IPG infxn

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MitchLevi

MitchLevi

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Sucks...My first one.

Meticulous technique during implant (Ioban, vanc powder, IV Abx, etc).

L3-S1 fusion with autoimmune Hx on DMARDs (Cosentyx). I wouldn't want to stop Cosentyx for an implant because that takes awhile to restart it and ppl are often miserable for 2-3 months.

POD 10 yesterday with erythema, pain and swelling at the IPG site (Abbott Eterna).

Midline wound is great, sutures removed without incident.

IPG wound is painful and warm. I expressed a decent amount of serous fluid from the wound, and I'm leaving the sutures in place and doing pressure dressings with gauze, ABD pads, abdominal binder and Bactrim DS BID. Even had one of spine surgeons come in and look at the wound with me.

See her back Friday of this week.

Do whatever we can to keep that system in place without explanting it.

My question for everyone - Is there any utility to washing out an IPG pocket while keeping the IPG internalized?

I've never done that and I'm concerned I could mobilize bacteria into other areas by doing that.

If this doesn't resolve with the above measures, I'm yanking this thing out and we can try again after a few months and an ID consult.
 
when in doubt.... take it out

did you culture the wound?
 
That sucks man. Happens to us all if we put in enough. I’d recommend getting ID on board early in case they need to admit and start a PICC line. I agree with serial ESR CRP CBC.

I’d also ask the patient if they came in with something brewing they didn’t tell anyone about. Meaning perhaps there was hematagenous spread rather than poor sterile technique. I’ve seen this a couple of times.
 
SSdoc33 said:
when in doubt.... take it out

did you culture the wound?
Click to expand...
Didn't culture it, and truly don't see the benefit of doing it TBH.

If I explant it, I'll culture the device.

I'm going to try and salvage it. Gauze, ABD pads, binder and Bactrim.

If by Friday it isn't better, I'll prob remove it.
 
That IPG is fully contaminated and there are all sorts of nooks and crannies critters can hide in. Short of autoclaving it there is nothing you can do to make it sterile again. Bacteria have a direct route to the epidural space.

If you try to salvage it, it will just get reinfected again a few months from now and might be even worse.

I'd take it and the leads out and try again in 6mo or so.
 
I know ppl who have salvaged these things. I'm gonna see what it looks like Friday.
 
You’re doing it correct. Try and salvage. The patient deserves that chance. Just educate the patient the likelihood of the system staying in is probably 1 in 5..
 
MitchLevi said:
I know ppl who have salvaged these things. I'm gonna see what it looks like Friday.
Click to expand...
NACC guidelines quote >50% reinfection of infected ICDs and less than 40% success rate of salvage of infected deep brain stimulators. I definitely understand the desire to salvage it but it's playing a losing hand with potential catastrophic consequences if you lose.

I'd recommend have a really frank discussion with the patient about risks vs benefits and document, document, document if you decide to proceed with salvage.
 
If you don’t explant, should she be on PICC line antibiotics? I thought that’s what they did for hardware infection. Might not be a bad idea asking ID considering she’s on a biologic.
 
In fellowship we always put bacitracin ointment over the incisions after wound closure, not sure if that’s superstition or sound practice but I always do that now. Nice layer of bacitracin ointment, 4x4 then tegaderm.
 
Just called her.

Nontender, still somewhat red but much improved. Minimal drainage. Afebrile. Not sick. No systemic issues.

I'll see her tomorrow in the clinic.

Short leash for explant. We're POD 12 today, and she's taken 4 doses of Bactrim.

If tomorrow it looks better and she is doing well, I'll see her Tuesday.

I am aware of the fact this could stabilize over the course of the next few days and subsequently worsen next week or 6 weeks from now.

Let's see how it goes.

I've already spoken to the OR schedulers and have a plan for ED admission to OR for explant at any time.

Appreciate everyone's input. We should talk more often about this stuff. I do a good bit of stim, and I've been lucky so far. I had one emergent explant in 2018 that turned out NOT to be an infection at all, and was unrelated to my SCS. Other than that, I'm clean until this one...Twas a matter of time!
 
MitchLevi said:
Just called her.

Nontender, still somewhat red but much improved. Minimal drainage. Afebrile. Not sick. No systemic issues.

I'll see her tomorrow in the clinic.

Short leash for explant. We're POD 12 today, and she's taken 4 doses of Bactrim.

If tomorrow it looks better and she is doing well, I'll see her Tuesday.

I am aware of the fact this could stabilize over the course of the next few days and subsequently worsen next week or 6 weeks from now.

Let's see how it goes.

I've already spoken to the OR schedulers and have a plan for ED admission to OR for explant at any time.

Appreciate everyone's input. We should talk more often about this stuff. I do a good bit of stim, and I've been lucky so far. I had one emergent explant in 2018 that turned out NOT to be an infection at all, and was unrelated to my SCS. Other than that, I'm clean until this one...Twas a matter of time!
Click to expand...
I appreciate you sharing the whole exper once with us.
 
Dramatic improvement. Bactrim since Tuesday. I tried to get Rocephin IM but can't get my hands on it so we ordered a few vials to keep on hand in case this happens again in the future.

I'll see her again next Friday.

She has several days left of Bactrim.

Top pic - I had removed three sutures on Tuesday when it began pouring serous fluid. That's why the suture line looks incomplete. The left corner pocket tie is the one that began pouring.

Not completely out of the woods yet, but this is night and day.

1000013415.jpg
1000013416.jpg
 
still a bit red. hopefully the antibiotics will be good.

in this case, if you had planned on saving the device from the start, i might have suggested at the start of getting a culture, to confirm antibiotic sensitivity. too late now.

if it gets worse, i suppose you are going to explant? would seem the logical choice over switching antibiotics.
 
nice, thanks for sharing! interesting, wonder if this is just superficial cellulitis, a suture abscess, not really pig infection. Congratulations for salvaging the device.
 
BobBarker said:
Is the first pic from Tuesday? It didn’t look that bad to me.
Click to expand...
Both pics from today.

I took out the remaining sutures today.

Tuesday was warm, red and blanching with finger pressure. I bet I got 5-10 cc of serous fluid out of that thing. No drainage since Wed BTW. The gauze, ABD pad and binder worked great. Allowed it to drain those last few cc out Tuesday night and Wed AM.

On Tuesday I squeezed and squeezed and got a lot of fluid out. She felt better even before leaving the office that day.

Weird how much better it looks. I was expecting to pull it out tonight.
 
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Ducttape said:
still a bit red. hopefully the antibiotics will be good.

in this case, if you had planned on saving the device from the start, i might have suggested at the start of getting a culture, to confirm antibiotic sensitivity. too late now.

if it gets worse, i suppose you are going to explant? would seem the logical choice over switching antibiotics.
Click to expand...
Not out of the woods yet. Will explant the moment this gets worse.

Far better though. Looks nothing like it did Tuesday.
 
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I too think it was cellulitis with a little seroma development. Your pic is satisfying to me. I like popping things, and that's a nice one you got right there.

Unfortunately, it looks like a single dissection implant which isn't ideal IMO. Then again, I can't really see much.
 
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what do you all do after explanting? Culture, irrigation, ID consult/abx, and then close the wound? Anybody leave the incision open with wound vac?
 
Next time, try not to scratch your head with your sterile glove.

I don’t do a ton of stim and I had an infection a few times ago. It does suck. It made me not want to ever do them again.

This one, however pissed me off. After it got removed and I saw him on follow up, the patient says to me “yeah I thought that might happen. I get staph infections all the time. I have some weird white blood cell disorder so they don’t work great.”

One time, early in my attending career, I closed up everything only to realize - holy crap- I completely forgot to irrigate! Turned out okay though.
 
Of all the infections I’ve had over the years , in almost every case there was “poor protoplasm” at work. Although I did have a doctors wife scratch open an ipg pocket because it itched! Infections are going to happen. Just handle them appropriately
 
First in-house stim case in my practice was a trial of mine. A man with the following data points:

1. HIV+
2. Hep C+
3. 10" x 10" tattoo of two men having sex while Satan masturbates off to the side while watching

Comes in on day 5 for lead removal. I get TL imaging. Can't find the leads. They're not on the XRAY. I walk over to XRAY and I'm like, "Did yall mix up films between pts? The trial pt...Can't find leads."

I walk in the room and the most inferior 3 electrodes are hanging out.

This dude and his partner removed the leads, played with them and tried to put them back without me knowing it.

We got rid of him.




Edit - The ads on this site are ruining the forum. In the last few days, I have ads throughout the forum thread list. It sucks.
 
Last edited:
MitchLevi said:
First in-house stim case in my practice was a trial of mine. A man with the following data points:

1. HIV+
2. Hep C+
3. 10" x 10" tattoo of two men having sex while Satan masturbates off to the side while watching

Comes in on day 5 for lead removal. I get TL imaging. Can't find the leads. They're not on the XRAY. I walk over to XRAY and I'm like, "Did yall mix up films between pts? The trial pt...Can't find leads."

I walk in the room and the most inferior 3 electrodes are hanging out.

This dude and his partner removed the leads, played with them and tried to put them back without me knowing it.

We got rid of him.
Click to expand...
1688495524027.jpeg
 
MitchLevi said:
First in-house stim case in my practice was a trial of mine. A man with the following data points:

1. HIV+
2. Hep C+
3. 10" x 10" tattoo of two men having sex while Satan masturbates off to the side while watching

Comes in on day 5 for lead removal. I get TL imaging. Can't find the leads. They're not on the XRAY. I walk over to XRAY and I'm like, "Did yall mix up films between pts? The trial pt...Can't find leads."

I walk in the room and the most inferior 3 electrodes are hanging out.

This dude and his partner removed the leads, played with them and tried to put them back without me knowing it.

We got rid of him.
Click to expand...
OMG-
 
MitchLevi said:
Edit - The ads on this site are ruining the forum. In the last few days, I have ads throughout the forum thread list. It sucks.
Click to expand...

I KNOW!!’

What is up with that?!! They are huge and everywhere. It has gotten a lot worse these last few days.
 
MitchLevi said:
First in-house stim case in my practice was a trial of mine. A man with the following data points:

1. HIV+
2. Hep C+
3. 10" x 10" tattoo of two men having sex while Satan masturbates off to the side while watching

Comes in on day 5 for lead removal. I get TL imaging. Can't find the leads. They're not on the XRAY. I walk over to XRAY and I'm like, "Did yall mix up films between pts? The trial pt...Can't find leads."

I walk in the room and the most inferior 3 electrodes are hanging out.

This dude and his partner removed the leads, played with them and tried to put them back without me knowing it.

We got rid of him.




Edit - The ads on this site are ruining the forum. In the last few days, I have ads throughout the forum thread list. It sucks.
Click to expand...

What do you even say to a patient like that?
 
...comin' out this week.

Draining started back. Wound reopened.

Not systemically ill.
 
I’m curious to know how you closed it? Wound vac, or primary closure with a drain? Some other way?
 
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