Chapters Transcript Video Planning of the Extraction Procedure for Systemic Infection: When, Where and How Dr. Love shows us the planning involved and his steps to take when extracting a patient with an systemic infection. but just want to reiterate the importance. One of the reasons why lead extraction system extraction is a class one indication is that there's an awful lot of good data that if you don't take out systems, the relapse rates are horrific. You simply don't cure things by leaving prosthetic material inside people. You gotta get all this stuff out just working. So um for some patients it may not be an option to do extraction. You guys are hopefully gonna be properly prepared, but there may be a family or patient preference not to do with, the patient may be too ill or fragile. But I want to say something about that because uh in some cases you consider you can consider doing a salvage procedure. There will be some cases where the surgeon will just say, you know what, I can't back you up. I mean if something happens this patients gonna die and I there's nothing I'm going to do that's going to salvage that patient. On the other hand, this might be the only shot for the patient to survive. And we had a case like this not too long ago. Uh patient, a really crappy ejection fraction old person, 90 years old or whatever. And they had again infected system. And the surgeon said it's not gonna happen. Okay, Prior sonata me everything. There's no way I'm getting into that chest. If if something happens, that's gonna be it. So we talked to the patient, we talked to the family and we told him, listen, if we don't do this procedure, Not gonna work out too well for you. If we do it and something happens in that rare case, one or 2% chance that something bad is gonna happen here, then That's gonna be the end. But there's a 98% chance that everything's gonna go fine. And guess what? It all went fine and the patient did well and got out of the hospital. So just because the surgeon says, I can't back you up, doesn't mean you can't do the procedure because you know, the patient may be too well because the alternative is certain death from Sepsis. So remember that the hospital, if they can't provide the services or can't transfer a patient, you can't find a physician for backup extraction risk may be judged too high. It might be because you've got extra cardiac or extra vascular portions of the leads or patients. There may be reasons why it's just not the appropriate thing for the patient, but there may be a reason not to chronic suppressive antibiotics. They are not going to cure you. Okay. If you have a pocket infection or you have an intravascular infection, you're rarely rarely, rarely ever going to get a cure. But there are certain cases we've had a couple in the last few years where we had very elderly person, very old leads that I literally had a woman who is over 100 years old. She was like 100 and one years old, but actually still getting around and I'll show you a picture of her pocket here in a second. But you know it just she had 30 some year old uni polar leads that were working just beautifully. But she had this horrific pocket infection after a generator change. And so we decided we did a debridement and we did chronic suppressive antibiotics and she did fine. She's two years out now and she's still doing fine. But she takes her her Bactrim every day and she's doing okay. So there are rare cures but but basically not gonna happen real and you're not gonna get cures in the vast majority. Usually you gonna get the recurrence as soon as you stop and of course there are all sorts of complications when you're on long term antibiotics and why don't antibiotics work? Biofilm biofilm protects those bacteria from the antibiotics. And as soon as you stop the antibiotic they just they just flourish again. It's just not gonna happen. So so you can't penetrate an abscess. You can't overcome biofilm. You have to open and debris. It's critical to get a species diagnosis before starting antibiotics that cannot be emphasized enough. You know the patient comes to the E. D. They see a hot pocket, what do they do? They started on bank and advance f. And god knows what else. And then you go to get blood cultures. You go to to get specimens and you come up culture negative and now you're kind of stuck in terms of how you're going to manage this patient. So always try to get your species diagnosis before starting antibiotics because culture negative is real problem. So that's why I don't just get pocket fluid but send tissue, send the leads, send the generator because a lot of times you grow stuff out of tissue that you won't grow out of the pocket up. So, so you may need other other help too. You need to have your team in a case like this. This is a huge mess. This this pocket was just terrible and you might need plastic surgery to come in, maybe do a skin flat. We use wound care service, thoracic and vascular surgery. If you have a navy fistula, interventional radiology may be helpful. Also, if you have fistulas or occluded vessels and you want to stent them. Things like that. So anybody that might be helpful to manage the patient, they become part of this team that's out there. So when do you extract for systemic infection? Eric went through this a little bit bottom line as soon as you can. My fellows. No, I get horrifically irritated when they tell me, oh yeah, we can get this patient in two weeks. It's like now, now this this is like every day we wait. It's another, you know, straw in the back of that Campbell and sooner or later you're gonna end up with a problem that patients not going to do as well, get it out as soon as possible. That's you just can't get enough of that. We saw that previous slide so lengths of stay are much higher. If you wait treatment cosmos higher. If you wait just get it done. I'm not gonna do this because we just spent a lot of time on this stuff. Please be aware that you don't have time to move a patient. Just got a case. Uh looking at where actually on the patient's side. And they had the patient in a lab and they had to move the patient to an O. R. Because they couldn't open the chest in the lab. And it was a 30 minute delay to open the chest. Really bad thing. So you have got to have a really good attorney and good luck finding a credible expert. If you do if you have to move patients, seconds count minutes matter. Um And you can lose just half a liter of blood every minute with an S. V. C. Tear. We talked about a lot of this stuff. This is my 100 year old lady. This this was not a breast, this is her pacemaker pocket over here. Um And this is what we pulled out of the pocket all of this necrotic junk and stuff. Um And so actually worked with the cardiac surgeon on this to help me do a big debridement. We ended up using this pulse lavage system to clean things out and show that to you in a moment. And uh we we put the device back in, put on chronic suppressive antibiotics and she's actually done really, really well. So even if it's already open, you want to do a wide excision to a lot of access to get to good healthy tissue. So when you have something like this, uh you know, it's really hard to close a pocket like that eventually. So you want to do a wide excision around this. So you get all that nasty infected material out of there, remove the device from the pocket to set the leads and suturing sleeves carefully, get out as much inflamed tissue as you can. And sometimes very very hard because the skin can be very thin across the chest wall between the pocket and the chest wall. And if you try to do breed that, you come right through the skin. So I I do a lot of times where we'll leave that still to breed some of the base of the pocket, Then we'll end up packing it overnight for Toyota four Gauze and then our wound care people come in and put a wound back in there the next day. Very, very important to get all foreign bodies out of there. There can be, you know, sometimes there'll be a buried lede and you pull on your dissecting it and the lead pops out. Okay, we got the lead. Okay, dissect that. But there was a cap on the end of that lead and they're not radio opaque. And you got to remember that there's probably a cap there and you got to dissect down and you find that cap because guess what? You don't get that out, you're gonna end up with a chronic training science. Um caps suturing suturing sleeves, All of that crap has to come out of there and you don't know how much stuff people put in every now and then somebody uses to suturing sleeves on a lead. Some of the old guidance leads came with suturing sleeves on them. You gotta be aware that those things might be in there. Had a patient come to me at N. Y. U. With this little thing here looks like a little little beak. This was after a an extraction had been done in another place and the patient said, what the hell is going on here? And while we pulled out a little, this little guy, so again, stuff has to come out. These are radio opaque. So you should be able to see those irrigate copious, lots of it. I use about 10% of an iodine solution. Um and we just irrigate the hell out of it with that. You don't use the full strength, it's just really hyper smaller. So you want to do that antibiotics. You know, they're not gonna really kill a lot of stuff. I like to use uh some people use hydrogen peroxide too. That's another thing that's been shown to be pretty good, the pulse lava system is really cool. If you have a big pocket, you really want to, you know, help irrigate and to breed the crap out of it. This is a battery powered squirt gun. Think of a super soaker kind of thing. And it's got you hook a suction line into one port and you put a three liter bag or whatever into the other ports. We used the loot beta nine for that. And uh this is what it looks like. So it's got um this is the pulse fluid comes out through one area and this is hooked to the suction and it sucks the fluid back in and this is on a foot, but this just kind of running around and it just the fluids coming through getting sucked out and it really is great for debris. The other thing that you can use when you, when you have, has anybody here used Aquaman is other than my fellows. So, Aquaman is is a bipolar Kateri system that squirt saline between the two electrodes here and it hooks up to the same unit that the what's the name of that? Doctor, surgical? Yeah, not that that's not the regular Bobi. The other one that we use plasma blade. Thank you. Hook up the same unit, plasma blade. Um and if you, when you do this debridement, you're gonna get all this using, that's gonna come back off of the muscle and this is terrific for forgetting homeostasis. So if you've got a lot of muscle and it's bleeding or whatever, you just activate this thing taken down and it's, it Sears it like a steak. In fact, when they first demoed this to me, they literally had a piece of steak and they showed you could have a nice rare steak done with this thing. It is marvelous when you have a lot of bruising and bleeding. What about the T. Rex envelope when you've got an infected pocket, they're actually labeled against use in an active infection. And I've seen this done numerous times with numerous failures. People go in and they'll they'll do a pocket revision or a salvage thing. They'll they'll irrigate it out, they'll read it and they put a T. Rex thing in there and put the device back in and it all get infected again. Okay, it's just not gonna work. Um It's no way to cure an infection. Very good. And a patient who's had an infection, you're putting it in on the other side, as eric mentioned because they are high risk. I think that's very, very important. So assembled a great team, get everybody involved, do the procedure in a good venue with great floor. Oh, do the procedure that allows for surgical rescue as soon as possible for infection. I can't emphasize that enough. Have all the tools that you might need. Don't go in with a single tool That's a real big mistake. You can't go in with just a laser. Just a tight race or whatever. The more stuff you have, you don't know what you're gonna need until you need it. Nobody's gonna go to a car with one wrench and say I'm gonna fix your car, okay? You gotta have a toolbox and that you really, really need that. Consider the timing of the new implant and whether they even need a new device. We mentioned that an alternative such as lead list devices, things like that erIC mentioned using a leaderless device as a bridge to your new device. That's a great idea except Micro cost $10,000. That's that's the downside to that kind of thing. So anyway, I think that the most important take home on infection is get everything it out, get it out as soon as possible and and don't try to salvage pockets. It just, it just simply isn't gonna work Published July 19, 2022 Created by Related presenters Charles J. Love, MD, FACC, FAHA, FHRS, CCDS Professor of MedicineJohns Hopkins HospitalPresident, International Board of Heart Rhythm Examiners
