and treatment
options. For anatomic details, see Chest
the facts.
Chest the facts
Sternal separation The mediastinum, the area between the right and left pleural cavities, is
Why does mediastinitis develop? Re- bordered by the diaphragm and the thoracic inlet. The middle medias-
tinum, the area affected by the midline sternotomy incision, includes
searchers believe these events open the
the heart, the aorta and aortic arch, vena cavae, main pulmonary arter-
door to infection:
ies and veins, phrenic nerves, the tracheal bifurcation and the main
• A localized area of sternal osteo- bronchus, the hilum of each lung, the esophagus, and lymph nodes.
myelitis extends, separating the ster- Blood is supplied to the area primarily by the left and right internal tho-
num. racic mammary arteries.
• Separation of the sternum leads to
skin breakdown and bacterial contami-
nation of deep tissues. Mediastinitis may occur as early as 3 days postop-
• If the mediastinum isn’t sufficiently drained after eratively or as late as 3 months, but it typically occurs
surgery, large amounts of fluids can collect in the between postoperative days five and seven.
retrosternum and contribute to a deep infection. Depending on the causative organism, the wound
However, new investigations suggest that medias- may or may not look infected.
tinitis also is the result of a systemic inflammatory Patients with chronic diseases and those undergo-
reaction involving the activation of complement, ing lengthy surgeries are at particular risk for medias-
cytokines such as chemokines and interleukins, and tinitis. (See Who’s at risk?) In some patients, fever,
other cell-derived proteins. leukocytosis, and a positive blood culture may be the

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Who’s at risk?
Patient risk factors for mediastinitis include obesity,
diabetes (especially if uncontrolled), chronic obstruc-
tive pulmonary disease (COPD), smoking, renal dys-
function, peripheral vascular disease, advanced age,
impaired nutritional status, advanced heart failure
(New York Heart Association class IV), and preexisting
infection. Patients with a tracheostomy, those with a
preoperative hospital stay of more than 5 days, and
women also are at higher risk for mediastinitis.
Intraoperative risk factors include emergency
surgery, repeat surgery, surgery lasting more than 4
hours, cardiopulmonary bypass lasting more than 2
hours, cross-clamping of the aorta, intra-aortic balloon
pump therapy, and use of both internal mammary
arteries (especially in patients with diabetes).
Postoperative risk factors include excessive medi-
astinal bleeding, reexploration for bleeding, transfu-
sions of more than five units of blood, prolonged ven-
tilatory support, delayed sternal closure, low cardiac
output requiring inotropic support, long ICU stay, post-
operative tracheostomy, and infection at another site.
The more risk factors the patient has, the greater the
risk of developing mediastinitis. You can estimate his
risk using one of two tools. The Pre-operative
Estimation of Risk of Cerebrovascular Accident and
Mediastinitis, developed by the Northern New England
Cardiovascular Disease Study Group, assigns weighted
values to patient characteristics, such as diabetes and
COPD. The higher the score, the higher the patient’s
risk of developing mediastinitis.
A second tool is the National Nosocomial Infections
Surveillance risk index, which is based on three vari-
ables proven to be predictive of surgical site infections:
the intrinsic degree of microbial contamination at the
surgical site, the duration of the operative procedure,
and host susceptibility. Patients who score more than
2 on the 0 (no risk)-to-3 (highest risk) scale are at
increased risk for mediastinitis.
warning signs of an impending wound infection.
Minor or superficial infections may occur first; you’ll
note localized erythema and tenderness. The sternal
incision may produce serous drainage, or you may
find a localized area of tissue breakdown at the inci-
sion site with purulent drainage. The sternum usually
is stable.
In some patients, purulent drainage is the first sign
of trouble; between 70% and 90% of these patients
have an unstable sternum. The patient also may have
fever, chills, lethargy, leukocytosis, wound pain, and
chest wall pain. (Pain from the infection can be
64cc2 Nursing2006, Volume 36, Number 8
masked by postoperative pain.) Extensive cellulitis
may surround the sternal incision.
Suspect a serious sternal wound infection if your
patient has chest wall pain or a slow recovery not
explained by other conditions, Gram-positive bac-
teremia, leukocytosis, or fever. The infected area may
involve any or all areas of the mediastinum, including
the surgical cannulation and anastomosis sites.
Obtain specimens for blood culture if your patient
develops a temperature above 100.4º F (38º C) after
the first 48 postoperative hours. The initial chest X-
ray may appear normal, but serial X-rays may be use-
ful. As the infection develops, X-rays may reveal air in
the mediastinum and a “sternal stripe” (a vertical
sternal lucency), indicating that air is separating the
two halves of the sternum. A computed tomography
(CT) scan may reveal the loss of integrity of soft tis-
sue in the retrosternum, bilateral pleural effusions, or
bone destruction. It may also show fluid in the nor-
mally air-filled retrosternal space. (Interpretive skills
are required because it may be difficult to distinguish
hematoma formation from an infection.) Needle aspi-
ration of this fluid guided by CT may help with the
diagnosis. Radionucleotide scans may also help iden-
tify the presence and location of infection.
Up to 50% of sternal wound infections are related
to Gram-positive bacteremias. The cause of most
mediastinal infections is Staphylococcus aureus,
including methicillin-resistant S. aureus; other
causative organisms include coagulase-negative
staphylococci, Staphylococcus epidermidis,
Enterobacter, Enterococcus, Klebsiella, Pseudomonas,
and Serratia. When secondary bacteremias occur,
they’re typically associated with S. aureus. Mixed
infections and fungal infections are rare.
Treatment priorities
The first step in treating mediastinitis is to assess the
degree of sternal stability and classify the infection
by type. (See Defining mediastinitis.)
Sternal preservation is a primary goal of treatment
for a deep wound infection such as mediastinitis. If
surgery is performed early, before the sternum deteri-
orates (type I mediastinitis), the procedure may con-
sist of debridement of the sternal edges, exposing
fresh bone and cartilage, and rigorous irrigation of
the mediastinum with placement of drainage
catheters. The sternum is rewired, the incision is
closed, and the patient is put on antibiotic therapy.
More serious infections (generally types IV or V)
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Defining mediastinitis
According to the Centers for Disease Control and
Prevention, an infection is considered mediastinitis if it
meets one or more of the following criteria:
• Organisms are cultured from mediastinal tissue or
fluid obtained during a surgical operation or needle
aspiration.
• The patient has evidence of mediastinitis seen dur-
ing surgery of histopathologic examination.
• The patient has at least one of the following signs
and symptoms that can’t be attributed to another
cause: fever (greater than 100.4º F [38º C]), chest
pain, or sternal instability. The patient also has at least
one of the following: purulent discharge from the
mediastinal area, organisms cultured from blood or
discharge from mediastinal area, or mediastinal
widening on X-ray.
Mediastinitis can be classified as follows:
• type I—developing within 2 weeks of surgery in a
patient with no risk factors
• type II—developing 2 to 6 weeks after surgery in a
patient with no risk factors
• type III—types I and II in patients with risk factors
• type IV—type I, II, or III after one or more failed ther-
apeutic trial
• type V—developing more than 6 weeks after surgery.
are treated with aggressive sternal debridement and
wound packing with moist gauze that’s changed fre-
quently. In the worst cases, the sternum is removed.
When the infection is under control, the surgeon
(usually a plastic surgeon) will use muscle and skin
flaps to close the incision by secondary intention.
The bone may be approximated, depending on the
degree of sternal resection required. He may use a
technique known as the Robicsek procedure to give
the weakened sternum additional support.
The newest method of treating mediastinitis
involves vacuum-assisted closure. The wound is
debrided and a polyurethane foam is applied. An
evacuation tube, vacuum pump, and transparent
drape complete the dressing. Negative pressure is
applied to the wound to drain fluid, inhibit bacterial
colonization, stimulate tissue granulation, and reduce
the frequency of dressing changes. Delayed primary
closure may occur, or the wound may be prepared for
secondary closure with flaps.
Patients must be carefully selected for negative-
pressure wound therapy: If arteries are lying superfi-
cially in the wound bed, negative pressure can cause
arterial thrombosis. This method may require more
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days of therapy to achieve healing and remains under
investigation.
What if my patient needs CPR?
When performing cardiopulmonary resuscitation
(CPR) on a patient with an unstable sternum, you
need to equally distribute the pressure of chest com-
pressions across the entire chest wall, rather than
applying pressure directly over the sternum. The
best way to do this is to use a fracture bedpan,
which can be easily placed on the chest to disperse
the pressure of compressions while protecting the
sternum. Place the bedpan inside a pillowcase, then
place it sideways with the open end over the mid-
sternum and the lipped end on the right side of the
chest. The smooth bottom of the pan should be
against the patient’s chest; place your hands in the
pan opening to perform CPR.
Perioperative precautions
What can you do to reduce your patient’s risk of
mediastinitis? Take these steps before surgery:
• Identify and treat any preexisting infections, such
as urinary tract infections or pneumonia.
• For patients undergoing elective surgery, use a na-
sopharyngeal swab to determine if they’re carriers of
methicillin-resistant staphylococci. Treat patients
who are carriers with mupirocin (Bactroban) nasal
preoperatively, as ordered.
• In the operating room (OR), if necessary, the pa-
tient’s hair at the incision site will be clipped (not
shaved) immediately before surgery.
• Provide an antibacterial skin wash the night before
surgery. Before surgery, in the OR, the patient’s skin
will be prepared with a topical antiseptic containing
chlorhexidine.
• Administer prophylactic antibiotics 30 to 60 min-
utes before the time of incision, as ordered. For
more details, see “Best-Practice Interventions: Pre-
venting Surgical Site Infections” in the June issue of
Nursing2006.
During surgery, these steps reduce infection risks:
• reducing OR traffic
• using laminar airflow ventilation in the OR
• maintaining meticulous surgical technique, includ-
ing the use of double-glove barrier techniques for
the OR team
• using a midline sternotomy incision (as opposed
to a “lazy S” incision) with secure sternal closure
• using subcuticular sutures and a topical skin adhe-
Nursing2006, August 64cc3
sive instead of staples for skin closure
• avoiding the use of bone wax to establish hemo-
stasis and control bleeding. Bone wax provides a
culture medium for bacteria, particularly S. aureus,
and also may embolize to the lungs.
• minimizing operative time and the use of electro-
cautery, which can make tissue more susceptible to
infection.
After surgery, you can help reduce your patient’s
risk of infection by:
• maintaining tight glycemic control (blood glucose
level of 80 to 110 mg/dL), especially in patients with
diabetes. Blood glucose levels over 180 mg/dL are
associated with cellular damage. Administer a con-
tinuous insulin infusion to avoid the peaks and
troughs in blood glucose that can occur with subcu-
taneous insulin.
• maintaining the sterile surgical dressing for the
first 24 to 48 hours postoperatively, unless gross
drainage is evident
• avoiding homologous blood transfusions, which may
increase the possibility of viral or bacterial infection
64cc4 Nursing2006, Volume 36, Number 8
• discontinuing prophylactic antibiotics 24 hours af-
ter incision closure, in accordance with the Centers
for Disease Control and Prevention’s guidelines for
surgical site infection prevention for open-heart
surgery. Continued use of antibiotics following the
initial postoperative period should be based upon
suspected or confirmed infection.
Staying vigilant
By understanding how to recognize mediastinitis,
minimize risks, and respond to problems, you can
help your patient avoid serious postoperative com-
plications. ‹›
SELECTED REFERENCES
Abboud CS, et al. Risk factors for mediastinitis after cardiac surgery.
Annals of Thoracic Surgery. 77(2):676-683, February 2004.
Bojar RM. Manual of Perioperative Care in Cardiac Surgery. Boston,
Mass., Blackwell Publishing, 2005.
Risnes I, et al. Complement activation and cytokine and chemokines re-
lease during mediastinitis. Annals of Thoracic Surgery. 75(3):981-985,
March 2003.
At St. Joseph Mercy Oakland Hospital in Pontiac, Mich., Diane M. Bosen is a clini-
cal nurse specialist in critical care and Soundra D. Mackavich is an advanced tho-
racic cardiac surgery physician extender.
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