From Rwmfglycar at aol.com Mon Oct 1 00:00:47 2007 From: Rwmfglycar at aol.com (Rwmfglycar@aol.com) Date: Sun Sep 30 23:02:55 2007 Subject: [HSF] (OT?) Medicine as practice: what every surgeon should know Message-ID: Dear Tea, In 1949 I had a different experience from yours. I spent time with a fellow student and his uncle who was a doctor in the Transkei in South Africa looking after a rural population of Xosas leading a traditoional tribal life. He provided weekly Clinics within a quite wide area. Many of the clinics could not be reached by a road. The locals still used ox drawn sleds for moving heavy loads. We travelled in a surplus WWII Jeep. At each there were a couple of ************************************** See what's new at http://www.aol.com From Rwmfglycar at aol.com Mon Oct 1 00:00:47 2007 From: Rwmfglycar at aol.com (Rwmfglycar@aol.com) Date: Sun Sep 30 23:12:05 2007 Subject: [HSF] (OT?) Medicine as practice: what every surgeon should know Message-ID: Dear Tea, In 1949 I had a different experience from yours. I spent time with a fellow student and his uncle who was a doctor in the Transkei in South Africa looking after a rural population of Xosas leading a traditoional tribal life. He provided weekly Clinics within a quite wide area. Many of the clinics could not be reached by a road. The locals still used ox drawn sleds for moving heavy loads. We travelled in a surplus WWII Jeep. At each there were a couple of ************************************** See what's new at http://www.aol.com From battr at medizin.uni-leipzig.de Mon Oct 1 09:09:39 2007 From: battr at medizin.uni-leipzig.de (Dr. Roberto Battellini) Date: Mon Oct 1 02:02:57 2007 Subject: AW: [HSF] Abnormal LIMA In-Reply-To: <396834.68958.qm@web35914.mail.mud.yahoo.com> References: <396834.68958.qm@web35914.mail.mud.yahoo.com> Message-ID: <00a501c803f1$a7187a20$b3160a06@HZLPC0679> We are waiting for your hystological report! Roberto -----Urspr?ngliche Nachricht----- Von: openheart-l-bounces@lists.hsforum.com [mailto:openheart-l-bounces@lists.hsforum.com] Im Auftrag von john pj Gesendet: Montag, 1. Oktober 2007 03:50 An: OpenHeart-L@lists.hsforum.com Betreff: [HSF] Abnormal LIMA 2 days back we operated a 54 yr old man for LT main stenosis with lesions in LAD and OM.The LIMA[2.5 mm in size] was harvested with out any difficulty and had good pulsation and flow when divided. When we divided the distal end we noted that the thick intima was telescoping beyond the remaining layers. When it was cut opened the intima was more opaue and lacked the lustre of normal intima. The thickened Intima was sliding against other layers as if they are separated. It was not like dissection. We did not see any localised atherosclerosis plaques . . We exised about 3 cm LIMA and there was no change in teh appearence . We went ahead with LIMA to LAD grafting takinkincare to incluse all the layers cautiously.We are watching the patient closely. We have low threshold to go back to replace it with a vein in case of any problems in the LAD territory. Any comments? --------------------------------- Check out the hottest 2008 models today at Yahoo! Autos. _______________________________________________ OpenHeart-L mailing list Send postings to: OpenHeart-L@lists.hsforum.com To UNSUBSCRIBE, to CHANGE email address, or to view archives: http://mmp.cjp.com/mailman/listinfo/openheart-l All messages transmitted by the OpenHeart-L are subject to the policies and disclaimers posted at: http://www.hsforum.com/listdisclaim ----------------------------------------- From grescigno at mac.com Mon Oct 1 06:34:03 2007 From: grescigno at mac.com (Giuseppe Rescigno) Date: Mon Oct 1 08:34:33 2007 Subject: [HSF] Abnormal LIMA In-Reply-To: <396834.68958.qm@web35914.mail.mud.yahoo.com> References: <396834.68958.qm@web35914.mail.mud.yahoo.com> Message-ID: I would restudy the patient before hospital dismissal. Giuseppe Rescigno M.D. Cardiothoracic Surgeon Lancisi Hospital Torrette - Ancona Italy On Monday, October 01, 2007, at 04:51AM, "john pj" wrote: >2 days back we operated a 54 yr old man for LT main stenosis with lesions in LAD and OM.The LIMA[2.5 mm in size] was harvested with out any difficulty and had good pulsation and flow when divided. When we divided the distal end we noted that the thick intima was telescoping beyond the remaining layers. When it was cut opened the intima was more opaue and lacked the lustre of normal intima. The thickened Intima was sliding against other layers as if they are separated. It was not like dissection. We did not see any localised atherosclerosis plaques . > . > We exised about 3 cm LIMA and there was no change in teh appearence . We went ahead with LIMA to LAD grafting takinkincare to incluse all the layers cautiously.We are watching the patient closely. We have low threshold to go back to replace it with a vein in case of any problems in the LAD territory. > >Any comments? > >--------------------------------- > Check out the hottest 2008 models today at Yahoo! Autos. >_______________________________________________ >OpenHeart-L mailing list > >Send postings to: > OpenHeart-L@lists.hsforum.com > >To UNSUBSCRIBE, to CHANGE email address, or to view archives: >http://mmp.cjp.com/mailman/listinfo/openheart-l > >All messages transmitted by the OpenHeart-L are subject to the policies and >disclaimers posted at: >http://www.hsforum.com/listdisclaim >----------------------------------------- > > From sukumarhmehta at yahoo.com Mon Oct 1 07:48:39 2007 From: sukumarhmehta at yahoo.com (Mehta Sukumar) Date: Mon Oct 1 09:49:11 2007 Subject: [HSF] Abnormal LIMA In-Reply-To: <396834.68958.qm@web35914.mail.mud.yahoo.com> Message-ID: <770821.8738.qm@web36508.mail.mud.yahoo.com> Probably you got away with a diseased and fragile LIMA. Histology finding would be interesting. So will be angiographic study, as suggested by other members. You must have had to muster all the skill and patience for suturing this. You opened up a potential space between LIMA layers when you divided it at the lower end, but then closed it successfully by a circular stitch of the careful anastomosis. Sukumar. john pj wrote: 2 days back we operated a 54 yr old man for LT main stenosis with lesions in LAD and OM.The LIMA[2.5 mm in size] was harvested with out any difficulty and had good pulsation and flow when divided. When we divided the distal end we noted that the thick intima was telescoping beyond the remaining layers. When it was cut opened the intima was more opaue and lacked the lustre of normal intima. The thickened Intima was sliding against other layers as if they are separated. It was not like dissection. We did not see any localised atherosclerosis plaques . . We exised about 3 cm LIMA and there was no change in teh appearence . We went ahead with LIMA to LAD grafting takinkincare to incluse all the layers cautiously.We are watching the patient closely. We have low threshold to go back to replace it with a vein in case of any problems in the LAD territory. Any comments? --------------------------------- Fussy? Opinionated? Impossible to please? Perfect. Join Yahoo!'s user panel and lay it on us. From MDavalle at aol.com Mon Oct 1 13:20:03 2007 From: MDavalle at aol.com (MDavalle@aol.com) Date: Mon Oct 1 12:20:56 2007 Subject: [HSF] Abnormal LIMA Message-ID: In a similar "vein", I am wondering what do do when I take down a LIMA and it has small islands of non obstructive plaque. I have seen this mostly in young diabetics and went ahead and used them documenting good flow at completion with Medi-stem. What do others think? ************************************** See what's new at http://www.aol.com From tacuff at swbell.net Mon Oct 1 14:43:09 2007 From: tacuff at swbell.net (Tea Acuff) Date: Mon Oct 1 16:43:39 2007 Subject: [HSF] (OT?) Medicine as practice: what every surgeon should know Message-ID: <382183.17587.qm@web81609.mail.mud.yahoo.com> Bob, Sounds like an interesting story if you can get around to finishing it. tea ----- Original Message ---- From: "Rwmfglycar@aol.com" To: OpenHeart-L@lists.hsforum.com Sent: Sunday, September 30, 2007 10:00:47 PM Subject: Re: [HSF] (OT?) Medicine as practice: what every surgeon should know Dear Tea, In 1949 I had a different experience from yours. I spent time with a fellow student and his uncle who was a doctor in the Transkei in South Africa looking after a rural population of Xosas leading a traditoional tribal life. He provided weekly Clinics within a quite wide area. Many of the clinics could not be reached by a road. The locals still used ox drawn sleds for moving heavy loads. We travelled in a surplus WWII Jeep. At each there were a couple of ************************************** See what's new at http://www.aol.com _______________________________________________ OpenHeart-L mailing list Send postings to: OpenHeart-L@lists.hsforum.com To UNSUBSCRIBE, to CHANGE email address, or to view archives: http://mmp.cjp.com/mailman/listinfo/openheart-l All messages transmitted by the OpenHeart-L are subject to the policies and disclaimers posted at: http://www.hsforum.com/listdisclaim ----------------------------------------- From benjamin.bidstrup at bigpond.com Tue Oct 2 08:35:58 2007 From: benjamin.bidstrup at bigpond.com (Ben Bidstrup) Date: Mon Oct 1 17:36:56 2007 Subject: [HSF] (OT?) Medicine as practice: what every surgeon should know In-Reply-To: <382183.17587.qm@web81609.mail.mud.yahoo.com> References: <382183.17587.qm@web81609.mail.mud.yahoo.com> Message-ID: Why? We have good imaginations. >Bob, Sounds like an interesting story if you can get around to >finishing it. tea ----- Original Message ---- From: >"Rwmfglycar@aol.com" To: >OpenHeart-L@lists.hsforum.com Sent: Sunday, September 30, 2007 >10:00:47 PM Subject: Re: [HSF] (OT?) Medicine as practice: what >every surgeon should know Dear Tea, In 1949 I had a different >experience from yours. I spent time with a fellow student and his >uncle who was a doctor in the Transkei in South Africa looking after >a rural population of Xosas leading a traditoional tribal life. He >provided weekly Clinics within a quite wide area. Many of the >clinics could not be reached by a road. The locals still used ox >drawn sleds for moving heavy loads. We travelled in a surplus WWII >Jeep. At each there were a couple of >************************************** See what's new at >http://www.aol.com _______________________________________________ >OpenHeart-L mailing list Send postings to: >OpenHeart-L@lists.hsforum.com To UNSUBSCRIBE, to CHANGE email >address, or to view archives: >http://mmp.cjp.com/mailman/listinfo/openheart-l All messages >transmitted by the OpenHeart-L are subject to the policies and >disclaimers posted at: http://www.hsforum.com/listdisclaim >----------------------------------------- >_______________________________________________ >OpenHeart-L mailing list > >Send postings to: > OpenHeart-L@lists.hsforum.com > >To UNSUBSCRIBE, to CHANGE email address, or to view archives: >http://mmp.cjp.com/mailman/listinfo/openheart-l > >All messages transmitted by the OpenHeart-L are subject to the policies and >disclaimers posted at: >http://www.hsforum.com/listdisclaim >----------------------------------------- -- Ben Bidstrup FRACS FRCSEd FEBCTS Consultant Cardiothoracic Surgeon From tacuff at swbell.net Mon Oct 1 16:13:00 2007 From: tacuff at swbell.net (Tea Acuff) Date: Mon Oct 1 18:13:32 2007 Subject: [HSF] (OT?) Medicine as practice: what every surgeon should know Message-ID: <225738.25597.qm@web81615.mail.mud.yahoo.com> It may seem strange coming from me, but I have always been more interested in "reality" than someone's "imagination". It takes all my effort to imagine any reality. tea ----- Original Message ---- From: Ben Bidstrup To: OpenHeart-L@lists.hsforum.com Sent: Monday, October 1, 2007 4:35:58 PM Subject: Re: [HSF] (OT?) Medicine as practice: what every surgeon should know Why? We have good imaginations. >Bob, Sounds like an interesting story if you can get around to >finishing it. tea ----- Original Message ---- From: >"Rwmfglycar@aol.com" To: >OpenHeart-L@lists.hsforum.com Sent: Sunday, September 30, 2007 >10:00:47 PM Subject: Re: [HSF] (OT?) Medicine as practice: what >every surgeon should know Dear Tea, In 1949 I had a different >experience from yours. I spent time with a fellow student and his >uncle who was a doctor in the Transkei in South Africa looking after >a rural population of Xosas leading a traditoional tribal life. He >provided weekly Clinics within a quite wide area. Many of the >clinics could not be reached by a road. The locals still used ox >drawn sleds for moving heavy loads. We travelled in a surplus WWII >Jeep. At each there were a couple of >************************************** See what's new at >http://www.aol.com _______________________________________________ >OpenHeart-L mailing list Send postings to: >OpenHeart-L@lists.hsforum.com To UNSUBSCRIBE, to CHANGE email >address, or to view archives: >http://mmp.cjp.com/mailman/listinfo/openheart-l All messages >transmitted by the OpenHeart-L are subject to the policies and >disclaimers posted at: http://www.hsforum.com/listdisclaim >----------------------------------------- >_______________________________________________ >OpenHeart-L mailing list > >Send postings to: > OpenHeart-L@lists.hsforum.com > >To UNSUBSCRIBE, to CHANGE email address, or to view archives: >http://mmp.cjp.com/mailman/listinfo/openheart-l > >All messages transmitted by the OpenHeart-L are subject to the policies and >disclaimers posted at: >http://www.hsforum.com/listdisclaim >----------------------------------------- -- Ben Bidstrup FRACS FRCSEd FEBCTS Consultant Cardiothoracic Surgeon _______________________________________________ OpenHeart-L mailing list Send postings to: OpenHeart-L@lists.hsforum.com To UNSUBSCRIBE, to CHANGE email address, or to view archives: http://mmp.cjp.com/mailman/listinfo/openheart-l All messages transmitted by the OpenHeart-L are subject to the policies and disclaimers posted at: http://www.hsforum.com/listdisclaim ----------------------------------------- From drdharris at yahoo.co.uk Tue Oct 2 00:50:49 2007 From: drdharris at yahoo.co.uk (David Harris) Date: Mon Oct 1 18:51:19 2007 Subject: [HSF] Re: Post op antibiotics In-Reply-To: Message-ID: <753114.59608.qm@web26710.mail.ukl.yahoo.com> Dear Ani, Many thanks for your interesting comments, yes i think double gloving makes more sense than anything else, and has better protection for the patient AND surgeon. In our speciality this is seldom done. When I was a resident doing orthopaedics, this was standard practice (when the initial fear for the HIV virus was much greater than now!). I think you have raised an essential point that we should all be using double gloves, for the sake of ourselves, and our patients (even if it is a bit uncomfortable) Dave Harris --- Ani Anyanwu wrote: > Dr Harris > > Do you really think scrubbing matters that much? I > must confess that I have not scrubbed with water and > a brush for over 2 years. I just use a chlorexidine > cream which I rub for maybe 20 to 30 seconds. I have > not noted an out of ordinary problem with infection > even for the heart transplants who are > immunosuppressed. I must say though that I do double > glove for all cases and I think this is more > important than scrubbing. Within the course of most > cardiac operations the surgeon's hand is repopulated > with microbes which makes me ponder the usefulness > of scrubbing. The surgeon with a single pair of > gloves may often have a (unrecognised) defect in the > gloves and a possible source of contamination which > is why i wear two gloves. Also glove changes of a > single glove may themselves be a source of > contamination, compared to double gloves where glove > changes are certainly aspetic. > > I would suggest that it is your attention to detail > and your technique that gets you a low infection > rate and not the manner of scrubbing - I find in > particular the comments on the impact of volume, > personnel, large operating rooms and ICU size very > interesting and are likely far more relevant. > > > Ani > > > > > > Date: Sun, 23 Sep 2007 01:27:22 +0100> From: > drdharris@yahoo.co.uk> Subject: RE: [HSF] Re: Post > op antibiotics> To: OpenHeart-L@lists.hsforum.com> > CC: > > Thanks, Ani.> > I have been in private > practice for a few years so> have no trainees > working with me. In the training> hospital where I > worked, the mediastinitis rate was> also low, less > than 1 %.> I think there are a number of factors: > Lower volume of> cases in each centre, so less > crowded icu, strict> antibiotic policy, very large > operating rooms in each> centre, less complex cases > performed (therefore> shorter operating times). Also > we had fewer surgeons> than the average unit, and > each surgeon therefore> performing more cases.> We > are also very strict with our aseptic technique in> > the OR, especially a long period scrubbing up,> > changing cloves frequently if contamination > suspected.> When I visited surgeons in the USA I was > amazed about> the short period of time spent > scrubbing for a case,> compared with back home, and > noticed that generally> only washing of hands and > forearms was done, and no> scrubbing of the nails.> > > Dave Harris> > > --- Ani Anyanwu > wrote:> > > Dr Harris> > > > > Amazing series - I suspect more though that your> > > surgical technique and infection control > practices> > may contribute more to the rarity of > mediastinitis> > than the antibiotics and CRP. What > protocol did you> > use before the last 700 cases > and what was your> > infection rate then? Do you > have trainee surgeons? > > > > Thanks> > > > Ani> > > > > > > > > > Date: Sat, 22 Sep 2007 22:16:23 +0100> > From:> > drdharris@yahoo.co.uk> Subject: RE: [HSF] > Re: Post> > op antibiotics> To: > OpenHeart-L@lists.hsforum.com>> > CC: > > For CABG > patients 24 hrs.> > For valves,> > until lines and > drains out.> > Then track the CRP> > levels every > second day to make> sure the trend is> > downward, > and there is no peak just> before> > discharge. This > way you can avoid> mediastinitis, as> > you can > treat it as it starts.> Since doing this> > have not > had a single case of sternal> sepsis in the> > last > 700 patients, but have had CRP> peaks which we> > > then confirm the next day, then treat.> Some> > > developed cellulitis a few days afterwards, while>> > > on treatment, but we were able to avoid> > > debridements.> > Dave Harris> > > --- Adam Saltman> > > wrote:> > > It is > actually> > policy at our institution now to> > > discontinue all> > prophylactic antibiotics > according> > to a time> > schedule. For general > surgery patients> > this is> > after 24 hours, and > for cardiac patients it> > is 48> > hours (which > actually has no data behind it,> > just> > some > hysterical cardiac surgeons). This is now> >> > > becoming a nation-wide initiative in the > prevention>> > > of infection by drug-resistant > organisms... But> > as> > far as I know, there is no > data to support or> > refute> > any particular > strategy in cardiac> > patients...> > > > Adam> > > > > > > > > > From:> > alsadd@ksu.edu.sa> > > To:> > > OpenHeart-L@lists.hsforum.com> > > Date: Wed, 19 > Sep> > 2007 14:58:29 -0700> > > CC: > > > Subject: > [HSF]> > Re: Post op antibiotics > > > > > > Dear > Forum> > Members:> > > > > > > > > > > > Do the > honorable> > members keep the open heart> > patients > on> > antibiotics for as> > > long as they have> > > mediastinal and chest tubes in> > place? I do not,> > > but some> > > of my colleagues do. I went over > the> > STS> > guidelines the two parts and I> > > > could not> > find the answer to this question.> > > > > > > Your> > response is greatly appreciated.> > > > > > > Thank> > you> > > > > > > > > > > > Ahmed> > > > > > >> > > _______________________________________________> > > >> > OpenHeart-L mailing list> > > > > > Send > postings> > to:> > > OpenHeart-L@lists.hsforum.com> > > > > > > To> > UNSUBSCRIBE, to CHANGE email > address, or to> > view> > archives:> > >> > > http://mmp.cjp.com/mailman/listinfo/openheart-l> > > >> > > > > All messages transmitted by the > OpenHeart-L> > are> > subject to the policies and > > > > disclaimers> > posted at:> > > > http://www.hsforum.com/listdisclaim>> > > > > -----------------------------------------> > >> > > >>> >> > _________________________________________________________________>> > > > Gear up for Halo? 3 with free downloads and an> > >> > exclusive offer. It?s our way of saying thanks > for>> > > using Windows Live?.> >>> >> > http://gethalo3gear.com?ocid=SeptemberWLHalo3_WLHMTxt_2_______________________________________________>> > > > OpenHeart-L mailing list> > > > Send postings > to:>> > > OpenHeart-L@lists.hsforum.com> > > > To> > > UNSUBSCRIBE, to CHANGE email address, or to view> >> > > archives:> >> > > http://mmp.cjp.com/mailman/listinfo/openheart-l> > > >> > > All messages transmitted by the OpenHeart-L > are> >> > subject to the policies and> > disclaimers > posted> > at:> > > http://www.hsforum.com/listdisclaim> >> > > -----------------------------------------> > > > >> > > Dr. David G. Harris, FCS, MMED,> Cardiothoracic> > > Surgeon > Suite 207 > Kuils River Private Hospital,> > > > PO Box 1200, Kuils River, 7579, Cape Town, > South> > Africa. > Tel +27-21-9006411 > Fax > +27-21-9006412> > Mobile +27-83-3309587> >> > > _______________________________________________>> > > OpenHeart-L mailing list> > Send postings to:>> > > OpenHeart-L@lists.hsforum.com> > To UNSUBSCRIBE, to> > > CHANGE email address, or to view archives:>> > > http://mmp.cjp.com/mailman/listinfo/openheart-l> >> > > All messages transmitted by the OpenHeart-L are> > > subject to the policies and > disclaimers posted> > > at:> http://www.hsforum.com/listdisclaim>> > > -----------------------------------------> >> > _________________________________________________________________> > > Feel like a local wherever you go.> >> > http://www.backofmyhand.com_______________________________________________> > > OpenHeart-L mailing list> > > > Send postings to:> > > OpenHeart-L@lists.hsforum.com> > > > To > UNSUBSCRIBE, to CHANGE email address, or to view> > > archives:> > > http://mmp.cjp.com/mailman/listinfo/openheart-l> > > > > All messages transmitted by the OpenHeart-L are> > > subject to the policies and> > disclaimers posted > at:> > http://www.hsforum.com/listdisclaim> > > -----------------------------------------> > > > > > Dr. David G. Harris, FCS, MMED,> Cardiothoracic > Surgeon > Suite 207 > Kuils River Private Hospital, > > PO Box 1200, Kuils River, 7579, Cape Town, South > Africa. > Tel +27-21-9006411 > Fax +27-21-9006412 > Mobile +27-83-3309587> > > _______________________________________________> > OpenHeart-L mailing list> > Send postings to:> > OpenHeart-L@lists.hsforum.com> > To UNSUBSCRIBE, to > CHANGE email address, or to view archives:> > http://mmp.cjp.com/mailman/listinfo/openheart-l> > > All messages transmitted by the OpenHeart-L are > subject to the policies and > disclaimers posted > at:> http://www.hsforum.com/listdisclaim> > ----------------------------------------- > _________________________________________________________________ > Feel like a local wherever you go. > http://www.backofmyhand.com_______________________________________________ > OpenHeart-L mailing list > > Send postings to: > OpenHeart-L@lists.hsforum.com > > To UNSUBSCRIBE, to CHANGE email address, or to view > archives: > http://mmp.cjp.com/mailman/listinfo/openheart-l > > All messages transmitted by the OpenHeart-L are > subject to the policies and > disclaimers posted at: > http://www.hsforum.com/listdisclaim > ----------------------------------------- > Dr. David G. Harris, FCS, MMED, Cardiothoracic Surgeon Suite 207 Kuils River Private Hospital, PO Box 1200, Kuils River, 7579, Cape Town, South Africa. Tel +27-21-9006411 Fax +27-21-9006412 Mobile +27-83-3309587 From drdharris at yahoo.co.uk Tue Oct 2 02:32:47 2007 From: drdharris at yahoo.co.uk (David Harris) Date: Mon Oct 1 20:33:19 2007 Subject: [HSF] Re: Post op antibiotics In-Reply-To: <20070923121401.CC709D5FF0@smtp.ksu.edu.sa> Message-ID: <890586.61263.qm@web26707.mail.ukl.yahoo.com> Dear Ahmed, and Hal Sorry for the late reply, have been on vacation. As far as I know there is no literature reference to back this up...although I am also the first to look at evidence based concepts, an absence of literature reference at this stage does not mean there is no validity in the concept. I first started to do the CRP levels in all my patients in 2000, when I started to do a randomised study in my OPCAB patients. At that stage I was already doing 70% OPCAB, but was wondering if I was really doing the right thing, and also having local criticism, thought I would then randomise all my patients for the next year or so. I collected about 120 patients in each group, and did post op cardiac enzymes and inflammatory markers in all patients. What we did find was that the OPCAB patients had a statistically significant decrease in duration of ventilation, CRP level, low cardiac output, and enzyme release. We sent it in for publication to the European Journal, and it was rejected, and we did not bother further (in retrospect a mistake, as I have seen that persistence does work!). What we also found, though, was that the CRP levels helped to identify patients developing early sepsis such as pneumonia (CRP > 350 day 1 or 2, it should never be more than this),and helped identify patients developing mediastinitis (rising CRP, after it has started to drop). Usually it should be < 100 by day 5, and if it is more than this we repeat after a few days to make sure it is still going down. If it is > 100 by day 7, then do not be surprised if this patient has more chest pain than usual (Dressler`s), especially if it takes a while to settle. A subsequent peak in CRP is interesting to note, as this, in my personal experience correlates with mediastinitis (or possible endocarditis in valve patients). STarting treatment has always aborted a disaster, in my experience, but at the same time the patient has still become sick, with cellulitis and fever, and in one case, in a diabetic the patient developed SIRS 2 days after initiating treatment, and had to be transferred to icu (2 days prior to this I was about to send him home, until I got the CRP result). The intensivists that look after my patients always do a procalcitonin level if the CRP is high, or if they suspect sepsis, but in my experience, I do not find this too useful as an early indicator, but find the CRP TREND more useful. If there is a significant CRP peak (after it has dropped), and I cannot identify a local source of sepsis, then usually I start them on Vancomycin and Amicasin, or just Teicoplanin if the kidneys are bad It will be interesting to see what other surgeons` findings will be. You will find you will do lots of CRP levels, and initially it will seem useless, but you will find it interesting when you match it with the patient`s clinical recovery, and rewarding when you detect the odd potential disaster Dave Harris --- A wrote: > Dave: > I add my voice to Hal's very interesting concept CRP > level as a marker for a > potential mediastinitis. In your case what > antibiotic do you start the > patient on and for how long if the CRP level is > rising? Reference please. > Thank you for this info > > Ahmed > > -----Original Message----- > From: openheart-l-bounces@lists.hsforum.com > [mailto:openheart-l-bounces@lists.hsforum.com] On > Behalf Of David Harris > Sent: Saturday, September 22, 2007 2:16 PM > To: OpenHeart-L@lists.hsforum.com > Subject: RE: [HSF] Re: Post op antibiotics > > For CABG patients 24 hrs. > > For valves, until lines and drains out. > > Then track the CRP levels every second day to make > sure the trend is downward, and there is no peak > just > before discharge. This way you can avoid > mediastinitis, as you can treat it as it starts. > Since doing this have not had a single case of > sternal > sepsis in the last 700 patients, but have had CRP > peaks which we then confirm the next day, then > treat. > Some developed cellulitis a few days afterwards, > while > on treatment, but we were able to avoid > debridements. > > Dave Harris > > > --- Adam Saltman wrote: > > > It is actually policy at our institution now to > > discontinue all prophylactic antibiotics according > > to a time schedule. For general surgery patients > > this is after 24 hours, and for cardiac patients > it > > is 48 hours (which actually has no data behind it, > > just some hysterical cardiac surgeons). This is > now > > becoming a nation-wide initiative in the > prevention > > of infection by drug-resistant organisms... But as > > far as I know, there is no data to support or > refute > > any particular strategy in cardiac patients... > > > > Adam > > > > > > > > > From: alsadd@ksu.edu.sa > > > To: OpenHeart-L@lists.hsforum.com > > > Date: Wed, 19 Sep 2007 14:58:29 -0700 > > > CC: > > > Subject: [HSF] Re: Post op antibiotics > > > > > > Dear Forum Members: > > > > > > > > > > > > Do the honorable members keep the open heart > > patients on antibiotics for as > > > long as they have mediastinal and chest tubes in > > place? I do not, but some > > > of my colleagues do. I went over the STS > > guidelines the two parts and I > > > could not find the answer to this question. > > > > > > Your response is greatly appreciated. > > > > > > Thank you > > > > > > > > > > > > Ahmed > > > > > > _______________________________________________ > > > OpenHeart-L mailing list > > > > > > Send postings to: > > > OpenHeart-L@lists.hsforum.com > > > > > > To UNSUBSCRIBE, to CHANGE email address, or to > > view archives: > > > http://mmp.cjp.com/mailman/listinfo/openheart-l > > > > > > All messages transmitted by the OpenHeart-L are > > subject to the policies and > > > disclaimers posted at: > > > http://www.hsforum.com/listdisclaim > > > ----------------------------------------- > > > > > _________________________________________________________________ > > Gear up for HaloR 3 with free downloads and an > > exclusive offer. It's our way of saying thanks for > > using Windows LiveT. > > > http://gethalo3gear.com?ocid=SeptemberWLHalo3_WLHMTxt_2_____________________ > __________________________ > > OpenHeart-L mailing list > > > > Send postings to: > > OpenHeart-L@lists.hsforum.com > > > > To UNSUBSCRIBE, to CHANGE email address, or to > view > > archives: > > http://mmp.cjp.com/mailman/listinfo/openheart-l > > > > All messages transmitted by the OpenHeart-L are > > subject to the policies and > > disclaimers posted at: > > http://www.hsforum.com/listdisclaim > > ----------------------------------------- > > > > > Dr. David G. Harris, FCS, MMED, > Cardiothoracic Surgeon > Suite 207 > Kuils River Private Hospital, > PO Box 1200, Kuils River, 7579, Cape Town, South > Africa. > Tel +27-21-9006411 > Fax +27-21-9006412 Mobile +27-83-3309587 > > _______________________________________________ > OpenHeart-L mailing list > > Send postings to: > OpenHeart-L@lists.hsforum.com > > To UNSUBSCRIBE, to CHANGE email address, or to view > archives: > http://mmp.cjp.com/mailman/listinfo/openheart-l > > All messages transmitted by the OpenHeart-L are > subject to the policies and > disclaimers posted at: > http://www.hsforum.com/listdisclaim > ----------------------------------------- > > _______________________________________________ > OpenHeart-L mailing list > > Send postings to: > OpenHeart-L@lists.hsforum.com > > To UNSUBSCRIBE, to CHANGE email address, or to view > archives: > http://mmp.cjp.com/mailman/listinfo/openheart-l > > All messages transmitted by the OpenHeart-L are > subject to the policies and > disclaimers posted at: > http://www.hsforum.com/listdisclaim > ----------------------------------------- > Dr. David G. Harris, FCS, MMED, Cardiothoracic Surgeon Suite 207 Kuils River Private Hospital, PO Box 1200, Kuils River, 7579, Cape Town, South Africa. Tel +27-21-9006411 Fax +27-21-9006412 Mobile +27-83-3309587 From msfirst at gmail.com Mon Oct 1 21:43:10 2007 From: msfirst at gmail.com (Michael Firstenberg) Date: Mon Oct 1 21:12:49 2007 Subject: [HSF] Re: Post op antibiotics In-Reply-To: <890586.61263.qm@web26707.mail.ukl.yahoo.com> References: <890586.61263.qm@web26707.mail.ukl.yahoo.com> Message-ID: <96F0DAB4-D5F9-45B6-A8AF-641E4A12657D@gmail.com> very interesting observations - you need to write it up. If the CRPs went up and you started abx without an obvious source - how long did you treat? was there any correlation between the rate of elevation and severity of illness? wetting my appetite for more data! We did a lot of TEG on our VAD patients and while the data was very hard to get our hands around sudden (i.e. one day to the next) changes in TEG predicted an infection usually a day or two in advance. I think there is a lot to be learned from these inflammatory markers - the Cards use them a lot for predicting or understanding AMIs. -michael On Oct 1, 2007, at 8:32 PM, David Harris wrote: > Dear Ahmed, and Hal > > Sorry for the late reply, have been on vacation. > > As far as I know there is no literature reference to > back this up...although I am also the first to look at > evidence based concepts, an absence of literature > reference at this stage does not mean there is no > validity in the concept. > > I first started to do the CRP levels in all my > patients in 2000, when I started to do a randomised > study in my OPCAB patients. At that stage I was > already doing 70% OPCAB, but was wondering if I was > really doing the right thing, and also having local > criticism, thought I would then randomise all my > patients for the next year or so. I collected about > 120 patients in each group, and did post op cardiac > enzymes and inflammatory markers in all patients. What > we did find was that the OPCAB patients had a > statistically significant decrease in duration of > ventilation, CRP level, low cardiac output, and enzyme > release. > > We sent it in for publication to the European Journal, > and it was rejected, and we did not bother further (in > retrospect a mistake, as I have seen that persistence > does work!). > > What we also found, though, was that the CRP levels > helped to identify patients developing early sepsis > such as pneumonia (CRP > 350 day 1 or 2, it should > never be more than this),and helped identify patients > developing mediastinitis (rising CRP, after it has > started to drop). Usually it should be < 100 by day 5, > and if it is more than this we repeat after a few days > to make sure it is still going down. If it is > 100 by > day 7, then do not be surprised if this patient has > more chest pain than usual (Dressler`s), especially if > it takes a while to settle. A subsequent peak in CRP > is interesting to note, as this, in my personal > experience correlates with mediastinitis (or possible > endocarditis in valve patients). STarting treatment > has always aborted a disaster, in my experience, but > at the same time the patient has still become sick, > with cellulitis and fever, and in one case, in a > diabetic the patient developed SIRS 2 days after > initiating treatment, and had to be transferred to icu > (2 days prior to this I was about to send him home, > until I got the CRP result). > > The intensivists that look after my patients always do > a procalcitonin level if the CRP is high, or if they > suspect sepsis, but in my experience, I do not find > this too useful as an early indicator, but find the > CRP TREND more useful. > > If there is a significant CRP peak (after it has > dropped), and I cannot identify a local source of > sepsis, then usually I start them on Vancomycin and > Amicasin, or just Teicoplanin if the kidneys are bad > > It will be interesting to see what other surgeons` > findings will be. You will find you will do lots of > CRP levels, and initially it will seem useless, but > you will find it interesting when you match it with > the patient`s clinical recovery, and rewarding when > you detect the odd potential disaster > > Dave Harris > > --- A wrote: > >> Dave: >> I add my voice to Hal's very interesting concept CRP >> level as a marker for a >> potential mediastinitis. In your case what >> antibiotic do you start the >> patient on and for how long if the CRP level is >> rising? Reference please. >> Thank you for this info >> >> Ahmed >> >> -----Original Message----- >> From: openheart-l-bounces@lists.hsforum.com >> [mailto:openheart-l-bounces@lists.hsforum.com] On >> Behalf Of David Harris >> Sent: Saturday, September 22, 2007 2:16 PM >> To: OpenHeart-L@lists.hsforum.com >> Subject: RE: [HSF] Re: Post op antibiotics >> >> For CABG patients 24 hrs. >> >> For valves, until lines and drains out. >> >> Then track the CRP levels every second day to make >> sure the trend is downward, and there is no peak >> just >> before discharge. This way you can avoid >> mediastinitis, as you can treat it as it starts. >> Since doing this have not had a single case of >> sternal >> sepsis in the last 700 patients, but have had CRP >> peaks which we then confirm the next day, then >> treat. >> Some developed cellulitis a few days afterwards, >> while >> on treatment, but we were able to avoid >> debridements. >> >> Dave Harris >> >> >> --- Adam Saltman wrote: >> >>> It is actually policy at our institution now to >>> discontinue all prophylactic antibiotics according >>> to a time schedule. For general surgery patients >>> this is after 24 hours, and for cardiac patients >> it >>> is 48 hours (which actually has no data behind it, >>> just some hysterical cardiac surgeons). This is >> now >>> becoming a nation-wide initiative in the >> prevention >>> of infection by drug-resistant organisms... But as >>> far as I know, there is no data to support or >> refute >>> any particular strategy in cardiac patients... >>> >>> Adam >>> >>> >>> >>>> From: alsadd@ksu.edu.sa >>>> To: OpenHeart-L@lists.hsforum.com >>>> Date: Wed, 19 Sep 2007 14:58:29 -0700 >>>> CC: >>>> Subject: [HSF] Re: Post op antibiotics >>>> >>>> Dear Forum Members: >>>> >>>> >>>> >>>> Do the honorable members keep the open heart >>> patients on antibiotics for as >>>> long as they have mediastinal and chest tubes in >>> place? I do not, but some >>>> of my colleagues do. I went over the STS >>> guidelines the two parts and I >>>> could not find the answer to this question. >>>> >>>> Your response is greatly appreciated. >>>> >>>> Thank you >>>> >>>> >>>> >>>> Ahmed >>>> >>>> _______________________________________________ >>>> OpenHeart-L mailing list >>>> >>>> Send postings to: >>>> OpenHeart-L@lists.hsforum.com >>>> >>>> To UNSUBSCRIBE, to CHANGE email address, or to >>> view archives: >>>> http://mmp.cjp.com/mailman/listinfo/openheart-l >>>> >>>> All messages transmitted by the OpenHeart-L are >>> subject to the policies and >>>> disclaimers posted at: >>>> http://www.hsforum.com/listdisclaim >>>> ----------------------------------------- >>> >>> >> > _________________________________________________________________ >>> Gear up for HaloR 3 with free downloads and an >>> exclusive offer. It's our way of saying thanks for >>> using Windows LiveT. >>> >> > http://gethalo3gear.com? > ocid=SeptemberWLHalo3_WLHMTxt_2_____________________ >> __________________________ >>> OpenHeart-L mailing list >>> >>> Send postings to: >>> OpenHeart-L@lists.hsforum.com >>> >>> To UNSUBSCRIBE, to CHANGE email address, or to >> view >>> archives: >>> http://mmp.cjp.com/mailman/listinfo/openheart-l >>> >>> All messages transmitted by the OpenHeart-L are >>> subject to the policies and >>> disclaimers posted at: >>> http://www.hsforum.com/listdisclaim >>> ----------------------------------------- >>> >> >> >> Dr. David G. Harris, FCS, MMED, >> Cardiothoracic Surgeon >> Suite 207 >> Kuils River Private Hospital, >> PO Box 1200, Kuils River, 7579, Cape Town, South >> Africa. >> Tel +27-21-9006411 >> Fax +27-21-9006412 Mobile +27-83-3309587 >> >> _______________________________________________ >> OpenHeart-L mailing list >> >> Send postings to: >> OpenHeart-L@lists.hsforum.com >> >> To UNSUBSCRIBE, to CHANGE email address, or to view >> archives: >> http://mmp.cjp.com/mailman/listinfo/openheart-l >> >> All messages transmitted by the OpenHeart-L are >> subject to the policies and >> disclaimers posted at: >> http://www.hsforum.com/listdisclaim >> ----------------------------------------- >> >> _______________________________________________ >> OpenHeart-L mailing list >> >> Send postings to: >> OpenHeart-L@lists.hsforum.com >> >> To UNSUBSCRIBE, to CHANGE email address, or to view >> archives: >> http://mmp.cjp.com/mailman/listinfo/openheart-l >> >> All messages transmitted by the OpenHeart-L are >> subject to the policies and >> disclaimers posted at: >> http://www.hsforum.com/listdisclaim >> ----------------------------------------- >> > > > Dr. David G. Harris, FCS, MMED, > Cardiothoracic Surgeon > Suite 207 > Kuils River Private Hospital, > PO Box 1200, Kuils River, 7579, Cape Town, South Africa. > Tel +27-21-9006411 > Fax +27-21-9006412 Mobile +27-83-3309587 > > _______________________________________________ > OpenHeart-L mailing list > > Send postings to: > OpenHeart-L@lists.hsforum.com > > To UNSUBSCRIBE, to CHANGE email address, or to view archives: > http://mmp.cjp.com/mailman/listinfo/openheart-l > > All messages transmitted by the OpenHeart-L are subject to the > policies and > disclaimers posted at: > http://www.hsforum.com/listdisclaim > ----------------------------------------- From Hgrmd at aol.com Mon Oct 1 22:18:32 2007 From: Hgrmd at aol.com (Hgrmd@aol.com) Date: Mon Oct 1 21:19:05 2007 Subject: [HSF] Re: Post op antibiotics Message-ID: Dave, Thanks for the reply. Whether or not you can abort brewing mediastinitis with IV antibiotics alone is subject to debate. Obviously, the only way to answer that question would be to randomize patients with high CRP's to antibiotics versus placebo, and then see if there is a significant difference in the incidence of mediastinitis. Hal ************************************** See what's new at http://www.aol.com From prasannasimha at gmail.com Tue Oct 2 07:53:56 2007 From: prasannasimha at gmail.com (psimha) Date: Mon Oct 1 21:24:29 2007 Subject: [HSF] Abnormal LIMA In-Reply-To: <396834.68958.qm@web35914.mail.mud.yahoo.com> References: <396834.68958.qm@web35914.mail.mud.yahoo.com> Message-ID: <47019DAC.2030800@gmail.com> That is a "traction dissection" due to a friable LIMA and traction during dissection. I have seen this a few times when I was initially dissecting the LIMA but after making a "No traction" policy " I stopped having it. Basically I have seen many people tugging on the LIMA during dissection to get a better view . This causes a tube in tube dissection (usually distal where the initial dissection is done). I recently saw one by a colleague who was in the LIMA taking down learning curve . Prasanna john pj wrote: > 2 days back we operated a 54 yr old man for LT main stenosis with lesions in LAD and OM.The LIMA[2.5 mm in size] was harvested with out any difficulty and had good pulsation and flow when divided. When we divided the distal end we noted that the thick intima was telescoping beyond the remaining layers. When it was cut opened the intima was more opaue and lacked the lustre of normal intima. The thickened Intima was sliding against other layers as if they are separated. It was not like dissection. We did not see any localised atherosclerosis plaques . > . > We exised about 3 cm LIMA and there was no change in teh appearence . We went ahead with LIMA to LAD grafting takinkincare to incluse all the layers cautiously.We are watching the patient closely. We have low threshold to go back to replace it with a vein in case of any problems in the LAD territory. > > Any comments? > > --------------------------------- > Check out the hottest 2008 models today at Yahoo! Autos. > _______________________________________________ > OpenHeart-L mailing list > > Send postings to: > OpenHeart-L@lists.hsforum.com > > To UNSUBSCRIBE, to CHANGE email address, or to view archives: > http://mmp.cjp.com/mailman/listinfo/openheart-l > > All messages transmitted by the OpenHeart-L are subject to the policies and > disclaimers posted at: > http://www.hsforum.com/listdisclaim > ----------------------------------------- > > > From tacuff at swbell.net Mon Oct 1 21:42:37 2007 From: tacuff at swbell.net (Tea Acuff) Date: Mon Oct 1 23:43:09 2007 Subject: [HSF] Re: Post op antibiotics Message-ID: <919698.66130.qm@web81603.mail.mud.yahoo.com> What specifically in the TEG suggested early infection? I would agree that our "categories" are not likely intrinsic in the biology itself that we observe. Looking thru different lens (types of measurements) will reveal different "species of categories". tea ----- Original Message ---- From: Michael Firstenberg To: OpenHeart-L@lists.hsforum.com Sent: Monday, October 1, 2007 7:43:10 PM Subject: Re: [HSF] Re: Post op antibiotics very interesting observations - you need to write it up. If the CRPs went up and you started abx without an obvious source - how long did you treat? was there any correlation between the rate of elevation and severity of illness? wetting my appetite for more data! We did a lot of TEG on our VAD patients and while the data was very hard to get our hands around sudden (i.e. one day to the next) changes in TEG predicted an infection usually a day or two in advance. I think there is a lot to be learned from these inflammatory markers - the Cards use them a lot for predicting or understanding AMIs. -michael On Oct 1, 2007, at 8:32 PM, David Harris wrote: > Dear Ahmed, and Hal > > Sorry for the late reply, have been on vacation. > > As far as I know there is no literature reference to > back this up...although I am also the first to look at > evidence based concepts, an absence of literature > reference at this stage does not mean there is no > validity in the concept. > > I first started to do the CRP levels in all my > patients in 2000, when I started to do a randomised > study in my OPCAB patients. At that stage I was > already doing 70% OPCAB, but was wondering if I was > really doing the right thing, and also having local > criticism, thought I would then randomise all my > patients for the next year or so. I collected about > 120 patients in each group, and did post op cardiac > enzymes and inflammatory markers in all patients. What > we did find was that the OPCAB patients had a > statistically significant decrease in duration of > ventilation, CRP level, low cardiac output, and enzyme > release. > > We sent it in for publication to the European Journal, > and it was rejected, and we did not bother further (in > retrospect a mistake, as I have seen that persistence > does work!). > > What we also found, though, was that the CRP levels > helped to identify patients developing early sepsis > such as pneumonia (CRP > 350 day 1 or 2, it should > never be more than this),and helped identify patients > developing mediastinitis (rising CRP, after it has > started to drop). Usually it should be < 100 by day 5, > and if it is more than this we repeat after a few days > to make sure it is still going down. If it is > 100 by > day 7, then do not be surprised if this patient has > more chest pain than usual (Dressler`s), especially if > it takes a while to settle. A subsequent peak in CRP > is interesting to note, as this, in my personal > experience correlates with mediastinitis (or possible > endocarditis in valve patients). STarting treatment > has always aborted a disaster, in my experience, but > at the same time the patient has still become sick, > with cellulitis and fever, and in one case, in a > diabetic the patient developed SIRS 2 days after > initiating treatment, and had to be transferred to icu > (2 days prior to this I was about to send him home, > until I got the CRP result). > > The intensivists that look after my patients always do > a procalcitonin level if the CRP is high, or if they > suspect sepsis, but in my experience, I do not find > this too useful as an early indicator, but find the > CRP TREND more useful. > > If there is a significant CRP peak (after it has > dropped), and I cannot identify a local source of > sepsis, then usually I start them on Vancomycin and > Amicasin, or just Teicoplanin if the kidneys are bad > > It will be interesting to see what other surgeons` > findings will be. You will find you will do lots of > CRP levels, and initially it will seem useless, but > you will find it interesting when you match it with > the patient`s clinical recovery, and rewarding when > you detect the odd potential disaster > > Dave Harris > > --- A wrote: > >> Dave: >> I add my voice to Hal's very interesting concept CRP >> level as a marker for a >> potential mediastinitis. In your case what >> antibiotic do you start the >> patient on and for how long if the CRP level is >> rising? Reference please. >> Thank you for this info >> >> Ahmed >> >> -----Original Message----- >> From: openheart-l-bounces@lists.hsforum.com >> [mailto:openheart-l-bounces@lists.hsforum.com] On >> Behalf Of David Harris >> Sent: Saturday, September 22, 2007 2:16 PM >> To: OpenHeart-L@lists.hsforum.com >> Subject: RE: [HSF] Re: Post op antibiotics >> >> For CABG patients 24 hrs. >> >> For valves, until lines and drains out. >> >> Then track the CRP levels every second day to make >> sure the trend is downward, and there is no peak >> just >> before discharge. This way you can avoid >> mediastinitis, as you can treat it as it starts. >> Since doing this have not had a single case of >> sternal >> sepsis in the last 700 patients, but have had CRP >> peaks which we then confirm the next day, then >> treat. >> Some developed cellulitis a few days afterwards, >> while >> on treatment, but we were able to avoid >> debridements. >> >> Dave Harris >> >> >> --- Adam Saltman wrote: >> >>> It is actually policy at our institution now to >>> discontinue all prophylactic antibiotics according >>> to a time schedule. For general surgery patients >>> this is after 24 hours, and for cardiac patients >> it >>> is 48 hours (which actually has no data behind it, >>> just some hysterical cardiac surgeons). This is >> now >>> becoming a nation-wide initiative in the >> prevention >>> of infection by drug-resistant organisms... But as >>> far as I know, there is no data to support or >> refute >>> any particular strategy in cardiac patients... >>> >>> Adam >>> >>> >>> >>>> From: alsadd@ksu.edu.sa >>>> To: OpenHeart-L@lists.hsforum.com >>>> Date: Wed, 19 Sep 2007 14:58:29 -0700 >>>> CC: >>>> Subject: [HSF] Re: Post op antibiotics >>>> >>>> Dear Forum Members: >>>> >>>> >>>> >>>> Do the honorable members keep the open heart >>> patients on antibiotics for as >>>> long as they have mediastinal and chest tubes in >>> place? I do not, but some >>>> of my colleagues do. I went over the STS >>> guidelines the two parts and I >>>> could not find the answer to this question. >>>> >>>> Your response is greatly appreciated. >>>> >>>> Thank you >>>> >>>> >>>> >>>> Ahmed >>>> >>>> _______________________________________________ >>>> OpenHeart-L mailing list >>>> >>>> Send postings to: >>>> OpenHeart-L@lists.hsforum.com >>>> >>>> To UNSUBSCRIBE, to CHANGE email address, or to >>> view archives: >>>> http://mmp.cjp.com/mailman/listinfo/openheart-l >>>> >>>> All messages transmitted by the OpenHeart-L are >>> subject to the policies and >>>> disclaimers posted at: >>>> http://www.hsforum.com/listdisclaim >>>> ----------------------------------------- >>> >>> >> > _________________________________________________________________ >>> Gear up for HaloR 3 with free downloads and an >>> exclusive offer. It's our way of saying thanks for >>> using Windows LiveT. >>> >> > http://gethalo3gear.com? > ocid=SeptemberWLHalo3_WLHMTxt_2_____________________ >> __________________________ >>> OpenHeart-L mailing list >>> >>> Send postings to: >>> OpenHeart-L@lists.hsforum.com >>> >>> To UNSUBSCRIBE, to CHANGE email address, or to >> view >>> archives: >>> http://mmp.cjp.com/mailman/listinfo/openheart-l >>> >>> All messages transmitted by the OpenHeart-L are >>> subject to the policies and >>> disclaimers posted at: >>> http://www.hsforum.com/listdisclaim >>> ----------------------------------------- >>> >> >> >> Dr. David G. Harris, FCS, MMED, >> Cardiothoracic Surgeon >> Suite 207 >> Kuils River Private Hospital, >> PO Box 1200, Kuils River, 7579, Cape Town, South >> Africa. >> Tel +27-21-9006411 >> Fax +27-21-9006412 Mobile +27-83-3309587 >> >> _______________________________________________ >> OpenHeart-L mailing list >> >> Send postings to: >> OpenHeart-L@lists.hsforum.com >> >> To UNSUBSCRIBE, to CHANGE email address, or to view >> archives: >> http://mmp.cjp.com/mailman/listinfo/openheart-l >> >> All messages transmitted by the OpenHeart-L are >> subject to the policies and >> disclaimers posted at: >> http://www.hsforum.com/listdisclaim >> ----------------------------------------- >> >> _______________________________________________ >> OpenHeart-L mailing list >> >> Send postings to: >> OpenHeart-L@lists.hsforum.com >> >> To UNSUBSCRIBE, to CHANGE email address, or to view >> archives: >> http://mmp.cjp.com/mailman/listinfo/openheart-l >> >> All messages transmitted by the OpenHeart-L are >> subject to the policies and >> disclaimers posted at: >> http://www.hsforum.com/listdisclaim >> ----------------------------------------- >> > > > Dr. David G. Harris, FCS, MMED, > Cardiothoracic Surgeon > Suite 207 > Kuils River Private Hospital, > PO Box 1200, Kuils River, 7579, Cape Town, South Africa. > Tel +27-21-9006411 > Fax +27-21-9006412 Mobile +27-83-3309587 > > _______________________________________________ > OpenHeart-L mailing list > > Send postings to: > OpenHeart-L@lists.hsforum.com > > To UNSUBSCRIBE, to CHANGE email address, or to view archives: > http://mmp.cjp.com/mailman/listinfo/openheart-l > > All messages transmitted by the OpenHeart-L are subject to the > policies and > disclaimers posted at: > http://www.hsforum.com/listdisclaim > ----------------------------------------- _______________________________________________ OpenHeart-L mailing list Send postings to: OpenHeart-L@lists.hsforum.com To UNSUBSCRIBE, to CHANGE email address, or to view archives: http://mmp.cjp.com/mailman/listinfo/openheart-l All messages transmitted by the OpenHeart-L are subject to the policies and disclaimers posted at: http://www.hsforum.com/listdisclaim ----------------------------------------- From tacuff at swbell.net Mon Oct 1 22:10:17 2007 From: tacuff at swbell.net (Tea Acuff) Date: Tue Oct 2 00:10:46 2007 Subject: [HSF] Re: Post op antibiotics Message-ID: <314899.99076.qm@web81614.mail.mud.yahoo.com> David, Thanks for the interesting serial observations. If CRP is a good marker of inflammatory changes your results of off pump match my clinical impressions. How many CRP peaks and infections (if any) did you observe before you decided on what that meant (eg decided to treat as early infection)? How many have you thought that you aborted or as a percentage? Have you withheld treatment for other reasons and had your fears confirmed? tea ----- Original Message ---- From: David Harris To: OpenHeart-L@lists.hsforum.com Sent: Monday, October 1, 2007 7:32:47 PM Subject: RE: [HSF] Re: Post op antibiotics Dear Ahmed, and Hal Sorry for the late reply, have been on vacation. As far as I know there is no literature reference to back this up...although I am also the first to look at evidence based concepts, an absence of literature reference at this stage does not mean there is no validity in the concept. I first started to do the CRP levels in all my patients in 2000, when I started to do a randomised study in my OPCAB patients. At that stage I was already doing 70% OPCAB, but was wondering if I was really doing the right thing, and also having local criticism, thought I would then randomise all my patients for the next year or so. I collected about 120 patients in each group, and did post op cardiac enzymes and inflammatory markers in all patients. What we did find was that the OPCAB patients had a statistically significant decrease in duration of ventilation, CRP level, low cardiac output, and enzyme release. We sent it in for publication to the European Journal, and it was rejected, and we did not bother further (in retrospect a mistake, as I have seen that persistence does work!). What we also found, though, was that the CRP levels helped to identify patients developing early sepsis such as pneumonia (CRP > 350 day 1 or 2, it should never be more than this),and helped identify patients developing mediastinitis (rising CRP, after it has started to drop). Usually it should be < 100 by day 5, and if it is more than this we repeat after a few days to make sure it is still going down. If it is > 100 by day 7, then do not be surprised if this patient has more chest pain than usual (Dressler`s), especially if it takes a while to settle. A subsequent peak in CRP is interesting to note, as this, in my personal experience correlates with mediastinitis (or possible endocarditis in valve patients). STarting treatment has always aborted a disaster, in my experience, but at the same time the patient has still become sick, with cellulitis and fever, and in one case, in a diabetic the patient developed SIRS 2 days after initiating treatment, and had to be transferred to icu (2 days prior to this I was about to send him home, until I got the CRP result). The intensivists that look after my patients always do a procalcitonin level if the CRP is high, or if they suspect sepsis, but in my experience, I do not find this too useful as an early indicator, but find the CRP TREND more useful. If there is a significant CRP peak (after it has dropped), and I cannot identify a local source of sepsis, then usually I start them on Vancomycin and Amicasin, or just Teicoplanin if the kidneys are bad It will be interesting to see what other surgeons` findings will be. You will find you will do lots of CRP levels, and initially it will seem useless, but you will find it interesting when you match it with the patient`s clinical recovery, and rewarding when you detect the odd potential disaster Dave Harris --- A wrote: > Dave: > I add my voice to Hal's very interesting concept CRP > level as a marker for a > potential mediastinitis. In your case what > antibiotic do you start the > patient on and for how long if the CRP level is > rising? Reference please. > Thank you for this info > > Ahmed > > -----Original Message----- > From: openheart-l-bounces@lists.hsforum.com > [mailto:openheart-l-bounces@lists.hsforum.com] On > Behalf Of David Harris > Sent: Saturday, September 22, 2007 2:16 PM > To: OpenHeart-L@lists.hsforum.com > Subject: RE: [HSF] Re: Post op antibiotics > > For CABG patients 24 hrs. > > For valves, until lines and drains out. > > Then track the CRP levels every second day to make > sure the trend is downward, and there is no peak > just > before discharge. This way you can avoid > mediastinitis, as you can treat it as it starts. > Since doing this have not had a single case of > sternal > sepsis in the last 700 patients, but have had CRP > peaks which we then confirm the next day, then > treat. > Some developed cellulitis a few days afterwards, > while > on treatment, but we were able to avoid > debridements. > > Dave Harris > > > --- Adam Saltman wrote: > > > It is actually policy at our institution now to > > discontinue all prophylactic antibiotics according > > to a time schedule. For general surgery patients > > this is after 24 hours, and for cardiac patients > it > > is 48 hours (which actually has no data behind it, > > just some hysterical cardiac surgeons). This is > now > > becoming a nation-wide initiative in the > prevention > > of infection by drug-resistant organisms... But as > > far as I know, there is no data to support or > refute > > any particular strategy in cardiac patients... > > > > Adam > > > > > > > > > From: alsadd@ksu.edu.sa > > > To: OpenHeart-L@lists.hsforum.com > > > Date: Wed, 19 Sep 2007 14:58:29 -0700 > > > CC: > > > Subject: [HSF] Re: Post op antibiotics > > > > > > Dear Forum Members: > > > > > > > > > > > > Do the honorable members keep the open heart > > patients on antibiotics for as > > > long as they have mediastinal and chest tubes in > > place? I do not, but some > > > of my colleagues do. I went over the STS > > guidelines the two parts and I > > > could not find the answer to this question. > > > > > > Your response is greatly appreciated. > > > > > > Thank you > > > > > > > > > > > > Ahmed > > > > > > _______________________________________________ > > > OpenHeart-L mailing list > > > > > > Send postings to: > > > OpenHeart-L@lists.hsforum.com > > > > > > To UNSUBSCRIBE, to CHANGE email address, or to > > view archives: > > > http://mmp.cjp.com/mailman/listinfo/openheart-l > > > > > > All messages transmitted by the OpenHeart-L are > > subject to the policies and > > > disclaimers posted at: > > > http://www.hsforum.com/listdisclaim > > > ----------------------------------------- > > > > > _________________________________________________________________ > > Gear up for HaloR 3 with free downloads and an > > exclusive offer. It's our way of saying thanks for > > using Windows LiveT. > > > http://gethalo3gear.com?ocid=SeptemberWLHalo3_WLHMTxt_2_____________________ > __________________________ > > OpenHeart-L mailing list > > > > Send postings to: > > OpenHeart-L@lists.hsforum.com > > > > To UNSUBSCRIBE, to CHANGE email address, or to > view > > archives: > > http://mmp.cjp.com/mailman/listinfo/openheart-l > > > > All messages transmitted by the OpenHeart-L are > > subject to the policies and > > disclaimers posted at: > > http://www.hsforum.com/listdisclaim > > ----------------------------------------- > > > > > Dr. David G. Harris, FCS, MMED, > Cardiothoracic Surgeon > Suite 207 > Kuils River Private Hospital, > PO Box 1200, Kuils River, 7579, Cape Town, South > Africa. > Tel +27-21-9006411 > Fax +27-21-9006412 Mobile +27-83-3309587 > > _______________________________________________ > OpenHeart-L mailing list > > Send postings to: > OpenHeart-L@lists.hsforum.com > > To UNSUBSCRIBE, to CHANGE email address, or to view > archives: > http://mmp.cjp.com/mailman/listinfo/openheart-l > > All messages transmitted by the OpenHeart-L are > subject to the policies and > disclaimers posted at: > http://www.hsforum.com/listdisclaim > ----------------------------------------- > > _______________________________________________ > OpenHeart-L mailing list > > Send postings to: > OpenHeart-L@lists.hsforum.com > > To UNSUBSCRIBE, to CHANGE email address, or to view > archives: > http://mmp.cjp.com/mailman/listinfo/openheart-l > > All messages transmitted by the OpenHeart-L are > subject to the policies and > disclaimers posted at: > http://www.hsforum.com/listdisclaim > ----------------------------------------- > Dr. David G. Harris, FCS, MMED, Cardiothoracic Surgeon Suite 207 Kuils River Private Hospital, PO Box 1200, Kuils River, 7579, Cape Town, South Africa. Tel +27-21-9006411 Fax +27-21-9006412 Mobile +27-83-3309587 _______________________________________________ OpenHeart-L mailing list Send postings to: OpenHeart-L@lists.hsforum.com To UNSUBSCRIBE, to CHANGE email address, or to view archives: http://mmp.cjp.com/mailman/listinfo/openheart-l All messages transmitted by the OpenHeart-L are subject to the policies and disclaimers posted at: http://www.hsforum.com/listdisclaim ----------------------------------------- From battr at medizin.uni-leipzig.de Tue Oct 2 09:26:31 2007 From: battr at medizin.uni-leipzig.de (Dr. Roberto Battellini) Date: Tue Oct 2 02:19:50 2007 Subject: AW: [HSF] Abnormal LIMA In-Reply-To: References: Message-ID: <00bd01c804bd$2d0d8550$b3160a06@HZLPC0679> We do the same as you did. With Intuition and experience. Last year we discarded a big atherosclerotic LIMA in an coarctatio aortae operated patient who came 30 years later for AVR (bicuspid valve) and bypass. I have discarded also many radial arteries because of calcification. Roberto -----Urspr?ngliche Nachricht----- Von: openheart-l-bounces@lists.hsforum.com [mailto:openheart-l-bounces@lists.hsforum.com] Im Auftrag von MDavalle@aol.com Gesendet: Montag, 1. Oktober 2007 17:20 An: OpenHeart-L@lists.hsforum.com Betreff: Re: [HSF] Abnormal LIMA In a similar "vein", I am wondering what do do when I take down a LIMA and it has small islands of non obstructive plaque. I have seen this mostly in young diabetics and went ahead and used them documenting good flow at completion with Medi-stem. What do others think? ************************************** See what's new at http://www.aol.com _______________________________________________ OpenHeart-L mailing list Send postings to: OpenHeart-L@lists.hsforum.com To UNSUBSCRIBE, to CHANGE email address, or to view archives: http://mmp.cjp.com/mailman/listinfo/openheart-l All messages transmitted by the OpenHeart-L are subject to the policies and disclaimers posted at: http://www.hsforum.com/listdisclaim ----------------------------------------- From battr at medizin.uni-leipzig.de Tue Oct 2 09:30:50 2007 From: battr at medizin.uni-leipzig.de (Dr. Roberto Battellini) Date: Tue Oct 2 02:23:58 2007 Subject: AW: [HSF] Re: Post op antibiotics In-Reply-To: <753114.59608.qm@web26710.mail.ukl.yahoo.com> References: <753114.59608.qm@web26710.mail.ukl.yahoo.com> Message-ID: <00be01c804bd$c7073ed0$b3160a06@HZLPC0679> In Germany after washing our hands we use a germicide solution called Skinman or Spitacid. We believe it works.I personally cannot palpate plaques and do a LIMA anastomosis with 8 x 0 and 2 pairs of gloves. Roberto -----Urspr?ngliche Nachricht----- Von: openheart-l-bounces@lists.hsforum.com [mailto:openheart-l-bounces@lists.hsforum.com] Im Auftrag von David Harris Gesendet: Montag, 1. Oktober 2007 23:51 An: OpenHeart-L@lists.hsforum.com Betreff: RE: [HSF] Re: Post op antibiotics Dear Ani, Many thanks for your interesting comments, yes i think double gloving makes more sense than anything else, and has better protection for the patient AND surgeon. In our speciality this is seldom done. When I was a resident doing orthopaedics, this was standard practice (when the initial fear for the HIV virus was much greater than now!). I think you have raised an essential point that we should all be using double gloves, for the sake of ourselves, and our patients (even if it is a bit uncomfortable) Dave Harris --- Ani Anyanwu wrote: > Dr Harris > > Do you really think scrubbing matters that much? I > must confess that I have not scrubbed with water and > a brush for over 2 years. I just use a chlorexidine > cream which I rub for maybe 20 to 30 seconds. I have > not noted an out of ordinary problem with infection > even for the heart transplants who are > immunosuppressed. I must say though that I do double > glove for all cases and I think this is more > important than scrubbing. Within the course of most > cardiac operations the surgeon's hand is repopulated > with microbes which makes me ponder the usefulness > of scrubbing. The surgeon with a single pair of > gloves may often have a (unrecognised) defect in the > gloves and a possible source of contamination which > is why i wear two gloves. Also glove changes of a > single glove may themselves be a source of > contamination, compared to double gloves where glove > changes are certainly aspetic. > > I would suggest that it is your attention to detail > and your technique that gets you a low infection > rate and not the manner of scrubbing - I find in > particular the comments on the impact of volume, > personnel, large operating rooms and ICU size very > interesting and are likely far more relevant. > > > Ani > > > > > > Date: Sun, 23 Sep 2007 01:27:22 +0100> From: > drdharris@yahoo.co.uk> Subject: RE: [HSF] Re: Post > op antibiotics> To: OpenHeart-L@lists.hsforum.com> > CC: > > Thanks, Ani.> > I have been in private > practice for a few years so> have no trainees > working with me. In the training> hospital where I > worked, the mediastinitis rate was> also low, less > than 1 %.> I think there are a number of factors: > Lower volume of> cases in each centre, so less > crowded icu, strict> antibiotic policy, very large > operating rooms in each> centre, less complex cases > performed (therefore> shorter operating times). Also > we had fewer surgeons> than the average unit, and > each surgeon therefore> performing more cases.> We > are also very strict with our aseptic technique in> > the OR, especially a long period scrubbing up,> > changing cloves frequently if contamination > suspected.> When I visited surgeons in the USA I was > amazed about> the short period of time spent > scrubbing for a case,> compared with back home, and > noticed that generally> only washing of hands and > forearms was done, and no> scrubbing of the nails.> > > Dave Harris> > > --- Ani Anyanwu > wrote:> > > Dr Harris> > > > > Amazing series - I suspect more though that your> > > surgical technique and infection control > practices> > may contribute more to the rarity of > mediastinitis> > than the antibiotics and CRP. What > protocol did you> > use before the last 700 cases > and what was your> > infection rate then? Do you > have trainee surgeons? > > > > Thanks> > > > Ani> > > > > > > > > > Date: Sat, 22 Sep 2007 22:16:23 +0100> > From:> > drdharris@yahoo.co.uk> Subject: RE: [HSF] > Re: Post> > op antibiotics> To: > OpenHeart-L@lists.hsforum.com>> > CC: > > For CABG > patients 24 hrs.> > For valves,> > until lines and > drains out.> > Then track the CRP> > levels every > second day to make> sure the trend is> > downward, > and there is no peak just> before> > discharge. This > way you can avoid> mediastinitis, as> > you can > treat it as it starts.> Since doing this> > have not > had a single case of sternal> sepsis in the> > last > 700 patients, but have had CRP> peaks which we> > > then confirm the next day, then treat.> Some> > > developed cellulitis a few days afterwards, while>> > > on treatment, but we were able to avoid> > > debridements.> > Dave Harris> > > --- Adam Saltman> > > wrote:> > > It is > actually> > policy at our institution now to> > > discontinue all> > prophylactic antibiotics > according> > to a time> > schedule. For general > surgery patients> > this is> > after 24 hours, and > for cardiac patients it> > is 48> > hours (which > actually has no data behind it,> > just> > some > hysterical cardiac surgeons). This is now> >> > > becoming a nation-wide initiative in the > prevention>> > > of infection by drug-resistant > organisms... But> > as> > far as I know, there is no > data to support or> > refute> > any particular > strategy in cardiac> > patients...> > > > Adam> > > > > > > > > > From:> > alsadd@ksu.edu.sa> > > To:> > > OpenHeart-L@lists.hsforum.com> > > Date: Wed, 19 > Sep> > 2007 14:58:29 -0700> > > CC: > > > Subject: > [HSF]> > Re: Post op antibiotics > > > > > > Dear > Forum> > Members:> > > > > > > > > > > > Do the > honorable> > members keep the open heart> > patients > on> > antibiotics for as> > > long as they have> > > mediastinal and chest tubes in> > place? I do not,> > > but some> > > of my colleagues do. I went over > the> > STS> > guidelines the two parts and I> > > > could not> > find the answer to this question.> > > > > > > Your> > response is greatly appreciated.> > > > > > > Thank> > you> > > > > > > > > > > > Ahmed> > > > > > >> > > _______________________________________________> > > >> > OpenHeart-L mailing list> > > > > > Send > postings> > to:> > > OpenHeart-L@lists.hsforum.com> > > > > > > To> > UNSUBSCRIBE, to CHANGE email > address, or to> > view> > archives:> > >> > > http://mmp.cjp.com/mailman/listinfo/openheart-l> > > >> > > > > All messages transmitted by the > OpenHeart-L> > are> > subject to the policies and > > > > disclaimers> > posted at:> > > > http://www.hsforum.com/listdisclaim>> > > > > -----------------------------------------> > >> > > >>> >> > _________________________________________________________________>> > > > Gear up for Halo? 3 with free downloads and an> > >> > exclusive offer. It?s our way of saying thanks > for>> > > using Windows Live?.> >>> >> > http://gethalo3gear.com?ocid=SeptemberWLHalo3_WLHMTxt_2_____________________ __________________________>> > > > OpenHeart-L mailing list> > > > Send postings > to:>> > > OpenHeart-L@lists.hsforum.com> > > > To> > > UNSUBSCRIBE, to CHANGE email address, or to view> >> > > archives:> >> > > http://mmp.cjp.com/mailman/listinfo/openheart-l> > > >> > > All messages transmitted by the OpenHeart-L > are> >> > subject to the policies and> > disclaimers > posted> > at:> > > http://www.hsforum.com/listdisclaim> >> > > -----------------------------------------> > > > >> > > Dr. David G. Harris, FCS, MMED,> Cardiothoracic> > > Surgeon > Suite 207 > Kuils River Private Hospital,> > > > PO Box 1200, Kuils River, 7579, Cape Town, > South> > Africa. > Tel +27-21-9006411 > Fax > +27-21-9006412> > Mobile +27-83-3309587> >> > > _______________________________________________>> > > OpenHeart-L mailing list> > Send postings to:>> > > OpenHeart-L@lists.hsforum.com> > To UNSUBSCRIBE, to> > > CHANGE email address, or to view archives:>> > > http://mmp.cjp.com/mailman/listinfo/openheart-l> >> > > All messages transmitted by the OpenHeart-L are> > > subject to the policies and > disclaimers posted> > > at:> http://www.hsforum.com/listdisclaim>> > > -----------------------------------------> >> > _________________________________________________________________> > > Feel like a local wherever you go.> >> > http://www.backofmyhand.com_______________________________________________> > > OpenHeart-L mailing list> > > > Send postings to:> > > OpenHeart-L@lists.hsforum.com> > > > To > UNSUBSCRIBE, to CHANGE email address, or to view> > > archives:> > > http://mmp.cjp.com/mailman/listinfo/openheart-l> > > > > All messages transmitted by the OpenHeart-L are> > > subject to the policies and> > disclaimers posted > at:> > http://www.hsforum.com/listdisclaim> > > -----------------------------------------> > > > > > Dr. David G. Harris, FCS, MMED,> Cardiothoracic > Surgeon > Suite 207 > Kuils River Private Hospital, > > PO Box 1200, Kuils River, 7579, Cape Town, South > Africa. > Tel +27-21-9006411 > Fax +27-21-9006412 > Mobile +27-83-3309587> > > _______________________________________________> > OpenHeart-L mailing list> > Send postings to:> > OpenHeart-L@lists.hsforum.com> > To UNSUBSCRIBE, to > CHANGE email address, or to view archives:> > http://mmp.cjp.com/mailman/listinfo/openheart-l> > > All messages transmitted by the OpenHeart-L are > subject to the policies and > disclaimers posted > at:> http://www.hsforum.com/listdisclaim> > ----------------------------------------- > _________________________________________________________________ > Feel like a local wherever you go. > http://www.backofmyhand.com_______________________________________________ > OpenHeart-L mailing list > > Send postings to: > OpenHeart-L@lists.hsforum.com > > To UNSUBSCRIBE, to CHANGE email address, or to view > archives: > http://mmp.cjp.com/mailman/listinfo/openheart-l > > All messages transmitted by the OpenHeart-L are > subject to the policies and > disclaimers posted at: > http://www.hsforum.com/listdisclaim > ----------------------------------------- > Dr. David G. Harris, FCS, MMED, Cardiothoracic Surgeon Suite 207 Kuils River Private Hospital, PO Box 1200, Kuils River, 7579, Cape Town, South Africa. Tel +27-21-9006411 Fax +27-21-9006412 Mobile +27-83-3309587 _______________________________________________ OpenHeart-L mailing list Send postings to: OpenHeart-L@lists.hsforum.com To UNSUBSCRIBE, to CHANGE email address, or to view archives: http://mmp.cjp.com/mailman/listinfo/openheart-l All messages transmitted by the OpenHeart-L are subject to the policies and disclaimers posted at: http://www.hsforum.com/listdisclaim ----------------------------------------- From battr at medizin.uni-leipzig.de Tue Oct 2 09:37:38 2007 From: battr at medizin.uni-leipzig.de (Dr. Roberto Battellini) Date: Tue Oct 2 02:30:21 2007 Subject: AW: [HSF] Re: Post op antibiotics In-Reply-To: <890586.61263.qm@web26707.mail.ukl.yahoo.com> References: <20070923121401.CC709D5FF0@smtp.ksu.edu.sa> <890586.61263.qm@web26707.mail.ukl.yahoo.com> Message-ID: <00bf01c804be$ba219700$b3160a06@HZLPC0679> Very good comments, Dave. We agree. When a patient has dropping CRP and after a peak, specially with leucocitosis, we order a thorax CT looking for sternal infection or mediastinitis. In patients with fever I use to make a punction between the two hemisternae, sometimes I get blood which can be cultivated (or pus). Roberto -----Urspr?ngliche Nachricht----- Von: openheart-l-bounces@lists.hsforum.com [mailto:openheart-l-bounces@lists.hsforum.com] Im Auftrag von David Harris Gesendet: Dienstag, 2. Oktober 2007 01:33 An: OpenHeart-L@lists.hsforum.com Betreff: RE: [HSF] Re: Post op antibiotics Dear Ahmed, and Hal Sorry for the late reply, have been on vacation. As far as I know there is no literature reference to back this up...although I am also the first to look at evidence based concepts, an absence of literature reference at this stage does not mean there is no validity in the concept. I first started to do the CRP levels in all my patients in 2000, when I started to do a randomised study in my OPCAB patients. At that stage I was already doing 70% OPCAB, but was wondering if I was really doing the right thing, and also having local criticism, thought I would then randomise all my patients for the next year or so. I collected about 120 patients in each group, and did post op cardiac enzymes and inflammatory markers in all patients. What we did find was that the OPCAB patients had a statistically significant decrease in duration of ventilation, CRP level, low cardiac output, and enzyme release. We sent it in for publication to the European Journal, and it was rejected, and we did not bother further (in retrospect a mistake, as I have seen that persistence does work!). What we also found, though, was that the CRP levels helped to identify patients developing early sepsis such as pneumonia (CRP > 350 day 1 or 2, it should never be more than this),and helped identify patients developing mediastinitis (rising CRP, after it has started to drop). Usually it should be < 100 by day 5, and if it is more than this we repeat after a few days to make sure it is still going down. If it is > 100 by day 7, then do not be surprised if this patient has more chest pain than usual (Dressler`s), especially if it takes a while to settle. A subsequent peak in CRP is interesting to note, as this, in my personal experience correlates with mediastinitis (or possible endocarditis in valve patients). STarting treatment has always aborted a disaster, in my experience, but at the same time the patient has still become sick, with cellulitis and fever, and in one case, in a diabetic the patient developed SIRS 2 days after initiating treatment, and had to be transferred to icu (2 days prior to this I was about to send him home, until I got the CRP result). The intensivists that look after my patients always do a procalcitonin level if the CRP is high, or if they suspect sepsis, but in my experience, I do not find this too useful as an early indicator, but find the CRP TREND more useful. If there is a significant CRP peak (after it has dropped), and I cannot identify a local source of sepsis, then usually I start them on Vancomycin and Amicasin, or just Teicoplanin if the kidneys are bad It will be interesting to see what other surgeons` findings will be. You will find you will do lots of CRP levels, and initially it will seem useless, but you will find it interesting when you match it with the patient`s clinical recovery, and rewarding when you detect the odd potential disaster Dave Harris --- A wrote: > Dave: > I add my voice to Hal's very interesting concept CRP > level as a marker for a > potential mediastinitis. In your case what > antibiotic do you start the > patient on and for how long if the CRP level is > rising? Reference please. > Thank you for this info > > Ahmed > > -----Original Message----- > From: openheart-l-bounces@lists.hsforum.com > [mailto:openheart-l-bounces@lists.hsforum.com] On > Behalf Of David Harris > Sent: Saturday, September 22, 2007 2:16 PM > To: OpenHeart-L@lists.hsforum.com > Subject: RE: [HSF] Re: Post op antibiotics > > For CABG patients 24 hrs. > > For valves, until lines and drains out. > > Then track the CRP levels every second day to make > sure the trend is downward, and there is no peak > just > before discharge. This way you can avoid > mediastinitis, as you can treat it as it starts. > Since doing this have not had a single case of > sternal > sepsis in the last 700 patients, but have had CRP > peaks which we then confirm the next day, then > treat. > Some developed cellulitis a few days afterwards, > while > on treatment, but we were able to avoid > debridements. > > Dave Harris > > > --- Adam Saltman wrote: > > > It is actually policy at our institution now to > > discontinue all prophylactic antibiotics according > > to a time schedule. For general surgery patients > > this is after 24 hours, and for cardiac patients > it > > is 48 hours (which actually has no data behind it, > > just some hysterical cardiac surgeons). This is > now > > becoming a nation-wide initiative in the > prevention > > of infection by drug-resistant organisms... But as > > far as I know, there is no data to support or > refute > > any particular strategy in cardiac patients... > > > > Adam > > > > > > > > > From: alsadd@ksu.edu.sa > > > To: OpenHeart-L@lists.hsforum.com > > > Date: Wed, 19 Sep 2007 14:58:29 -0700 > > > CC: > > > Subject: [HSF] Re: Post op antibiotics > > > > > > Dear Forum Members: > > > > > > > > > > > > Do the honorable members keep the open heart > > patients on antibiotics for as > > > long as they have mediastinal and chest tubes in > > place? I do not, but some > > > of my colleagues do. I went over the STS > > guidelines the two parts and I > > > could not find the answer to this question. > > > > > > Your response is greatly appreciated. > > > > > > Thank you > > > > > > > > > > > > Ahmed > > > > > > _______________________________________________ > > > OpenHeart-L mailing list > > > > > > Send postings to: > > > OpenHeart-L@lists.hsforum.com > > > > > > To UNSUBSCRIBE, to CHANGE email address, or to > > view archives: > > > http://mmp.cjp.com/mailman/listinfo/openheart-l > > > > > > All messages transmitted by the OpenHeart-L are > > subject to the policies and > > > disclaimers posted at: > > > http://www.hsforum.com/listdisclaim > > > ----------------------------------------- > > > > > _________________________________________________________________ > > Gear up for HaloR 3 with free downloads and an > > exclusive offer. It's our way of saying thanks for > > using Windows LiveT. > > > http://gethalo3gear.com?ocid=SeptemberWLHalo3_WLHMTxt_2_____________________ > __________________________ > > OpenHeart-L mailing list > > > > Send postings to: > > OpenHeart-L@lists.hsforum.com > > > > To UNSUBSCRIBE, to CHANGE email address, or to > view > > archives: > > http://mmp.cjp.com/mailman/listinfo/openheart-l > > > > All messages transmitted by the OpenHeart-L are > > subject to the policies and > > disclaimers posted at: > > http://www.hsforum.com/listdisclaim > > ----------------------------------------- > > > > > Dr. David G. Harris, FCS, MMED, > Cardiothoracic Surgeon > Suite 207 > Kuils River Private Hospital, > PO Box 1200, Kuils River, 7579, Cape Town, South > Africa. > Tel +27-21-9006411 > Fax +27-21-9006412 Mobile +27-83-3309587 > > _______________________________________________ > OpenHeart-L mailing list > > Send postings to: > OpenHeart-L@lists.hsforum.com > > To UNSUBSCRIBE, to CHANGE email address, or to view > archives: > http://mmp.cjp.com/mailman/listinfo/openheart-l > > All messages transmitted by the OpenHeart-L are > subject to the policies and > disclaimers posted at: > http://www.hsforum.com/listdisclaim > ----------------------------------------- > > _______________________________________________ > OpenHeart-L mailing list > > Send postings to: > OpenHeart-L@lists.hsforum.com > > To UNSUBSCRIBE, to CHANGE email address, or to view > archives: > http://mmp.cjp.com/mailman/listinfo/openheart-l > > All messages transmitted by the OpenHeart-L are > subject to the policies and > disclaimers posted at: > http://www.hsforum.com/listdisclaim > ----------------------------------------- > Dr. David G. Harris, FCS, MMED, Cardiothoracic Surgeon Suite 207 Kuils River Private Hospital, PO Box 1200, Kuils River, 7579, Cape Town, South Africa. Tel +27-21-9006411 Fax +27-21-9006412 Mobile +27-83-3309587 _______________________________________________ OpenHeart-L mailing list Send postings to: OpenHeart-L@lists.hsforum.com To UNSUBSCRIBE, to CHANGE email address, or to view archives: http://mmp.cjp.com/mailman/listinfo/openheart-l All messages transmitted by the OpenHeart-L are subject to the policies and disclaimers posted at: http://www.hsforum.com/listdisclaim ----------------------------------------- From alsadd at ksu.edu.sa Tue Oct 2 10:44:23 2007 From: alsadd at ksu.edu.sa (A) Date: Tue Oct 2 02:44:58 2007 Subject: [HSF] Re: Post op antibiotics In-Reply-To: <890586.61263.qm@web26707.mail.ukl.yahoo.com> Message-ID: <20071002064213.84FBCD5FF0@smtp.ksu.edu.sa> Dave: Thank you for the detailed response. I think that you should not be discouraged and publish it in a different Journal. The main thing is to keep trying you have the basis for a good manuscript. Ahmed -----Original Message----- From: openheart-l-bounces@lists.hsforum.com [mailto:openheart-l-bounces@lists.hsforum.com] On Behalf Of David Harris Sent: Monday, October 01, 2007 5:33 PM To: OpenHeart-L@lists.hsforum.com Subject: RE: [HSF] Re: Post op antibiotics Dear Ahmed, and Hal Sorry for the late reply, have been on vacation. As far as I know there is no literature reference to back this up...although I am also the first to look at evidence based concepts, an absence of literature reference at this stage does not mean there is no validity in the concept. I first started to do the CRP levels in all my patients in 2000, when I started to do a randomised study in my OPCAB patients. At that stage I was already doing 70% OPCAB, but was wondering if I was really doing the right thing, and also having local criticism, thought I would then randomise all my patients for the next year or so. I collected about 120 patients in each group, and did post op cardiac enzymes and inflammatory markers in all patients. What we did find was that the OPCAB patients had a statistically significant decrease in duration of ventilation, CRP level, low cardiac output, and enzyme release. We sent it in for publication to the European Journal, and it was rejected, and we did not bother further (in retrospect a mistake, as I have seen that persistence does work!). What we also found, though, was that the CRP levels helped to identify patients developing early sepsis such as pneumonia (CRP > 350 day 1 or 2, it should never be more than this),and helped identify patients developing mediastinitis (rising CRP, after it has started to drop). Usually it should be < 100 by day 5, and if it is more than this we repeat after a few days to make sure it is still going down. If it is > 100 by day 7, then do not be surprised if this patient has more chest pain than usual (Dressler`s), especially if it takes a while to settle. A subsequent peak in CRP is interesting to note, as this, in my personal experience correlates with mediastinitis (or possible endocarditis in valve patients). STarting treatment has always aborted a disaster, in my experience, but at the same time the patient has still become sick, with cellulitis and fever, and in one case, in a diabetic the patient developed SIRS 2 days after initiating treatment, and had to be transferred to icu (2 days prior to this I was about to send him home, until I got the CRP result). The intensivists that look after my patients always do a procalcitonin level if the CRP is high, or if they suspect sepsis, but in my experience, I do not find this too useful as an early indicator, but find the CRP TREND more useful. If there is a significant CRP peak (after it has dropped), and I cannot identify a local source of sepsis, then usually I start them on Vancomycin and Amicasin, or just Teicoplanin if the kidneys are bad It will be interesting to see what other surgeons` findings will be. You will find you will do lots of CRP levels, and initially it will seem useless, but you will find it interesting when you match it with the patient`s clinical recovery, and rewarding when you detect the odd potential disaster Dave Harris --- A wrote: > Dave: > I add my voice to Hal's very interesting concept CRP > level as a marker for a > potential mediastinitis. In your case what > antibiotic do you start the > patient on and for how long if the CRP level is > rising? Reference please. > Thank you for this info > > Ahmed > > -----Original Message----- > From: openheart-l-bounces@lists.hsforum.com > [mailto:openheart-l-bounces@lists.hsforum.com] On > Behalf Of David Harris > Sent: Saturday, September 22, 2007 2:16 PM > To: OpenHeart-L@lists.hsforum.com > Subject: RE: [HSF] Re: Post op antibiotics > > For CABG patients 24 hrs. > > For valves, until lines and drains out. > > Then track the CRP levels every second day to make > sure the trend is downward, and there is no peak > just > before discharge. This way you can avoid > mediastinitis, as you can treat it as it starts. > Since doing this have not had a single case of > sternal > sepsis in the last 700 patients, but have had CRP > peaks which we then confirm the next day, then > treat. > Some developed cellulitis a few days afterwards, > while > on treatment, but we were able to avoid > debridements. > > Dave Harris > > > --- Adam Saltman wrote: > > > It is actually policy at our institution now to > > discontinue all prophylactic antibiotics according > > to a time schedule. For general surgery patients > > this is after 24 hours, and for cardiac patients > it > > is 48 hours (which actually has no data behind it, > > just some hysterical cardiac surgeons). This is > now > > becoming a nation-wide initiative in the > prevention > > of infection by drug-resistant organisms... But as > > far as I know, there is no data to support or > refute > > any particular strategy in cardiac patients... > > > > Adam > > > > > > > > > From: alsadd@ksu.edu.sa > > > To: OpenHeart-L@lists.hsforum.com > > > Date: Wed, 19 Sep 2007 14:58:29 -0700 > > > CC: > > > Subject: [HSF] Re: Post op antibiotics > > > > > > Dear Forum Members: > > > > > > > > > > > > Do the honorable members keep the open heart > > patients on antibiotics for as > > > long as they have mediastinal and chest tubes in > > place? I do not, but some > > > of my colleagues do. I went over the STS > > guidelines the two parts and I > > > could not find the answer to this question. > > > > > > Your response is greatly appreciated. > > > > > > Thank you > > > > > > > > > > > > Ahmed > > > > > > _______________________________________________ > > > OpenHeart-L mailing list > > > > > > Send postings to: > > > OpenHeart-L@lists.hsforum.com > > > > > > To UNSUBSCRIBE, to CHANGE email address, or to > > view archives: > > > http://mmp.cjp.com/mailman/listinfo/openheart-l > > > > > > All messages transmitted by the OpenHeart-L are > > subject to the policies and > > > disclaimers posted at: > > > http://www.hsforum.com/listdisclaim > > > ----------------------------------------- > > > > > _________________________________________________________________ > > Gear up for HaloR 3 with free downloads and an > > exclusive offer. It's our way of saying thanks for > > using Windows LiveT. > > > http://gethalo3gear.com?ocid=SeptemberWLHalo3_WLHMTxt_2_____________________ > __________________________ > > OpenHeart-L mailing list > > > > Send postings to: > > OpenHeart-L@lists.hsforum.com > > > > To UNSUBSCRIBE, to CHANGE email address, or to > view > > archives: > > http://mmp.cjp.com/mailman/listinfo/openheart-l > > > > All messages transmitted by the OpenHeart-L are > > subject to the policies and > > disclaimers posted at: > > http://www.hsforum.com/listdisclaim > > ----------------------------------------- > > > > > Dr. David G. Harris, FCS, MMED, > Cardiothoracic Surgeon > Suite 207 > Kuils River Private Hospital, > PO Box 1200, Kuils River, 7579, Cape Town, South > Africa. > Tel +27-21-9006411 > Fax +27-21-9006412 Mobile +27-83-3309587 > > _______________________________________________ > OpenHeart-L mailing list > > Send postings to: > OpenHeart-L@lists.hsforum.com > > To UNSUBSCRIBE, to CHANGE email address, or to view > archives: > http://mmp.cjp.com/mailman/listinfo/openheart-l > > All messages transmitted by the OpenHeart-L are > subject to the policies and > disclaimers posted at: > http://www.hsforum.com/listdisclaim > ----------------------------------------- > > _______________________________________________ > OpenHeart-L mailing list > > Send postings to: > OpenHeart-L@lists.hsforum.com > > To UNSUBSCRIBE, to CHANGE email address, or to view > archives: > http://mmp.cjp.com/mailman/listinfo/openheart-l > > All messages transmitted by the OpenHeart-L are > subject to the policies and > disclaimers posted at: > http://www.hsforum.com/listdisclaim > ----------------------------------------- > Dr. David G. Harris, FCS, MMED, Cardiothoracic Surgeon Suite 207 Kuils River Private Hospital, PO Box 1200, Kuils River, 7579, Cape Town, South Africa. Tel +27-21-9006411 Fax +27-21-9006412 Mobile +27-83-3309587 _______________________________________________ OpenHeart-L mailing list Send postings to: OpenHeart-L@lists.hsforum.com To UNSUBSCRIBE, to CHANGE email address, or to view archives: http://mmp.cjp.com/mailman/listinfo/openheart-l All messages transmitted by the OpenHeart-L are subject to the policies and disclaimers posted at: http://www.hsforum.com/listdisclaim ----------------------------------------- From donross at bigpond.com Tue Oct 2 20:43:13 2007 From: donross at bigpond.com (Donald Ross) Date: Tue Oct 2 05:44:48 2007 Subject: [HSF] Abnormal LIMA In-Reply-To: <47019DAC.2030800@gmail.com> References: <396834.68958.qm@web35914.mail.mud.yahoo.com> <47019DAC.2030800@gmail.com> Message-ID: <1F9AE018-C87E-444E-81C8-0DB57C96EE78@bigpond.com> Yes!! You know all , I have seen it recently and had to discard half the ima! I will have to read the "no traction" riot act to my fellows, one of whom is hoping to practice in your city next year. Thanks, Don > That is a "traction dissection" due to a friable LIMA and traction > during dissection. I have seen this a few times when I was > initially dissecting the LIMA but after making a "No traction" > policy " I stopped having it. Basically I have seen many people > tugging on the LIMA during dissection to get a better view . This > causes a tube in tube dissection (usually distal where the initial > dissection is done). I recently saw one by a colleague who was in > the LIMA taking down learning curve . > Prasanna > john pj wrote: >> 2 days back we operated a 54 yr old man for LT main stenosis with >> lesions in LAD and OM.The LIMA[2.5 mm in size] was harvested with >> out any difficulty and had good pulsation and flow when >> divided. When we divided the distal end we noted that the thick >> intima was telescoping beyond the remaining layers. When it was >> cut opened the intima was more opaue and lacked the lustre of >> normal intima. The thickened Intima was sliding against other >> layers as if they are separated. It was not like dissection. We >> did not see any localised atherosclerosis plaques . >> . >> We exised about 3 cm LIMA and there was no change in teh >> appearence . We went ahead with LIMA to LAD grafting takinkincare >> to incluse all the layers cautiously.We are watching the patient >> closely. We have low threshold to go back to replace it with a >> vein in case of any problems in the LAD territory. >> Any comments? >> --------------------------------- >> Check out the hottest 2008 models today at Yahoo! Autos. >> _______________________________________________ >> OpenHeart-L mailing list >> >> Send postings to: >> OpenHeart-L@lists.hsforum.com >> >> To UNSUBSCRIBE, to CHANGE email address, or to view archives: >> http://mmp.cjp.com/mailman/listinfo/openheart-l >> >> All messages transmitted by the OpenHeart-L are subject to the >> policies and disclaimers posted at: >> http://www.hsforum.com/listdisclaim >> ----------------------------------------- >> >> >> > > _______________________________________________ > OpenHeart-L mailing list > > Send postings to: > OpenHeart-L@lists.hsforum.com > > To UNSUBSCRIBE, to CHANGE email address, or to view archives: > http://mmp.cjp.com/mailman/listinfo/openheart-l > > All messages transmitted by the OpenHeart-L are subject to the > policies and disclaimers posted at: > http://www.hsforum.com/listdisclaim > ----------------------------------------- From prasannasimha at gmail.com Tue Oct 2 16:28:47 2007 From: prasannasimha at gmail.com (psimha) Date: Tue Oct 2 06:06:09 2007 Subject: [HSF] Abnormal LIMA In-Reply-To: <1F9AE018-C87E-444E-81C8-0DB57C96EE78@bigpond.com> References: <396834.68958.qm@web35914.mail.mud.yahoo.com> <47019DAC.2030800@gmail.com> <1F9AE018-C87E-444E-81C8-0DB57C96EE78@bigpond.com> Message-ID: <47021657.8060701@gmail.com> Very unwise for your fellow to come to Bangalore - We have now probably the highest concentration of cardiac surgeons in one city in the world !!! (Crossing 50 at the last count !!) Prasanna Donald Ross wrote: > Yes!! > You know all , I have seen it recently and had to discard half the ima! > I will have to read the "no traction" riot act to my fellows, one of > whom is hoping to practice in your city next year. > Thanks, > Don > >> That is a "traction dissection" due to a friable LIMA and traction >> during dissection. I have seen this a few times when I was >> initially dissecting the LIMA but after making a "No traction" policy >> " I stopped having it. Basically I have seen many people tugging on >> the LIMA during dissection to get a better view . This causes a tube >> in tube dissection (usually distal where the initial dissection is >> done). I recently saw one by a colleague who was in the LIMA taking >> down learning curve . >> Prasanna >> john pj wrote: >>> 2 days back we operated a 54 yr old man for LT main stenosis with >>> lesions in LAD and OM.The LIMA[2.5 mm in size] was harvested with >>> out any difficulty and had good pulsation and flow when divided. >>> When we divided the distal end we noted that the thick intima was >>> telescoping beyond the remaining layers. When it was cut opened the >>> intima was more opaue and lacked the lustre of normal intima. The >>> thickened Intima was sliding against other layers as if they are >>> separated. It was not like dissection. We did not see any localised >>> atherosclerosis plaques . >>> . >>> We exised about 3 cm LIMA and there was no change in teh >>> appearence . We went ahead with LIMA to LAD grafting takinkincare to >>> incluse all the layers cautiously.We are watching the patient >>> closely. We have low threshold to go back to replace it with a vein >>> in case of any problems in the LAD territory. >>> Any comments? >>> --------------------------------- >>> Check out the hottest 2008 models today at Yahoo! Autos. >>> _______________________________________________ >>> OpenHeart-L mailing list >>> >>> Send postings to: >>> OpenHeart-L@lists.hsforum.com >>> >>> To UNSUBSCRIBE, to CHANGE email address, or to view archives: >>> http://mmp.cjp.com/mailman/listinfo/openheart-l >>> >>> All messages transmitted by the OpenHeart-L are subject to the >>> policies and disclaimers posted at: >>> http://www.hsforum.com/listdisclaim >>> ----------------------------------------- >>> >>> >>> >> >> _______________________________________________ >> OpenHeart-L mailing list >> >> Send postings to: >> OpenHeart-L@lists.hsforum.com >> >> To UNSUBSCRIBE, to CHANGE email address, or to view archives: >> http://mmp.cjp.com/mailman/listinfo/openheart-l >> >> All messages transmitted by the OpenHeart-L are subject to the >> policies and disclaimers posted at: >> http://www.hsforum.com/listdisclaim >> ----------------------------------------- > _______________________________________________ > OpenHeart-L mailing list > > Send postings to: > OpenHeart-L@lists.hsforum.com > > To UNSUBSCRIBE, to CHANGE email address, or to view archives: > http://mmp.cjp.com/mailman/listinfo/openheart-l > > All messages transmitted by the OpenHeart-L are subject to the > policies anddisclaimers posted at: > http://www.hsforum.com/listdisclaim > ----------------------------------------- > > From GoldmanS at MLHS.ORG Tue Oct 2 09:57:59 2007 From: GoldmanS at MLHS.ORG (Goldman, Scott) Date: Tue Oct 2 08:58:57 2007 Subject: [HSF] Re: Post op antibiotics In-Reply-To: <753114.59608.qm@web26710.mail.ukl.yahoo.com> Message-ID: <6764E7F21669F64C81BBE14C902CDEDD041FE4CB@TLH-MAIL.ad.mlhs.org> We use indicator gloves, green under light. You can see a break in the outer glove by darkening of the underlying green glove. It is more comfortable to use 1/2 size larger underneath. I use 8 1/2 green and 8 light. Scott -----Original Message----- From: openheart-l-bounces@lists.hsforum.com [mailto:openheart-l-bounces@lists.hsforum.com] On Behalf Of David Harris Sent: Monday, October 01, 2007 6:51 PM To: OpenHeart-L@lists.hsforum.com Subject: RE: [HSF] Re: Post op antibiotics Dear Ani, Many thanks for your interesting comments, yes i think double gloving makes more sense than anything else, and has better protection for the patient AND surgeon. In our speciality this is seldom done. When I was a resident doing orthopaedics, this was standard practice (when the initial fear for the HIV virus was much greater than now!). I think you have raised an essential point that we should all be using double gloves, for the sake of ourselves, and our patients (even if it is a bit uncomfortable) Dave Harris --- Ani Anyanwu wrote: > Dr Harris > > Do you really think scrubbing matters that much? I > must confess that I have not scrubbed with water and > a brush for over 2 years. I just use a chlorexidine > cream which I rub for maybe 20 to 30 seconds. I have > not noted an out of ordinary problem with infection > even for the heart transplants who are > immunosuppressed. I must say though that I do double > glove for all cases and I think this is more > important than scrubbing. Within the course of most > cardiac operations the surgeon's hand is repopulated > with microbes which makes me ponder the usefulness > of scrubbing. The surgeon with a single pair of > gloves may often have a (unrecognised) defect in the > gloves and a possible source of contamination which > is why i wear two gloves. Also glove changes of a > single glove may themselves be a source of > contamination, compared to double gloves where glove > changes are certainly aspetic. > > I would suggest that it is your attention to detail > and your technique that gets you a low infection > rate and not the manner of scrubbing - I find in > particular the comments on the impact of volume, > personnel, large operating rooms and ICU size very > interesting and are likely far more relevant. > > > Ani > > > > > > Date: Sun, 23 Sep 2007 01:27:22 +0100> From: > drdharris@yahoo.co.uk> Subject: RE: [HSF] Re: Post > op antibiotics> To: OpenHeart-L@lists.hsforum.com> > CC: > > Thanks, Ani.> > I have been in private > practice for a few years so> have no trainees > working with me. In the training> hospital where I > worked, the mediastinitis rate was> also low, less > than 1 %.> I think there are a number of factors: > Lower volume of> cases in each centre, so less > crowded icu, strict> antibiotic policy, very large > operating rooms in each> centre, less complex cases > performed (therefore> shorter operating times). Also > we had fewer surgeons> than the average unit, and > each surgeon therefore> performing more cases.> We > are also very strict with our aseptic technique in> > the OR, especially a long period scrubbing up,> > changing cloves frequently if contamination > suspected.> When I visited surgeons in the USA I was > amazed about> the short period of time spent > scrubbing for a case,> compared with back home, and > noticed that generally> only washing of hands and > forearms was done, and no> scrubbing of the nails.> > > Dave Harris> > > --- Ani Anyanwu > wrote:> > > Dr Harris> > > > > Amazing series - I suspect more though that your> > > surgical technique and infection control > practices> > may contribute more to the rarity of > mediastinitis> > than the antibiotics and CRP. What > protocol did you> > use before the last 700 cases > and what was your> > infection rate then? Do you > have trainee surgeons? > > > > Thanks> > > > Ani> > > > > > > > > > Date: Sat, 22 Sep 2007 22:16:23 +0100> > From:> > drdharris@yahoo.co.uk> Subject: RE: [HSF] > Re: Post> > op antibiotics> To: > OpenHeart-L@lists.hsforum.com>> > CC: > > For CABG > patients 24 hrs.> > For valves,> > until lines and > drains out.> > Then track the CRP> > levels every > second day to make> sure the trend is> > downward, > and there is no peak just> before> > discharge. This > way you can avoid> mediastinitis, as> > you can > treat it as it starts.> Since doing this> > have not > had a single case of sternal> sepsis in the> > last > 700 patients, but have had CRP> peaks which we> > > then confirm the next day, then treat.> Some> > > developed cellulitis a few days afterwards, while>> > > on treatment, but we were able to avoid> > > debridements.> > Dave Harris> > > --- Adam Saltman> > > wrote:> > > It is > actually> > policy at our institution now to> > > discontinue all> > prophylactic antibiotics > according> > to a time> > schedule. For general > surgery patients> > this is> > after 24 hours, and > for cardiac patients it> > is 48> > hours (which > actually has no data behind it,> > just> > some > hysterical cardiac surgeons). This is now> >> > > becoming a nation-wide initiative in the > prevention>> > > of infection by drug-resistant > organisms... But> > as> > far as I know, there is no > data to support or> > refute> > any particular > strategy in cardiac> > patients...> > > > Adam> > > > > > > > > > From:> > alsadd@ksu.edu.sa> > > To:> > > OpenHeart-L@lists.hsforum.com> > > Date: Wed, 19 > Sep> > 2007 14:58:29 -0700> > > CC: > > > Subject: > [HSF]> > Re: Post op antibiotics > > > > > > Dear > Forum> > Members:> > > > > > > > > > > > Do the > honorable> > members keep the open heart> > patients > on> > antibiotics for as> > > long as they have> > > mediastinal and chest tubes in> > place? I do not,> > > but some> > > of my colleagues do. I went over > the> > STS> > guidelines the two parts and I> > > > could not> > find the answer to this question.> > > > > > > Your> > response is greatly appreciated.> > > > > > > Thank> > you> > > > > > > > > > > > Ahmed> > > > > > >> > > _______________________________________________> > > >> > OpenHeart-L mailing list> > > > > > Send > postings> > to:> > > OpenHeart-L@lists.hsforum.com> > > > > > > To> > UNSUBSCRIBE, to CHANGE email > address, or to> > view> > archives:> > >> > > http://mmp.cjp.com/mailman/listinfo/openheart-l> > > >> > > > > All messages transmitted by the > OpenHeart-L> > are> > subject to the policies and > > > > disclaimers> > posted at:> > > > http://www.hsforum.com/listdisclaim>> > > > > -----------------------------------------> > >> > > >>> >> > _________________________________________________________________>> > > > Gear up for Halo(r) 3 with free downloads and an> > >> > exclusive offer. It's our way of saying thanks > for>> > > using Windows Live(tm).> >>> >> > http://gethalo3gear.com?ocid=SeptemberWLHalo3_WLHMTxt_2_________________ ______________________________>> > > > OpenHeart-L mailing list> > > > Send postings > to:>> > > OpenHeart-L@lists.hsforum.com> > > > To> > > UNSUBSCRIBE, to CHANGE email address, or to view> >> > > archives:> >> > > http://mmp.cjp.com/mailman/listinfo/openheart-l> > > >> > > All messages transmitted by the OpenHeart-L > are> >> > subject to the policies and> > disclaimers > posted> > at:> > > http://www.hsforum.com/listdisclaim> >> > > -----------------------------------------> > > > >> > > Dr. David G. Harris, FCS, MMED,> Cardiothoracic> > > Surgeon > Suite 207 > Kuils River Private Hospital,> > > > PO Box 1200, Kuils River, 7579, Cape Town, > South> > Africa. > Tel +27-21-9006411 > Fax > +27-21-9006412> > Mobile +27-83-3309587> >> > > _______________________________________________>> > > OpenHeart-L mailing list> > Send postings to:>> > > OpenHeart-L@lists.hsforum.com> > To UNSUBSCRIBE, to> > > CHANGE email address, or to view archives:>> > > http://mmp.cjp.com/mailman/listinfo/openheart-l> >> > > All messages transmitted by the OpenHeart-L are> > > subject to the policies and > disclaimers posted> > > at:> http://www.hsforum.com/listdisclaim>> > > -----------------------------------------> >> > _________________________________________________________________> > > Feel like a local wherever you go.> >> > http://www.backofmyhand.com_____________________________________________ __> > > OpenHeart-L mailing list> > > > Send postings to:> > > OpenHeart-L@lists.hsforum.com> > > > To > UNSUBSCRIBE, to CHANGE email address, or to view> > > archives:> > > http://mmp.cjp.com/mailman/listinfo/openheart-l> > > > > All messages transmitted by the OpenHeart-L are> > > subject to the policies and> > disclaimers posted > at:> > http://www.hsforum.com/listdisclaim> > > -----------------------------------------> > > > > > Dr. David G. Harris, FCS, MMED,> Cardiothoracic > Surgeon > Suite 207 > Kuils River Private Hospital, > > PO Box 1200, Kuils River, 7579, Cape Town, South > Africa. > Tel +27-21-9006411 > Fax +27-21-9006412 > Mobile +27-83-3309587> > > _______________________________________________> > OpenHeart-L mailing list> > Send postings to:> > OpenHeart-L@lists.hsforum.com> > To UNSUBSCRIBE, to > CHANGE email address, or to view archives:> > http://mmp.cjp.com/mailman/listinfo/openheart-l> > > All messages transmitted by the OpenHeart-L are > subject to the policies and > disclaimers posted > at:> http://www.hsforum.com/listdisclaim> > ----------------------------------------- > _________________________________________________________________ > Feel like a local wherever you go. > http://www.backofmyhand.com_____________________________________________ __ > OpenHeart-L mailing list > > Send postings to: > OpenHeart-L@lists.hsforum.com > > To UNSUBSCRIBE, to CHANGE email address, or to view > archives: > http://mmp.cjp.com/mailman/listinfo/openheart-l > > All messages transmitted by the OpenHeart-L are > subject to the policies and > disclaimers posted at: > http://www.hsforum.com/listdisclaim > ----------------------------------------- > Dr. David G. Harris, FCS, MMED, Cardiothoracic Surgeon Suite 207 Kuils River Private Hospital, PO Box 1200, Kuils River, 7579, Cape Town, South Africa. Tel +27-21-9006411 Fax +27-21-9006412 Mobile +27-83-3309587 _______________________________________________ OpenHeart-L mailing list Send postings to: OpenHeart-L@lists.hsforum.com To UNSUBSCRIBE, to CHANGE email address, or to view archives: http://mmp.cjp.com/mailman/listinfo/openheart-l All messages transmitted by the OpenHeart-L are subject to the policies and disclaimers posted at: http://www.hsforum.com/listdisclaim ----------------------------------------- From anianyanwu at hotmail.com Tue Oct 2 15:07:27 2007 From: anianyanwu at hotmail.com (Ani Anyanwu) Date: Tue Oct 2 10:08:00 2007 Subject: AW: [HSF] Re: Post op antibiotics In-Reply-To: <00be01c804bd$c7073ed0$b3160a06@HZLPC0679> References: <753114.59608.qm@web26710.mail.ukl.yahoo.com> <00be01c804bd$c7073ed0$b3160a06@HZLPC0679> Message-ID: Dear Roberto I also use 8/0 prolene for coronary bypass and have no problems doing it with two pairs of gloves. One just has to adjust to reduced sensitivity and feedback in the way one does when performing minimally invasive surgery. Tactile feedback becomes a less critical part of the technique and one learns to compensate with visual, indirect tactile and auditory perceptions. If one wishes to minimize the reduction in tactile perception, then rather than use standard gloves, you could double glove with "microsurgery" or "supersensitive" gloves like the ophthalmic surgeons use to handle 10/0 prolene and such fine sutures. I used to use two supersensitive gloves in training and found them equivalent to a single standard glove. Now I use two standard gloves and find it satisfactory. Do you not double glove in a known Hepatitis C or HIV patient or you not use 8/0 prolene for those cases? What about valve cases - why could we not double glove on those, after all infection of our prosthesis is far more catastrophic than the now relatively rare occurrence of infection in an orthopaedic prosthesis? Ani > From: battr@medizin.uni-leipzig.de> To: OpenHeart-L@lists.hsforum.com> Subject: AW: [HSF] Re: Post op antibiotics> Date: Tue, 2 Oct 2007 08:30:50 +0200> CC: > > In Germany after washing our hands we use a germicide solution called> Skinman or Spitacid. We believe it works.I personally cannot palpate plaques> and do a LIMA anastomosis with 8 x 0 and 2 pairs of gloves.> Roberto> > -----Urspr?ngliche Nachricht-----> Von: openheart-l-bounces@lists.hsforum.com> [mailto:openheart-l-bounces@lists.hsforum.com] Im Auftrag von David Harris> Gesendet: Montag, 1. Oktober 2007 23:51> An: OpenHeart-L@lists.hsforum.com> Betreff: RE: [HSF] Re: Post op antibiotics> > Dear Ani,> > Many thanks for your interesting comments, yes i think> double gloving makes more sense than anything else,> and has better protection for the patient AND surgeon.> In our speciality this is seldom done. When I was a> resident doing orthopaedics, this was standard> practice (when the initial fear for the HIV virus was> much greater than now!).> > I think you have raised an essential point that we> should all be using double gloves, for the sake of> ourselves, and our patients (even if it is a bit> uncomfortable)> > Dave Harris> > > --- Ani Anyanwu wrote:> > > Dr Harris> > > > Do you really think scrubbing matters that much? I> > must confess that I have not scrubbed with water and> > a brush for over 2 years. I just use a chlorexidine> > cream which I rub for maybe 20 to 30 seconds. I have> > not noted an out of ordinary problem with infection> > even for the heart transplants who are> > immunosuppressed. I must say though that I do double> > glove for all cases and I think this is more> > important than scrubbing. Within the course of most> > cardiac operations the surgeon's hand is repopulated> > with microbes which makes me ponder the usefulness> > of scrubbing. The surgeon with a single pair of> > gloves may often have a (unrecognised) defect in the> > gloves and a possible source of contamination which> > is why i wear two gloves. Also glove changes of a> > single glove may themselves be a source of> > contamination, compared to double gloves where glove> > changes are certainly aspetic.> > > > I would suggest that it is your attention to detail> > and your technique that gets you a low infection> > rate and not the manner of scrubbing - I find in> > particular the comments on the impact of volume,> > personnel, large operating rooms and ICU size very> > interesting and are likely far more relevant.> > > > > > Ani> > > > > > > > > > > Date: Sun, 23 Sep 2007 01:27:22 +0100> From:> > drdharris@yahoo.co.uk> Subject: RE: [HSF] Re: Post> > op antibiotics> To: OpenHeart-L@lists.hsforum.com>> > CC: > > Thanks, Ani.> > I have been in private> > practice for a few years so> have no trainees> > working with me. In the training> hospital where I> > worked, the mediastinitis rate was> also low, less> > than 1 %.> I think there are a number of factors:> > Lower volume of> cases in each centre, so less> > crowded icu, strict> antibiotic policy, very large> > operating rooms in each> centre, less complex cases> > performed (therefore> shorter operating times). Also> > we had fewer surgeons> than the average unit, and> > each surgeon therefore> performing more cases.> We> > are also very strict with our aseptic technique in>> > the OR, especially a long period scrubbing up,>> > changing cloves frequently if contamination> > suspected.> When I visited surgeons in the USA I was> > amazed about> the short period of time spent> > scrubbing for a case,> compared with back home, and> > noticed that generally> only washing of hands and> > forearms was done, and no> scrubbing of the nails.>> > > Dave Harris> > > --- Ani Anyanwu> > wrote:> > > Dr Harris> > >> > > Amazing series - I suspect more though that your>> > > surgical technique and infection control> > practices> > may contribute more to the rarity of> > mediastinitis> > than the antibiotics and CRP. What> > protocol did you> > use before the last 700 cases> > and what was your> > infection rate then? Do you> > have trainee surgeons? > > > > Thanks> > > > Ani> >> > > > > > > > > Date: Sat, 22 Sep 2007 22:16:23 +0100>> > From:> > drdharris@yahoo.co.uk> Subject: RE: [HSF]> > Re: Post> > op antibiotics> To:> > OpenHeart-L@lists.hsforum.com>> > CC: > > For CABG> > patients 24 hrs.> > For valves,> > until lines and> > drains out.> > Then track the CRP> > levels every> > second day to make> sure the trend is> > downward,> > and there is no peak just> before> > discharge. This> > way you can avoid> mediastinitis, as> > you can> > treat it as it starts.> Since doing this> > have not> > had a single case of sternal> sepsis in the> > last> > 700 patients, but have had CRP> peaks which we> >> > then confirm the next day, then treat.> Some> >> > developed cellulitis a few days afterwards, while>>> > > on treatment, but we were able to avoid> >> > debridements.> > Dave Harris> > > --- Adam Saltman>> > > wrote:> > > It is> > actually> > policy at our institution now to> >> > discontinue all> > prophylactic antibiotics> > according> > to a time> > schedule. For general> > surgery patients> > this is> > after 24 hours, and> > for cardiac patients it> > is 48> > hours (which> > actually has no data behind it,> > just> > some> > hysterical cardiac surgeons). This is now> >> >> > becoming a nation-wide initiative in the> > prevention>> > > of infection by drug-resistant> > organisms... But> > as> > far as I know, there is no> > data to support or> > refute> > any particular> > strategy in cardiac> > patients...> > > > Adam> > >> > > > > > > > From:> > alsadd@ksu.edu.sa> > > To:> >> > OpenHeart-L@lists.hsforum.com> > > Date: Wed, 19> > Sep> > 2007 14:58:29 -0700> > > CC: > > > Subject:> > [HSF]> > Re: Post op antibiotics > > > > > > Dear> > Forum> > Members:> > > > > > > > > > > > Do the> > honorable> > members keep the open heart> > patients> > on> > antibiotics for as> > > long as they have> >> > mediastinal and chest tubes in> > place? I do not,>> > > but some> > > of my colleagues do. I went over> > the> > STS> > guidelines the two parts and I> > >> > could not> > find the answer to this question.> > >> > > > > Your> > response is greatly appreciated.> > >> > > > > Thank> > you> > > > > > > > > > > > Ahmed> > >> > > > >> >> > _______________________________________________> >> > >> > OpenHeart-L mailing list> > > > > > Send> > postings> > to:> > > OpenHeart-L@lists.hsforum.com>> > > > > > > To> > UNSUBSCRIBE, to CHANGE email> > address, or to> > view> > archives:> > >> >> > http://mmp.cjp.com/mailman/listinfo/openheart-l> >> > >> > > > > All messages transmitted by the> > OpenHeart-L> > are> > subject to the policies and >> > > > disclaimers> > posted at:> > >> > http://www.hsforum.com/listdisclaim>> > > >> > -----------------------------------------> > >> >> > >>> >>> >> _________________________________________________________________>>> > > > Gear up for Halo? 3 with free downloads and an>> > >> > exclusive offer. It?s our way of saying thanks> > for>> > > using Windows Live?.> >>> >>> >> http://gethalo3gear.com?ocid=SeptemberWLHalo3_WLHMTxt_2_____________________> __________________________>>> > > > OpenHeart-L mailing list> > > > Send postings> > to:>> > > OpenHeart-L@lists.hsforum.com> > > > To> >> > UNSUBSCRIBE, to CHANGE email address, or to view> >>> > > archives:> >> >> > http://mmp.cjp.com/mailman/listinfo/openheart-l> >> > >> > > All messages transmitted by the OpenHeart-L> > are> >> > subject to the policies and> > disclaimers> > posted> > at:> >> > http://www.hsforum.com/listdisclaim> >> >> > -----------------------------------------> > > > >>> > > Dr. David G. Harris, FCS, MMED,> Cardiothoracic> >> > Surgeon > Suite 207 > Kuils River Private Hospital,>> > > > PO Box 1200, Kuils River, 7579, Cape Town,> > South> > Africa. > Tel +27-21-9006411 > Fax> > +27-21-9006412> > Mobile +27-83-3309587> >> >> > _______________________________________________>> >> > OpenHeart-L mailing list> > Send postings to:>> >> > OpenHeart-L@lists.hsforum.com> > To UNSUBSCRIBE, to>> > > CHANGE email address, or to view archives:>> >> > http://mmp.cjp.com/mailman/listinfo/openheart-l> >>> > > All messages transmitted by the OpenHeart-L are> >> > subject to the policies and > disclaimers posted> >> > at:> http://www.hsforum.com/listdisclaim>> >> > -----------------------------------------> >>> >> _________________________________________________________________>> > > Feel like a local wherever you go.> >>> >> http://www.backofmyhand.com_______________________________________________>> > > OpenHeart-L mailing list> > > > Send postings to:>> > > OpenHeart-L@lists.hsforum.com> > > > To> > UNSUBSCRIBE, to CHANGE email address, or to view> >> > archives:> >> > http://mmp.cjp.com/mailman/listinfo/openheart-l> > >> > > All messages transmitted by the OpenHeart-L are> >> > subject to the policies and> > disclaimers posted> > at:> > http://www.hsforum.com/listdisclaim> >> > -----------------------------------------> > > > >> > Dr. David G. Harris, FCS, MMED,> Cardiothoracic> > Surgeon > Suite 207 > Kuils River Private Hospital,> > > PO Box 1200, Kuils River, 7579, Cape Town, South> > Africa. > Tel +27-21-9006411 > Fax +27-21-9006412> > Mobile +27-83-3309587> >> > _______________________________________________>> > OpenHeart-L mailing list> > Send postings to:>> > OpenHeart-L@lists.hsforum.com> > To UNSUBSCRIBE, to> > CHANGE email address, or to view archives:>> > http://mmp.cjp.com/mailman/listinfo/openheart-l> >> > All messages transmitted by the OpenHeart-L are> > subject to the policies and > disclaimers posted> > at:> http://www.hsforum.com/listdisclaim>> > -----------------------------------------> >> _________________________________________________________________> > Feel like a local wherever you go.> >> http://www.backofmyhand.com_______________________________________________> > OpenHeart-L mailing list> > > > Send postings to:> > OpenHeart-L@lists.hsforum.com> > > > To UNSUBSCRIBE, to CHANGE email address, or to view> > archives:> > http://mmp.cjp.com/mailman/listinfo/openheart-l> > > > All messages transmitted by the OpenHeart-L are> > subject to the policies and> > disclaimers posted at:> > http://www.hsforum.com/listdisclaim> > -----------------------------------------> > > > > Dr. David G. Harris, FCS, MMED,> Cardiothoracic Surgeon > Suite 207 > Kuils River Private Hospital, > PO Box 1200, Kuils River, 7579, Cape Town, South Africa. > Tel +27-21-9006411 > Fax +27-21-9006412 Mobile +27-83-3309587> > _______________________________________________> OpenHeart-L mailing list> > Send postings to:> OpenHeart-L@lists.hsforum.com> > To UNSUBSCRIBE, to CHANGE email address, or to view archives:> http://mmp.cjp.com/mailman/listinfo/openheart-l> > All messages transmitted by the OpenHeart-L are subject to the policies and > disclaimers posted at:> http://www.hsforum.com/listdisclaim> -----------------------------------------> > _______________________________________________> OpenHeart-L mailing list> > Send postings to:> OpenHeart-L@lists.hsforum.com> > To UNSUBSCRIBE, to CHANGE email address, or to view archives:> http://mmp.cjp.com/mailman/listinfo/openheart-l> > All messages transmitted by the OpenHeart-L are subject to the policies and > disclaimers posted at:> http://www.hsforum.com/listdisclaim> ----------------------------------------- _________________________________________________________________ Celeb spotting ? Play CelebMashup and win cool prizes https://www.celebmashup.com From Rwmfglycar at aol.com Tue Oct 2 11:44:03 2007 From: Rwmfglycar at aol.com (Rwmfglycar@aol.com) Date: Tue Oct 2 10:48:27 2007 Subject: AW: [HSF] Re: Post op antibiotics, double gloving Message-ID: In a message dated 10/2/2007 10:10:19 A.M. Eastern Daylight Time, anianyanwu@hotmail.com writes: Dear Roberto I also use 8/0 prolene for coronary bypass and have no problems doing it with two pairs of gloves. One just has to adjust to reduced sensitivity and feedback in the way one does when performing minimally invasive surgery. Tactile feedback becomes a less critical part of the technique and one learns to compensate with visual, indirect tactile and auditory perceptions. If one wishes to minimize the reduction in tactile perception, then rather than use standard gloves, you could double glove with "microsurgery" or "supersensitive" gloves like the ophthalmic surgeons use to handle 10/0 prolene and such fine sutures. I used to use two supersensitive gloves in training and found them equivalent to a single standard glove. Now I use two standard gloves and find it satisfactory. Do you not double glove in a known Hepatitis C or HIV patient or you not use 8/0 prolene for those cases? What about valve cases - why could we not double glove on those, after all infection of our prosthesis is far more catastrophic than the now relatively rare occurrence of infection in an orthopaedic prosthesis? Ani Dear Ani, In Dec 1984 we did the first open heart operation on a patient with known + HIV status. (The test had just been developed at Rockefeller). We wore double gloves but this was not new to us; we had already been wearing double gloves as a routine not for fear of acquiring infection from our patients but to avoid passing our infections to the patients. It had been one of multiple measures adopted during an outbreak of staphylococcal infections some time in the past. The epidemic was long since over but we continued the practice. At the time there were hip replacement surgeons doing the same. We never tried t