Did SCS implant for a patient. Day 3 she complained of brown fluid from midline wound (not battery pocket). Seen in office, expressed fluid which was consistent with serous fluid. Compression dressing applied. Seen on day 5, still serous fluid but less volume. Seen on post op day 10 and still had some serous fluid coming out. No signs of infection. Wound is healing fine, no dehiscence. Would you consider draining under US or taking back to OR or just give it some more time and see if it improves?
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Just give her time. Place in abdominal binder. If it is quite large and fluctuant drain it in the office. Do not open back up the incision.
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Agreed.
I would compression is binder for longer.. Document no f/c. If s/s infection. Try to get it out.
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CBC, ESR, CRP. Prove it is a seroma. See the wound 3x a week until closed.
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i will continue daily dressing change until close, this is more commonly seen in spinal and paramedian incision. I do not have high quality evidence, since I do water-tight closure, it is rarely seen.
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Did you culture the fluid that you expressed the first day in the clinic?
I have placed her in abdominal binder. She was on prophylactic abx post op for 10 days. Pretty healthy patient - no diabetic, non smoker. Will send out labs and culture to r/o infection although it was clear, thin liquid consistent with serous fluid with no signs of infection.
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All scs cases get prophy abx in my book. I do 5 days. If anything it just makes me feel better. Do your realize the casualness that a pcp will write a patient an abx rx for virtually anything? Should I feel remotely guilty about a few days of abx for a surgically implanted device in a patient? Nope.
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I give post abx. Obese, diabetic, smoker, poor hygiene. All of my patients fit one or multiple of these descriptors.
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Post op antibiotics are not recommended by guidelines.
Two things here:
1. A large portion of people don't follow the NACC guidelines
Antibiotics for Spinal Cord Stimulation Trials and Implants: A Survey Analysis of Practice Patterns
Spinal cord stimulation (SCS) is an established treatment modality for neuropathic pain. Published guidelines exist to aid physicians in proper antibiotic use during and after spinal cord stimulation trials and implants. In this brief review, we present ...
www.ncbi.nlm.nih.gov
2. The NACC guidelines didn't include this large dataset which showed occlusive dressings and post-operative antibiotics reduced the risk of infections. The major issue is that the post-op antibiotic data is from other surgical events, and so they're part and parcel of the SCIP guidelines, but the data for neuromodulation isn't consistent with the rest of the work.
Spinal Cord Stimulator Implant Infection Rates and Risk Factors: A Multicenter Retrospective Study
Spinal cord stimulation is an evidence-based treatment for a number of chronic pain conditions. While this therapy offers improvement in pain and function it is not without potential complications. These complications include device failure, migration, loss of therapeutic paresthesia, and...
www.neuromodulationjournal.org
NACC guidelines for reference: The Neurostimulation Appropriateness Consensus Committee (NACC) Recommendations for Infection Prevention and Management - PubMed
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Two things here:
1. A large portion of people don't follow the NACC guidelines
Antibiotics for Spinal Cord Stimulation Trials and Implants: A Survey Analysis of Practice Patterns
Spinal cord stimulation (SCS) is an established treatment modality for neuropathic pain. Published guidelines exist to aid physicians in proper antibiotic use during and after spinal cord stimulation trials and implants. In this brief review, we present ...
2. The NACC guidelines didn't include this large dataset which showed occlusive dressings and post-operative antibiotics reduced the risk of infections. The major issue is that the post-op antibiotic data is from other surgical events, and so they're part and parcel of the SCIP guidelines, but the data for neuromodulation isn't consistent with the rest of the work.
Spinal Cord Stimulator Implant Infection Rates and Risk Factors: A Multicenter Retrospective Study
Spinal cord stimulation is an evidence-based treatment for a number of chronic pain conditions. While this therapy offers improvement in pain and function it is not without potential complications. These complications include device failure, migration, loss of therapeutic paresthesia, and...www.neuromodulationjournal.org
NACC guidelines for reference: The Neurostimulation Appropriateness Consensus Committee (NACC) Recommendations for Infection Prevention and Management - PubMed
Stupid is as stupid does. Defend against this:
The Surgical Care Improvement Project and Prevention of Post-Operative Infection, Including Surgical Site Infection
In response to inconsistent compliance with infection prevention measures, the Centers for Medicare & Medicaid Services collaborated with the U.S. Centers for Disease Control and Prevention on the Surgical Infection Prevention (SIP) project, introduced ...
www.ncbi.nlm.nih.gov
Seven of the SCIP initiatives apply to the peri-operative period: Prophylactic antibiotics should be received within 1 h prior to surgical incision (1), be selected for activity against the most probable antimicrobial contaminants (2), and be discontinued within 24 h after the surgery end-time (3); (4) euglycemia should be maintained, with well-controlled morning blood glucose concentrations on the first two post-operative days, especially in cardiac surgery patients; (6) hair at the surgical site should be removed with clippers or by depilatory methods, not with a blade; (9) urinary catheters are to be removed within the first two post-operative days; and (10) normothermia should be maintained peri-operatively.
I think going against this can jeopardize hospital standing.
