[HSF] Re: Post op antibiotics

Tea Acuff tacuff at swbell.net
Mon Oct 1 21:42:37 EDT 2007 

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 <msfirst at gmail.com>
To: OpenHeart-L at 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 <alsadd at ksu.edu.sa> 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 at lists.hsforum.com
>> [mailto:openheart-l-bounces at lists.hsforum.com] On
>> Behalf Of David Harris
>> Sent: Saturday, September 22, 2007 2:16 PM
>> To: OpenHeart-L at 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 <aes.md.phd at hotmail.com> 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 at ksu.edu.sa
>>>> To: OpenHeart-L at 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
>>>>
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>>
>> 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
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>
>
> 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
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