Vascular Surgery Case - what would you do?

[jbalsly]

As PA taking first call for vascular surgery, you get paged 3AM by ER. They have 61 yo M POD#3 s/p L CEA who c/o increased neck swelling/redness. Pt states he noticed new swelling the previous morning and some redness, both swelling and redness increased "greatly" throughout the day. Also c/o nausea &chills that day, denies any difficulty breathing or swallowing, vomiting, diarrhea, dysuria. CT neck shows "severe stranding w/ inflammatory changes throughout the tract of the left carotid artery which extends to esophagus and trachea with some midline shift to right, however trachea and esophagus are patent. No abscess or extravasation from carotid." On exam, pt is resting comfortably. Temp is 101, otherwise BP, HR, and RR are WNL. Left neck is swollen, red, warm to touch and tender to palpation. Incision is C/D/I. No exudates. Labs: urine neg for UTI. WBC is WNL. BC x2 pending. Obviously pt has post op cellulitis. My question is would you: A) Tell pt he is ok, have ER give oral abx and send home to f/u in clinic 2 wks. B) Admit pt for IV abx and observation or C)Tell patient he should just come to clinic tomorrow during normal hours for a closer look.

 

Just curious....

[rev ronin]

Of the three options you pose, B seems the only reasonable one. I don't like the fever, I don't like the CT findings of tracheal impingement--a bit more inflammation and this patient is in serious trouble, no way I want him at home without definitive assurance that the inflammation is not going to worsen.

[jmj11]

Of the three options you pose, B seems the only reasonable one. I don't like the fever, I don't like the CT findings of tracheal impingement--a bit more inflammation and this patient is in serious trouble, no way I want him at home without definitive assurance that the inflammation is not going to worsen.

Ditto. Not my area but certainly sounds acute if not approaching on emergent and needs inpatient observation.

[pahopeful]

B is the answer!

[andersenpa]

Admit/IV abx. If you're wrong on infection....big deal. If it is infected and you send him...you're sued.

[pawag]

I would have to same the same, admit with IV ABx. Honestly I couldn't imagine anyone doing different.

[rsqdvr]

Being in Vascular Surgery, the only reasonable answer is B. Given that he is so recently post-op and the area that we are talking about the other two options are nothing short of extremely irresponsible. At the very least he needs IV abx and monitoring to make sure this doesn't get worse. Worse case is that this cellulitis turns in to a deeper wound infection compromising the patch. If there is even a hint of that, he would need to go back to the OR urgently, which is tough to do when he's at home. You would want to do everything possible to make sure it doesn't get to the point that going back to the OR would be needed.

[Doc Savage]

What prophylactic IV ABX regimen do you choose?

[andersenpa]

What prophylactic IV ABX regimen do you choose?

 

There is no ppx ABX needed for a CEA other than standard periop ppx (staph/strep covering cephalosporin) at the time of surgery.

For tx in this patient you would want similar skin flora coverage, and if MRSA is a concern, Vanco.

you could broaden coverage if the infection was acquired in a health care setting.

[Just Steve]

SSQ...(silly student question)

 

At what point during the admission would you opt to secure their airway (if it's decided to be prudent)? What method would you choose? Do you wait until there is mild, moderate, or severe difficulty of breathing? If it's fluculent, do you I&D before invasive airway management and hope that will be sufficient to avoid taking their airway or do you just not monkey around with it and be aggressive, getting ahead of the power curve? Do you opt for the standard ET, using a fiber optic scope prn or depending on the location of the impingement, do you go straight for the trach to avoid the chance of the ET causing an unintentional internal I&D of the abcess?

 

Or am I just drinking too much tonight and this sort of scenario would not really come into reality?

[ventana]

WWW POD #3 is wound....

 

neck infections are SCARY and the fact this is a surgical complication

 

Admit and blast him with big gun ABX....

 

also consider opening surgical site - it is CDI - but it is likely holding infection in - also get cultures of the area once open (talk to your attending and likely will want ID invovlement)

 

 

would be really wrong to do anything but admit and IV abx as he is having midline shift - d/c home if you want to end up in court and kill the patient

[LT_Oneal_PAC]

SSQ...(silly student question)

 

At what point during the admission would you opt to secure their airway (if it's decided to be prudent)? What method would you choose? Do you wait until there is mild, moderate, or severe difficulty of breathing? If it's fluculent, do you I&D before invasive airway management and hope that will be sufficient to avoid taking their airway or do you just not monkey around with it and be aggressive, getting ahead of the power curve? Do you opt for the standard ET, using a fiber optic scope prn or depending on the location of the impingement, do you go straight for the trach to avoid the chance of the ET causing an unintentional internal I&D of the abcess?

 

Or am I just drinking too much tonight and this sort of scenario would not really come into reality?

 

As anesthesia, being called for anything worse than mild dyspnea would get you mean looks. It takes a good amount of distortion to cause dyspnea. If that far gone, it will make intubation difficult and more likely to have complications. If called, I would bring a FOB and go nasally to look for cords (with nasal ETT loaded). If I could see them, I'll give prop and sux to place to prevent recall/cord movement/ and bucking that would place unneccessary pressure on wound. If I could see them, but not well and the anatomy was very distorted, I'd squirt some lidocaine on the cords to help prevent reflexes, and then do an awake FO intubation and place nasal ETT.

 

Key points: muscle relaxation may be damning in this case if muscle tension is all that is prevent airway collapse. You might get by with a Mac blade (more than likely you could), but it requires at least some sedation (though high co2 from poor ventilation can make an excellent sedative) to take a look with it and then you've depressed their breathing before you know if you can intubate with most likely severely distorted anatomy (it takes a lot of shift to disrupt breathing).

[Doc Savage]

There is no ppx ABX needed for a CEA other than standard periop ppx (staph/strep covering cephalosporin) at the time of surgery.

For tx in this patient you would want similar skin flora coverage, and if MRSA is a concern, Vanco.

you could broaden coverage if the infection was acquired in a health care setting.

 

I really did not mean "Prophylactic" I guess I meant more "emperic" ABX treatment. Since we suspect infection and blood cultures and wound cultures take a few days to grow I was wondering what IV ABX to choose for cellulitis... no abscess growing in his neck yet so the literature says Nafcillin/Oxicillin/Ancef... but wouldn't he have gotten one of these as his prophylactic ABX already... and if he is infected it obviously did not work, so would you put him on Vanc anyways and not screw around with the others since it is presumedly post op related and in the neck area?

 

And what about adding Gent to the Vanc until the blood/wound cultures return (not in the literature, just wondering what you guys have seen in practice)???

 

my source:

http://emedicine.medscape.com/article/2012280-overview

[deborah212]

WWW POD #3 is wound....

neck infections are SCARY and the fact this is a surgical complication

Admit and blast him with big gun ABX....

I agree. Scary case- especially the rapidity and degree of onset. Even though there's no gas on CT, I'd be worried about nec fasc.

 

My thought as a former hospitalist would be to treat big quickly. Mostly likely this is strept but I'd cover for MRSA with his recent hospitalization as well as anaerobes. My preference would be Vanc and Unasyn. Key to remember that Vanc is NOT great for strept. Also, it's bacteriostatic. I'd have a very low threshold to add clindamycin if he develops a rash or becomes hypotensive (specifically targets strept toxins).

 

Hopefully he went back to surgical service. Agree with ID c/s. Would be interesting to know what happened.

[vaston]

I know, I know. This is a serious discussion about a serious case. But I couldn't help but think of this:

 

Skip to ~1:15 for the good stuff

[jsfelder0417]

I'm with rev and ventana on this one. Midline deviation is not something that I am going to sit on. Explore wound more, hit with big bore abx-covering the flora and being mindful of MRSA and Iatrogenic bugs.