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Jacob Hantla, BSBME, MS, CRNA, CCDS, FHRS, with Arizona Anesthesia Solutions, discusses his abstract ahead of Heart Rhythm 2025, which takes place April 24-27, 2025. This study was done with Dr. Akash Makkar.

Please start by introducing yourself.

My name is Jacob Hantla. I am a nurse anesthesiologist, specialized in EP, both in the inpatient and outpatient setting. I am a certified cardiac device specialist and also a fellow of the Heart Rhythm Society, so I am unique in that I am dedicated to anesthesia but with a very intense EP focus both in ablations and devices in inpatient and outpatient settings. I also have clinical expertise running a large group here in Arizona.

Summarize the background and relevance of the topic. Tell us about your upcoming session and what you will be presenting on.

Our abstract looks at whether we can optimize costs in an outpatient setting, in an ambulatory surgical center (ASC) in particular, where we are very cost conscious. When implanting devices, it's critical that we do not have any device infections. So, some providers use pouches or envelopes to minimize device infection risk, but those can come with substantial cost. Due to those costs or questions about their efficacy, some providers do not use any prophylaxis besides a pocket washout and systemic antibiotics. However, we have heard anecdotal evidence that in the outpatient setting, there may be a slight increase in infections as well as questions as to whether that is true and what the reason is. We took a cue from orthopedics, where, especially in spine cases, use of intra-wound antibiotic powder has become relatively routine. It is not yet standard of care, but we have seen increased reports about it, and in a recent report, there were very good effects in sternal wounds avoiding an infection. So, we wanted to see if there would be any role for that in the cardiac ASC for device implants.

Over 20 months, we did the following protocol for every single patient. We used a gram of vancomycin powder placed directly into the wound. If the patient had a vancomycin allergy, we use cefazolin instead. Across those 507 consecutive patients over 20 months, we had zero pocket infections, no reported allergic reactions, and no site irritation. That had been one of our major concerns—that having powder in the site would impair healing or cause any local irritation—and we saw none of that across all those patients. While we did not prove that it stopped any infections in our case series, we did show that it had no negative outcomes in our patients and very well may have contributed to our result of zero pocket infections. So, it seems like a safe and very cost-effective way ($4 per application compared to $800) to take your infection control above and beyond the standard.

What are the take-home messages you would like readers to leave with? 

One of the major benefits of this is you give very high antibiotic concentrations in the pocket where you want it with very little systemic increase, systemic toxicity, systemic exposure, or antibiotic resistance. The take-home message is that this is something that I think should be considered. More study is needed, even in orthopedics where it is used routinely, but formal guidelines are evolving. It is debated and there is mixed efficacy in randomized control trials. But in a situation where the side effects of complications can be devastating, and given minimal risk, I think it should be considered.

The transcripts have been edited for clarity and length.