•A 58 years old male presenting to A&E with fever and general unwellness. His wife describes that he has been having worsening Rt foot pain for the last 3 days and started to become smelly on the day before.
•PMHx
DM-II on insulin, HTN, IHD
•Physical Examination
Wet necrosis of the Right foot as shown in the picture.
Difficult to feel any pedal pulses in the foot because of tissue edema but good signals with hand held doppler over DPA can be heard
•Blood Tests
Hb 89 g/dl, WBC 18 x 109/L, CRP 220 mg/dl
•Questions:
1.Discuss the steps of your immediate management plan
2. Discuss your long term management plan.
A1-Short term management
full labs
duplex u/s
urgent debridement
if he is ischemic revascularization and 2nd definitive surgical debridement
A2-Long term management
Blood glucose control
Offloading
Foot care
A1 i will manage the patient according to ccrisp protocol
maintain airway and breathing by o2 mask
insert 2 large bore cannula and start fluid resusitation
start iv broad antibiotics
measure lactate level and ABG and cbc -glucose level
withdraw blood culture
xray foot and ABI
monitor uop and patient vitals
immediate debridment for wound
A2 long term assessment
endocrine consultation and Bp and DM control
heel off loading
foot care and dressing
duplex asessment and ABI
monitor patient inflammtory markers and wound
may need 2nd intervention
1-A-Arterial Duplex with or without cat if angioplasty decided + kidney function Tests + x-ray foot
B-Resuscitation, good hydration, tight control of blood sugar, start antibiotics, blood Reservation can give one unit pre operative ( before urgent debriement than arrange for angioplasty guided normal kidney function normal)
2-Cta (aorta + both Lowe limbs) guided normal kidney function or Co2 angioplasty if impaired function
+ Follow lab tests
admission for monitoring of his vitals & further assessment including xray. of the foot with culture & sensitivity
Patient. is need for urgent debridement & drainage of involved foot compartment
Broad antibiotic coverage adjusted. To C and S
tight glycemic control
Follow up crop and cbc after debridement
patient needs long term management including daily dressing, antibiotic which could extend to 4-6 weeks if associated with osteomyelitis
patients needs adequate monitoring of blood glucose level and follow up of HBA1C
Q1:
immediate manegment : general examination for the patient( vital data,blood sugar level/)
look for any signs of DKA, resuscitation
local exam : check for crepitation and WIFI staging
investig: order foot x-ray , renal functions ,ABG, input &output
urgent debridement is needed as for primary relief and control of sepsis
long term:
internal medicine consultation.and HBA1C
arterial duplex
good care for dressing
may need proper debridement according to dressing and xray
1_ immediately obtain vital data of the patient and start resuscitation by working on 2 axices : A-Hyperglycemia and its complications lika DKA ordering RBG, ABG, internal medicine opinion
B- Infection and its complications like septic shock qSOFA score to determine presence of sepsis, order a cbc INR KFTs albumin, if patient is shocked ICU consultation and immediate fluid resuscitation, broad spectrum iv ABs, O2, blood culture, Foley cath and UOP monitoring
Prepare for immediate debridement after stabilization order an xray and probe to bone before foot surgery,
WIFI class and consent that the patient might need major amputation later if infection is not controlled
Removal of all infected tissues and obtaining tissue and bone cultures
Daily dressing and ABs modification acc to cultures
2- Foot pic shows amputation of the big toe and infection and necrosis of the medial compartment of the foot wih point of entry may be non healed stump of halux, or peneterating ulcer over the head of 1st metatarsal or foreign body brick
So removal of Osteomyelitis is needed
Correction of anemia and malnutrition and control blood glucose level
Vascular assessment to exclude ischeamia and garantee inline straight flow if needed
Woundcare with suitable dressing
Choosing a suitable offloading method
Steps of immediately managing
1 – general exam
Check body temp
Chech heart rate
Check BP
Check glucose level
2- local exam
And wIFI staging
3 -investigation
X-ray
S.creat
4-
Start antibiotics
Prepare for surgical debridement
Prepare for off loading
Glycemic control
————-
Long term management
Debridement
Antibiotics
Off loading
Revascularization in f needed
Follow up with endocrinologist
Follow up with podiatrist
Q1. Immediate management plane should start with resuscitation and good hydration, parenteral broad spectrum Antibiotics .
Intra operative aggressive surgical Depridment up to major amputation after counseling the patient about his life threatening condition.
Q2. Compleat assessment of vascularity of limb by examination and arterial Duplex.
Plane for revascularization if needed as soon as possible.
Daily dressing and good wound care by follow up.
Done
Q2: long term management:
Q1: immediate management
Short term management
Admission up to the ICU and resuscitation with x ray for gas FB or OM would be helpful, urgent debridement at the same night because the patient is in sepsis regarding his gen condition and labs along with broad spectrum antibiotics until c/s from the wound results
Complete the vascular examination with duplex if he is ischemic so revascularization and 2nd definitive surgical debridement after stabilization
Long term management
Bl glucose control
Nutrition
Rehabilitation
Offloading
Vascular follow up
Bl pressure control and other comorbidities management
Foot care
Thank you for highlighting that the patient may need 2nd more definitive surgery, the 1st intervention is always a damage control surgery to control the sepsis.
Q1 regarding immediate management plan, my goal is to stabilize the patient and the surgical intervention
>> Resuscitation:
careful assessment of the general condition with initiation of intravenous fluid therapy to maintain hemodynamic stability.
>> Antibiotics:
broad-spectrum parentral antibiotics immediately ( depending on local guidelines).
>> Workup:
Full lab investigations, and foot x-ray/MRI
arterial duplex to check the state of limb vascularity
blood and wound cultures before starting antibiotics to guide therapy.
>> Surgical Intervention:
must be ASAP surgical debridement or amputation according to the extension of necrosis and infection.
* check for Sepsis:
monitor vital signs, urine output, lactate, and clinical signs to assess for septic shock.
Consider possibility of ICU admission if hemodynamically unstable.
Q2 my long term management plan will focus on preventing recurrence and patient rehab
>> Wound care:
post debridement including dressings and infection control measures.
>> Multidisciplinary team:
Involve endocrinology, internal medicine to strictly control blood sugar levels.
For patients requiring amputation, referral for physiotherapist and prosthesis specialist.
>> Education and rehabilitation:
counselling on proper foot care, regular foot inspections, and early detection of issues to prevent future complications
Physical therapy and occupational therapy to improve mobility post-surgery.
Well done Dr Muhammad.
1.Discuss the steps of your immediate management plan
ADMISSION OF THE PATIENT
ASSESSMENT OF HIS VITALS:
– is he feverish or not
– Bp: is his HTN controlled or not, on what anti hypertensive medications, hypotension suggests septic shock
– HR can be elevated in case of hypotension and hyperthermia
– RR & RBS
RESUCITATION if needed by IV fluids and empirical IV antibiotics
HISTORY TAKING
If he is on metformin along with insulin, it should be stopped 24 hours before using contrast – either for angiography or angioplasty – for fear of lactic acidosis
LABS:
he already has cbc and crp
Urea, creat, Na, K, VBG, PT, PTT, INR, RBS, HbA1c, acetone in urine, virology, lipid profile, CK-MB, troponin, albumin, blood culture
IMAGING:
– ECG & ECHO (pt gave hx of IHD)
– Foot x ray and MRI if foot x ray suggests osteomyelitis
– ABPI and toe pressure
– Arterial Duplex US
– CT angiopgraphy
CONSULTATIONS:
– Anesthesia consultation
– Cardiology consultation for HTN control and IHD
– Internal medicine consultation for glycemic control
– ICU bed in case of septic shock or active cardiac condition
– Microbiologist consultation regarding the empirical broad spectrum antibiotics according to hospital protocol waiting for the definitive antibiotics after culture and sensitivity
INTERVENTION:
– Pt is for urgent debridement and drainage for fear of sepsis with culture and sensitivity and bone biopsy for culture and histological examination for osteomyelitis
– Angioplasty for any stenotic lesion as soon as debridement is done to ensure good blood flow to the wound and good healing preventing wound ischemia
POST OPERATIVE CARE:
– Daily dressing by H2O2 and glycerine manesia or iruxol (plus daily wound photograph for follow up of wound status). Also adequate daily bedside debridement if needed
– Empirical antibiotics
– analgesics, anti inflammatory, anti platelets, statins, sliding scale of insulin
– Good glycemic control by endocrinologist (RBS every 6 hours with sliding scale of insulin)
– Nutritionist consultation for diet control
– Neurology consultation for assessment of neuropathy and possible treatment
– Good hydration ( 500 cc normal saline / 8 hours) and follow up urine output and kidney functions
– Daily follow up of CBC(TLC) & CRP
I will not offer the patient blood transfusion over 8.9 Hb (which is not bad) to avoid the the unneeded risks of Blood Transfusion
Also I will not offer vac therapy except after full debridement of necrotic tissue and full drainage of pus and the wound become clean after at least one week of daily dressings
2. Discuss your long term management plan.
– Offloading
– Foot care
– Plastic surgery consultation
– Proper glycemic control
Thank you Dr Muhammad, very systematic, I liked your answer.
two points:
-Is cardiology/ECHO indicated for every patient with IHD before any surgery?
-Are you aware of any evidence that support VAC dressing over the standard dressing?
These questions are for you to search to enrich your knowledge and then to apply on your patients.
1- admission and management of patient according to CCRISP protocol and SEPSIS -6 starting broad-spectrum antibiotics and resuscitation fluids together with liaising with an endocrinologist for glycemic control and requesting laboratory investigations like Rft, and electrolytes and foot xray then liaising with the anesthesia team about the urgent debridement to remove all necrotic tissues up gluten amputation to irradicate infected tissues and sending tissue and bone cultures
2-long term management includes strict glycemic control with foot offloading and regular follow-up for the wound status and regular wound dressing to prevent deterioration of the wound
Thank you for your answer.
Immediate Management Plan:
1. Urgent Surgical Intervention:
Debridement: Immediate surgical debridement is crucial to remove all necrotic tissue and infected material. This will help to control the infection and prevent further tissue damage. Amputation: If the extent of tissue damage is severe and irreversible, amputation may be necessary to save the patient’s life and prevent further complications.
2. Antibiotic Therapy:
Broad-spectrum antibiotics: Initiate broad-spectrum intravenous antibiotics to cover a wide range of potential pathogens, including both aerobic and anaerobic bacteria. Antibiotic selection: The specific choice of antibiotics should be based on local antibiotic susceptibility patterns and the patient’s clinical condition.
3. Pain Management:
Opioid analgesics: Administer strong opioid analgesics to control severe pain associated with the wound and surgical procedure. Non-opioid analgesics: Combine opioid analgesics with non-opioid analgesics like paracetamol or NSAIDs to provide additional pain relief.
4. Fluid Resuscitation:
Intravenous fluids: Monitor the patient’s fluid status and administer intravenous fluids to correct any fluid deficits.
5. Blood Transfusion:
Packed red blood cells: If the patient is anemic, consider blood transfusion to improve oxygen delivery to tissues.
Long-Term Management:
1. Wound Care:
Regular debridement: Continue regular debridement to remove necrotic tissue and promote wound healing. Negative pressure wound therapy: Consider using negative pressure wound therapy to accelerate wound healing and reduce infection risk. Skin grafts or flaps: If necessary, perform skin grafts or flaps to cover the wound and promote healing.
2. Infection Control:
Antibiotic therapy: Continue antibiotic therapy as needed, adjusting the regimen based on culture and sensitivity results. Strict aseptic technique: Maintain strict aseptic technique during wound care to prevent further infection.
3. Diabetes Management:
Intensive glycemic control: Optimize the patient’s diabetes management to improve blood sugar control and promote wound healing. Regular monitoring: Monitor blood glucose levels closely and adjust insulin therapy as needed.
4. Vascular Assessment:
Vascular consultation: Consult with a vascular surgeon to assess the patient’s peripheral vascular disease and consider revascularization procedures if appropriate.
5. Psychological Support:
Counseling: Provide psychological support to help the patient cope with the physical and emotional impact of the amputation or significant wound.
6. Rehabilitation:
Physical therapy: Initiate physical therapy to help the patient regain mobility and function, including prosthetic fitting and training if necessary.
7. Long-term Follow-up:
Regular wound care: Schedule regular follow-up appointments to monitor wound healing and address any complications. Diabetes management: Continue to monitor and manage the patient’s diabetes. Vascular surveillance: Monitor the patient’s peripheral vascular disease and consider additional interventions as needed
Despite the illustrative answer, I liked your answer in Q2. In Q1 I would like to know the order of steps of your management, definitely resuscitation once you see the patient with High flow O2, Securing 2 wire bore cannula, starting IV fluid after taking VBG and blood culture, starting IV broad spectrum Ab and urinary catheter to assess the UOP all come first before any plan for surgical intervention.
1_ immediately obtain vital data of the patient and start resuscitation by working on 2 axices : A-Hyperglycemia and its complications lika DKA ordering RBG, ABG, internal medicine opinion
B- Infection and its complications like septic shock qSOFA score to determine presence of sepsis, order a cbc INR KFTs albumin, if patient is shocked ICU consultation and immediate fluid resuscitation, broad spectrum iv ABs, O2, blood culture, Foley cath and UOP monitoring
Prepare for immediate debridement after stabilization order an xray and probe to bone before foot surgery,
WIFI class and consent that the patient might need major amputation later if infection is not controlled
Removal of all infected tissues and obtaining tissue and bone cultures
Daily dressing and ABs modification acc to cultures
2- Foot pic shows amputation of the big toe and infection and necrosis of the medial compartment of the foot wih point of entry may be non healed stump of halux, or peneterating ulcer over the head of 1st metatarsal or foreign body brick
So removal of Osteomyelitis is needed
Correction of anemia and malnutrition and control blood glucose level
Vascular assessment to exclude ischeamia and garantee inline straight flow if needed
Woundcare with suitable dressing
Choosing a suitable offloading method
Thank you Dr Anas for the illustrative answer, you mentioned all measures of sepsis 6 in 1.
Most of surgeons are not familiar with qSOFA score, however it is important to pick up on initial assessment if multiple organs are affected e.g circulatory (low BP), Kidney (AKI), immune system with raised inflamatory marker, respiratory if associated peumonia.. that indicates that this patient needs management in level 2 care (ICU), therefore ICU doctor assessment at the same time during the surgical assessment is needed.
Q1 after history taking and examination is pt shocked or not?, and i will go for sepsis six as immediate measurment , reserve and consult for giving pRBC as pt is ihd with hgb <10
Consult with anasthesia and itu units
Foot x-ray, arterial duplex "is pta patent? as it's an angiotome for pta"
Consenting pt if comptent and counsel him with relative about need for debridment and possibilities of need of foot level amputation or even highee level major ll amputation on 1 or 2 sessions
Q2 rehabilitation with risk factor modification
Thank you for mentioning sepsis 6 in Q1.
Q2 answer need to be expanded a bit e.g foot wear for offloading, glycemic control.. etc
1 after full history and examination and
ABI
Investigations as
laboratory CBC , INR , s.creat
X Ray
Arterial duplex
Prepare pt for Urgent debridement
Wound culture and give emperical antibiotics and other medications according to pt state
2 wound care
Offloading
Asses for revascularization possibility
Good diabetic control
Thank you Dr Mostafa, all sepsis 6 measures need to be in place in Q1. Please revise sepsis 6 protocol.
1.Discuss the steps of your immediate management plan
as full lab done, TLC: 18000, CRP: 220, I will recommend
2. Discuss your long-term management plan.
Dr Abdullah for your answer, it needs some clarification in some area, would give oral or IV Ab, what about IV fluids. I would recommend that you revise something called Sepsis 6 protocol for management of diabetic foot sepsis.
Q1: This patient is presented with RT diabetic foot infection with signs of sepsis (SIRS).
For hospital admission, fluid resuscitation and IV broad spectrum antibiotics.
Wound swab for culture and sensitivity tests.
Hyperglycemia control, plain X-ray of RT foot,
Incision and drainage of Diabetic foot abscess collection.
Follow-up ABPI after intervention and arterial duplex U/S if less than 0.7
Follow-up spesis by CBC and CRP.
Q2: Long term manangement plan needs a multi-disciplinary team :
Microbiologist for screening of the result of culture and sensitivity test for antibiotics modification.
Shifting IV antibiotics to oral in outpatient clinic.
Assess vascularity, offloading for ulcer to heal.
Diabetolgist for hyperglycemia control.
Orthosist for special diabetic foot shoes.
Podiatrist for good care of foot hygiene.
Nutritionist for proper diet.
Thank you Dr Ahmed for the systematic approach, however I do not think incision and drainage alone is enough in this case, removal of all infected/dead tissues in indicated. Damage control surgery is usually the aim in the emergency setting, drain the pus, remove all evident infected and dead tissue, leave the borderline tissue for second look after control of sepsis.
Q1: this patient considered to have SIRS so i will admit the patient for resuscitation and iv antibiotics and glycemic control accordingly
i will ask for x-ray foot and leg to asses the bone condition and extension of the infection
doing ABI to asses the vascularity of the limb and if below 0.5 i will go for duplex assessment
then surgical debridement to eradicate the source of sepsis and follow up of his sepsis markers
Q2: after aggressive surgical debridement and checking the vascularity and revascularization if it was ischemic
multidisciplinary team of diabetiologist for controlling of the patient glycemic level and dietitian for balanced high protein diet for wound healing
good wound care as dressing accordingly and offloading
education of the patient about the problem that happened because of the bad control of the diabetes and with good control we could avoid such complications and its recurrance
Thank you Dr Malek for your answer, focused and concise.
Q1 At first this is diabetic foot infection with fever and high white blood cell count and high CRP which indicates that it is sever infection
At first this patient needs to be admitted to the hospital
Then I will arrange for immediate drainage and debridment of mid and medial planter spaces
Once the patient is admitted I will start iv emperical anti biotics and IV fluids and anti pyretics
I will ask for urgent x ray for the foot before OR transfer to know the state of bone is there osteomyelitis or no, is there any forigne body or no
Then in the operating room I will do debridment and drainage of all necrotic tissues then I will take tissue culture from the ulcer base
After edema resolves we have to check the peripheral pulses again if still not present we should measure toe pressure to determine if this patient will need revascularization or not
Q2
After appearance of culture result I will switch to the sensitive antibiotic in the culture for 2 to 4 weeks and the patient will be discharged after normalization of vital signs and labs for follow up in the out patient clinic
Of course he will need to continu on anti biotics oral course may be for another 2 to 3 weeks
I will offer the patient variable dressing options according to his wound state also with this big necrotic tissues there will be expected large raw cavitary area and I think vac therapy will have a beneficial role in this case if it is available
Offloading is very important to allow ulcer healing in short course
Of course other specialists are important in such case
The diabetologist role is very important to control the pt blood sugar level
The orthosist role is also important as I think this patient will need special shoes with custom made insole
After healing of ulcer the patient must follow up with podiatrist to be educated how to exam his foot and how to care about it tp prevent future recurrence of foot infection
Well said dr Mahdy. Nice aproach.
Questions:
1.Discuss the steps of your immediate management plan
Admission+ resuscitation + full lab especially hga1c level urine analysis + x ray assessment and consultation of endocrinology for tight blood sugar control
+rapid cardiac assessment by cardiologist+culture and sensitivity
Duplex us to exclude pad
Start parenteral ab immediately
Uregent surgical debridement after anathesia consultation to eliminate sources of infection
IN case of pad preparation for PTA Vs surgery according to duplex us results and assessment for CTA if needed
2. Discuss your long term management plan
.PT education about his condition and foot care
Tight blood sugar control
Tight Wound care
Antibiotics according to culture
Plastic surgery consult for wound closure after complete subsidence of infection
Thank you dr Abdelraheem for the comprehensive answer, why due you think the patient needs cardiology assessmnet, is the history of previous IHD indicates cardiology assessment.
Also, what if you do not have doppler in the middle of the night and the patient presented with sepsis. Will wait for vascular imaging on the next day or will you proceed with surgery.
Here in our locality is mainly for medicolegal issues we ordered rapid assessment echo and Doppler us
+These investigation already available if needed with no delay
This why it looks like we abusing echo and duplex us