Gangrene gets admitted?

[Apollyon]

By definition, gangrene = necrosis with putrefaction, and I've always thought that gangrene gets admitted. However, last week, one of the surgeons on-call (community) said that, if the patient's not septic, they don't need to be admitted (despite a non-septic patient that was admitted with gangrene the week prior coded and died on the floor).

This patient is a paraplegic, and had a decub on his R butt cheek that was Stage IV. He had neither a fever nor an elevated white count, but he smelled like a dumpster, and needed to be debrided. And that was the difference to me - the smell of dead tissue, vs. infected.

What's the surgeon's take on this? Do you wait until they get septic (for which the survival rate after coding is 0%), or take care of it at that moment (or at least the next day)?

I had an out, since the pt's PMD is in the same group as my PMD, and the doc on call is a friend of mine - I told him what I thought, and he took this pt in transfer to the Uni hospital.

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[Winged Scapula]

Dry gangrene without sepsis doesn't necessarily need to be admitted.

Wet gangrene, without or without sepsis, needs to be admitted for debridement.

The fellow in your case sounds like he needed to be admitted, IMHO.

 

[ESU_MD]

sounds like the patient needed to be admitted and needs ALOT of issues taken care of

in other words- admit to medicine
surgery on consult to take care of the wound.

 

[JackADeli]

Dry gangrene without sepsis doesn't necessarily need to be admitted.
Wet gangrene, without or without sepsis, needs to be admitted for debridement...

That is my teaching. Only exception would be some sort of end-of-life decisions, etc....

 

[Winged Scapula]

That is my teaching. Only exception would be some sort of end-of-life decisions, etc....

Yep. Although I always sort of liked snapping off those mummified toes so its too bad they aren't admitted more often.

 

[jhonny depp]

These kind of cases need proper care in a dedicated unit. Most of the time, valuable time is lost getting consultations.
Both the things you said were right, not every dry gangrene needs admission or for that matter debridement.
In this case the patient was paraplegic with grade IV decubitus ulcer, I am sure there was deep seated abscess under it which was missed.

 

[logistic]

Just did a practice question on diabetic foot ulcers;
For clarification: admitted or not admitted, either way gangrene necessitates debridement + IV Abx, correct?
Thanks

 

[Winged Scapula]

Just did a practice question on diabetic foot ulcers;
For clarification: admitted or not admitted, either way gangrene necessitates debridement + IV Abx, correct?
Thanks

Only wet gangrene mandates that. And its generally a good idea to admit diabetics so you can tightly control their sugars while giving them the IV Abx.

 

[Apollyon]

These kind of cases need proper care in a dedicated unit. Most of the time, valuable time is lost getting consultations.
Both the things you said were right, not every dry gangrene needs admission or for that matter debridement.
In this case the patient was paraplegic with grade IV decubitus ulcer, I am sure there was deep seated abscess under it which was missed.

That's the interesting thing - the necrotic tissue was like a strip mine right down to the hole through the fascia, with the glute visible and mobile (albeit ulcerated, making it stage IV) through it.

As I did not clarify, it was wet gangrene. And, to reiterate - boy howdy, the smell was so bad, the patient himself couldn't take it.

 

[Winged Scapula]

That's the interesting thing - the necrotic tissue was like a strip mine right down to the hole through the fascia, with the glute visible and mobile (albeit ulcerated, making it stage IV) through it.

As I did not clarify, it was wet gangrene. And, to reiterate - boy howdy, the smell was so bad, the patient himself couldn't take it.

Those things are disgusting and pretty sad (as almost all paras/quads get them). Sounds like the guy needed to be admitted on many levels, not the least of which was social issues related to having a decub that bad. How about admitting him for debridement, vas dressing placement and consult PRS for flap once its cleaned? That would have been the appropriate management, IMHO.

 

[Apollyon]

Those things are disgusting and pretty sad (as almost all paras/quads get them). Sounds like the guy needed to be admitted on many levels, not the least of which was social issues related to having a decub that bad. How about admitting him for debridement, vas dressing placement and consult PRS for flap once its cleaned? That would have been the appropriate management, IMHO.

Without giving away too much personal info, this guy, whose been para since 1979, had his first decub EVER on the L butt cheek a few months ago - had it debrided, wound care, and a flap from PRS. It was a visit with PRS that started this whole line, b/c the PRS noted the new decub, said he didn't debride, and referred the pt back to GS. Per the family, the GS looked at it 2d prior to their visit to my ED, and they say "he didn't do anything".

He's pretty well maintained, and his PMD group is the best one in the area (that's why I go to them, myself).

 

[maxheadroom]

Ah yes, flap closure of decubiti . . . an operation that has almost 100% failure rate. I'm pretty sure that most decub patients can ride a VAC forever.

 

[Winged Scapula]

Ah yes, flap closure of decubiti . . . an operation that has almost 100% failure rate. I'm pretty sure that most decub patients can ride a VAC forever.

True. I have seen several fail. So are PRS now recommending that it not be done?

 

[maxheadroom]

Nobody will actually say that we shouldn't do them, but there are lots of surgeons who regard it as futile care. I think that my algorithm will be:

1. Must have never had decub in past
2. Must have identifiable and correctable problem that resulted in decub
3. Must be compliant with other medical care
4. Must be medically controlled (DM in particular)
5. Must be nutritionally balanced (nobody with albumin <2.5)
6. Must be prepared to spend a month on a Clinitron

This excludes almost all of the patients that I see now. I feel bad for many of them, but I'm tired of flapping someone and having them come back within six months with a hole in the middle of their flap. It just isn't worth the time/money/hassle for either me or the patient.

 

[Apollyon]

That's what I was trying to describe, although I may not have been clear. This patient has been para for 29 years, and just had his first decub. He is unlike virtually every other para I see, since the others are always at the Uni hospital, and have some aspect of being shot or beaten or stabbed or whatever associated, and continue to hang out with the same element.

 

[maxheadroom]

Recurrent decub means that the patient isn't following well-established protocols for pressure relief that they should have drilled into themselves after their first decub. Recurrent decub means patient non-compliance. Look up the numbers. Most papers put recurrence numbers at around 90% over two years. If at first you don't succeed . . . put a VAC on it because you ain't gonna do any better this time around.

 

[droliver]

Agree with max.

Pretty much the new paradigm is that (with very rare exception) pressure sores are not good reconstructive candidates. Decubitus ulcer surgery as traditionally practiced is a sinkhole of time, effort, & resources. I defer debridements to surgery when I get called for these consults as there's not much I can offer

 

[Apollyon]

Recurrent decub means that the patient isn't following well-established protocols for pressure relief that they should have drilled into themselves after their first decub. Recurrent decub means patient non-compliance. Look up the numbers. Most papers put recurrence numbers at around 90% over two years. If at first you don't succeed . . . put a VAC on it because you ain't gonna do any better this time around.

When you say "recurrent" do you mean in any location, or in the same location as the first? I ask, because the PRS that did the left flap is NOT known - at all - for throwing good money after bad (i.e., to flap recurrents - EVER).

 

[beaverfetus]

I don't know what the big deal is with gangrene. I caught a peck of the Fournier's Gangrene, slapped some neosporin on it, and it cleared right up.

 

[maxheadroom]

I consider ANY new decub on a pt who has previously been treated to be recurrent.

 

[johnniewalker11]

.

 

[jhonny depp]

I'm a premed so I don't have much to add to this but...
I've been working for a vascular surgeon and I've seen a lot of patients with gangrene. Most of them are diabetic and have PVD. The Surgeon seems to always have them admitted, especially if it's wet gangrene with foul smelling puss. Depending on their ability to heal the wound (it's usually on their feet) and age he will do one or two of the following things: Debriding followed by a regimen of treatment at a woundcare center (It can take a year or more of bi-monthy office visits and a visiting nurse every other day to heal these wounds). OR he does a trans-metatarsal amp or BKA in order to salvage the limb. This is usually when the infection is down to the bone and the patient does not have adequate blood supply to heal the foot wound.

Like I said I'm a premed so take it with a grain of salt, but this is what I've seen. If this isn't what you would, do I'm interested to hear other ideas. Thanks.

Thats what we used to do at the vascular surgery centre. Also Id like to add that vascular surgeons dont admit the cases like the one we are discussing.
The types of case you mention are generally the ones with failed vascular grafts and infection. Decision reagrding the time of amputation can be life laving in peripheral vascular diseases.

 

[Blade28]

The general orders here for a patient with a decub:

*Avoid direct pressure
*Turn Q2H
*Air mattress
*Optimize nutrition albumin > 3
*Sharp debridement at bedside prn
*Wet-to-dry dressing changes with 1/8th strength Dakin's Q12H
*Not a flap candidate if bedridden or paraplegic

 

[Celiac Plexus]

The general orders here for a patient with a decub:

*Avoid direct pressure
*Turn Q2H
*Air mattress
*Optimize nutrition albumin > 3
*Sharp debridement at bedside prn
*Wet-to-dry dressing changes with 1/8th strength Dakin's Q12H
*Not a flap candidate if bedridden or paraplegic

lol.

 

[roja]

That's the interesting thing - the necrotic tissue was like a strip mine right down to the hole through the fascia, with the glute visible and mobile (albeit ulcerated, making it stage IV) through it.

As I did not clarify, it was wet gangrene. And, to reiterate - boy howdy, the smell was so bad, the patient himself couldn't take it.

Sounds like you did the right thing. Wet gangrene gets admitted. Dry goes home with really good analgesia (In my experience, these patients usually understand they are waiting for their mummy toes to fall off, they are just in pain and the t3's aren't cutting it).

I have seen some pretty bad wet gangrene, even in para's who take really good care of themselves. One guy ended up with half of his rearend gone. Looked like a shark had bitten off his entire L buttock. Needed a hemicorpectomy but was refusing.