A case of Iatrogenic Mediastinitis

Deepa¹, Subadhra Devi², Maha Lakshmi³

¹Nursing Supervisor, Kauvery Hospital, Cantonment, Trichy, Tamil Nadu

²Nurse Educator Kauvery Hospital, Cantonment, Trichy, Tamil Nadu

³Nursing Superintendent, Kauvery Hospital, Cantonment, Trichy, Tamil Nadu

Abstract

Mediastinitis is a severe and potentially life-threatening inflammation or infection that involves the mediastinum. The mediastinum encompasses the space within the thoracic cavity, bordered by the pleural sacs laterally, the thoracic outlet superiorly, and the diaphragm inferiorly. The mediastinum contains many vital structures, including the heart, great vessels, trachea, mainstem bronchi, esophagus, phrenic nerve, vagus nerves, and thoracic duct. Although mediastinitis is uncommon, it should be considered in the differential diagnosis, as any infection involving these structures is life-threatening and requires immediate treatment.

Background

Mediastinitis can be caused by various pathologies that breach the integrity of the mediastinal structures, including iatrogenic, traumatic, or infectious causes. Iatrogenic causes are common and typically involve complications from medical procedures, such as cardiac surgery, esophageal dilation, or endoscopic interventions, where inadvertent injury to the mediastinal tissues can introduce infection. Traumatic causes include direct physical injuries to the chest from accidents or penetrating wounds, which can disrupt the trachea or esophagus, leading to contamination of the mediastinum. Infectious causes often arise from nearby infections spreading to the mediastinum, such as in descending necrotizing mediastinitis, where infections from the oropharynx extend into the mediastinal space. Additionally, infections from other areas, such as pulmonary infections or complications from pancreatitis, can occasionally spread and cause mediastinitis.

Mediastinitis due to esophageal perforation can occur regardless of the perforation’s cause, as the rupture allows gastric fluid to contaminate the mediastinum with digestive flora. This condition is often iatrogenic, accounting for 50% of cases, although it can also be spontaneous or traumatic. Common causes include tracheal or esophageal rupture from endoscopic procedures, Boerhaave syndrome, and foreign body aspiration. Other rare causes include, direct traumatic injury, spread of pulmonary infection, and pancreatitis.

Case presentation

A 45-years aged male referred to Kauvery hospital with complaints of breathing difficulty and retrosternal pain. Initially patient presented to an outside hospital with c/o retrosternal chest pain and regurgitation for the past 15 years and the symptoms had worsened in the past 5 years. The patient was evaluated and found to have Hiatus hernia for which he underwent Laparoscopic Fundoplication. During the procedure the patient was found to have a lesion at the lower end of esophagus for which partial excisional biopsy was done. The following POD -1 patient was extubated, developed breathing difficulty and referred here for further management with a right side ICD in-situ.

Social History

He does not have any history of cigarette smoking, alcohol or drug addiction.

Allergies

No known medicine or environmental allergies.

Past medical history

Systemic hypertension

Physical examination

Vitals signs: Temp – 99F, HR-68/min, BP- 110/70 mmhg, SpO2 – 92% on 40% Fio2, RR- 36/min

Airway – protected with 8 size ETT

Breathing- B/L adequate chest, diminished breath sounds.

Circulation – all peripheral pulse +

Disability – GCS –E4VTM6

In view of breathing difficulty and recent surgery, CECT chest was taken which showed contrast leakage into lower end of esophagus with widening of mediastinum indicating esophageal perforation and mediastinitis. The patient was taken up for emergency thoracoscopic drainage + Diversion Cervical Esophagostomy + Feeding Jejunostomy by the surgical gasteroenterology team. Patient was shifted to ICU post operatively. In the ICU patient was extubated on POD-6 with NIV. Gradually the patient was weaned from NIV with BIPAP and then shifted to ward.

Investigations

POCUS

Good LV systolic function

Grade I LV diastolic dysfunction

Markable Investigations

Sodium – 134 mmol/ dl

Potassium – 3.6 mmol/L

TSH – 1.37 mU/L

Urea – 34.24 mg/dL

Creatinine – 0.55mg/dL

Hb – 11.1 g/dL

PCV – 35 %

Platelet Count – 85600cells/µl

Total Bilirubin -0.40 mg/dL

Direct Bilirubin – 0.13 mg/dL

Indirect Bilirubin – 0.21 mg/dL

SGOT – 21.7

SGPT – 80.1

Albumin- 2.44

Imaging Examination

K/c/o Esophageal surgery post-operative status shows multi-loculated hydro pneumothorax right side with ICD tube in-situ and collapse of right lung with mediastinal shift to left side. Post-operative changes in distal esophagus with fluid collection around it in posterior mediastinal aspect with direct leakage of oral contrast from distal esophagus to right pleural cavity into the hydro pneumothorax. Minimal left pleural effusion with left basal atelectasis.

The CECT scan revealed an active contrast leak into the right thoracic cavity, indicating a serious condition requiring immediate attention.

The patient was started on oxygen support, intravenous fluids, antibiotics, analgesics, and proton pump inhibitors (PPIs) to stabilize condition. After obtaining informed high-risk consent and anesthetic fitness, the patient underwent emergency surgery. The surgical procedure included Thoracoscopic Drainage, Diversion Cervical Esophagostomy, and Feeding Jejunostomy.

Postoperatively, the patient was admitted to the Intensive Care Unit (ICU) and placed on mechanical ventilator support. Total Parenteral Nutrition (TPN) was initiated to provide nutritional support. A cardiologist’s opinion was obtained, and their advice was followed. Feeding through jejunostomy (FJ) was gradually started.

The patient showed signs of improvement and was extubated on POD – 4. Non-Invasive Ventilation (NIV) support was initiated. Antibiotics were escalated according to culture reports, and TPN was stopped. The patient was gradually weaned off NIV support and shifted to ward.

Repeat cultures were taken from the intercostal drain (ICD), and antibiotics were changed accordingly. FJ feeds increased gradually, and the patient’s bowel movements resumed. The abdominal drain and 1 ICD was removed. Although one ICD remained in-situ, the patient’s condition improved significantly, and he was discharged in a stable condition.

Management

IV Fluids

Inj. Meropenem	1gm	IV
Inj. Metrogyl	500mg	IV
Inj. Amikacin	750mg	IV
Inj. Clexane	40mg	SC
Inj. Labetalol	5mg	IV
Inj. Syscan	200mg	IV
Inj. Pantocid	40mg	IV
Inj. Emeset	4mg	IV
Inj. Tramadol	50mg	IV
Inj. Paracetamol	1gm	IV
Inj. Tigecycline	100mg	IV
Inj. Potassium chloride	60meq	IV Infusion

Non-Pharmacological

Nebulization
Chest physiotherapy
Incentive spirometry
Physiotherapy

Follow up treatment

Pantocid 40mg
Paracetamol 1gm
Ecosprin 75 mg
One Up Gold 1 Tab
Cremaffin 10ml

Skilled Nursing Care in Iatrogenic Mediastinitis

Monitoring Vital Signs and Lab Values to detect signs of sepsis or organ dysfunction.
Managing mediastinal drains, including monitoring output and ensuring proper placement.
Administering antibiotics and other medications as prescribed.
Providing wound care, including dressing changes and assessing for signs of infection.
Supporting respiratory function through mechanical ventilation or oxygen therapy.
Delivering nutritional support through enteral or parenteral nutrition.
Preventing complications, such as pressure ulcers or venous thromboembolism.
Collaborating with the healthcare team to develop and implement a comprehensive care plan.
Educating patients and families about the condition, treatment, and self-care.
Continuously assessing and responding to changes in the patient’s condition.

Conclusion

Iatrogenic Mediastinitis is a serious and potentially life-threatening complication that requires prompt recognition, aggressive treatment, and skilled nursing care. With a multidisciplinary approach, including surgical intervention, antimicrobial therapy, and supportive care, patients can recover and achieve optimal outcomes. Early detection, effective management, and prevention of complications are crucial in reducing morbidity and mortality associated with this condition.

A case of Iatrogenic Mediastinitis

A case of Iatrogenic Mediastinitis

Deepa1, Subadhra Devi2, Maha Lakshmi3

Nightingale Journals

Deepa¹, Subadhra Devi², Maha Lakshmi³