Prevention of Limb amputation as a result of a multidisciplinary treatment approach

Introduction: A multidisciplinary treatment approach to the care of extensive lower extremity vascular wounds has proven to show favorable outcomes in the Long term acute care hospital (LTACH) setting.  There is limited documentation in the literature as it relates to this clinical issue in LTACHs.

Clinical Problem: A patient with an extensive medical history of smoking, peripheral vascular disease and painful claudication underwent bifemoral bypass. The patient’s  recovery was complicated by a thrombus for which a thrombectomy was done but there were already signs of necrosis. Further medical complications of renal failure, anemia, multiple wound infections and other skin breakdown  occurred prior to admission to the long term acute care hospital.

The patient had several lower extremity vascular wounds in various stages of healing from full thickness necrosis, visible bone/tendon and partially granulating.  The patient had considerable lower extremity edema that impeded healing. Initial dressing changes were painful and anxiety and depression were barriers to proper care.

Clinical Approach: A multidisciplinary management process consisted of  surgical debridement, Hyperbaric oxygen therapy, Pulsatile Lavage  for mechanical debridement by physical therapy, pain management, nutritional counseling for oral and parenteral nutrition, and psychology  interventions for counseling and support of the patient and spouse. Treatment also included chemical debridement of necrotic tissue, specialized support surface, pressure relief and frequent repositioning.  When the wounds were beginning to granulate a Negative Pressure Wound Treatment was applied. The wound care team evaluated the patient weekly to monitor progress, modify the treatment plan and for education of staff and patient.

Patient Outcomes; All but  one wound healed avoiding the need for bilateral above knee amputation. The patient returned home, is ambulating and continues to have followup in an outpatient wound care center.

Conclusion: Superior outcomes were achieved because of the multidisciplinary treatment approach and advanced wound care modalities.