[HSF] Re: Post op antibiotics

Tue Oct 2 22:50:51 EDT 2007

Hi Tea,

During the first few days we generally observe, as the
CRP sometimes only turns around day 3 or 4, and I
accept spikes up to around 350. I can remember a
handful of patients that we observed, and developed
early pneumonia, and the CRP was generally over 400.
By that stage the problem was clinically obvious.

Some patients will have a moderate CRP spike later on,
and I have observed them, and if the upward trend is
not agressivly high (for example from 80 to 200 in 24
hours), but around 150, with no further rise, then I
have not started antibiotics. Very often a residual
non infected hemothorax will cause this, or local
wound sepsis.

If the CRP goes up to 200 after day 5 (after you have
documented it to be less), and continues to rise, then
I have always treated, and always there has been a
serious problem. 

One case I`ll never forget was a patient I sent home
day 8, CRP was 150 but he was clinically well. He came
back after 2 days, with dyspnoea. CRP went
progressively up, over 300. We could not identify any
problem, but started IV antibiotics, as we suspected
pneumonia. He developed ileus and distension. Abdomen
was completely non tender, and he did not look too
sick. To rule out an occult bowel perf, we did erect
CXR and there was free air under diaphragm!!
Laparotomy showed dead colon, which was all removed.
He did surprisingly well initially, but died after 3
weeks.

Generally I will still send someone home if the CRP
has taken longer to come down, and is around 150, but
will send them for a repeat test in a few days.I am
not sure if this will avert a disaster like above, but
will give me peace of mind that there is no
mediastinitis brewing.

It is also nice to have a baseline when the patient
goes home, so if they call back saying they feel
febrile, or having chest pain, dyspnoea, etc, you can
send them to the lab, and it is a nice relief to see
that the CRP has normalised.

Dave
--- Tea Acuff <tacuff at swbell.net> wrote:

> 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 <drdharris at yahoo.co.uk>
> To: OpenHeart-L at 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 <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
> > > > 
> > > >  
> > > > 
> 
=== message truncated ===

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