Post-Surgical Complication of a Popliteal Nerve Catheter

Presented during Resident Case Presenta/ons at the 2013 Kent State University College of Podiatric Medicine Southeastern Conference in Lake Buena Vista, Florida. This had an interac/ve, ques/on and answer format.

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Pa/ent was seen by the primary consul/ng team

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Why not single injec/on? Indwelling is a con/nuous infusion of diluted local anesthe/c at a desired rate per hour. So 0.2% ropivicane at an infusion of 10ml/h. Can give bolus. Pa/ents can metabolize anesthe/c differently—some more quickly. Get over that 24h hump. Despite oral opioids could not be weaned off catheter.

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Dressing taken down by primary team at this /me. No infec/on there. Re-‐evaluated by pain management anesthesia team who felt PNC site “looked good.” Primary team also got chest xray and US to r/o DVT

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Primary team also got UA and BCs. WBC has increased

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POD #4

Fever failed to improve

The pa/ent complained of dizziness and lethargy

Primary team requested pain management anesthesia team to remove catheter as that was the only possible infec/ous source not removed

PNC was removed – no purulence or indura/on noted at site

Erythematous patches were noted peri-‐

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POST OP DAY FIVE: INFECTIOUS DISEASE CONSULTED. Also complains of nausea and burning urina/on. Denies sob, chest pain, diarrhea, vomi/ng, sore throat, no deep thigh pain

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General: anxious Lower extremity exam:

Vascular: DP/PT/popliteal pulse palpable

Neurological: Light and gross sensa/on was intact

Dermatological:

Incisions: well approximated

Mild peri-‐incisional erythema

No purulence

PNC site

Indura/on

No crepitus or purulence

Erythema, which extends proximally along the

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Despite the ini/a/on of an/bio/cs POD #5, the white count did not con/nue to trend down—jumped back up to 15.6. Vanc and Zosyn empiric therapy (adjust as needed) un/l known cultures.

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The primary team ordered a CT scan. Ques/on of air or fluid/abscess…clinical correla/on.

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Despite the ini/a/on of IV an/bio/cs the pa/ent did not improve and with the CT results, it was decided the pa/ent would undergo an Incision and drainage in the OR

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POD #10 ORIF and POD#4 I&D: white count 23.49. Previous ORIF surgical site remains unaffected Rifampin as adjuvant therapy

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What next? Incision planning? Extend the incision? Get more imaging?

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Serpen/ne incision extended from the ischial tuberosity to the proximal calf. Extended to medial/lateral heads of gastrocnemius.

Significant phlegmon of the scia/c nerve: /bial and common peroneal nerve.

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Transferred to SICU due to hypovolemic shock. Intubated and restrained. Pt received "1500cc crystalloids, 1L Hextend, 500cc Albumin, 6units PRBCs 2units FFP" during the procedure. Pa/ent afebrile and WBC downtrending. Was removed from rifampin due to nausea. Microscopy of urine shows -‐ Muddy brown casts sugges/ve of Acute tubular necrosis.

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CoPAT Vancomycin: dose and length? Discharged to rehabilita/on center for extensive physical therapy

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Con/nued physical therapy at 9 months. No brace or deficit. Cannot sit for long periods Radiographs: well-‐healed fracture with no loosening of fixa/on and no bony reac/on sugges/ve of seeding

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The con/nuous popliteal nerve catheter is an increasingly accepted means to reduce postopera/ve pain of the lower extremity in orthopedic surgery. It has few noted complica/ons in the literature with serious infec/ous complica/ons reported at 0.75%.

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Post-Surgical Complication of a Popliteal Nerve Catheter

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