Abx prophylaxis for SCS trials

[wscott]

Hi,

What protocol do you use for antibiotic prophylaxis for SCS trials? For the perms? Again, I've found this to be all over the map.

Thanks

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[mid|ine]

Hi,

For the perms? Again, I've found this to be all over the map.

Because there is no evidence I am aware of. I use a gram of IV ancef for both trial and perms.

 

[lonelobo]

Same with the Ancef, though only do trials.

 

[Aether2000]

2 grams cephazolin sodium 30-60 min pre-needle placement or pre-incision (for perms) and 500mg PO QID x 7 days; longer for diabetics.
Allergic to cephalosporins: clindamycin IV and PO after the procedure.

Has a patient 2 weeks ago that did not get her script filled for the antibiotic and developed meningitis after purulent discharge from the skin entry site of the trial lead on day 5 of the trial. She ended up in the hospital on vanc.

 

[drusso]

2 grams cephazolin sodium 30-60 min pre-needle placement or pre-incision (for perms) and 500mg PO QID x 7 days; longer for diabetics.
Allergic to cephalosporins: clindamycin IV and PO after the procedure.

Has a patient 2 weeks ago that did not get her script filled for the antibiotic and developed meningitis after purulent discharge from the skin entry site of the trial lead on day 5 of the trial. She ended up in the hospital on vanc.

I do what algos does except one gram for trials and two grams for implants.

I used to not give antibiotics for trials, but I had one patient develop non-specific signs of spinal meningismus (fever, rigors, chills) negative neuro imaging and negative blood cultures. I long since changed my practice.

 

[lobelsteve]

DO what Algos does.

I recommend IV ABX starting 30 min before trials and perms.

I use PO ABX during the course of the trial. A wire hanging out of the epidural space and wrapped in tegaderm and gauze is the best portal of infection we will see in our clinics. Not using prophylaxis during a trial cannot be a good thing if you ever get called to court.

Not if, but when will he infection occur.

Choice of antibiotic is regional. We like Ancef IV, and Keflex or Cipro PO for trials in Georgia

 

[Pain_doc]

For patients weighing more than 60kg (all my patients...), 2 grams cefazolin not more than 30min prior to procedure. Same for perms. I don't use any oral antibiotics after perms. Currently, I'm using keflex tid-qid during perc trials.

 

[Jcm800]

2 grams cephazolin sodium 30-60 min pre-needle placement or pre-incision (for perms) and 500mg PO QID x 7 days; longer for diabetics.
Allergic to cephalosporins: clindamycin IV and PO after the procedure.

Has a patient 2 weeks ago that did not get her script filled for the antibiotic and developed meningitis after purulent discharge from the skin entry site of the trial lead on day 5 of the trial. She ended up in the hospital on vanc.

trial-ancef 1 gm or cleocin IV, keflex or cleocin x 5 days

perm vanc IV, then keflex or cleocin PO x 7 days

Thinking about just doing Cleocin now that there has been greater resistence to Keflex...

 

[Ligament]

Keflex 4 days before and 3 days after
Hibiclens soap every day three days before
Clinda IV 30 minutes before stim or perm. Don't use Ancef cause of small risk of status epilipticus from intrathecal placement.
Ioban drape
Chloroprep for procedure, dont wash it off

 

[ampaphb]

I do what algos does except one gram for trials and two grams for implants..

Why do you give a different dose with trials than with perms?

 

[hyperalgesia]

Because there is no evidence I am aware of. I use a gram of IV ancef for both trial and perms.

This is what I do. If the hardware is contaminated, the abx won't do jack so I think it's kind of arbitrary. A NS told me once that he gives a 7 day course of PO abx for the trials and perms. Why? Because patients don't read the literature.

 

[Pain_doc]

Ligament: where are you giving the antibiotic that you have to worry about intrathecal/seizures?

Whether its a trial or perm, if the desired goal is adequate tissues levels of antibiotic, you need 2 gm of cefazolin if your patient weighs more than 60kg. If the antibiotic is given too early or you are really slow, consider re-dosing after 4 hours for perms.

 

[lobelsteve]

Let's just make this easy:

http://hopkins-abxguide.org/diagnosis/surgical_infections/full_surgical_prophylaxis.html

Only decision to make is what type of surgery are we closest to performing.
I'll stick with lami guidelines.

 

[nugene]

in our institution, pretty much everyone used either ancef or vanc (if with allergy to penicillin) and depending on risk factors +/- 10 days of keflex

 

[wscott]

update:

Patient for SCS trial with allergy to penicillin.

Which antibiotic to use pre and post SCS trial? Dosing/course ?

 

[Ducttape]

Keflex 500 mg 4 times daily for trial.

Still give Ancef based on body weight pre op.

 

[drrosenrosen]

Cephalosporins are safe to give in PCN allergy. Cross-reactivity rate is much lower than traditionally believed, not to mention many "PCN allergies" are not real.

Ancef 2-3g IV preop and keflex tid during trial

 

[painfree23]

Any of you skip the IV antibiotics in your clinic procedures and only use PO? Hate starting IVs in the clinic

 

[lobelsteve]

Any of you skip the IV antibiotics in your clinic procedures and only use PO? Hate starting IVs in the clinic

Rocephin, ancef, lincocin, clinda can all be given im.

 

[emd123]

Any of you skip the IV antibiotics in your clinic procedures and only use PO? Hate starting IVs in the clinic

I give an IM antibiotic 15-30 min prior to a stim trial, then send the patient home with PO.

 

[painfree23]

I give an IM antibiotic 15-30 min prior to a stim trial, then send the patient home with PO.

Same dose? 2g ancef?

 

[emd123]

Same dose? 2g ancef?

1 g

 

[BobBarker]

Ancef burns like a mofo IM. Just start an IV!

 

[emd123]

Ancef burns like a mofo IM. Just start an IV!

Put a cc of lidocaine in with it. No burn.

 

[painfree23]

Put a cc of lidocaine in with it. No burn.

What’s the total volume ur injecting IM???

 

[emd123]

What’s the total volume ur injecting IM???

I don't know. I order it and my nurse gives it.

 

[lobelsteve]

If giving clinda 900mg IM, it is 4ml total. Best to give 2ml on each glute.

 

[Pacman27]

Also to add to this. I just did a perm with a Neurosurgery buddy of mine as I have not done a perm in awhile so he scrubbed in He added 500 mg vanco power to both the pockets site prior to closing. He stated he has done that with all his cases with 0 infections to date.

 

[Orin]

Also to add to this. I just did a perm with a Neurosurgery buddy of mine as I have not done a perm in awhile so he scrubbed in He added 500 mg vanco power to both the pockets site prior to closing. He stated he has done that with all his cases with 0 infections to date.

We moved to the antibiotic impregnated envelopes. Wrap it around the hardware and cut off a piece for the midline incision. Safer and on-label.

The powder's messy and increases the risk of seroma formation around the hardware. Some of the anesthesia folks were also telling me in big back surgeries, folks were putting Vanc powder in and having patients code due to the quick absorption/hypotension in the setting of already being volume down/etc.

 

[SommeRiver]

I hate the fact that it seems everything is all over the map. No one I ever trained with gave PO ABx after an implant, and that is residency and fellowship. Obviously, it was always given during trials. I'm out of fellowship now like 9 months and I've not given any PO ABx after an implant. I do 2g cefazolin prior to incision, NS irrigation, and vancomycin powder.

I'm thinking of dropping implants and only doing trials bc I am really tired of basically flying by the seat of my pants during an implant and there's nowhere to go to find consensus about certain things regarding SCS. Everyone has their own opinion and it varies in a major way.

It makes it worse during the two NANS courses I've done now when some of the instructors were lying to my face about their stim experiences.

 

[lobelsteve]

IDSA and SCIP guidelines are out there and should be followed.

IDSA : Antimicrobial Prophylaxis for Surgery

https://www.ashp.org/-/media/assets...hash=A15B4714417A51A03E5BDCAC150B94EAF899D49B

Lots of voodoo mentioned in this thread. Stick out like a sore thumb, get hit with a hammer.

 

[SommeRiver]

I didn't see anything in there about PO ABx post op. Granted, I may have missed it bc that is a wall of words and citations.

 

[lobelsteve]

I didn't see anything in there about PO ABx post op. Granted, I may have missed it bc that is a wall of words and citations.

They are not indicated and should not be used after implant.

 

[SommeRiver]

They are not indicated and should not be used after implant.

That is what I thought. Sorry for the confusion.

 

[Ducttape]

I have not done the implants myself and feel that having a neurosurgeon put them in and manage any postop issues works great. Don’t have to worry about getting extra OR time either. And they are all paddle leads so I can encourage any form of exercise, including golf...

 

[Timeoutofmind]

I have not done the implants myself and feel that having a neurosurgeon put them in and manage any postop issues works great. Don’t have to worry about getting extra OR time either. And they are all paddle leads so I can encourage any form of exercise, including golf...

Do u guys place permanent movements restrictions with perc leads??

 

[SommeRiver]

I have not done the implants myself and feel that having a neurosurgeon put them in and manage any postop issues works great. Don’t have to worry about getting extra OR time either. And they are all paddle leads so I can encourage any form of exercise, including golf...

I'm starting to think I'm going to quit implants and just do trials. I just do not think that paddles and cylindrical leads are the same. I've not read anything that proves paddles are superior to cylindrical, but when I'm honest about it and I pretend I'm the patient I would choose a paddle.

 

[painfree23]

Any extra precautions for smokers? (For trials) as smoking may increase infection risk? Any cya stuff?

 

[Timeoutofmind]

I'm starting to think I'm going to quit implants and just do trials. I just do not think that paddles and cylindrical leads are the same. I've not read anything that proves paddles are superior to cylindrical, but when I'm honest about it and I pretend I'm the patient I would choose a paddle.

Why???

I have heard so many people say the opposite!

Why get a lami if u don’t need it? And any revision is gonna be basically impossible

 

[Orin]

I'm starting to think I'm going to quit implants and just do trials. I just do not think that paddles and cylindrical leads are the same. I've not read anything that proves paddles are superior to cylindrical, but when I'm honest about it and I pretend I'm the patient I would choose a paddle.

Paddles and percs are different for sure. There are data about paddles being superior implants, but that was in the tonic stim era where it helped to have very stable positioning and back then people really didn't pay attention to the perc leads implant techniques. The paddle still uses less juice though and should be more durable in the long term, but I don't think they're equivalent at all in terms of surgical risk, tissue trauma, and invasiveness.

I don't think folks should do paddle trials unless you've got to do the lami anyway.

I don't think you should get a paddle unless you have to due to anatomy or repeated failure of percs.

 

[SommeRiver]

I would have a perc trial and a paddle implant. I get the risk is higher and it is more invasive but if I'm to the point I need a stimulator I'm getting a surgical procedure regardless, and paddles seem to migrate less, use less energy, and I like the idea of it being pushed down flat onto the dorsal columns. I understand the idea of fail a perc and then get a paddle due to the greater risk with the lami but a lami isn't exactly an L2-S1 PSF.

 

[lobelsteve]

Perc all the way.
Been in plenty of lami lead surgeries to know better.

 

[Ducttape]

lead migration is the biggest reason for stim failure. There is some low level evidence that might suggest less migration with paddles. And paddles with their contact placement may provide slightly better coverage than 2 perc leads...

That and not having to schedule 1-2 hours for the stim placement and postsurg fu means 4-10 extra slots to counsel patients on cbt....

 

[SommeRiver]

lead migration is the biggest reason for stim failure. There is some low level evidence that might suggest less migration with paddles. And paddles with their contact placement may provide slightly better coverage than 2 perc leads...

That and not having to schedule 1-2 hours for the stim placement and postsurg fu means 4-10 extra slots to counsel patients on cbt....

This is EXACTLY the way I feel about it.

 

[Ronin1]

I would probably say that overall poor patient selection is the main reason for scs failure. If you have many lead migrations take a serious look at your anchoring technique. I have revised many from others that were clearly anchored to nothing substantial. Personally I like the click anchors to prevent lead motion through the anchor and use a three suture technique on each anchor.