Hi Nora

Thanks for your question. Cases like those are sometimes not that straightforward to treat. Cathy and I talked today about this case, she mentioned she has already shared her suggestions with you. Below are some additional complementary thoughts (Scott Robinson's, Cathy's and mine)

Assessment [1]:
- This is a complex VLU due to infection. Consider reassessing blood supply to the ulcer to determine if it's a mixed arterial venous ulcer. Regarding the ABI being normal: since the patient has type 2 diabetes, ABI may be falsely elevated - it'd be important to have another form of noninvasive arterial test done (TP, TBI, continuous doppler wave ultrasound, transcutaneous oximetry (TcPO2) or skin pressure perfusion (SPP)) [2]
- Is this ulcer considered healable? If patient has any of the conditions that impede wound healing below, consider a maintenance-healing program until element impeding healing is eliminated
> Co-morbidities: Uncontrolled diabetes, Immunosuppression, Obesity: BMI > 40?, Inadequate nutrition (abnormal serum protein, unintended weight loss), Cognitive, emotional, psychological dysfunction, Calf muscle pump dysfunction (arthritic conditions, paralysis, etc)
> Drugs and interventions : Steroids, Chemotherapy/ radiation
> Lifestyle: Regular smoking, Impaired mobility, Financial or resource constraints Patient has history of pseudomonas pneumonia - patient may still have systemic infection. Does the patient have any signs of spreading or systemic infection?

Management [3][4]:
- Treat the cause: Mitigate/ eliminate any factors impeding healing, Compression therapy, leg elevation
- Infection management: culture guided IV antibiotics seem indicated in this case. One option is to admit patient to initiate IV therapy and optimize care, then continue on with outpatient IV therapy or switch to oral
- Local wound care:
> Cleanse wound: may use acetic acid solution <2%, which is effective against Pseudomonas (soak gauze and leave it on for 10 min, then cleanse)
> Perform debridement: scrub off necrotic tissue and debris with monofilament fiber pads [may apply topical anesthetic (e.g emla) before hand]
> Periwound skin care: protect periwound from exudate with barrier products
> Apply dressing: dressing with antimicrobial activity (e.g. alginate, with silver and maltodextrin such as Algidex Ag paste, cover paste with secondary dressing )
> Apply compression: apply compression after 24 hours of systemic antibiotics and if afebrile, assuming no other contraindication. Consider reducing level of compression if difficult to tolerate. Follow up in 24 hours. Inspect dressing more frequently to monitor infection. Assuming adequate blood supply to the ulcer, consider starting with multi-component bandages if patient ambulates (2 or 4 layers, eg. Profore, Profore Lite). Other options are inelastic bandages (short stretch, Unna boot), 2 layer gradient compression stockings.  If patient does not ambulate, consider elastic bandages (long stretch, e.g. Shur band; tubular dressing, e.g. Tubigrip). Another helpful element is to utilize Intermittent Sequential Pneumatic Compression in addition to the aforementioned compression bandages, especially if the patient does not ambulate
> Monitor infection and VLU for signs of improvement. 


[1] https://woundreference.com/files/1532.pdf[
2] https://woundreference.com/app/topic?id=how-to-select-compression-therapy#based-on-audible-handheld-doppler-ultrasound-or-continuous-waveform-analysis
[3] https://woundreference.com/files/1590.pdf
[4] https://www.woundinfection-institute.com/wp-content/uploads/2017/03/IWII-Wound-infection-in-clinical-practice.pdf

In addition to the great suggestions above, I'll add one other 'trick' for these types of wounds/ulcers. I have used the dilute acetic acid solution to great effect, however, you might consider also giving the patient a prescription for gentamicin ophthalmic solution (or otic solution ... either will work). With each dressing change, and right before applying the dressings, put several drops of this solution and make sure that it is spread (Q-tip or equivalent) to cover the entirety of the wounds.

If your clinic/hospital is the same as the ones I practiced in ... you'll need the patient to bring the bottle with him to every clinic visit. I know, I know ... we aren't supposed to do that. But, difficult times requires difficult solutions.

gene

thank you very much for all of the information. Looks like I have no way to obtain Acetic Acid <2% here at my facility so will be looking into the gentamicin ophthalmic solution to use instead - just confirming this is indicated for use on venous wounds specifically with pseudomonas infection?

In some facilities, acetic acid solution is prepared by diluting white vinegar (which is 5% acetic acid) with sterile water. For 250 ml of 1% acetic acid solution, add 50ml of Solution of Acetic Acid 5% (white vinegar) to 200 ml of sterile water.
See interesting article: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5868106/

Nora: Absolutely not indicated … this is off-label use of the gentamicin drops. However, there is very good basis in science to use medications off-label.

So, your providers will need to make that decision. However, there isn’t any downside to doing it … from my opinion.

Apologies to keep this conversation going. I'm not sure how potentially serious this situation is so just looking for any suggestions you may have. This patient was d/c'd from acute care last Friday (with plans to follow up with PCP and vascular) and came back to ED on Sunday and was re-admitted for increased SOB, fever, and increased pain in his wounds. Pseudomonas infection in ulcer looks better. However patient's pain to wound is significant, seems unproportioned to wound (no other signs though of nec fac?). I have attached updated photo. X-ray was done which showed no osseous abnormalities (MRI was not done), and advanced vascular calcifications. I have strongly recommended this patient go to the vascular services and outpatient wound clinic that is about 45 minutes away from us as they have the means to do a thorough work up and treat this patient and his wounds, and can take him quickly. Since we do not have vascular department or ID here, it's difficult to know what else to do for him. Emla cream is no relief to pain in wounds. Patient calls it burning pain. ID from another hospital was consulted over the phone and they suggested continuing with antibiotic course, as wound culture isn't as informative as a tissue biopsy would be, which has not been done. I have stopped using the acetic acid 1% as of now, last used it on the wound last Friday.

No worries about keeping the thread going! We will try to help you in your decision making ... even though difficult from a distance.

1. Not sure from this response if you are also using the gentamicin drops.
2. Regardless of the answer to #1, I think the ulcer is much improved from the first picture you sent.
3. Let's disregard the pain for now, I'm not sure why you stopped the Acetic acid. It does not cause this type of pain any more than saline wash. It has a topical static control of superficial pseudomonas.
4. I'm looking for resolution of edema, and I know that you said severe PVD, but most of these patients tolerate at least a firm double layer of Tubigrips. I would try a 3M (or your favorite brand) double layer wrap and replace it 3 times per week until you have control of the edema, see advancing skin margins, and good granulation. (You would also have a good argument not to do this ... fine ... your choice.)
5. The pain sounds more neuropathic, especially since it doesn't respond to EMLA or other topical. And, the patient describes it as a burning pain ... pretty typical for neuropathic pain. The only other pain would be end stage vascular disease, in which the pain is much worse in an extremity at heart level and much better when dangling dependent.
6. This (unfortunately) is what I call a banana peel patient ... he is going downhill clinically ... in a hurry. The wound seems the least of his problems. (I don't mean this disrespectfully at all.)

Thanks for the feedback!!

gene