The use of a sump antibiotic irrigation system to save infected hardware in a patient with a vagal nerve stimulator:
Technical note
Article Outline
Abstract
The authors describe the use of a sump irrigation system that was used to successfully treat the battery implantation site of a vagal nerve stimulator (VNS). Irrigation was composed of a dilution of vancomycin in lactated Ringer's solution. At long-term follow up, the patient has not returned with signs or symptoms of wound infection. She continues to effectively combat her epilepsy with VNS. The authors believe this to be the first description of this technique for salvaging an implanted VNS.
Abbreviations: VNS, Vagal nerve stimulation/stimulator
Keywords: Peripheral nerve, Neurosurgery, Neck, Wound, Cranial nerve, Seizures, Treatment
1. Introduction
VNS is accepted as a safe and efficacious modality in the treatment of severely refractory epilepsy [5], [8], [10]. The implantation of a VNS, however, carries possible complications. Examples would include stimulation-induced symptoms such as hoarseness, dysphagia, or torticollis and surgical complications such as hardware failure or deep infection resulting in device removal. The incidence of infected VNS that ultimately require removal is approximately 3.5% [10]. The traditional methodology for the treatment of deeply infected hardware or grafts is removal. Although superficial infections can be treated with the hardware left in place [2], [4], [7], [9], [10], [11], it has been described that device removal is required in all patients to achieve infectious cure [5]. We describe a technique to treat a deep infection of an implanted VNS (Cyberonics, Houston, TX) in a patient who benefited greatly from its implantation. Our patient presented to the emergency department with a 3-day history of fever (100 °F-102 °F) and an erythematous anterior chest incision that was warm and tender to touch. Staphylococcus epidermidis was cultured from the wound.
2. Operative technique
The patient was placed in the supine position, and after an antiseptic skin preparation, the battery pocket incision was opened, and the battery was removed from the pocket. This pocket was copiously irrigated with bacitracin irrigation. Next, a small stab incision was made superior to the battery pocket. A hemostat was passed from the battery pocket through the stab incision. A 7F Jackson-Pratt drain was pulled into the battery pocket with the hemostat (Fig. 1). The battery was placed back into the pocket over the drain. A Foley catheter was next placed over the battery exiting through the previous incision. The balloon was inflated to increase flow space throughout the pocket. All skin incisions were closed with nylon suture. A diluted (lactated Ringer's) vancomycin solution was attached to the drain perfusing the pocket with egress via the Foley catheter into a collecting system (Fig. 1). Irrigation input and Foley catheter output were meticulously followed to ensure equality. Irrigation was maintained at 15 mL/h. The patient was also maintained on IV vancomycin as well. The system was used for 7 days. Oral antibiotics were maintained for 2 weeks after discharge.
Fig. 1.
Sump antibiotic irrigation system as used in our patient.
3. Discussion
Sump antibiotic irrigation systems are commonly used for infections of spinal hardware [1], [3], [4], [11], [12]. We felt that this was a viable option for our patient. Eight months have elapsed since her procedure, and she has done well. This patient's seizures are well controlled, and she is free of any evidence of infection. One factor that contributed to our treatment decision was that our patient would not have tolerated the absence of the VNS in the interim. However, recently, some have advocated the use of right-sided VNS after the infection of a left-sided VNS system [6].
With further successful reports of the technique we have described, the surgeon may wish to consider a similar system for irrigation of infected VNS neck wounds. In addition, and if possible, another pocket location might be chosen for the battery site. In summary, our patient greatly benefited from this procedure and has not shown signs of infection after this maneuver. We would recommend this as an option in patients with a suspected VNS battery site infection especially where removal of the VNS would be poorly tolerated.
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PII: S0090-3019(05)00382-4
doi:10.1016/j.surneu.2005.04.045
© 2006 Elsevier Inc. All rights reserved.
