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Rommel Q. de Leon, MD Department of Surgery Ospital ng Maynila Medical Center

CASE MANAGEMENT DISCUSSION- PRESENTATION AND SHARING OF INFORMATION ON COMPLICATED SKIN AND SOFT TISSUE INFECTION. Rommel Q. de Leon, MD Department of Surgery Ospital ng Maynila Medical Center. GENERAL DATA. D. F. 58/M From Intramuros, Manila. CHIEF COMPLAINT. NON-HEALING WOUND,

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Rommel Q. de Leon, MD Department of Surgery Ospital ng Maynila Medical Center

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  1. CASE MANAGEMENT DISCUSSION- PRESENTATION AND SHARING OF INFORMATION ON COMPLICATED SKIN AND SOFT TISSUE INFECTION Rommel Q. de Leon, MD Department of Surgery Ospital ng Maynila Medical Center

  2. GENERAL DATA D. F. 58/M From Intramuros, Manila

  3. CHIEF COMPLAINT NON-HEALING WOUND, FOOT, RIGHT

  4. HISTORY OF PRESENT ILLNESS • 2 weeks PTA  Patient noted crusting lesions over the dorsum and interdigital areas of the right foot noted to be non- healing accompanied by pruritus No medications taken No consult done

  5. HISTORY OF PRESENT ILLNESS • 1week PTA  Spread of the lesions to other parts of the foot Lesions with foul- smelling discharge Swelling and erythema No medications taken No consult done

  6. HISTORY OF PRESENT ILLNESS • Few hrs PTA  Increased severity of swelling Increased spread of lesions Consult

  7. PAST MEDICAL HISTORY • (+) Diabetes Mellitus Type II x 20 yrs- Regular and Intermediate Insulin - Regular Insulin 5 u SQ for CBG > 250 mg/dl - Intermediate insulin 16 u in AM 8 u in PM NON-COMPLIANT • S/P BKA, Left- 2004, OMMC • PTB Minimal- 2004, OMMC Rx: anti-Koch’s, non- compliant

  8. FAMILY HISTORY • (+) Diabetes Mellitus Type II- both parents

  9. PERSONAL AND SOCIAL HISTORY • Smoker, 20 pack years • Alcoholic Beverage Drinker 4x a week

  10. PHYSICAL EXAMINATION • GENERAL SURVEY: conscious, coherent, NICRD BP= 120/ 80 CR= 78 RR= 22 T= 37º • HEENT: pink palpebral conjunctiva, anicteric sclera, no TPC, no CLAD • CHEST / LUNGS: SCE, no retractions, clear breath sounds • HEART: adynamic precordium, NRRR, no murmur

  11. PHYSICAL EXAMINATION • ABDOMEN: flat, NABS, soft, non-tender

  12. PHYSICAL EXAMINATION(lower extremities)

  13. PHYSICAL EXAMINATION

  14. PHYSICAL EXAMINATION(lower extremities) • BKA scar, Left foot • DERMATOLOGIC: (+) swollen erythematous right foot; (+) multiple crusting weeping lesions over the dorsum of the forefoot and on the interdigital areas, R; (+) ulcerating wound with multiple crusting weeping lesions, dorsum and sole foot, R • VASCULAR: (+) pitting edema above the ankle; diminished dorsalis pedis pulses; strong posterior tibial, popliteal and femoral pulses; poor capillary filling time (> 3 sec); (-) temperature gradient

  15. PHYSICAL EXAMINATION(lower extremities) • NEUROLOGIC: Poor light touch perception; poor pinprick sensation; poor two-point discrimination; poor temperature discrimination

  16. SALIENT FEATURES • 58/M • 2 wks history non-healing wound right foot with pruritic crusting lesions accompanied by erythema and swelling that spread to other parts of the foot with foul-smelling discharge • (+) DM Type II x 20 yrs, non-compliant to medications • (+) History of previous amputation for diabetic gangrene of the left foot (2004-OMMC) • (+) DM Type II both parents

  17. SALIENT FEATURES 6. PE of the Right foot: DERMATOLOGIC: (+) swollen erythematous right foot; (+) multiple crusting weeping lesions over the dorsum of the forefoot and on the interdigital areas, R; (+) ulcerating wound with multiple crusting weeping lesions, dorsum and sole foot, R VASCULAR: (+) pitting edema above the ankle; diminished dorsalis pedis pulses; strong posterior tibial, popliteal and femoral pulses; poor capillary filling time (> 3 sec); (-) temperature gradient NEUROLOGIC: Poor light touch perception; poor pinprick sensation; poor two-point discrimination; poor temperature discrimination

  18. DM TYPE II PATIENT POOR DM CONTROL NON-HEALING WOUND ON THE FOOT SIGNS AND SYMPTOMS OF INFECTION SUPERFICIAL DEEP

  19. DM TYPE II PATIENT POOR DM CONTROL NON-HEALING WOUND ON THE FOOT SIGNS AND SYMPTOMS OF INFECTION SUPERFICIAL DEEP • FUNGAL INFECTION • WITH SUPERIMPOSED • BACTERIAL INFECTION • SWELLING AND INDURATION • DERMATOLOGIC PRESENTATION • ERYTHEMA AND EDEMA ABOVE THE ANKLE • WOUND BREAKDOWN • ULCERATION / UNDERMINING • VASCULAR CHANGES • DIMINISHED SENSORY PERCEPTION

  20. CLINICAL DIAGNOSIS

  21. PARACLINICAL DIAGNOSTIC PROCEDURE • DO I NEED A PARACLINICAL DIAGNOSTIC PROCEDURE? YES. - TO INCREASE THE DEGREE OF CERTAINTY OF MY PRIMARY CLINICAL DIAGNOSIS - THEY HAVE DIFFERENT TREATMENT MODALITIES

  22. GOALS OF PARACLINICAL DIAGNOSTIC PROCEDURE • DETERMINE THE DEPTH OF INFECTION

  23. PARACLINICAL DIAGNOSTIC PROCEDURES

  24. XRAY RESULTS: • - OSTEOPOROTIC OSSEOUS • STRUCTURE WITH SOME • OSTEOLYTIC CHANGES • ON THE DISTAL DIGITS • SOFT TISSUE ABSCESSES • NOTED ON ALL DIGITS

  25. PRE-TREATMENT DIAGNOSIS DIABETIC FOOT, RIGHT DIABETES MELLITUS TYPE II POORLY CONTROLLED S/P BKA, LEFT

  26. GOALS OF TREATMENT • REMOVAL OF NECROTIC TISSUE • CONTROL OF THE INFECTION • RESTORATION OF VASCULAR PERFUSION • MEDICAL MANAGEMENT OF HYPERGLYCEMIA

  27. TREATMENT OPTIONS – GOALS 1 TO 3 * ALL PROCEDURES REQUIRE ADEQUATE ANTIBIOTIC COVERAGE

  28. TREATMENT OPTIONS – GOAL 4

  29. TREATMENT PLAN (SURGICAL) BELOW THE KNEE AMPUTATION, RIGHT

  30. TREATMENT PLAN (MEDICAL) INSULIN (SHORT AND LONG ACTING) FOR CONTROL OF HYPERGLYCEMIA

  31. PRE-OP PREPARATION • PSYCHOSOCIAL SUPPORT • SCREENING FOR MEDICAL PROBLEMS DM TYPE II- CBC, CBG MONITORING, FBS, BUN, CREATININE, SERUM K, URINALYSIS, LIPID PROFILE, HgbA1C CHEST X-RAY – PTB MINIMAL ECG- NON-SPECIFIC ST-T WAVE CHANGES

  32. PRE-OP PREPARATION • OPTIMIZE PHYSICAL CONDITION OF THE PATIENT FLUID RESUSCITATION ADEQUATE ANTIBIOTIC COVERAGE CONTROL OF HYPERGLYCEMIA (Co-Management with IM) CBG monitoring AC/HS Regular Insulin 5 units SQ for CBG > 250 mg/dl Intermediate Insulin 16 units SQ in AM, 8 units SQ in PM

  33. SURGICAL TREATMENT (Intra-op) • Tourniquet • Level of bony resection marked and AP diameter measured • Anterior and posterior flaps (1/2 AP diameter) marked

  34. SURGICAL TREATMENT (Intra-op) • Skin, subcutaneous fat and fascia divided in the same line as with the periosteum of the antero-medial surface of the tibia • Flaps elevated to the level of the amputation

  35. INTRAOPERATIVE FINDINGS • Gangrenous material noted with foul-smelling purulent discharge • Good pulses and good muscle viability with brisk bleeding noted at the level of amputation

  36. SURGICAL TREATMENT (Intra-op) • Superficial peroneal nerve identified, pulled distally and divided • Anterior tibial vessels and deep peroneal nerve divided • Anterior muscles sectioned 0.75 cm distal the bony resection

  37. SURGICAL TREATMENT (Intra-op) • Tibia bevelled at level of resection prior to division of the bone • Fibula sectioned 3 cm proximal to tibia

  38. SURGICAL TREATMENT (Intra-op) • Posterior vessels and nerve divided • Posterior flap and aponeurosis of gastrocnemius fashioned to meet anterior muscles • Tourniquet released and obtained haemostasis

  39. SURGICAL TREATMENT (Intra-op) • Wound closed in layers (fascia, fat and skin) and apply a stump bandage

  40. OPERATION DONE BELOW THE KNEE AMPUTATION, RIGHT

  41. FINAL DIAGNOSIS DIABETIC FOOT, RIGHT DIABETES MELLITUS TYPE II POORLY CONTROLLED S/P BKA, LEFT

  42. POST-OPERATIVE CARE • SUPPLY THE BASIC NEEDS OF THE PATIENT • COMFORT • ANALGESICS • CBG MONITORING AND CONTROL OF HYPERGLYCEMIA • MEDICATIONS – ANTIBIOTICS • FLUIDS AND ELECTROLYTES • REHABILITATION / POSSIBLE PROSTHESIS

  43. POST-OPERATIVE CARE • SUPPORT ORGAN FUNCTION • WOUND CARE • MONITORING FOR COMPLICATIONS • ADVICE ON • HOME CARE • FOLLOW-UP PLAN

  44. POST-OPERATIVE CARE • PATIENT DISCHARGED ON 3RD POD: 1. LIVE 2. WITH NO COMPLICATION 3. SATISFIED 4. WITH NO MEDICO-LEGAL SUIT

  45. FOLLOW-UP PLAN • REMOVAL OF SUTURES AFTER 10-14 DAYS • ADVICE ON WOUND CARE • ORAL ANTIBIOTICS FOR 5-7 DAYS • CONTINUATION OF CBG MONITORING • CONTROL OF HYPERGLYCEMIA WITH CO-MANAGEMENT WITH INTERNAL MEDICINE • ADVICE FOR PROSTHESES AND REHABILITATION

  46. SHARING OF INFORMATION DIABETIC FOOT

  47. DEFINITION • “Infection, ulceration and/or destruction of deep tissues associated with neurological abnormalities and various degrees of peripheral vascular disease in the lower limb” (WHO, 1985) • “The term “diabetic” foot indicates that there are specific qualities about the feet of people with diabetes that sets this disease apart from other conditions that affect the lower extremity” (Habershaw & Chzran, 1995)

  48. DEFINITION • “…the many different lesions of the skin, nails, bone and connective tissue in the foot which occur more often in diabetic patients than non-diabetic patients such as ulcers, neuropathic fractures, infections, gangrene and amputations”(De Heus-van Putten, 1994) • “The term ‘diabetic foot’ implies that the pathophysiological processes of diabetes mellitus does something to the foot that puts it at increased risk for tissue damage”. (Payne & Florkowski, 1998)

  49. GENERALITIES THREE BROAD TYPES OF DIABETIC FOOT ULCERS: • neuropathic • ischaemic • neuroischaemic

  50. Diabetic foot ulcers are classified using the commonly used Wagner’s Classification

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