68 year old with cervical myelopathy and cervical stenosis. He is a heavy smoker and not a candidate for fusion. Has c4-5, c5-c6 cervical laminectomy on Jun 10, 2024
OP note unremarkable, D/C 2 days later ambulating and voiding, PO intake and Hemovac.
June 13, 2024 returns to ER for pain control and increased shortness of breath. He is admitted for COPD exacerbation, consult to neuro for post-op eval. Did not require O2 at home, however now requires 2 lpm to maintain O2 sat above 95%.
Neurology defers mostly to IM for COPD maintenance, noting no specific neurological symptoms associated with surgery.
Radiology done includes CXR, Head CT and CTA chest. Unremarkable. Despite being afebrile throughout, WBC on admit is 10.0. It rises to 12.1 on day 2 then 16.1 on discharge. There is no specific mention of the rise in WBCs during admission and notes of not likely infectious process? Blood pressures are soft in the 100s, but no tachycardia. JP drain placed post-op is showing serosanguineous output 100-150mls per day during admission, however no cultures drawn on fluid. No blood cultures. No further radiology on neck/spine. This is all chalked up to balancing opioids/COPD.
D/C on June 19, 2024 with home oxygen and Augmentin 7 day PO.
Returns the next day, June 20 for increased pain and hypoxia. Gave gabapentin, muscle relaxants, and multimodal pain control with good effect No breathing issues during pain management. Physical Therapy (PT) recommended inpatient rehab due to residual pains and need for functional therapy. Neurosurgery recommended keeping spinal drain in place due to high output, but still no exploration of CSF leak during the first 3 days. Initially planned for rehab on 6/24, but that night, spiked a fever (101°F), became extremely drowsy, altered mental status. Vitals normal, no hypercapnia, clinically dry, so given IV fluids. Blood, urine, and spinal drain cultures obtained.
Started on Levaquin (quinolone antibiotic) due to severe penicillin/cephalosporin allergies. Suspected UTI initially (mucus plug noted on catheterization). Later, spinal drain culture grew Gram-negative rods, so Infectious Disease (ID) consulted.
CSF (spinal fluid) cultures grew multiple bacteria & fungi: Serratia marcescens, Acinetobacter, Candida dubliniensis, Granulicatella adjacens, Enterococcus faecalis. CSF lab values: WBC3,467 CSF glucose: 16 CSF protein: 167 Concern for associated osteomyelitis (bone infection). Hemovac drain removed by Neurosurgery on 07/01/2024.
Physical therapy recommended inpatient rehab. Neurology & Infectious Disease recommended outpatient follow-up. Discharged finally on 7/8/2024
Antibiotic Treatment Plan: IV vancomycin and meropenem started, fluconazole added by ID. Prolonged IV antibiotics required for 6 weeks. Meropenem (1g IV every 8 hours) and Fluconazole (400mg PO daily) to continue until 8/16/2024.
Was there a failure to timely diagnose the CSF infection during the June 13 admission? Possible hospital-acquired infection due to poor infection control? Delay in appropriate antibiotic treatment?
Thank you in advance
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Do you believe there might have been medical error?
The rising WBC, hypotension, clinical decline would warrant complete evaluation to rule out sepsis as it meets SIRS criteria. And one should always evaluate the surgical site with the history of recent surgery
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
Maybe earlier initiation of ABx would have resulted in lesser duration of hospitalization and avoided meningitis.
What makes you a good expert for this case?
Having managed many cases with severe infections in the inpatient and outpatient setting since I work at a center which has robust spine surgery program.
How often do you encounter cases similar to this one in your practice?
It is variable but generally around 6-10 cases annually. We have a low threshold to scan and identify source of infection.
Do you believe there might have been medical error?
I see a lot of these cases. The use of JP drain is to remove the remaining fluid caused by inflammation in the cervical area. This was likely left in purpose due to high risk factors for poor healing in a heavy smoker. Second, there is no need to culture the JP drain fluid on that admission. Later, he developed signs of infection and cultures were properly obtained. No medical error
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
All steps were followed under standard of care. There is no deviation of SOC.. all the procedures were done properly, no need to culture the drain on second admission. Culture was then properly done when an infection was suspected. ID management was appropriate.
What makes you a good expert for this case?
I see hundreds of these cases during my career as ID specialist. In addition, the bacteria and candida that grew from the JP drain seems to be gut flora and likely the patients had poor compliance in keeping the JP drain in a clean environment
How often do you encounter cases similar to this one in your practice?
I see these cases All the time The major problem on this back surgeries is that the back gets contaminated easily due to patients position in bed or contamination due to poor maintaince of JP drain
Do you believe there might have been medical error?
Patient with cervical spine laminectomy develops increasing WBC count as he is being discharged..No attempt made to evaluate the spinal fluid for infection. Certainly developed a hospital acquired infection due to inadequate infection control. By delaying the appropriate infection workup the appropriate antibiotic treatment was delayed.
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
Lack of appropriate evaluation of a rising WBC delayed the diagnosis of a CSF infection and led to a delay in appropriated treatment of bone infection.
What makes you a good expert for this case?
I have been reviewing medical malpractice cases since 2012. Between 60-80 cases in total. I am well aware of cases in which inappropriate evaluation of infection leads to systemic infection and further morbidity and mortality.
How often do you encounter cases similar to this one in your practice?
I do see occasional cases that are admitted to the inpatient service.
Do you believe there might have been medical error?
There is no CSF leak, and it does not appear that he was treated for one; there is a post-op infection, though.
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
Infection is a common complication of surgery.
What makes you a good expert for this case?
Neurocritical care, over 20 years of experience managing post-op neurosurgical complications
How often do you encounter cases similar to this one in your practice?
Infrequently, since these are rare complications, we see a bunch of sepsis post-op and CSF leaks.
Do you believe there might have been medical error?
The leukocytosis was not addressed but did the pt recieve streroids for COPD as they usually do--that would explain the increase in WBC
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
What injury? So long as the infection cleared with the antibiotics and pt did not get endocarditis, etc
What makes you a good expert for this case?
Ideal expert is ID which I am not
How often do you encounter cases similar to this one in your practice?
Very unsual to have GNR infection from the surgery
Do you believe there might have been medical error?
Given the symptoms and history there should have been a set of cultures done with csf fluid and evaluation of the leak. With clear imaging and rising white count on the visit after initial discharge, would have considered all causes f possible infection.
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
If the infection was caught earlier, they could’ve been on the correct treatment for the correct organism that would’ve avoided the follow up visit and decline.
What makes you a good expert for this case?
I’ve seen patients in the hospital with similar postop complications and infections that have emerge. I’ve also seen them in my outpatient practice and follow up. Were we immediately sent the patient to the ER for evaluation of CSF and other causes for infection and imaging.
How often do you encounter cases similar to this one in your practice?
Encounter cases in which I have to do hospital follow up weekly. I have encountered cases just like this with complications from a procedure that may be infection or other impacts on kidney and organ function once every 3 to 6 months
Do you believe there might have been medical error?
Clearly, there was an infection in the CSF. This would not have developed spontaneously in such a case wherein there has been considerable manipulation of the cervical spine; therefore, it was iatrogenic by definition. That’s one part of it. The second part is the apparent failure to recognize this as a possibility, not assessing for it promptly and being dismissive of or obligated to a rising WBC count. I would also be interested in seeing the patient’s bicarbonate values on a CMP or BMP to see if these show a relative metabolic acidosis as the body is trying to fight off infection (it would further corroborate the rising WBC count). Especially with a drain in place and with the drain putting out a large amount of fluid, it would’ve been so easy to test for infection in the CSF.
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
See above. Moreover, the delay in diagnosis led to worse/more severe/more complicated infection than what may have developed had the infection been promptly detected and treated. The patient developed altered mental status and frankly could have died from this. I can picture how stressful it was for the patient and those around him, not to mention the additional hospitalization/care that was needed to overcome this..
What makes you a good expert for this case?
This is a multidisciplinary case involving not only neurosurgery, but also internal medicine (I completed my IM training at Johns Hopkins in 2010), infectious disease, and so forth. I myself have had a CSF leak and can thus picture/understand what this patient went through consequent to delayed diagnosis, which I also myself went through.
How often do you encounter cases similar to this one in your practice?
I would say on a near weekly basis I encounter cases of cryptogenic infection/leukocytosis. Various specialties and sub-specialties have to come together to find the source and come up with a treatment plan once that’s been achieved (or empiric therapy if a clear source can’t be found).
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