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CASE STUDY #1 DEHISCED STERNAL MUSCLE FLAP, DEHISCED LEG, ABDOMINAL WOUND.

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Presentation on theme: "CASE STUDY #1 DEHISCED STERNAL MUSCLE FLAP, DEHISCED LEG, ABDOMINAL WOUND."— Presentation transcript:

1 CASE STUDY #1 DEHISCED STERNAL MUSCLE FLAP, DEHISCED LEG, ABDOMINAL WOUND

2 The Patient 55 years old Female Married 5 children 22 grandchildren Non-smoker

3 CO-MORBIDITIES Diabetic Hypertension Coronary Artery Disease Hyperlipidemia Probable Sleep Apnea Obesity

4 Treatment Course Bypass Surgery 10/01 Dismissed from hospital 10/04 Sternal Wound and Donor Site Infection- Readmitted 10/28 Incision and debridement of leg and sternum - sternum removal 11/06 Closure of chest with muscle flap Debridement of leg wound 11/14 Transferred to NHS Clarkson Hospital 12/05 Hyperbaric Oxygen Treatments Initiated 12/06 Debridement of Sternal/chest/leg wounds - VAC Therapy Initiated 12/12

5 Treatment Course Debridement of sternal and leg wounds - abdominal wound 01/13 STSG to sternal and leg wounds with VAC therapy 1/20 Transferred from acute care to sub-acute rehab unit 02/05

6 TRANSFERRED TO NHS 12/05 Sternal muscle flap and donor site are open Lower leg is dehisced and infected leg sternum rectus

7 STERNAL, RECTUS AND LEG WOUNDS IMPROVE QUICKLY 12/12 Use of HBO and VAC therapy along with Multi-disciplinary approach leg sternum rectus

8 STERNUM AND LEG GRANULATE ABDOMINAL WOUND DEBRIDED 01/13 Abdominal wound measures 15x10x4cm leg abdomen rectus sternum

9 SKIN GRAFT TO STERNUM AND LEG 1/20 VAC therapy replaced post skin graft for 5 days leg sternum abdomen

10 COMPLETE TAKE ON SKIN GRAFTS TO LEG AND STERNUM 1/26 At first dressing change grafts have 100% take leg sternum

11 ABDOMEN CONTINUES TO HEAL 2/5 Patient is transferred to Sub-acute rehab floor abdomen

12 INTERDISCIPLINARY PLAN OF CARE Plastic Surgery General Surgery Infectious Disease Cardiology Pulmonary Medicine Endocrinology Nutrition Nursing Physical and Occupational Therapy

13 STERNUM PHOTOGRAPHIC REVIEW

14 RECTUS PHOTOGRAPHIC REVIEW

15 LEG PHOTOGRAPHIC REVIEW

16 ABDOMEN PHOTOGRAPHIC REVIEW 1 2 3

17 CASE STUDY #2 SHOULDER WOUND OSTEOMYLITIS REMOVAL OF HARDWARE

18 THE PATINET 39 Years Old Male 2 Children Non-Smoker In Nebraska visiting family

19 CO-MORBIDITIES Healthy Young Man No co-morbidities Wound occurred when dirt biking

20 Treatment Course Accident occurred Closed, grossly displaced clavicle fracture 11/10 Presented at ER 11/15 Surgical reduction/fixation with plate and 6 screws 11/24 Released from hospital without any problems 11/25 Presented with signs and symptoms of infection 11/29 Staph cultured – plate and screws noted to be dislodged IV antibiotics initiated 12/01 Plate and screws surgically removed Systemic reaction to Nafcillin and oral dicloxacillin 12/12 Released to home 12/20

21 Treatment Course Readmitted for further evaluation of non-healing wound 1/23 Surgical resection of mid third of clavicle with debridement of soft tissue infection Infectious disease consulted 1/30 Plastics called in – V.A.C. placed 2/2 Released with home care and V.A.C. 2/7 Clinic follow-up – V.A.C. discontinued-alginate initiated 2/14 IV antibiotics discontinued 2/21 Released from care-healed 2/28

22 Resection of Clavicle with debridement VAC placed 2/02

23 First VAC dressing change 2/05 ABDOMEN

24 Released to home with Home Care 2/07 V.A.C. therapy IV antibiotics ABDOMEN

25 First Clinic Follow Up 2/14 V.A.C. discontinued Alginate dressing applied ABDOMEN

26 Clinic Follow up 2/21 IV antibiotics discontinued

27 Wound is closed 2/28 Hypergranulation area in center Removed with silver nitrate stick ABDOMEN

28 INTERDISCIPLINARY PLAN OF CARE Plastic Surgery Orthopedic Surgery Infectious Disease Nutrition Nursing Home healthcare

29 CLAVICLE PHOTOGRAPHIC REVIEW

30 CASE STUDY #3 Perineal cyst Necrotizing Component Radical Surgical Debridement

31 THE PATINET 51 years old Female Single Smoker

32 CO-MORBIDITIES Diabetic Hypertension Hyperlipidemia Probable Sleep Apnea Obesity

33 Treatment Course Presented to Emergency Room with Perineal Cyst Infection Adult Onset Diabetes Mellitus Diagnosis Massive Infection with necrotizing features Emergency Surgery for debridement 1/16 Infectious Disease Consult 1/18 Plastic Surgery Consult V.A.C. Placement 1/24 Sub Acute Care Transfer 1/28 Released to Home 2/28 Healed 4/21

34 1/24 Vac placed 18cm – length 7cm – width 5cm 4:00 5cm 9:00

35 1/26 18cm length 5cm width 1cm undermining 0 tunnels

36 2/14 12cm length 5cm width

37 2/19 10cm length 4cm width

38 Released to Home 2/28 9cm length 4cm width

39 Clinic Follow-up 3/07 6cm length 4cm width

40 Clinic Follow-up 3/14 6cm length 3cm width V.A.C. discontinued Normal Saline Moist dressings

41 Clinic Follow-Up 03/21 6cm length 3cm width

42 Clinic Follow-Up 03/28 5cm length 3cm width

43 Clinic Follow-Up 4/05 2.5cm length 2cm width

44 Clinic Follow-Up 4/13 2cm length 2cm width

45 4/21 Healed Released from care

46 INTERDISCIPLINARY PLAN OF CARE Plastic Surgery General Surgery Infectious Disease Endocrinology Nutrition Nursing Home health care

47 Photographic Review Groin/peri-rectal

48

49 CASE STUDY #4 Perirectal Abscess Necrotizing Component Radical Debridement

50 The Patient 62 year old Female Widow 2 Children

51 CO-MORBIDITIES Adult Onset Diabetes Mellitus Hypertension Hyperlipidemia Status Post hysterectomy related to cervical cancer with abdominal radiation therapy Obesity Nutritional Deficit

52 Treatment Course Surgical debridement of necrotizing rectal-perineal abscess Performed at rural hospital 3/24 Further surgical debridement and diverting colostomy performed at rural hospital 3/25 Transferred to NHS Clarkson for Interdisciplinary care Infectious Disease Consult 3/26 Hyperbaric Oxygen Treatments Started Hyperalimentation for Nutrition 3/26 Plastics Consulted Many organisms ¼ strength Betadine packs q8hours 3/30

53 Treatment Course Acute Renal Failure Atelectasis Bronchoscopy with Removal of Large Mucous Plug 4/5 Transferred from Intensive Care Unit to Floor Tube feeding initiated 4/10 V.A.C. Placed 4/13 Respiratory Arrest Ventilator Placement 4/21 Removed from Ventilator 4/23 Retention Sutures Placed in Wound 4/25 Patient Requested “No Code Status Last Dressing Change 4/27 Respiratory and Cardiac Arrest 5/1

54 4/13 Status Post Radical Debridement V.A.C. Placed

55 4/16 First V.A.C. dressing Change

56 4/18 NG tube feeding Hyperbaric Oxygen Treatments

57 4/23 V.A.C. continues I.V. Antibiotics – Hyperbaric Oxygen Treatments

58 4/25 Retention Sutures placed to encourage adhesion of skin flaps V.A.C. continues

59 4/27 Multiple setbacks Renal Failure

60 INTERDISCIPLINARY PLAN OF CARE Plastic Surgery General Surgery Infectious Disease Pulmonology Endocrinology Oncology Nutrition Nursing Social Services Physical Therapy Occupational Therapy

61 Peri-rectal Photographic Review

62

63 CASE STUDY #5 Diabetic Foot Wound Radical Debridement Partial Bone Removal

64 The Patient 77 Year Old Woman Married 3 Children 9 Grandchildren 3 Great Grandchildren

65 CO-MORBIDITIES Breast Cancer Ongoing Chemotherapy Peripheral Neuropathy CAD CABG

66 Treatment Course Admission related to acute infection left foot 9/20 Infectious Disease Consultation Orthopedic Consultation 9/21 Surgical Debridement of left foot 9/24 Surgical Debridement of left foot 9/28 Plastic Surgery Consultation 10/1 V.A.C. Placed 10/3

67 Prior to first V.A.C. dressing change First Metatarsal debridement for osteo – bone exposed Measures 5cm Length 2.5cm Width 4cm Depth

68 First V.A.C. Dressing Change I.V. antibiotic continue Hyperbaric Oxygen continues Measures 3.5cm Length 1.2cm Width 2cm Depth

69 Last V.A.C. Dressing Change Patient dismissed to home with alginate dressing changes qod Measures 2cm Length 0.9cm Width <0.2cm Depth

70 INTERDISCIPLINARY PLAN OF CARE Plastic Surgery Orthopedic Surgery Infectious Disease Pulmonary Medicine Endocrinology Nutrition Nursing Pedorthics Physical and Occupational Therapy

71 Photographic Review Foot

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