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Please help - Wound with severe fluid output and maceration

Discussion in 'Diabetic Foot & Wound Management' started by RStone, Aug 3, 2011.

  1. RStone

    RStone Active Member

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    Hi All

    I need some advice in regards to a resident of an Aged Care Facility - the EEN sent me an email late this afternoon as they are at a complete loss of what to do.

    Briefly the situation is as follows:

    - patient has severe oedema in both legs
    - right leg has several lesions (medial malleolus, heel) that are leaking LOTS of fluid - about 1 drop every 2 seconds like a dripping tap
    - on the advice of a senior medical officer in the Emergency Dept at the Royal Brisbane and Women's Hospital they are currently applying Idosorb paste, melolin, DryMax, Ziploc's and Tubigrip.
    - the GP has the patient on 80mg Lasix mane and a Norspan patch and Ibilex antibiotics for cellulitis
    - tis situation has worsened significantly in last 4 weeks with the patient now ulcerating in the affected areas (I don't have any details in regards to wound size or appearance but I suspect a lot of this will be due to heavily macerated skin under pressure)

    - this resident has severe dementia

    I'm not due to visit this facility for another 3 weeks but I'm trying to fit in a flying visit one night to conduct and ABI to determine arterial supply - if no impairment than we can increase the compression therapy. However this resident is really resistant to sitting or lying with feet elevated for any longer than 5 minutes - he is much happier sitting with feet down or walking. This may be due to the dementia or it may indicate pain or discomfort in which case arterial impairment may be a factor.

    I know there's a lot of information missing - I'm going to ring the EEN tomorrow for more information in regards to wound size, appearance, other medications, fluid intake/output, heart/kidney condition etc but if anyone has any information on how to help with the maceration and fluid output I would loev your input

    Thank you in advance
  2. W J Liggins

    W J Liggins Well-Known Member

    Given your description and the dosage of furosemide, I would guess that the pt. suffers from chronic heart failure or at the least, recalcitrant and severe oedema. If this is the case, then unfortunately the outlook is not positive. That being the case the best bet is to treat symptomatically and keep her as comfortable as possible. I suspect that no particular dressing will be a great deal better than any other, so the SMO's advice seems good. Plenty of gauze and regular and frequent dressing changes will help.

    All the best

    Bill Liggins
  3. Erp

    Erp Member

    Clearly this patient's medical management needs to be improved and without a complete history, it is hard to conclude what the underlying cause of the exudate may be. A patient of ours recently had severe oedema when going into end stage renal failure so his legs blew up like balloons.
    Once he started dialysis, they went down significantly within 10 days.

    Iodosorb will not work with heavy exudate as it will just wash off.
    I would suggest a highly absorbant silver dressing such as Aquacel Ag Rope (cost permitting) with a secondary dressing of Biatain or Allevyn. This will likely need daily dressing changes.

    It sounds like he needs a comprehensive management program and may need an admission to sort it out.

    Good luck!

    The Alfred Podiatry Service
  4. RStone

    RStone Active Member


    Thanks for the responses so far. I was able to gather some more information today although it is second hand.

    The wounds are quite small and "slightly deeper than surface". Wound bed is pink. Surrounding skin is heavily macerated and wound is sometimes sloughy.

    There seems to be some issues between the nurses and the GP so I rang the GP direct for a medical history:

    - 90 year old male with severe dementia
    - severe peripheral vascular disease with significant arterial impairment
    - hypertension
    - mild kidney problems ("what you'd expect with a 90 yo")
    - severe osteoarthritis in knees and feet
    - probable prostate cancer

    The GP's comment is "what do you expect to achieve at this age with these problems". The nurses would like a hospital admission and assessment by a vascular surgeon (which means hospitals 2.5 hours away) but the GP has pretty much said no.

    Personally I don't think a vascular surgeon is going to do anything and the upheaval could be more detrimental. I'm getting the impression the wound is only there due to pressure on macerated skin. Compression therapy is going to be limited due to vascular status. The nurses think they're getting improvement by leaving the leg undressed at night which seems to be letting most of the foot dry out except around the medial malleolus.

    The main aim that I can see at this point is to absorb as much fluid as possible to keep the skin dry and improve integrity to reduce the risk of ulceration and further pain etc. The patient may be old but I'd rather they live out their last years with as much mobility/independence as possible and as little pain and indignity as we can reasonably manage.

    I do agree that foam such as allevyn would be good in combination with the highly absorbent silver dressing like Aquacel rope - I think cost may be a deterrent but I'm going to strongly suggest it in regards to preventing more costly treatments later with poorer outcomes.

    Thanks for the feedback - it's helpful to be able to ask when cases get complicated.

  5. W J Liggins

    W J Liggins Well-Known Member

    Sorry that I got the incorrect gender. You did say the Royal Brisbane and Women's Hospital. - PC I suppose.

    All the best

  6. footsteps2

    footsteps2 Active Member

    Thats the way that I would go with dressings too but as previous poster said until lymphodeama controlled it will be hard to heal any wound with Hydrofiber dressings...I don't use Iodosorb for sloughy or exudating wounds. Allevyn is a good secondary dressing with Combine layers over that. Aquacel AG rope great is wound has a cavity or even Curasalt, otherwise Aquacel AG..
  7. dannytso

    dannytso Welcome New Poster

    Hi, this is my first post on this site and would like to contribute any helpful information based on my own academic and clinical experience. I am a Certified Pedorthist.

    As I am not a medical doctor and cannot contribute to discussions regarding global pathology, my contributions will be within my Pedorthic Scope of Practice and nothing else. I may make comments that may contradict certain treatment outcomes so I am open to any constructive criticism for future reference/posts. I noticed that no one has made any suggestions which address the mechanics of the foot so if there is a medically legitimate reason why, I am happy to back down :).

    In general, my focus would be
    1.)to remove any sources of pressure on ulcerations,
    2.)improve any antalgic or cautious gait (as I suspect due to age and mental illness) as this may also be leading to increased pressure in the ulcerated regions,

    therefore at least attempting to improve the overall quality of life.

    You have mentioned the presence of ulcerations at the medial malleolus and heel. My approach would be to identify sources of pressure on these which and refer to the correct professional to minimize these forces.

    Because this patient feels more comfortable walking rather than sitting, every attempt should be made to minimize these weight bearing forces.

    A.)I would assess the patients footwear to ensure it is appropriate fit and function based on their foot mechanics. If the patient is pronated leading to sheer pressure of the medial malleolus against the patients shoe (if one is worn), than standard diabetic footwear with a soft leather upper and lined with plastezote interior lining will be my first suggestion. Seamless interior is a MUST to minimize chance of micro lesions. Hindfoot and forefoot rocker will reduce pressure at any one point of the foot throughout the gait cycle. A wide base of support (or a straight last) may help with improving medial/lateral balance.

    B.)The ulceration at the heel should be accommodated for either through direct cushion, or in my opinion, a full contact accommodative foot orthosis (if justified by full biomechanical assessment) lined with a thicker plastezote top cover may provide much benefit to redistribute pressure across the foot and decrease forces at the heel. Sweet spot as necessary. A secondary benefit is prevention of future ulcerations. As soft accommodative orthotics tend to pack down overtime, regular follow up is required to assess the function of the orthotic and to update as necessary.

    In my experience, another common protocol to treat diabetic ulceration through the use a walker boot to completely stabilize the foot (as what would be done if theres presence of a fracture.) Medial lateral cushioning is usually provided and also a cushioned plantar platform. These usually are equipped with aggressive HF and FF rockers. The accommodative orthotic may be integrated into this system as well. Ossur carries a great walker boot where the plantar pad has removable hexagons to directly relieve pressure under any ulcer. You may wish to consider this.

    http://orthotape.com/plantar_ulcers_Offloading_Walker.asp [I am not employed or affiliated with this company in any way, just the first site through google search ;) ]

    Whether you use a shoe or a walker boot is really dependent on factors such as the severity of the ulcerations, the amount of bandaging on the foot, and the risk of cultivating bacteria by being confined in a warm and moist environment like a shoe or walker boot.

    I hope the source of this patients problems are adequately resolved. All the best to him.

    Danny Tso, C Ped (C)
  8. RStone

    RStone Active Member

    Hi All

    Really do appreciate the comments.

    Situation as of Tuesday:
    Nursing staff are swapping to Allevyn with combine dressings overlying Allevyn to help soak up fluid. They're looking at the Alginates (they're less familiar with using them) but are staying with the idosorb in the meantime as they feel it is actually sealing the shallow ulcers a little and temporarily stopping the leakage for periods of time(has anyone else experienced this?).

    I've given them some suggestions to avoid pressure on these areas at rest but this gentleman is not wearing footwear at all at moment due amount of oedema and the fact he won't keep them on. None of the ulcers are in weightbearing areas during gait so not so worried there. The other reason for no footwear is that the patient is much more balance when barefoot than in footwear (he has spent most of his life barefoot).

    Of more concern at the moment is the development of a blister on the dorsal aspect of the left 1st MPJ which began at 2 cm and has now progressed to 10cm but still intact. It is creeping down the medial aspect of the foot so becoming difficult to pad around and protect - I haven't seen any photos of this yet but not sure if just a result of oedema or pressure/trauma from somewhere - perhaps during rest.

    Dressings are now occurring 2 x daily instead of every 4-5 hours which is an improvement.

    Will keep posted on developments.

  9. Erp

    Erp Member

    Our vascular surgeons are happy to use 2 layers of firm fitting tubigrip to provide patients with PAD some reduction to their oedema. This is not as compressive as true compression hosiery, but is certainly better than nothing.

    The GP clearly has some ageism going on and I would discuss this with him further as the issue of elder abuse is a hidden and common attitude in modern society.
    Not treating this man the same as someone of a younger age is elder abuse!

    Letting someone rot in a nursing home is not quality of life and if they were related to him, would he have the same attitude?

    Sorry to get on the high horse, but this makes my blood boil.

  10. markjohconley

    markjohconley Well-Known Member

    goodaye robert, richard, rhonda, rex,.....
    the wound care nurse at my work advised trying Zetuvit Plus or similar for super absorption instead of the Allevyn/Biatain, mconley

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