Removing old lines perioperatively for AV endocarditis?

[jope]

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Hi all,

Just wanted to get your opinions on this issue. At my prior institutions, any patient coming for endocarditis surgery would have their old lines removed perioperative usually at induction and new ones placed to decrease the chance of reinfection.

I had a case on patient that was treated with antibiotics for 10 days with a PICC line and in the end still had to have a redo bioprosthetic valve for AV endocarditis. He did have bacteremia, but last cultures were negative but needed surgery since his symptoms worsened.

I removed the PICC line at the time of the surgery and the patient is doing well POD 2. He is upset that he needs a new PICC now since the first one was hard to put in. The surgeon is upset that the patient's complaining and thinks I was overzealous. I've always done this at other places I've trained at and it seems odd not to do so. Is there any evidence to remove old lines or not?

 

[nimbus]

You did the right thing.

 

[pgg]

The surgeon's probably just mad he won't get to put in yet another valve in a few months.

 

[Robotic Wis-Hipple]

What does ID say at your current institution?

 

[urge]

Hi all,

Just wanted to get your opinions on this issue. At my prior institutions, any patient coming for endocarditis surgery would have their old lines removed perioperative usually at induction and new ones placed to decrease the chance of reinfection.

I had a case on patient that was treated with antibiotics for 10 days with a PICC line and in the end still had to have a redo bioprosthetic valve for AV endocarditis. He did have bacteremia, but last cultures were negative but needed surgery since his symptoms worsened.

I removed the PICC line at the time of the surgery and the patient is doing well POD 2. He is upset that he needs a new PICC now since the first one was hard to put in. The surgeon is upset that the patient's complaining and thinks I was overzealous. I've always done this at other places I've trained at and it seems odd not to do so. Is there any evidence to remove old lines or not?

My philosophy is if you didn't put it in you shouldn't take it out.

Sugery can do it themselves if they want.

 

[Ronin786]

The risk benefit ratio is so terribly in favor of taking out that PICC, what an idiotic thing to be pissed off about.

Redo, redo valve vs. another needle stick. Patient needs to suck it up.

 

[jope]

ID here will strongly advocate for removing them if there is persistent bacteremia, but have no official position on this situation where cultures have come back negative, but the patient still requires surgery for it. I am surprised though that there are no reputable guidelines on what to do though.

 

[bigdan]

OP -

I do what you do; of course that makes me biased in my view: you did the right thing.

Regarding the patient, I'm sorry he's upset. Although I don't know him, it sounds like he is alive, and what you did lowers his risk (at least in my mind) of needing another surgery. Regarding the surgeon, WTF. You did something to DECREASE the risk of reoperation/re-infection, and he's bent. Fu*k that noise, son.

 

[Psai]

Tell the surgeon to **** off

 

[deleted171991]

I wonder why the patient was not properly consented/informed regarding the lines.

We are still failing at respecting/communicating with our patients. I am no better, but I will tell mine even that I plan to place a second IV intraop.

 

[Robotic Wis-Hipple]

Because the idea of informed consent is idealistic, the layman-physician knowledge gap is insane, not to mention it’s been shown that patients don’t recall anything you tell them anyway. I have sick heart patients that are annoyed about PIVs places before “I’m knocked out” let alone more invasive lines.

 

[deleted171991]

Because the idea of informed consent is idealistic, the layman-physician knowledge gap is insane, not to mention it’s been shown that patients don’t recall anything you tell them anyway. I have sick heart patients that are annoyed about PIVs places before “I’m knocked out” let alone more invasive lines.

As idealistic as it may be, legally, one HAS TO ask the patient's permission for anything one does to her. While one cannot go into every little detail, removing a long-term line that will need to be replaced separately (and painfully) IS a big deal, and should have been mentioned.

I am sorry to say but many anesthesia providers are shortsighted, and don't think about long-term implications of everything they do/give in the OR. Ideally, the surgeon should have known that this patient had been a difficult PICC placement, and should have made sure that the line would be replaced while the patient was still asleep in the ICU.

This is the typical fall through the cracks of assembly-lane medicine, where everybody cares only about their own phase of care, and nobody looks at the big picture. (And then we are shocked when some people prefer to be cared for by nurses.) Also, this is a great example of how there is almost no relationship between excellent medical care and patient satisfaction.

 

[MoMoGesiologist]

All these people saying to tell the surgeon to eff off, it's the surgeon who brought his patient to the hospital, did the surgery, and is taking care of the patient postop. While it sounds like the right thing to do, you made a decision that had consequences into the postop period when you are no longer involved in the care of this patient. It wouldn't be unreasonable to discuss such a decision with the primary team/service who end up taking care of this person long after your care is done.

That being said, it's just a PICC line. Hopefully it's not that hard to replace.

 

[Robotic Wis-Hipple]

As idealistic as it may be, legally, one HAS TO ask the patient's permission for anything one does to her. While one cannot go into every little detail, removing a long-term line that will need to be replaced separately (and painfully) IS a big deal, and should have been mentioned.

I am sorry to say but many anesthesia providers are shortsighted, and don't think about long-term implications of everything they do/give in the OR. Ideally, the surgeon should have known that this patient had been a difficult PICC placement, and should have made sure that the line would be replaced while the patient was still asleep in the ICU.

This is the typical fall through the cracks of assembly-lane medicine, where everybody cares only about their own phase of care, and nobody looks at the big picture. (And then we are shocked when some people prefer to be cared for by nurses.) Also, this is a great example of how there is almost no relationship between excellent medical care and patient satisfaction.

While I agree with your statements about the incongruity between good medical care and patient satisfaction, I still blame the surgeon here. The surgeon/anesthesiologist relationship has morphed (in many/most places) to one without dialogue, and it’s not from our desire to avoid it imo. We check that blood is available, screens are done, appropriate abx are given, lines are placed, etc and in the end do end up making a few decisions on our own based on our evaluation of risk/benefit.

Is this ideal? No, but I’ve met maybe 10% of surgeons that don’t act like you’re annoying them or holding up their whole day to ask a few questions or try to discuss a plan. In my experience if the surgeon isn’t afraid of the patient/case for whatever reason they don’t want to talk about any planning. It doesn’t take much negative feedback to stop a behavior.

And, in this PICC case, while I see the postop physicians stances, I also see both the surgeon, and the intensivist, and likely an ID doc that clearly spent more time with the patient and should’ve seen this coming preop or immediately postop. The intensivist couldn’t get the PICC done before extubating?

 

[deleted171991]

While I agree with your statements about the incongruity between good medical care and patient satisfaction, I still blame the surgeon here. The surgeon/anesthesiologist relationship has morphed (in many/most places) to one without dialogue, and it’s not from our desire to avoid it imo. We check that blood is available, screens are done, appropriate abx are given, lines are placed, etc and in the end do end up making a few decisions on our own based on our evaluation of risk/benefit.

Is this ideal? No, but I’ve met maybe 10% of surgeons that don’t act like you’re annoying them or holding up their whole day to ask a few questions or try to discuss a plan. In my experience if the surgeon isn’t afraid of the patient/case for whatever reason they don’t want to talk about any planning. It doesn’t take much negative feedback to stop a behavior.

And, in this PICC case, while I see the postop physicians stances, I also see both the surgeon, and the intensivist, and likely an ID doc that clearly spent more time with the patient and should’ve seen this coming preop or immediately postop. The intensivist couldn’t get the PICC done before extubating?

My guess is that the "intensivist" was a PA or APRN, aka surgeon's monkey. Most anesthesiologist-intensivists try to stay away from the CTICU and the cardiac prima donnas.

It also means they have a bad timeout process, because that's when the lines should have been discussed.

 

[AdmiralChz]

My guess is that the "intensivist" was a PA or APRN, aka surgeon's monkey. Most anesthesiologist-intensivists try to stay away from the CTICU and the cardiac prima donnas.

It also means they have a bad timeout process, because that's when the lines should have been discussed.

You’re not being fair, that PA is fellowship-trained just like you! *sarcasm*