Question about blood flow

[Creflo]

Had a patient S/P multiple revascularizations in lower extremity with an abscess at plantar calcaneus, bone cortex intact. Vascular said no more attempts at revascularization. Non palpable pulses. Connected to abscess were two ulcers, fibrin slough/serous crust/hyperkeratotic base. I did a PT nerve block, debrided the ulcer bases with 15 blade, then drained and flushed the abscess at bedside. After the fact, Vascular told the patient that my attending should have asked vascular before we did this procedure. So here's my question: How do you know when its safe to drain an abscess from a blood flow perspective?

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[347932]

Had a patient S/P multiple revascularizations in lower extremity with an abscess at plantar calcaneus, bone cortex intact. Vascular said no more attempts at revascularization. Non palpable pulses. Connected to abscess were two ulcers, fibrin slough/serous crust/hyperkeratotic base. I did a PT nerve block, debrided the ulcer bases with 15 blade, then drained and flushed the abscess at bedside. After the fact, Vascular told the patient that my attending should have asked vascular before we did this procedure. So here's my question: How do you know when its safe to drain an abscess from a blood flow perspective?

If it's a limb or life threatening abscess, it should be drained. The only thing that could have been done differently is you could have let vascular drain the wound in the OR, just in case they felt that a more proximal amp needed to be done ASAP due to the extent of the infection.

Did you talk to your attending before the bedside procedure and fill him/her in beforehand? If so, I assume your attending gave you the go ahead. Also, what did you do after the fact? Did you talk to your attending about what you overheard, or address it with your attending before talking to the patient again? No doubt the patient will have questions for you/your attending at this point.

I must say, if what you say is accurate, that wasn't very professional of the vascular team. They should have just called your attending up and talked to him or her about it, rather than point out an error (in their opinion) to a patient like that. Especially if it was your attending's private patient admitted for the infection. One thing to realize is that even if there is some dispute over plan of care, this should always be handled with kid gloves. You certainly don't want to upset one of your attendings' referral sources/team members. You also have to wary of this when going into private practice. You don't want to be the guy/gal who upsets all the hospitalists/consultants by misstepping (even if you feel you didn't and certainly not saying you did in this case). Diplomatic and wise are the order of the day, even if you want to tear someone's throat out out of frustration and anger. Ahhhh the joys of interdisciplinary medicine!

 

[Creflo]

My attending asked that I clarify the MRI findings with the radiologist, which I did personally, he agreed the abscess should be drained. I then discussed this with my attending via telephone, who said to go drain it at bedside. The next day, the vascular PA visited the patient and expressed vascular's concerns to the patient, and told that patient that the vascular attending would be contacting the podiatry attending to express that vascular should have been asked before the I&D. The patient later told me this just to clue me in. It's good to learn some about the hospital politics, but my main concern is whether it was appropriate to do the procedure considering the blood flow. The ulcers had no foul odor, neither did the fluid that I obtained. The skin surrounding the ulcers was red extending about 3 cm around the ulcer, no necrotic skin or eschar or gangrenous changes. I'm trying to figure out when to avoid local ulcer debridement based on poor blood flow, its still a gray area for me.

 

[347932]

My attending asked that I clarify the MRI findings with the radiologist, which I did personally, he agreed the abscess should be drained. I then discussed this with my attending via telephone, who said to go drain it at bedside. The next day, the vascular PA visited the patient and expressed vascular's concerns to the patient, and told that patient that the vascular attending would be contacting the podiatry attending to express that vascular should have been asked before the I&D. The patient later told me this just to clue me in. It's good to learn some about the hospital politics, but my main concern is whether it was appropriate to do the procedure considering the blood flow. The ulcers had no foul odor, neither did the fluid that I obtained. The skin surrounding the ulcers was red extending about 3 cm around the ulcer, no necrotic skin or eschar or gangrenous changes. I'm trying to figure out when to avoid local ulcer debridement based on poor blood flow, its still a gray area for me.

If you can justify a potentially limb or life threatening situation (an MRI suspecting an abscess) then draining it is almost required. With the ulceration you described, and no abscess potential, it should be left alone.

Basically, if the heel area was as described without the abcess, then no debridement with poor circulation. IF there is an deep abscess, as per the MRI, then you should debride it to evacuate the abscess and potentially avoid a sepsis situation.

With the MRI you described there was no choice but to evacuate it. As I mentioned, it may have been an option to contact vascular to see if they would do it, but you are within your care of the patient to perform it yourself, assuming you have CYA.

Was the heel fluctuant? Why was an MRI ordered in the first place?

 

[PADPM]

This is a tough call, and also one reason why we treat patients and not xrays.

In these cases, you must use clinical judgement above everything else, AND you must document your rationale. IF you decide not to debride, despite the MRI findings of abscess/possible abscess, you must document what you've already stated. There was no odor, no drainage, no fluctuance, no ascending cellulitis, no local increase in temperature, etc., etc., DESPITE the MRI findings. If you DO decide to debride, you must justify that decision and state that not only did you read the MRI report but also REVIEWED the MRI and in your clinical judgement there appeared to be a collection of fluid/abscess DESPITE the fact the clinically there was no odor, fluctuance, drainage, etc.

Therefore, once you make a decision, you must be able to justify your decision and document the reason for your decision. You can't or shouldn't make your decision based on an MRI report alone, etc., but should make that decision on YOUR findings and instincts. If you can't decide, then you must rely on the experience of your attending(s). That's what the residency/training process is all about.

Once vascular passed on any additional intervention, in my opinion they had no right to intervene unless they were going to perform a BKA.

 

[Creflo]

Thanks for the replies, the MRI was initially ordered to determine if there was osteomyelitis, x ray was negative. No fluctuance on physical exam initially. Culture grew gram neg rods, light growth. We have been continuing betadine/saline flushes daily, but the abscess still has yellow fibrin material within it that won't come out with the flushes. Current plan is to continue daily flushes, iv abx, and see how the patient does.

 

[347932]

Thanks for the replies, the MRI was initially ordered to determine if there was osteomyelitis, x ray was negative. No fluctuance on physical exam initially. Culture grew gram neg rods, light growth. We have been continuing betadine/saline flushes daily, but the abscess still has yellow fibrin material within it that won't come out with the flushes. Current plan is to continue daily flushes, iv abx, and see how the patient does.

Oh my...there are so many other wound care options that would benefit the patient much more according to what I'm reading here.

If it is a deep wound that has been around for awhile and there IS suspected osteo has anyone considered a VAC? Do you have access to advanced wound care dressings and such? Those flushes may be hindering wound healing more than anyone realizes.

Weird...x-ray negative, then order an MRI for non fluctuant, stable wound with poor circulation. Something is not adding up to me. You had mentioned that the MRI showed an abscess, but when you expressed the fluid that it was not odorous. Was it purulence, serous, bloody or a mixture? What was the consistency of the fluid expressed? Once it was expressed did the wound now probe to bone? Did it undermine?

 

[PADPM]

Flushing a wound/abscess with Betadine? Full strength Betadine to flush a wound is basically destroying any possible healthy/granular tissue or cells you are trying to create. Betadine is toxic to healthy, granulating tissue, and I'm not sure there is any REAL benefit to flushing a wound with Betadine. If you have an organism isolated, and you are really concerned about using an antimicrobial to "flush", I would possibly consider the use of an anbibiotic solution that is effective against the isolated organism.

However, unlike the use of pulsed lavage in the OR where you can visualize the tissues and have suction as you are lavaging, "flushing" the wound at bedside has the POTENTIAL to "push" or spread an infection into spaces you can't see, you don't realize exist, etc. I'm not sure I agree with this treatment protocol.

 

[Creflo]

Not full strength betadine, but saline with small amount of betadine mixed in. Original fluid was thickness of pus, slightly thinner, with yellow color, no odor. No concern for osteo. Definitely undermines, but doesn't probe to bone once the fluid was expressed. There is a connection between plantar and medial heel as fluid flushed into one ulcer comes out of the other ulcer.

 

[347932]

Not full strength betadine, but saline with small amount of betadine mixed in. Original fluid was thickness of pus, slightly thinner, with yellow color, no odor. No concern for osteo. Definitely undermines, but doesn't probe to bone once the fluid was expressed. There is a connection between plantar and medial heel as fluid flushed into one ulcer comes out of the other ulcer.

Sounds like liquified tissue (adipose?) due to poor blood flow. If the area is very dry now, it may need a hydro colloid type dressing/packing to fill in the gap and stimulate granular growth if that's even possible due to the circulatory status. If the area is still oozing, but it's not infected, perhaps consider a calcium alginate type dressing with silver impregnated gauze to limit the potential for infection and soak up some of that yucky ooze.

I always wonder about these types of patients. They have horrible ulcers, but vascular says it's a no go for revasc. Can't VAC them because their wound isn't "bad enough" due to no osteo and no circulation. What are you supposed to do with these people? Wait until an infection sets in so Vasc can then justify a BKA, but now patient is SICK and can't recover from the surgery and rehab of such a stressful process? OR get with Vasc and ask them when they intend to get to the BKA so the patient can leave the hospital sooner, healthier and more likely to survive and thrive with their new prosthesis or do better in rehab for a healthier future?When do we draw the line between limb salvage vs, what's best for the patient?

It reminds of an externship I did when I was student. I had words with one of the attendings because he would take the patient in and do a 5th toe amp. It wouldn't heal for a variety of reasons. Then he would take them back and do a partial 5th ray amp, and the patient wouldn't heal for a variety of reasons. This went on and on until several of his patients would get pneumonia from being bed bound for so long and then would be off podiatry service due to pulmonary issues and the BKA they got 10 weeks after being admitted with no pulses and a gangrenous, odorous 5th toe. Maybe it wasn't the time for me to be vocal about such things, but in my view, these patients were suffering and didn't want that to happen under my watch (I'm NOT suggesting or recommending to do this whatsoever btw) Where do we draw the line? Food for thought once you're out on your own in practice.

 

[PADPM]

Sounds like liquified tissue (adipose?) due to poor blood flow. If the area is very dry now, it may need a hydro colloid type dressing/packing to fill in the gap and stimulate granular growth if that's even possible due to the circulatory status. If the area is still oozing, but it's not infected, perhaps consider a calcium alginate type dressing with silver impregnated gauze to limit the potential for infection and soak up some of that yucky ooze.

I always wonder about these types of patients. They have horrible ulcers, but vascular says it's a no go for revasc. Can't VAC them because their wound isn't "bad enough" due to no osteo and no circulation. What are you supposed to do with these people? Wait until an infection sets in so Vasc can then justify a BKA, but now patient is SICK and can't recover from the surgery and rehab of such a stressful process? OR get with Vasc and ask them when they intend to get to the BKA so the patient can leave the hospital sooner, healthier and more likely to survive and thrive with their new prosthesis or do better in rehab for a healthier future?When do we draw the line between limb salvage vs, what's best for the patient?

It reminds of an externship I did when I was student. I had words with one of the attendings because he would take the patient in and do a 5th toe amp. It wouldn't heal for a variety of reasons. Then he would take them back and do a partial 5th ray amp, and the patient wouldn't heal for a variety of reasons. This went on and on until several of his patients would get pneumonia from being bed bound for so long and then would be off podiatry service due to pulmonary issues and the BKA they got 10 weeks after being admitted with no pulses and a gangrenous, odorous 5th toe. Maybe it wasn't the time for me to be vocal about such things, but in my view, these patients were suffering and didn't want that to happen under my watch (I'm NOT suggesting or recommending to do this whatsoever btw) Where do we draw the line? Food for thought once you're out on your own in practice.

This is EXACTLY one of the reasons Dr. Armstrong has created his "toe and flow" approach. He actually sees patients in conjunction with the vascular surgeon and as a TEAM they decide what is best for the patient and what is going to be done in a timely manner for optimal healing. It eliminates the miscommunication that often occurs and the pissing matches. It's a TRUE team approach and ultimately the patient benefits.