Post-Surgical Complication of a Popliteal Nerve Catheter
1. 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.
1
8. 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.
8
12. 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
12
14. 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-‐
14
15. 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
15
16. 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
16
18. 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.
18
19. The
primary
team
ordered
a
CT
scan.
Ques/on
of
air
or
fluid/abscess…clinical
correla/on.
19
20. 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
20
21. POD
#10
ORIF
and
POD#4
I&D:
white
count
23.49.
Previous
ORIF
surgical
site
remains
unaffected
Rifampin
as
adjuvant
therapy
21
25. 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.
25
26. 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.
26
27. CoPAT
Vancomycin:
dose
and
length?
Discharged
to
rehabilita/on
center
for
extensive
physical
therapy
27
28. 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
28
33. 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%.
33
