IPG infxn

[MitchLevi]

So, rather unimpressive case to be honest.

Ancef 2g IV 30 min prior to incision, with vancomycin powder 1g in the wounds and obviously I irrigated it before the vanc powder.

It was draining already so there really wasn't any fluid in the pocket when I reopened the IPG scar. No obvious pus. No warmth or erythema. No blanching to touch.

Just an IPG wound that wouldn't close. Perhaps a 7mm section that wouldn't close and we're at 6/16/2023 day of the implant.

It was initially cellulitis with perhaps a small seroma? The Bactrim, Rocephin IM (she did end up getting one dose) gauze, ABD pads and binder cleared that up quickly.

Rocephin 1g IM
Bactrim DS BID 14d
Repeated application of SteriStrips trying to keep the wound edges closed.
She was putting regular BandAids on it too by the way. The type that as you peel away the BandAid it pulls the skin with it, so I'm sure she was keeping tension on the wound edges.

At the very beginning she was very tender and felt slightly nauseated and fatigued. Never systemically ill or "sick." Afebrile.

I cultured the entire device, swabbed the IPG pocket x 2 and the midline wound x 1 (zero concern about the midline wound).

Two leads sitting nicely midline at the T7-8 disk space and mid T8.

Patient was experiencing benefit from her FBSS and persistent radic. Crying. We will revisit this perhaps in Nov or Dec.

I did not consult ID. I will wait and see the cultures before doing that.

That wound did not look infected other than the fact it just wouldn't close.

3-0 vicryl in the fascia with nylon on the skin, all simple interrupted. Dermabond. SteriStrips and Tegaderm.

The portion of the wound that wouldn't close was slightly friable and I did have to take care tying that tissue back together.

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[lobelsteve]

So, rather unimpressive case to be honest.

Ancef 2g IV 30 min prior to incision, with vancomycin powder 1g in the wounds and obviously I irrigated it before the vanc powder.

It was draining already so there really wasn't any fluid in the pocket when I reopened the IPG scar. No obvious pus. No warmth or erythema. No blanching to touch.

Just an IPG wound that wouldn't close. Perhaps a 7mm section that wouldn't close and we're at 6/16/2023 day of the implant.

It was initially cellulitis with perhaps a small seroma? The Bactrim, Rocephin IM (she did end up getting one dose) gauze, ABD pads and binder cleared that up quickly.

Rocephin 1g IM
Bactrim DS BID 14d
Repeated application of SteriStrips trying to keep the wound edges closed.
She was putting regular BandAids on it too by the way. The type that as you peel away the BandAid it pulls the skin with it, so I'm sure she was keeping tension on the wound edges.

At the very beginning she was very tender and felt slightly nauseated and fatigued. Never systemically ill or "sick." Afebrile.

I cultured the entire device, swabbed the IPG pocket x 2 and the midline wound x 1 (zero concern about the midline wound).

Two leads sitting nicely midline at the T7-8 disk space and mid T8.

Patient was experiencing benefit from her FBSS and persistent radic. Crying. We will revisit this perhaps in Nov or Dec.

I did not consult ID. I will wait and see the cultures before doing that.

That wound did not look infected other than the fact it just wouldn't close.

3-0 vicryl in the fascia with nylon on the skin, all simple interrupted. Dermabond. SteriStrips and Tegaderm.

The portion of the wound that wouldn't close was slightly friable and I did have to take care tying that tissue back together.

Sounds ideal to try and salvage. Biofilm wins.
ID consult for timing on re-implant. I use 0 vicryl deep, 3-0 superficial, dermabond skin, then opsite over the top.
I use Epifix 4x4 in wound bed for patients at risk for infection (over 75, immunocompromise status).
I also have asked no one touch any of the equipment except me. Tech just puts the stim kit on the mayo for me. I am only one handling IPG and leads.

 

[paindoc007]

I would have done three things differently.

One, I don’t leave the leads in. If battery comes out, it all comes out.

Two, I don’t start iv abx until I get in there, swab the wound, and send out cultures. Once that happens, IV abx can flow.

Three, this is a judgement call, but I lean toward closure by secondary intention, so wet to dry with home health doing daily changes. You describe some dehiscence and friability skin issues so my concern would be more closure problems in the next days but time will tell.

I agree on the no ID c/s. Not necessary.

Thanks for the case. Nice one for us to hash out and learn from.

 

[Baron Samedi]

Yeah leaving leads in leads to badness. You're going to have the re-open the midline anyways to tunnel to the new contralateral pocket site anyways so little to gain by leaving them in.

 

[MitchLevi]

Whole system came out. I just realized how that post read...I removed the leads. They were perfectly relaxed laying there in good position to stim this lady. They all came out.

 

[MitchLevi]

Tell me about Epifix.

Is that a biologic sheet? You just drop it on top of the IPG and close over it?

 

[SC Tian]

Sounds ideal to try and salvage. Biofilm wins.
ID consult for timing on re-implant. I use 0 vicryl deep, 3-0 superficial, dermabond skin, then opsite over the top.
I use Epifix 4x4 in wound bed for patients at risk for infection (over 75, immunocompromise status).
I also have asked no one touch any of the equipment except me. Tech just puts the stim kit on the mayo for me. I am only one handling IPG and leads.

interesting, i use 2-0 Vicryl for fascia closure, and 3-0 monocryl for subq, that is it, I encountered 2 cases of suture abscess from Vicryl in the 12 months or so. they all have I had our surgeons inspecting those as well, they just laughed at it, saying it is ok.

 

[lobelsteve]

Tell me about Epifix.

Is that a biologic sheet? You just drop it on top of the IPG and close over it?

4x4 sheet, used to have powder version. Lay it in deep wound bed and acts like a matrix to speed up healing. Ortho by me uses it in every shoulder. Gyn uses it on cervix/uterus.

 

[MitchLevi]

4x4 sheet, used to have powder version. Lay it in deep wound bed and acts like a matrix to speed up healing. Ortho by me uses it in every shoulder. Gyn uses it on cervix/uterus.

I am intrigued by this.

How do you order this? Just, "Epifix 4x4?"

 

[lobelsteve]

I am intrigued by this.

How do you order this? Just, "Epifix 4x4?"

There are tissue bank order sheets in OR so before case starts I ask for 2 4x4cm Epifix and they get a "tissue runner" to bring it in.
If you want more info I can ask the rep to get me data sheets.

 

[MitchLevi]

There are tissue bank order sheets in OR so before case starts I ask for 2 4x4cm Epifix and they get a "tissue runner" to bring it in.
If you want more info I can ask the rep to get me data sheets.

Please do. I may use these for hospital cases.

 

[lobelsteve]

Please do. I may use these for hospital cases.

SM or ARMC?

 

[MitchLevi]

SM or ARMC?

SM only. I won't do another case at ARMC. Ever.

 

[epidural man]

I am intrigued by this.

How do you order this? Just, "Epifix 4x4?"

When used it prostatectomies, the return to function rate for the male is significantly reduced in time. It has great stuff in it.

I wish it were used for so many more things.

I saw a picture from the company after a c-section from a woman who had keloid issues. The physician only had enough for half the wound, and the scar with the Epifix had no keloid, and the other half grew a big keloid as you would expect.

 

[MitchLevi]

This Epifix is severely extreme and I'm salivating.

Since it's a biologic, does that mean these are stem cells and they know where to go and they'll fix everything?

 

[lobelsteve]

This Epifix is severely extreme and I'm salivating.

Since it's a biologic, does that mean these are stem cells and they know where to go and they'll fix everything?

I tell the reps that it’s dead, baby dust. It is only amniotic tissue extract, and no cells.

 

[MitchLevi]

I tell the reps that it’s dead, baby dust. It is only amniotic tissue extract, and no cells.

Can I choose which baby we incinerate?

 

[lobelsteve]

Their headquarters are in Marietta. Come to the city for dinner and I’ll see what I can arrange.

 

[MitchLevi]

I'll PM you soon. Next few weeks or so.

 

[clubdeac]

not to be a Monday morning quarterback but I would've stopped the cosyntx. I think all those immunosuppressants are riskier than we realize when it comes to stim and infections. My only infection was a stim case in a guy on MTX that I didn't stop.

 

[lobelsteve]

not to be a Monday morning quarterback but I would've stopped the cosyntx. I think all those immunosuppressants are riskier than we realize when it comes to stim and infections. My only infection was a stim case in a guy on MTX that I didn't stop.

Not a simple thing.

Preoperative Evaluation and Management of Patients Receiving Biologic Therapies

The preoperative care of patients undergoing orthopedic surgery and treated with biologic agents is of great significance. Perioperative use of biologic agents could lead to such complications as infection and delayed postoperative wound healing. This ...

www.ncbi.nlm.nih.gov

Depends on the disease, drug, surgery. And which rheumatology guidelines you use. Anywhere from 1-8 weeks of holding the drug.

 

[MitchLevi]

All cultures negative - What an odd and unlucky sequence of events.

What we have an IPG wound that simply wouldn't close. I considered at one point just throwing a few nylon stitches in the skin because the fascia layers looked to be closed, but obviously that's not the best idea. I was going to do that in an exam room. During the wound exploration I can say the fascial layers were closed save one very small section of perhaps a couple mm.

By the way, with an implant date 6/16/23, the Vicryl stitches are not completely dissolved yet. So I pulled out all of the ones I could find.

Maybe cellulitis and a seroma at the beginning, but the ABx/ABD pads/binder took care of that.

Stopping Cosyntex is no small feat. Her RA would potentially go nuts for 2-3 months while we stop it and restart it. I've been told that medication takes 8-12 weeks to declare itself.

I'm going to re-implant her around Nov-Dec.

Good experience for me.

 

[Agast]

Did you draw labs when she showed up POD 10 with the warm and painful IPG pocket? Elevated white count/ESR/CRP?

 

[MitchLevi]

Did you draw labs when she showed up POD 10 with the warm and painful IPG pocket? Elevated white count/ESR/CRP?

No. Didn't think it would be of value TBH. She was tender at the site, but not sick. Afebrile.

 

[Agast]

I like to draw labs if I’m going to start antibiotics, so there’s a data point that can be trended later. If her labs were not concerning for infection throughout the process it may have turned the needle towards washout and wound revision.

 

[lobelsteve]

I like to draw labs if I’m going to start antibiotics, so there’s a data point that can be trended later. If her labs were not concerning for infection throughout the process it may have turned the needle towards washout and wound revision.

If you are starting antibiotics then you are treating an infection. But the labs are a must so you get a feel for how bad it is where you cannot see.
If WBC came back at 25 and ESR was 100: don't care if she is sick or not, the whole thing comes out that day.

 

[clubdeac]

On a side note, did an epidural on a young lady who called back 4 days later with worsening lbp and fever of 101.7. It was Friday afternoon and the office was closed so I sent her to the ER. You guys think that was the right call or overkill?

 

[Baron Samedi]

On a side note, did an epidural on a young lady who called back 4 days later with worsening lbp and fever of 101.7. It was Friday afternoon and the office was closed so I sent her to the ER. You guys think that was the right call or overkill?

Nah correct decision 100% of the time.

 

[paindoc007]

On a side note, did an epidural on a young lady who called back 4 days later with worsening lbp and fever of 101.7. It was Friday afternoon and the office was closed so I sent her to the ER. You guys think that was the right call or overkill?

Yep, no question about it. The real question here is say the phone call was Fri morning instead. How do you deal w/ that?

 

[clubdeac]

Yep, no question about it. The real question here is say the phone call was Fri morning instead. How do you deal w/ that?

Friday morning I would’ve had her come in for eval and lab work. As it were she went to the ER. They did the full work up, ESR, CRP, blood cultures, lactic acid, MRI and abd/pelvic CT, all were negative.

Depending on how she looked in clinic I think I would’ve just gotten a CBC, ESR and CRP and waited on the MRI until the labs came back

 

[RoloTomassi]

Friday morning I would’ve had her come in for eval and lab work. As it were she went to the ER. They did the full work up, ESR, CRP, blood cultures, lactic acid, MRI and abd/pelvic CT, all were negative.

Depending on how she looked in clinic I think I would’ve just gotten a CBC, ESR and CRP and waited on the MRI until the labs came back

While that's medically reasonable I always try to think like a plaintiff attorney. Assuming labs come back next week, if she ended up having an infection and had sequela...You waited a whole weekend before getting an MRI? Why didn't you start antibiotics if you suspected infection? Shouldn't someone with a suspected spine infection, that you know can cause paralysis and death, have had emergent medical treatment?

 

[lobelsteve]

On a side note, did an epidural on a young lady who called back 4 days later with worsening lbp and fever of 101.7. It was Friday afternoon and the office was closed so I sent her to the ER. You guys think that was the right call or overkill?

Pyelonephritis.

I have pt in office for Esr/Crp/Cbc/blood cx/Mri with and without. If unable to get in. Same thing for ER.

 

[Ducttape]

Friday morning I would’ve had her come in for eval and lab work. As it were she went to the ER. They did the full work up, ESR, CRP, blood cultures, lactic acid, MRI and abd/pelvic CT, all were negative.

Depending on how she looked in clinic I think I would’ve just gotten a CBC, ESR and CRP and waited on the MRI until the labs came back

agree, she needs to be seen and then a medical decision made as to whether she has spine infection (unlikely) or other infection (quite likely).

All cultures negative - What an odd and unlucky sequence of events.

culture negative after being on antibiotics does not mean that you did not have infection. it probably means that you started the appropriate antibiotic. i have never heard of an ID doctor stopping antibiotics in the similar situation of negative culture results in an already treated patient.

 

[MitchLevi]

culture negative after being on antibiotics does not mean that you did not have infection. it probably means that you started the appropriate antibiotic. i have never heard of an ID doctor stopping antibiotics in the similar situation of negative culture results in an already treated patient

ABx were started weeks ago. After she finished the ABx we went another 2+ weeks of a good looking wound that just wouldn't close.

Just not sure why it never closed.

 

[MitchLevi]

Interestingly, one of our spine surgeons closes with Vicryl only. Fascia 1-0, skin with 2-0 and subcuticular 3-0.

 

[epidural man]

All cultures negative - What an odd and unlucky sequence of events.

What we have an IPG wound that simply wouldn't close. I considered at one point just throwing a few nylon stitches in the skin because the fascia layers looked to be closed, but obviously that's not the best idea. I was going to do that in an exam room. During the wound exploration I can say the fascial layers were closed save one very small section of perhaps a couple mm.

By the way, with an implant date 6/16/23, the Vicryl stitches are not completely dissolved yet. So I pulled out all of the ones I could find.

Maybe cellulitis and a seroma at the beginning, but the ABx/ABD pads/binder took care of that.

Stopping Cosyntex is no small feat. Her RA would potentially go nuts for 2-3 months while we stop it and restart it. I've been told that medication takes 8-12 weeks to declare itself.

I'm going to re-implant her around Nov-Dec.

Good experience for me.

Because it is easy for me (and I like them), I would have gotten plastics involved.

 

[soccrwz]

Regarding ioban vs chlorhexidine. The chlorhexidine may not get to the depth of the hair root where infections live and the chlorhexidine coats the skin and hair follicle, the ioban gets to the depth of the hair follicle

 

[MitchLevi]

I use both.

 

[MitchLevi]

PostOp from explant.

Midline wound normal.

IPG site painful, blanching to palpation and slightly full.

Wound closed nicely however.

1g Rocephin IM and see back in 7 days.

Infuriating.