vcu death and complications conference. introduction complication graft infection procedure ...
TRANSCRIPT
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VCUDEATH AND COMPLICATIONS CONFERENCE
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Introduction
Complication Graft infection
Procedure Femoral-femoral bypass
Primary Diagnosis Left leg rest pain
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60 yo male presenting 2/24 to ER with left leg pain at rest
Sudden worsening that am from prior 2 block claudication
No foot wounds
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PMH: DM2, CAD, COPD, GERD, PVD, bipolar d/o,
arthritis, ED, hypothyroidism, chronic back pain
PSH: CABG, Penile implant
Soc Hx: Heavy smoker
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PE Cool left leg with decreased motor function, no
palpable pulses left side, palpable right femoral, dopplerable PT/DP, no tissue loss
Placed on heparin gtt WBC 10.5, CRE 1.15, other labs WNL Arterial dopplers:
right leg triphasic CFA, right femoral disease, ABI= 0.67
Left leg monophasic CFA, occlusion of SFA and PT, ABI = 0.27
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Underwent angiography on 2/27
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OR on 3/2 for fem-fem bypass Aortobifem not done due to subacute
presentation and medical comorbidities 8mm PTFE used Preop antibiotics given Did well post-op and was discharged on
3/5
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Returned to clinic on 3/13 with drainage from right incision
No fevers, good flow in bypass, improved symptoms
WBC 12, wound opened, MRSA cultured, blood cx negative
Deep layer remained closed with no graft exposure
On Vanc x7 days in hospital with resolution of leukocytosis, no fevers
d/c home on bactrim
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Returned on 3/23 with fever to 105, WBC 25.5, positive blood cx x2 for MRSA
Taken to OR where purulence found in right groin around graft
graft excision, redo of fem-fem with vein, sartorious flap of right groin
Did well with resolution of sepsis, d/c 5 days later
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Analysis of Complication
• Was the complication potentially avoidable?– No- patient had appropriate operation, known
infection rate
• Would avoiding the complication change the outcome for the patient?– Yes- graft excision, readmission x2
• What factors contributed the complication?– Poor hygiene, indwelling foreign body, diabetes
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Tatterton MR. Infections in Vascular Surgery. Injury Dec 2011;42 Suppl
5:S35-41 Most common organism in vascular
infections = S. aureus >80% from endogenous source
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Tatterton MR. Infections in Vascular Surgery. Injury Dec 2011;42 Suppl
5:S35-41 Vascular Surgery Site infections 5-10% Gram positives most common organism MRSA has mortality of 20.7% with SSI Extra 5 days in hospital and $40K
additional cost compared with MSSA Nasal carriage 2-9X risk of SSI
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Tatterton MR. Infections in Vascular Surgery. Injury Dec 2011;42 Suppl
5:S35-41 Vascular prosthetic graft infection (VPGI) 1-5% MRSA VPGI mortality 25-88%, amputation rate
80% PTFE 10-100x more resistant to infection than
Dacron Conservative management (Abx only) is highest
risk factor for mortality Surgical principles:
Graft removal Wide debridement Extraanatomic bypass (or in situ abx
inpregnated graft or vein)
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Teaching points
MRSA graft infection carries high mortality and complication rates
requires early graft excision and extraanatomic bypass