Mbbs with chronic smoldering TKA infx

[clubdeac]

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Got a guy that I just found out has a chronic yet actively infected TKA. Been smoldering since 2018 apparently. Did lumbar mbb’s on him last week as I was unaware of the infection. He’s calling back demanding a second block. Told him we need to wait until infx cleared

Curious what your guys’ thoughts were regarding risk of seeding infx with mbb’s vs ESIs? Obviously higher risk with ESI. Is the likelihood of seeding higher with ESI vs mbb or is it just that the location of subsequent infx is more devastating, epidural vs muscular?

I guess I’m trying to determine the chances of him getting a deep paraspinal infx from my mbb

 

[Blackmateria]

Got a guy that I just found out has a chronic yet actively infected TKA. Been smoldering since 2018 apparently. Did lumbar mbb’s on him last week as I was unaware of the infection. He’s calling back demanding a second block. Told him we need to wait until infx cleared

Curious what your guys’ thoughts were regarding risk of seeding infx with mbb’s vs ESIs? Obviously higher risk with ESI. Is the likelihood of seeding higher with ESI vs mbb or is it just that the location of subsequent infx is more devastating, epidural vs muscular?

I guess I’m trying to determine the chances of him getting a deep paraspinal infx from my mbb

Is he on chronic Abx? I had a guy with a chronic shoulder infection for years on chronic Abx, he had a TKA on this regimen and did fine. I did mbbs on him as well and he did ok thank God. Not sure I would do an epidural tho.

 

[clubdeac]

Is he on chronic Abx? I had a guy with a chronic shoulder infection for years on chronic Abx, he had a TKA on this regimen and did fine. I did mbbs on him as well and he did ok thank God. Not sure I would do an epidural tho.

No, scheduled to see ID next week

 

[manowar rules]

I would at least wait until he sees ID. The chance of an MBB spreading a TKA infection is effectively nil. But if somehow, unrelated to your injection, infection spreads to his bloodstream or something, somebody would probably attribute it to you.
An MBB isn’t curing anything, just have him wait a week or 2.

 

[hyperalgesia]

Argh... That's my contribution to this discussion.

 

[MitchLevi]

MBB I'd probably do because it's about as minimally invasive as anything. No steroids in the MBB/RFA. As long as he is on ABx and followed by ID I would do it.

 

[lobelsteve]

I wouldn't even blink at it. Extra-axial- zero risk procedure.
With chronic infection I would not go intra-axial. No ESI or SCS.
Everything else is no worse than a flu shot.

 

[au bon pain]

I wouldn't even blink at it. Extra-axial- zero risk procedure.
With chronic infection I would not go intra-axial. No ESI or SCS.
Everything else is no worse than a flu shot.

Only nit-picking this for potential benefit of any fellows reading this.

The risk of procedure site infection is higher in this patient then a patient without a chronic infection--how much higher is debatable and may range from trivial to significant.
It's not just due to the fact they have a smoldering infection somewhere, but depending on the patient probably moreso due to the predisposing health factors that may have led to the chronic/non-clearing infection in the first place (ie bad protoplasm).

Not saying that doing LMBBs in this patient is "wrong." But in these situations I always take an extra minute to consider the patient's overall health history and then if I think a procedure could be reasonable I do relevant education on risk+shared decision making and document it.

 

[clubdeac]

Great responses. Thank you for your thoughts this far

 

[callmeanesthesia]

Only nit-picking this for potential benefit of any fellows reading this.

The risk of procedure site infection is higher in this patient then a patient without a chronic infection--how much higher is debatable and may range from trivial to significant.
It's not just due to the fact they have a smoldering infection somewhere, but depending on the patient probably moreso due to the predisposing health factors that may have led to the chronic/non-clearing infection in the first place (ie bad protoplasm).

Not saying that doing LMBBs in this patient is "wrong." But in these situations I always take an extra minute to consider the patient's overall health history and then if I think a procedure could be reasonable I do relevant education on risk+shared decision making and document it.

Agree completely. And to emphasize, documentation of (and obviously actually having the conversation of) thorough risk/benefit discussion and shared decision making is key.

 

[Ducttape]

i never use steroids with MBB. i wouldnt in this case. i dont think you do either.

no issues, would do and have done (chronic UTI on lifelong abx for example), but put the ball in ID court and that would reassure the patient. tell him the risk is so low, but to ask ID about an injection that doesnt have steroids. they will say yes.