Sepsis 4 weeks after dry needling

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Hi all,
Firstly please allow me to apologise for the long post.
I have a question, I have a patient who came to see me with a large VP on the left foot, lateral arch. This person was in a fair amount of pain and said she needed this dealt with quickly as she needed to attend her daughters wedding in 3 weeks. This lady only takes diuretics p.r.n to deal with the occasional fluid retention. Health wise all fine. A week later I perform the needling under aseptic techniques, bearing in mind this is not the first needling I have performed, as I have a large number of these without issues in the past. Px comes to see me 3 days post needling. No issues apart from some discomfort, which is not unusal. The usual advice is given to the px and is asked to return after eschar has fallen off or if she has an issue. 4 weeks later Px calls me says is in severe pain she had had to attend a&e where doctors Rx'd antibiotics for prophylactic reasons, but couldn't see much wrong. I asked her to come in, she had a large area of dry sloughing, px was in pain but no signs of infection, foot was the same temp and colour as the other foot, she had pain +++, but as this px insisted that she did not want the eschar touched, I suggested she buy some intrasite or similar agent use this daily and see me in a week. A week later she calls back saying she had to go back to a&e where the doctor removed the eschar under l.a. and saif she had a massive infection. She is now attending a&e for dressings. Does anyone have any experience or heard of something similar, as this has never happened to me before??

 

Hi kayron,

Before I post a detailed reply, could you please clarify whether you were needling a suspected HPV lesion, as described originally by Falknor, or were you `dry needling` the area as a form of intramuscular stimulation/acupuncture? These are two very different procedures.

 

Dry needing for verruca plantaris not for intramuscular stimulation

 

Maybe I`m being pedantic, but the difference between `dry needling` and `needling verrucae` (as first described by Falknor) is vast.

So, did you use the multiple puncture technique for verrucae, originally described by Falknor and highlighted by Prof Kirby here on the Arena, or are you utilising an acupuncture technique?

 

The technique used was multiple punctues into the lesion not acupuncture.

 

Right. So, not dry needling then?

You say that on first presentation “this person was in a fair amount of pain”. Was the pain attributed to the VP or previous tx? For example; overuse of SalA, or liquid nitrogen, can cause tissue break-down and a deep seated abscess, which will require AB`s.

Whilst I have not personally experienced post op complications from needling verrucae, infection is a risk that I highlight during the pre-op consultation, as with all minor procedures where penetration of the epidermis is required.

Sounds like you did everything within your power to minimise risk. Just ensure that you documented everything that was said and carried out, in particular the pts refusal for intervention at the 4 week post op appointment.

Cheers,
Bel

 

I haven't seen any infections from all the verrucae needling procedures I have done over the years. In addition, your posting doesn't mention "sepsis" even though you put that in the title of your posting. Did she have a infection of the blood also (i.e. sepsis)? http://en.wikipedia.org/wiki/Sepsis

Here is how I would have handled this patient. First of all, I would see the patient back at two weeks post-needling to debride the eschar. This is important to avoid pain from eschar build-up at the needling site. I would never expect the eschar to "fall off" by itself. This is leaving too much to chance and is the likely reason for the patient's subsequent infection.

Secondly, I would have insisted that the patient have the painful eschar debrided. If she said she didn't want it debrided, then I would tell her that she is inviting a disastrous infection and permanent scarring to her foot by not allowing me to debride the eschar to see what was underneath and then document everything you told her in the chart, preferably with a dictated/transcribed chart note.

In other words, I would read her the riot act and tell her that her refusal to have appropriate medical treatment means that she is acting against medical advice (AMA) and she is taking her foot health and general health in her own hands. Therefore, if her actions cause complications to ensue, it is due to her bad judgement and not due to your lack of appropriate medical care.

Complications can occur from any invasive procedure, including verrucae needling. The key is to know how to handle complications appropriately, decisively and in the standard fashion of your medical community, and then document it legibly in your office chart to protect yourself. Consider this a valuable lesson for your future practice.

Hope this helps.:drinks

 

Thanks for the info guys, BTW has a name finally been decided for this procedure?

 

Yes. It`s called `needling`

 

Sounds as if the patient might have been 'picking' at it herself?

Bill

 

it is a possibilty

 

It's not called "dry needling", since that is something different. "Needling technique" is the term that most people use to describe this procedure.

Also, "sepsis" generally refers to a blood borne infection that causes dramatically increased body temperature, shaking chills and malaise. "Sepsis" isn't a term used for a wound infection, at least here in the United States. Is "sepsis" used to describe simple wound infections in Australia, England, Canada, Spain or elsewhere?

 

Sepsis, in my experience in Oz, is a fairly standard way of describing blood borne infection. If you come and see me and you have sepsis or I am suspicous of it, it's straight to the hospital for you my friend.
In fairness to the OP, she did state that the "the doctor removed the eschar under l.a. and saif she had a massive infection." Sepsis, it could be argued, is a massive infection, but........., leaves a bit for interpretation.

 

Hi Kevin

Have to agree with Deka here. According to Dorland's medical dictionary, sepsis is the presence in the blood or other tissues of pathogenic microorganisms. In the UK, Oz, NZ etc (I'll stand corrected if I'm wrong), the term septicaemia is used to describe systemic disease associated with pathogenic microorganisms in the bloodstream.

All the best

Bill