IPG seroma versus hematoma

[Timeoutofmind]

Not TTP at all

Six days post op

Saw him three days post op and was no swelling at all

No fevers or chills

I Know if it’s a hematoma people are more aggressive about draining it versus a seroma. What are your thoughts?

Hard to get a sense from the picture but there is a pretty decent amount of fluid and it is quite fluctuant

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[SommeRiver]

I'd keep pressure on it and watch it. I wouldn't expect an infection at poat op day 6 either. Watch it and let it declare itself. Follow up Friday.

 

[BobBarker]

I'd keep pressure on it and watch it. I wouldn't expect an infection at poat op day 6 either. Watch it and let it declare itself. Follow up Friday.

Agreed

 

[Ronin1]

Not TTP at all

Six days post op

Saw him three days post op and was no swelling at all

No fevers or chills

I Know if it’s a hematoma people are more aggressive about draining it versus a seroma. What are your thoughts?

Hard to get a sense from the picture but there is a pretty decent amount of fluid and it is quite fluctuant

Leave it alone

 

[Orin]

I would do your due diligence with lab work, CBC/Coags/ESR/CRP/Procalcitonin/etc

I would consider imaging, and I assume you have access to an ultrasound to look at the collection for loculations.
Emergency Ultrasound: Soft-Tissue Assessment

I agree with not tapping it unless you've started antibiotics already.

What is your surgical technique with that pocket creation? It looks a bit more caudal than I would expect for an IPG, though butt cracks can lie.

 

[emd123]

Not TTP at all

Six days post op

Saw him three days post op and was no swelling at all

No fevers or chills

I Know if it’s a hematoma people are more aggressive about draining it versus a seroma. What are your thoughts?

Hard to get a sense from the picture but there is a pretty decent amount of fluid and it is quite fluctuant

If it's a hematoma, leave it alone and it'll become a seroma after the blood breaks down. Drain and you increase the risk of infection by exposing to the outside world. Unless a hematoma is crushing a neural or vascular structure, often better to leave alone.

 

[Timeoutofmind]

I would do your due diligence with lab work, CBC/Coags/ESR/CRP/Procalcitonin/etc

I would consider imaging, and I assume you have access to an ultrasound to look at the collection for loculations.
Emergency Ultrasound: Soft-Tissue Assessment

I agree with not tapping it unless you've started antibiotics already.

What is your surgical technique with that pocket creation? It looks a bit more caudal than I would expect for an IPG, though butt cracks can lie.

I just use blunt dissection with my fingers after I bovie down a couple of cms. Are there any techniques that are associated with a lower risk of seroma formation?

Its just below the belt line, but above where they would sit on it. Thats my usual placement. Are you guys placing at/above the belt line?

 

[paindoc007]

I just use blunt dissection with my fingers after I bovie down a couple of cms. Are there any techniques that are associated with a lower risk of seroma formation?

Its just below the belt line, but above where they would sit on it. Thats my usual placement. Are you guys placing at/above the belt line?

I go for above belt line

 

[swamprat]

I just use blunt dissection with my fingers after I bovie down a couple of cms. Are there any techniques that are associated with a lower risk of seroma formation?

Its just below the belt line, but above where they would sit on it. Thats my usual placement. Are you guys placing at/above the belt line?

I do it in the paralumbar region. That's how I was trained to do it when I was in fellowship. Less tunneling required. If they are really skinny though it can be uncomfortable. Thankfully that doesn't apply to the majority of my patients.

 

[Orin]

For buttock pockets, I mark the belt line and use fluoro to find the iliac crest. I generally try to position the IPG entirely above or entirely below the belt line, but on the iliac wing somewhere. I try to avoid the crest itself so it doesn't mess with the cluneal nerves or fulcrum on that bone.

For most people, I try to dissect down to a fascial plane if possible as I find IPGs stuck just in fat tend to form this weird calcium deposit on the replacement that seems to be due to fat necrosis/mechanical trauma with it moving more. In bigger people which are most of my patients, that will be well outside depths where they can charge, so I have moved to paralumbar/flank pockets where there is less movement. The buttock ones would have patients complaining about sitting on/against them, feeling it moving, and challenges with charging.

I do also ask patients to wear abdominal binders or compressive undergarments for the first three or so days to prevent seroma/hematoma formation. Spanx makes everything amazing.

 

[lobelsteve]

For those of you going in the para lumbar area I would recommend taking an IP Jean take me to your skin and try and go to sleep with it in that position. It just does not make any sense.

 

[SommeRiver]

I do it in the paralumbar region. That's how I was trained to do it when I was in fellowship. Less tunneling required. If they are really skinny though it can be uncomfortable. Thankfully that doesn't apply to the majority of my patients.

Tunneling isn't a problem IMO.

 

[paindoc007]

This is Simple. Ask them where THEY want it in preop. Have an example battery from the rep that you tape on them and say lay down, etc. to see how that feels.

Too much paternalism. They decide. And you’ll get less complaints in 6 months because they feel ownership in that decision, whichever it is.

 

[SommeRiver]

This is Simple. Ask them where THEY want it in preop. Have an example battery from the rep that you tape on them and say lay down, etc. to see how that feels.

Too much paternalism. They decide. And you’ll get less complaints in 6 months because they feel ownership in that decision, whichever it is.

Disagree. I'm not putting your IPG paralumbar, so if you want that someone else will have to do it. I'll do you trial and send you out. By the way, no problem.

Preimplantation visit we go through all this stuff. I don't want to dig around paralumbar and catch bleeders that I didn't know existed. I know the buttock pouch and I know the regional anatomy and I see no reason to do it paralumbar. Close with 3 layers in the buttock to decrease dead space, use vanc powder (yes I'm aware it can cause local irritation and some say acidosis in the pocket), and give them a binder. Try not to Bovie the pocket too much. Try to make a pocket just big enough for the IPG. Tunneling length is a non issue. Take the time preop to mark a good IPG spot under the belt and superiorly in the buttock. I put an Abbott nonrechargeable big battery in the buttock of a 105 lb girl with CRPS and if that doesn't bother her or get in the way, my 260 lb bros with failed back will be fine.

SCS is all BS anyways. What I see in real life does not mirror what other ppl see. Those NANS dudes are liars. I had a very well known implanter during a NANS course tell me he's never seen a CSF leak or adverse event with a DRG lead and he had placed around 75 of them.

 

[pmrmd]

As far as hematoma vs seroma I’m betting hematoma. Blood around the pocket edge and blood inside.

See what it looks like under US.

 

[Timeoutofmind]

As far as hematoma vs seroma I’m betting hematoma. Blood around the pocket edge and blood inside.

See what it looks like under US.

But what is the point of looking at it under ultrasound if I am not going to do anything with it anyway?

 

[Ducttape]

document its size so that you can then document on a later US that it has resolved/decreased in size?

 

[Orin]

It's more to rule out loculated abscess, but seroma vs hematoma can be important for you to decide on anticoagulation, pressure, drainage, and technique improvements.

You don't get better if you don't look for what you're doing wrong.

 

[Timeoutofmind]

Update:

Resolved without issue after tight ace wrap for a few days

 

[soccrwz]

Anyone ever consider draining one of these under sterile conditions and ultrasound, they had a lecture on this at Asra

 

[lobelsteve]

Anyone ever consider draining one of these under sterile conditions and ultrasound, they had a lecture on this at Asra

Vs 1 week of a pressure dressing? No thanks.

 

[Orin]

Anyone ever consider draining one of these under sterile conditions and ultrasound, they had a lecture on this at Asra

Yeah, I have. Draining is immediately helpful but pressure dressing is still important to prevent reformation

 

[soccrwz]

Yeah, I have. Draining is immediately helpful but pressure dressing is still important to prevent reformation

Do you just look at the fluid color cloudy, serosang, purulent. Or do you send off a specimen. Has this ever been part of your decision tree on whether to explant

 

[Orin]

On the ones I have tapped, early on the pockets tend to be cloudy, serosanguinous, and sometimes tinged with that orangish rifampin color if there was Tyrex in there. The older seroma/fluid build ups tend to be clear to serous. Around the leads/anchors/catheters where there is less motion, that generally has almost always been clear to serous, with some orange tinge if a Tyrex was tehre.

When it worries me, I'll send off a gram stain with culture and wait for results, starting empiric abx if the gram stain shows bacteria. They almost always show some WBCs, so I don't get excited by that

I've never seen frank purulent drainage but I would get that explanted after antibiotics were started.

There are reports of referrals to wound care or percutaneous drainage/irrigation to salvage implants in cancer/terminal patients, but I have not had to pursue that either yet.

 

[soccrwz]

what abx to you prefer as an outpatient?

 

[thecentral09]

what abx to you prefer as an outpatient?

Bactria ds 1 po bid for 7-10
Also, this is why I have a patient wear an abd binder for the first few weeks