SCS infection
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What color drainage? Odor? Erythema?
No erythema. Milky colored. No particular odor.
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Get some blood markers to trend. If you want to salvage it, culture the drainage, start oral or IV abx. If you can't culture, Bactrim or Levaquin. If you want to play it safest from an infection perspective, take it back for a washout and explant if deep
keflex after ESR/CRP/CBC. Could CT pocket for fluid collection.
Thank you. CT shows subcutaneous edema. Started Keflex. Will be exploring next week. How do you determine whether to explant? Depth of involvement?
What do you use for washout?
Do you irrigate the pocket for the leads? I did not, usually only irrigate the IPG pocket.
A washout to me is exploring for damaged tissue and infection. If you're trying to salave it, I would normally get a good scrub and prep, open in layers, soak and irrigate in layers with antiseptic irrigation like Irrisept/Phase One/Surgiphore or their equivalent, and keep going until you see clean hardware or are confident the tissue has healed. For antiseptic irrigation, soaking is important to kill things and get into biofilms.
The question is where the infection is and if it's limited to the pocket, stay there. If it looks like it gets to the hardware as you get deeper, take it all out as it will track with time along the seeded hardware.
The question is where the infection is and if it's limited to the pocket, stay there. If it looks like it gets to the hardware as you get deeper, take it all out as it will track with time along the seeded hardware.
Irrigate everything. If there is infection in the pocket, it is probably on the leads, and they will have a biofilm and are unlikely to be salvageable. If it doesn’t look too bad and the patient understands, you may have to bring them back to take the leads out later. It’s a possibility but for me it’s usually one and done. I’ll get them seen by ID and implant them 3 to 6 months later.
Thanks. Really helpful
Thanks a lot
I agree with this
I would have a low threshold to just explant everything. Assuming you are saying this tenderness, swelling, and purulent discharge is at the midline incision, there usually is not a lot of physical tissue between the skin and the deeper structures and hardware there. The usual answer is if it is just a superficial infection with absolutely no involvement below Scarpa’s fascia then you can try to salvage it with antibiotics. If there is any involvement below the fascia then likely the hardware is involved and presumably a biofilm has been formed on the hardware which antibiotics will not get rid of.
If you are going to explant one part of the system then I would advocate for just explanting the whole system. I have seen numerous cases with other physicians where there was obvious involvement of the battery site and they explanted just the battery and left the leads in and then weeks to months later obvious infection recurred and then the leads had to be removed also.
And yes, you should absolutely copiously irrigate the midline incision as well as the battery pocket. Just out of curiosity, how did you do the closure for this case?
I will say that it seems I am more conservative than the other posters in this thread. Without actually seeing the wound, the imaging, labs, vitals, etc. it’s hard to give a definitive answer, though.
If you are going to explant one part of the system then I would advocate for just explanting the whole system. I have seen numerous cases with other physicians where there was obvious involvement of the battery site and they explanted just the battery and left the leads in and then weeks to months later obvious infection recurred and then the leads had to be removed also.
And yes, you should absolutely copiously irrigate the midline incision as well as the battery pocket. Just out of curiosity, how did you do the closure for this case?
I will say that it seems I am more conservative than the other posters in this thread. Without actually seeing the wound, the imaging, labs, vitals, etc. it’s hard to give a definitive answer, though.
Deep- interrupted 0 Vicryl, subcuticular with 2-0 Vicryl, then dermabond. Dressing applied.
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Explant. Your life will be easier and so will the patient’s
I will tell you that dermabond has been increasingly associated with an allergic skin reaction that looks a lot like a superficial wound infection. Consider using something like xeroform gauze with a tegaderm/dressing on top.
Will try to get this
Any reason for vicryl over monocryl for the subcuticular?
Not really. Used it in fellowship. I could switch to monocryl.
Most folks recommend non-braided/monofilament fibers as you get closer to the skin to reduce risk of the nooks and crannies holding onto bacteria, dragging tissue around, wicking fluids, and causing a more intense inflammatory reaction. It's valuable down deep as the sutures hold better, but shallower/subcuticular closures probably will do better with a monofilament like monocryl.
they do make a vicryl plus which has triclosan.
Skin show be monofilament undyed. If you all haven't used a barbed suture it will change your life, see stratafix for skin. Also you can use prolene which is a dyed monofilament for interrupted or mattress stitches, if you want to take it out later after an infection; its inert, nonabsorable, and nonreactive.
Skin show be monofilament undyed. If you all haven't used a barbed suture it will change your life, see stratafix for skin. Also you can use prolene which is a dyed monofilament for interrupted or mattress stitches, if you want to take it out later after an infection; its inert, nonabsorable, and nonreactive.
I explored last week and there was nothing in the pocket. In the subcutaneous layer, there was some questionable pinhead sized tissue discoloration, just under the skin. Tried to aspirate from IPG pocket. Nothing. We did a culture of the subcutaneous questionable tissue. Staph. On Bactrim. Irrigated the pocket with Vashe and a lot of saline. He was reprogrammed 2 days ago. Doing well. I had planned to explant but didn't. Had a senior colleague look over the pocket as well. I believe he will do well.
Used xerofoam as suggested here
