Transcript TRATAMENTUL CHIRURGICAL AL INFECTIILOR SEVERE ALE

Lidia Ionescu, Cozmin Radulescu,
Daniel Guta, Irina Trifescu
cl.III chirurgie, UMF Iasi
 The
prevelence of DM –rising dramatically
worldwide
 Largely related to increasing rates of obesity
 WHO- 5% of the world’s pop. DM- 2025
 The rising prevalence+increased longevity of
pop.- rise in DM-associated complications.
 One of the most feared and frequentamputation
 The sequence: ulceration of an insensate,
diformed foot- wound infection
 Considerable
morbidity
 Occasionally mortality- gas gangreneseptic shock
 Repeated and prolonged hospital
admissions
 Costly treatment
 9%
foot infection-2 years of follow-up,
despite:
• Educational sessions
• Therapeutic shoes
• Follow-up in a foot clinic
• Ready access to podiatric care
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DM-underlying cause of 60% amputations in
developed countries
Norway study-the rate of amputation 32 times higher
than among non-DM pts.
Postop. mortality: 10%-15%:
• advanced age,
• coronary and peripheral vascular disease,
• renal failure
Risk factor
Peripheral motor neuropathy
Mechanism of injury or impairment
Abnormal foot anatomy and biomechanics, with clawing of toes, high arch,
and subluxed metatarsophalangeal joints, leading to excess pressure,
callus formation, and ulcers
Peripheral sensory neuropathy
Peripheral autonomic neuropathy
Neuro-osteoarthropathic deformities
Vascular insufficiency
Metabolic derangements
Patient disabilities
Maladaptive patient behaviors
Health care system failures
control and foot care
Lack of protective sensation, leading to unattended minor injuries caused
by excess of pressure or mechanical or thermal injury
Deficient sweating leading to dry, cracking skin
Abnormal anatomy and biomechanics, leading to excess pressure,
especially in the midplantar area
Impaired tissue viability, wound healing, and delivery of
neutrophils
Impaired immunologic (especially neutrophil) function and
wound healing, and excess collagen cross-linking
Reduced vision, limited mobility, and previous amputation
Inadequate adherence to precautionary measures and foot inspection and
hygiene procedures, poor compliance with medical care, inappropriate
activities, excessive weight-bearing, and poor footwear
Inadequate patient education and monitoring of glycemic
 Obtaining
proper specimens, avoid:
• Missing true pathogens
• Isolating contaminating organisms
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Debride and cleanse the wound before taking a
specimen for culture
Obtain tissue specimens from ulcers by curettage
Aspirate purulent secretions
Biopsy deep tissue or bone infections
Avoid sending wound swab for culture
Obtain blood cultures if patient is seriously ill
Label and send specimens promptly in sterile
containers or transport media for aerobic and
anaerobic cultures
Request Gram-stained smear of specimen
 Foot
infections- potentially catastrophic
outcome
 Management must be:
• timely,
• rational,
• well coordinated.
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Initial assessment- severity and extent of the infection
Ischaemia of the affected limb confers a poor prognosis, the
vascular status must be delineated early in the assessment of the
inf.
It can be difficult to assess the extent of an inf. without carrying out
appropriate debridement, with the goal of removing all necrotic
tissue
Drain abscesses or remove necrotic soft tissue
Antibiotics are necessary but rarely sufficient for treating diabetic
foot inf., they are best seen as adjunctive not primary, therapy in
treating these infections
Coordinated, multidisciplinary approach: diabetologist, infection
specialist, vascular surgeon, plastic surgeon,podiatrist.
 When
a pt. presents with a foot wound,
the clinician should determine:
• whether or not it is infected
• if infected, how severely
• If hospital admission is needed
• If urgent surgery is required
• If parenteral and broad-spectrum antibiotics are
indicated
 Mild
infection: present pus or > 2 signs of
inflammation but:
• extent of cellulitis<2 cm. around the wound
• limited to skin and superf. sc. tissues,
• no other local complications.
• no systemic illness
 Moderate
infection: inf. in systemically
well and metabolically stable pt. who has:
• cellulitis extending>2cm.,
• lymphangitis,
• spread beneath the superf. fascia,
• deep tissue abscess,
• gangrene,
• involvement of muscle, tendons, joint, bone
 Severe
infection: infection in a pt. with
systemic toxicity or metabolic instability:
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fever, chills,
tachycardia,
hypotension,
confusion,
leukocytosis,
acidosis,
severe hyperglycaemia,
azotaemia
 Foot
ischeamia may increase the severity
of any infection
 The
rates of hospitalization and
amputation increase with infection
severity
 The
goals of therapy for patients with diabetic
foot infection are :
• the eradication of clinical evidence of infection
• the avoidance of soft tissue loss and amputations.
 Good
clinical response can be expected in
80%- 90% of mild to moderate infections and in
60%- 80% of severe infections or in cases of
osteomyelitis.
 Relapses occur in 20%- 30% of patients.
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Removal of non-viable tissue and surrounding
callus to eliminate a sourse of bacterial
colonization in the underlying tissue
Properly done, allows full assessment of the extent
and depth of ulceration and tissue necrosis
Adequate debridement must precede the
application of topical wound-healing agents, and
dressings.
 Debridement
on a regular basis is thought to
improve the rate of wound healing
 Failure of the treating clinician to adequately
debride a wound:
 - lack of training,
 - lack of knowledge ,
 - lack of time,
is a frequent cause of healing failure.
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The need for surgery must be carefully considered
early in the evaluation process
Mild infections- surgery unlikely
Severe infections
• excision of necrosis until healthy, bleeding tissues
are encountered
• Pus must be drained
• Joint resection/partial amputation of the foot may be
needed: osteomyelitis, septic arthritis, gangrene.
 Aim-
to stop the progression of infection
 Amputations
to the level of viable soft tissue
and bone
 All
post-surgical pts. require careful podiatric
follow-up and attention to any orthotic or
prosthetic needs.
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Many dressings on the market:
• Hydrogels- dry to minor draining wounds
• Hydrocolloids- moderate draining wounds
• Polyurethane foams- superabsorbent
• Calcium alginates- heavy exudative wounds
• Collagen dressings- heavily draining wounds
• Antimicrobial dressings (silver, iodine)
• Skin replacements
• Vacuum-assisted closure dressings- negative
pressure wound therapy
 To
facilitate healing:
• Should prevent desiccation
• Absorb excess fluid
• Protect the wound from contamination and
trauma
 The
type of the dressings selected
depends upon:
• Wound’s size
• Depth
• Location
• Surface characteristics
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PM, 69 years old, Vetrisoaia-Husi, DM-type I-for 34
years
Emergent hospital admission- april 2004
Dg.- severe sepsis, plantar necrotizing fasciitis
Referred from another hospital, where he refused
amputation.
1 week history of acute inflammatory signs around an
old foot ulcer
Surgical treatment- limited plantar incisions- extended
infection+systemic complications.
 On
admission: fever,chills, confused, pale,
poor urinary output but cardio-vascular
stable
 Local examination:
• 2 plantar incissions and retromaleolar, foul smelling
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secretions, necrotic subcut. tissues
Above knee cellulitis
Edema of the thigh and external genitalia organs
Inguinal lymphadenopathy
Peripheral pulses, present but weak
 Severe
septis:
• WBC=33200/mmc
• Sec. anemia, Hb=8,2g/dl., Ht=25%
• Hyperpgycemia-256mg/dl
• Renal failure-urinary output<50ml./h.
• Urea=76mg/dl, creatinine=1,13mg/dl
• Hyponatremia=129mEq/l
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Correction of deficits
Antibiotherapy iv- quinolone+flagyl
G-stained smear of specimen=+/-G cocci.
Emergent surgical treatment under iv GA:
• Enlargement of previous incisions
• Debridements till muscular layer
Cultures of necrotic tissue- enteroccocus
Persistent fever and high WBC- infectionistimipeneme 4g/day, 10 days
 Repeated
surgical debridements
 After 3 weeks- clean wounds, granulating
tissue
 But, large soft-tissue loss at the sole
 After 1 month- repeated skin grafting
 After 1 month-plastic surgeon- cross-leg to
cover the calcanean region defect
 After 3 weeks-separation of the cross-leg
 Hospital
stay- 4 months and 3 weeks
 Large amounts of dressings
 Time-consumer treatment
 Costly treatment
 BUT, the leg was saved and the patient
can walk and work in agriculture.