AW: [HSF] Re: Post op antibiotics

Dr. Roberto Battellini battr at medizin.uni-leipzig.de
Tue Oct 2 09:37:38 EDT 2007 

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

-----Ursprüngliche Nachricht-----
Von: openheart-l-bounces at lists.hsforum.com
[mailto:openheart-l-bounces at lists.hsforum.com] Im Auftrag von David Harris
Gesendet: Dienstag, 2. Oktober 2007 01:33
An: OpenHeart-L at 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 <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

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