Sternal osteomyelitis after cardiopulmonary resuscitation 87

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Nov 26, 1996 - Cardiopulmonary resuscitation (CPR) can result in various musculoskeletal injuries. Fracture of the sternum is a well- documented complicationĀ ...
JOURNAL OF THE ROYAL SOCIETY OF MEDICINE

Sternal osteomyelitis after cardiopulmonary resuscitation R H Mallinson MRCP1 C H Tremlett Dip RCPath2 B V Payne FRCP3 J E Richards FRCPath4 J R Soc Med 1999;92:87

SECTION OF GERIATRICS & GERONTOLOGY, 26 NOVEMBER 1996

Cardiopulmonary resuscitation (CPR) can result in various musculoskeletal injuries. Fracture of the sternum is a welldocumented complication, with an incidence of 20-40% in a necropsy series by Tilkian et al.1 Haematoma frequently complicates the fracture and may act as a nidus for infection; however, sternal osteomyelitis following closed sternal fracture has rarely been reported. CASE HISTORY

A diabetic woman aged 71 had an asystolic cardiac arrest during insertion of an intrauterine caesium implant for treatment of adenocarcinoma of the uterus. After successful cardiopulmonary resuscitation with defibrillation, closed chest compression, pharmacological therapy and endotracheal intubation, she was transferred to the intensive care unit and a right internal jugular line and right radial arterial line were inserted for supportive therapy. She was ventilated for 24 hours and required intravenous dopamine for 48 hours to maintain renal function. Cardiac enzymes were not raised and no electrocardiographic changes were noted after her arrest. Her condition was stabilized sufficiently to allow transfer to the general ward and her diabetes remained well controlled with insulin. She was apyrexial and showed no signs of infection at the time of transfer. She recovered well and four days after her arrest the internal jugular catheter was removed. The skin around the line was noted to be red and inflamed at this time and a swab from this site was sent for microbiological culture; although this yielded a heavy growth of Staphylococcus aureus sensitive to erythromycin, flucloxacillin and vancomycin, no antibiotics were prescribed. After six more days in hospital, she was discharged home on a maintenance dose of insulin, captopril, frusemide and aspirin. Seven days after discharge she was readmitted with increasing confusion, immobility and shortness of breath. 'Department of Medicine for the Elderly and 2Clinical Microbiology and Public Health Laboratory, Addenbrooke's Hospital, Hills Road, Cambridge CB2 2QW; 3Department of Medicine for the Elderly and 4Public Health Laboratory Service, West Norwich Hospital, Norwich NR2 3TX, UK

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She had a bruise on the right side of the sternum. Her temperature was 39.4Ā°C; blood pressure 110/60mmHg; pulse 120 beats per minute; white blood count 26.6 x 109/L. Sepsis was diagnosed; and, after blood had been taken for culture, she was started on thrice daily cefotaxime 1 g and metronidazole 500 mg. Despite full supportive therapy, she died within four hours of readmission. The blood cultures taken at the time of readmission grew S. aureus with the same antibiotic susceptibility profile as that isolated from inflamed skin around her right internal jugular line during her previous admission. Post-mortem examination revealed sternal osteomyelitis evolving from a fracture of the mid part of the body of the sternum. Pus from this infection had tracked into the subcutaneous tissues and into the left pleural space. Culture of this pus yielded S. aureus. The cause of death was judged to be staphylococcal septicaemia arising from osteomyelitis of the sternum following fracture. COMMENT S. aureus sternal osteomyelitis has been reported only twice as a complication of closed chest CPR2'3 though such infections are not uncommon in the setting of antecedent

chest wall trauma, such as thoracic surgery4 or sternal marrow aspiration and biopsy5. In this case, the patient's fracture probably became infected as a result of bacteraemia from infection of her right internal jugular line: the isolates from her line site, her blood cultures and her sternal pus all yielded the same antibiotic susceptibility profile. No likely source of infection was identified in the two previously reported cases2'3. We suggest that a potential focus of infection or signs of sepsis in patients with closed sternal fracture following CPR should be fully investigated and treated promptly to reduce the risk of sternal osteomyelitis secondary to bacteraemia. With established sternal osteomyelitis, surgical debridement may be required in addition to antimicrobial therapy. REFERENCES 1 Tilkian AG, Conover MB. Cardiopulmonary resuscitation. In: Tilkian AG, Daily EK, eds. Cardiovascular Procedures. St Louis: Mosby,

1986:409-34 2 Mensah GA, Gohl JP, Schreiber T, Isom OW. Acute purulent mediastinal and sternal osteomyelitis after closed chest cardiopulmonary resuscitation: a case report and review of the literature. Ann Thorac Surg

1988;46:353-5 3 Enat R, Pollack S, Wiener M, Barzilow D. Osteomyelitis in fractured sternum after cardiopulmonary resuscitation. N EnglJ Med 1979;301:

108 4 Cafferty MT, Luke DA, Keane CT. Sternal and costochondral infections

with gentamicin and methicillin resistant Staphylococcus aureus following

thoracic surgery. ScandJ Infect Dis 1983;15:267 5 Shah M, Watanakunakom C. Staphylococcus aureus sternal osteomyelitis complicating bone marrow aspiration. South MedJ 1978;71 :348

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