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Presented	
  during	
  Resident	
  Case	
  Presenta/ons	
  at	
  the	
  2013	
  Kent	
  State	
  University	
  
College	
 ...
Pa/ent	
  was	
  seen	
  by	
  the	
  primary	
  consul/ng	
  team	
  
2	
  
3	
  
4	
  
5	
  
6	
  
7	
  
Why	
  not	
  single	
  injec/on?	
  Indwelling	
  is	
  a	
  con/nuous	
  infusion	
  of	
  diluted	
  local	
  
anesthe/...
9	
  
10	
  
11	
  
Dressing	
  taken	
  down	
  by	
  primary	
  team	
  at	
  this	
  /me.	
  No	
  infec/on	
  there.	
  	
  
Re-­‐evaluate...
Primary	
  team	
  also	
  got	
  UA	
  and	
  BCs.	
  	
  
WBC	
  has	
  increased	
  
13	
  
POD	
  #4	
  
Fever	
  failed	
  to	
  improve	
  
The	
  pa/ent	
  complained	
  of	
  dizziness	
  and	
  
lethargy	
  
...
POST	
  OP	
  DAY	
  FIVE:	
  INFECTIOUS	
  DISEASE	
  
CONSULTED.	
  	
  
Also	
  complains	
  of	
  nausea	
  and	
  bur...
General:	
  anxious	
  
Lower	
  extremity	
  exam:	
  	
  
Vascular:	
  DP/PT/popliteal	
  pulse	
  palpable	
  
Neurolog...
17	
  
Despite	
  the	
  ini/a/on	
  of	
  an/bio/cs	
  POD	
  #5,	
  the	
  white	
  count	
  did	
  not	
  con/nue	
  to	
  tre...
The	
  primary	
  team	
  ordered	
  a	
  CT	
  scan.	
  Ques/on	
  of	
  air	
  or	
  fluid/abscess…clinical	
  
correla/o...
Despite	
  the	
  ini/a/on	
  of	
  IV	
  an/bio/cs	
  the	
  pa/ent	
  did	
  not	
  improve	
  and	
  with	
  the	
  CT	...
POD	
  #10	
  ORIF	
  and	
  POD#4	
  I&D:	
  white	
  count	
  23.49.	
  	
  
Previous	
  ORIF	
  surgical	
  site	
  rem...
What	
  next?	
  Incision	
  planning?	
  Extend	
  the	
  incision?	
  Get	
  more	
  imaging?	
  	
  
	
  
22	
  
23	
  
24	
  
Serpen/ne	
  incision	
  extended	
  from	
  the	
  ischial	
  tuberosity	
  to	
  the	
  
proximal	
  calf.	
  Extended	
...
Transferred	
  to	
  SICU	
  due	
  to	
  hypovolemic	
  shock.	
  Intubated	
  and	
  restrained.	
  	
  
Pt	
  received	...
CoPAT	
  Vancomycin:	
  dose	
  and	
  length?	
  	
  
Discharged	
  to	
  rehabilita/on	
  center	
  for	
  extensive	
  ...
Con/nued	
  physical	
  therapy	
  at	
  9	
  months.	
  No	
  brace	
  or	
  deficit.	
  	
  
Cannot	
  sit	
  for	
  long...
29	
  
30	
  
31	
  
32	
  
The	
  con/nuous	
  popliteal	
  nerve	
  catheter	
  is	
  an	
  increasingly	
  accepted	
  means	
  to	
  reduce	
  
po...
34	
  
35	
  
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Post-Surgical Complication of a Popliteal Nerve Catheter

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Transcript of "Post-Surgical Complication of a Popliteal Nerve Catheter"

  1. 1. Presented  during  Resident  Case  Presenta/ons  at  the  2013  Kent  State  University   College  of  Podiatric  Medicine  Southeastern  Conference  in  Lake  Buena  Vista,  Florida.   This  had  an  interac/ve,  ques/on  and  answer  format.     1  
  2. 2. Pa/ent  was  seen  by  the  primary  consul/ng  team   2  
  3. 3. 3  
  4. 4. 4  
  5. 5. 5  
  6. 6. 6  
  7. 7. 7  
  8. 8. Why  not  single  injec/on?  Indwelling  is  a  con/nuous  infusion  of  diluted  local   anesthe/c  at  a  desired  rate  per  hour.  So  0.2%  ropivicane  at  an  infusion  of  10ml/h.   Can  give  bolus.  Pa/ents  can  metabolize  anesthe/c  differently—some  more  quickly.   Get  over  that  24h  hump.     Despite  oral  opioids  could  not  be  weaned  off  catheter.     8  
  9. 9. 9  
  10. 10. 10  
  11. 11. 11  
  12. 12. Dressing  taken  down  by  primary  team  at  this  /me.  No  infec/on  there.     Re-­‐evaluated  by  pain  management  anesthesia  team  who  felt  PNC  site  “looked  good.”     Primary  team  also  got  chest  xray  and  US  to  r/o  DVT   12  
  13. 13. Primary  team  also  got  UA  and  BCs.     WBC  has  increased   13  
  14. 14. POD  #4   Fever  failed  to  improve   The  pa/ent  complained  of  dizziness  and   lethargy   Primary  team  requested  pain  management   anesthesia  team  to  remove  catheter  as  that   was  the  only  possible  infec/ous  source  not   removed     PNC  was  removed  –  no  purulence  or   indura/on  noted  at  site    Erythematous  patches  were  noted  peri-­‐   14  
  15. 15. POST  OP  DAY  FIVE:  INFECTIOUS  DISEASE   CONSULTED.     Also  complains  of  nausea  and  burning  urina/on.   Denies  sob,  chest  pain,  diarrhea,  vomi/ng,  sore   throat,  no  deep  thigh  pain     15  
  16. 16. General:  anxious   Lower  extremity  exam:     Vascular:  DP/PT/popliteal  pulse  palpable   Neurological:  Light  and  gross  sensa/on  was  intact   Dermatological:     Incisions:  well  approximated   Mild  peri-­‐incisional  erythema   No  purulence     PNC  site   Indura/on   No  crepitus  or  purulence     Erythema,  which  extends  proximally  along  the     16  
  17. 17. 17  
  18. 18. Despite  the  ini/a/on  of  an/bio/cs  POD  #5,  the  white  count  did  not  con/nue  to  trend   down—jumped  back  up  to  15.6.       Vanc  and  Zosyn  empiric  therapy  (adjust  as  needed)  un/l  known  cultures.     18  
  19. 19. The  primary  team  ordered  a  CT  scan.  Ques/on  of  air  or  fluid/abscess…clinical   correla/on.     19  
  20. 20. Despite  the  ini/a/on  of  IV  an/bio/cs  the  pa/ent  did  not  improve  and  with  the  CT   results,  it  was  decided  the  pa/ent  would  undergo  an  Incision  and  drainage  in  the  OR   20  
  21. 21. POD  #10  ORIF  and  POD#4  I&D:  white  count  23.49.     Previous  ORIF  surgical  site  remains  unaffected   Rifampin  as  adjuvant  therapy     21  
  22. 22. What  next?  Incision  planning?  Extend  the  incision?  Get  more  imaging?       22  
  23. 23. 23  
  24. 24. 24  
  25. 25. Serpen/ne  incision  extended  from  the  ischial  tuberosity  to  the   proximal  calf.  Extended  to  medial/lateral  heads  of   gastrocnemius.     Significant  phlegmon  of  the  scia/c  nerve:  /bial  and  common   peroneal  nerve.         25  
  26. 26. Transferred  to  SICU  due  to  hypovolemic  shock.  Intubated  and  restrained.     Pt  received  "1500cc  crystalloids,  1L  Hextend,  500cc  Albumin,  6units  PRBCs  2units   FFP"  during  the  procedure.     Pa/ent  afebrile  and  WBC  downtrending.  Was  removed  from  rifampin  due  to  nausea.     Microscopy  of  urine  shows  -­‐  Muddy  brown  casts  sugges/ve  of  Acute  tubular  necrosis.       26  
  27. 27. CoPAT  Vancomycin:  dose  and  length?     Discharged  to  rehabilita/on  center  for  extensive  physical  therapy     27  
  28. 28. Con/nued  physical  therapy  at  9  months.  No  brace  or  deficit.     Cannot  sit  for  long  periods   Radiographs:  well-­‐healed  fracture  with  no  loosening  of  fixa/on  and  no  bony  reac/on   sugges/ve  of  seeding   28  
  29. 29. 29  
  30. 30. 30  
  31. 31. 31  
  32. 32. 32  
  33. 33. The  con/nuous  popliteal  nerve  catheter  is  an  increasingly  accepted  means  to  reduce   postopera/ve  pain  of  the  lower  extremity  in  orthopedic  surgery.  It  has  few  noted   complica/ons  in  the  literature  with  serious  infec/ous  complica/ons  reported  at   0.75%.     33  
  34. 34. 34  
  35. 35. 35  

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