2016年8月30日 星期二

燙傷藥膏SSD的「清創作用」只是個傳說

安南醫院 游朝慶 醫師

     每當燙傷,不管是炒菜被油噴到、後小腿肚被煙檔管燙到、手臂熱水燙到、不管是一度發紅沒起水泡、或是二度有起水泡,到醫院門診或急診、或是診所、或是藥局,一律拿到的都是所謂燙傷藥膏的SSD,這SSD不是筆記型電腦裡面的固態硬碟(Solid State Disk),而是 Silver sulfadiazine(或Silver sulphadiazine,SSD,磺胺嘧啶銀)。

     在20年前當我還是見實習醫師時,學長跟我們說,『這燙傷藥膏裡面含有銀可殺菌,可軟化痂皮,還有清創(chemical debridement)的作用』1,十幾年來,我也一直對我的患者及我的學生這麼說,但是這十幾年來心裡漸漸浮起一個疑問,這SSD可清創的傳說是真的嗎?

   我以「Silver sulfadiazine」和「debride」為關鍵字去google,結果在灼膚星乳膏1%藥品說明的常用劑量及頻次真的有提到「Apply 1.5-2mm thickness of Cream to cleansed and debrided burn wound, then apply daily or bid.2 一天1-2次塗上1.5-2mm厚度的藥膏以清潔並清創燙傷傷口」,但這cleased及debrided為什麼是用過去式?是拼錯了嗎?  在Flamazine膚美淨軟膏的仿單上是這樣寫著「The burn wound should be cleaned and FLAMAZINE cream applied over all the affected areas to a depth of 3-5 mm. This application is best achieved with a sterile gloved hand and/or sterile spatula.3燙傷傷口應該先被清潔乾淨,再以flamazine 3-5mm的厚度塗在傷口上,可以戴無菌手套的手或壓舌板來操作。  而其他的資料也都是說傷口需要先被清創再使用藥膏。因此剛才塗黃色部分的英文翻譯是錯的,應該翻譯成「藥膏要塗在已被清潔後及已被清創後的傷口上」才對。

    我又去查了所謂的「chemical debridement」,這個清創方法主要是利用酵素的溶解作用,所以又稱為Enzymatic debridement,常用為Fibrinolysin, desoxyribonuclease, trypsin, and collagenase,目前美國唯一通過FDA以酵素來清創傷口用的只有Collagenase Santyl® Ointment(一瓶30gm約150美元,不過美國健保給付83.73元,CPT碼:97602,目前FDA共曾經通過三種酵素類清創藥膏:Santyl, Panafil, and Accuzyme,Santyl是利用膠原蛋白酶,利用基因工程,讓細菌製造出來,作用在沾黏壞死組織和傷口床之間的膠原蛋白束,讓壞死組織容易被清掉;而Panafil及Accuzyme是利用由天然植物萃取出來的木瓜蛋白酶(Papain),來直接讓壞死組織水解,但後兩種因為會導致致命性的過敏反應,故FDA規定從2009年開始禁止販賣)4,SSD說甚麼也和chemical debridement扯不上任何關係。

   再者有人說SSD是利用「自體清創,Autolytic debridement」以促進結痂的軟化5,6,但是所謂的自體清創(Autolytic debridement),根據維基百科,其是將有壞死組織的傷口處於密閉及潮濕的環境中,比如說用人工皮或防水薄膜將傷口密封,利用人體傷口自己產生出來的滲液及酵素來軟化、液化硬的痂皮eschar或腐肉slough7。若要用藥膏要將傷口密封,多使用保水力較好的凝膠gel或油膏oint或凡士林,不會使用較水水的乳霜cream,而SSD就是做成水性的乳霜,塗在傷口上比較容易化掉,不易密封傷口,甚至常常因塗得不夠厚而容易讓傷口乾掉,因此若要自體清創,還不如使用凡士林,況且說查遍所有的外國文獻,就是沒有說SSD有清創相關的作用,只有提到它優秀的抗菌作用。

   因此,我可以在這兒說:燙傷藥膏的清創作用只不過是一個傳說! 套句現在流行的那句話「假的、耳朵業障重啊!」

1. http://vghinnauru.blogspot.tw/2014/09/3.html

2. http://web-reg-server.803.org.tw:8090/Med_Web/med_info.asp?code=RE0SULF

3. https://www.smith-nephew.com/global/assets/pdf/products/wound/2-flamazinecreampi010610.pdf

4. http://woundmaster.blogspot.tw/2014/08/2013.html

5. http://sp1.hso.mohw.gov.tw/doctor/Often_question/type_detail.php?q_type=%E5%82%B7%E5%8F%A3&UrlClass=%E6%95%B4%E5%9E%8B%E5%A4%96%E7%A7%91

6. http://sunifeng.blogspot.tw/2015/06/blog-post_4.html

7. https://en.wikipedia.org/wiki/Debridement

2016年5月14日 星期六

壓瘡定性評估方法。NPUAP 2016年版壓傷分期

傷口大師 游朝慶 醫師

  在2016年4月8-9日的一場超過400位專家出席的共識會上(NPUAP 2016 Staging Consensus Conference,如圖1) (注:NPUAP,美國國家壓瘡諮詢委員會,National Pressure Ulcer Advisory Panel ),大家對於壓瘡的分期及定義這議題交互討論,以及對於爭議部分予以表決,在這會議中,與會者都使用照片來確認每一個新的術語( terminology)。最後NPUAP在4月13日向世界公布這新的壓傷(pressure injury)語言以及其修正後的分期。同時作為美國健保給付依據的OASIS (Outcome and Assessment Information Set,居家照護評估表)也將同步做修正。

clip_image002

圖1. NPUAP 2016 Staging Consensus Conference

  壓傷的分期是用來表示組織受傷的程度。之前臨床工作者嘗試去診斷及確認壓傷的期別所會遇到的問題都在這次被NPUAP修正。

"Pressure injuries are staged to indicate the extent of tissue damage. The stages were revised based on questions received by NPUAP from clinicians attempting to diagnose and identify the stage of pressure injuries. 

NPUAP Staging Task Force News Release 2016.4.13

   NPUAP並且免費提供13個圖示(圖2-1 - 2-13)來表示各期別(http://www.npuap.org/resources/educational-and-clinical-resources/pressure-injury-staging-illustrations/).

 

第1期壓傷: 完整的皮膚上有紅斑,給予指壓時不會消失

Stage 1 Pressure Injury: Non-blanchable erythema of intact skin

   在完整的皮膚上看到局部有指壓時不會消失的紅斑(如圖2-4, 圖2-6),但這在皮膚較黑的患者上可能會看不到變化(如圖2-5、圖3),雖然如此,可消失的紅斑、感覺異常、體溫異常及皮膚變得較硬都可能會緊接著出現不會消失的紅斑。然而皮膚顏色的變化並不包括紫色或栗色(maroon)(補充:也就是如瘀青般的顏色),其代表著深層組織傷害(deep tissue injury)。
Intact skin with a localized area of non-blanchable erythema, which may appear differently in darkly pigmented skin. Presence of blanchable erythema or changes in sensation, temperature, or firmness may precede visual changes. Color changes do not include purple or maroon discoloration; these may indicate deep tissue pressure injury.

clip_image004

圖2-1. Healthy skin – Caucasian(健康的皮膚–白種人,高加索人)

clip_image006

圖2-2.Healthy skin – Non-Caucasian(健康的皮膚–有色人種)

clip_image008

圖2-3.Stage 1 Pressure Injury – Caucasian(第1期壓傷–白種人,高加索人)

clip_image010

圖2-4.Stage 1 Pressure Injury – Edema(第1期壓傷–水腫),補充:這圖和上一張圖(圖2-3),我看不出差異性,水腫不是壓傷的症狀,但若患者因營養不良導致水腫、或者因失禁導致皮膚潮濕,則比較容易造成第1至第2期壓傷。

clip_image012

圖2-5.Stage 1 Pressure Injury - Non-Caucasian(第1期壓傷––有色人種)

clip_image014

圖2-6.Blanchable vs Non-Blanchable,給予指壓時會消失的紅斑vs不會消失的紅斑

clip_image016

圖3.如右圖,皮膚較黑的人可能無法判斷有無blanchable,圖片取自David Rokes, Debra Kurtz, WoundRounds: Clinical Reimbursement and Wound Care webinar slides, Health & Medicine, Economy & Finance, Business, Nov 11, 2011 http://image.slidesharecdn.com/woundroundsclinicalreimbursementandwoundcarewebinarslides-111111125701-phpapp02/95/woundrounds-clinical-reimbursement-and-wound-care-webinar-slides-36-728.jpg?cb=1321016386

2016年5月6日 星期五

『壓瘡』已被重新命名為『壓傷』

游朝慶 醫師

   The term “pressure injury” replaces “pressure ulcer” in the NPUAP Pressure Injury Staging System

   就在上個月,4/13/2016,美國國家壓瘡諮詢委員會(NPUAP)宣布將常用的『壓瘡pressure ulcer』這個字改名為『壓傷pressure injury』,因為有些壓瘡如第一度壓瘡及深層組織傷害deep tissue injury其皮膚是完整的。

   此外在這個會議中也決議使用阿拉伯數字來命名第1-4期,而不再使用羅馬數字的第I-IV期。並且也把『疑深層組織傷害』的『疑』字拿掉,表示我們可以有信心地正確診斷為『深層組織傷害』。最後這會議也正式承認兩種因醫療器材導致的傷害,也為壓傷的一種,雖然其不符合「在骨頭突出處」這舊定義,第一種傷害為Medical Device Related Pressure Injury:醫療器材導致的壓傷,如Bi-PAP的氧氣罩導致嘴巴鼻子周圍產生壓傷,這類傷口可以使用NPUAP的分期系統來分期,第二種傷害為Mucosal Membrane Pressure Injury:黏膜壓傷,如氣管內管導致口腔的潰瘍,鼻胃管導致的傷口,其無法再被分期。

   詳見 http://www.npuap.org/resources/educational-and-clinical-resources/npuap-pressure-injury-stages/

而且2016年的『壓傷』也被NPUAP重新定義為

    皮膚或皮膚下面的軟組織受損,其通常位於身體骨頭突出處或與某些醫療器材有關。這些傷害看起來可能皮膚是完整的,或有傷口的或者也許會疼痛。導致傷害的原因為強烈的或持續的受壓、或伴隨著剪力,而這些或許也和微氣候、營養、血循、合併症、及軟組織的狀況有關。

A pressure injury is localized damage to the skin and/or underlying soft tissue usually over a bony prominence or related to a medical or other device. The injury can present as intact skin or an open ulcer and may be painful. The injury occurs as a result of intense and/or prolonged pressure or pressure in combination with shear. The tolerance of soft tissue for pressure and shear may also be affected by microclimate, nutrition, perfusion, co-morbidities and condition of the soft tissue.

    相對於壓瘡2007年NPUAP定義(較簡單)

壓瘡是身體骨頭突出處,因為受到重壓,剪力或摩擦,而導致的皮膚或皮膚下面的脂肪或肌肉組織受損,有很多因素會為導致壓瘡,但這些因素的重要性仍然不明。

 

參考資料來源:

National Pressure Ulcer Advisory Panel (NPUAP) announces a change in terminology from pressure ulcer to pressure injury and updates the stages of pressure injury http://www.npuap.org/national-pressure-ulcer-advisory-panel-npuap-announces-a-change-in-terminology-from-pressure-ulcer-to-pressure-injury-and-updates-the-stages-of-pressure-injury/

2016年3月20日 星期日

糖尿病患者以骨內氣體及皮下氣腫表現的沙門氏桿菌骨髓炎

  這是今年外科醫學會上發表的第二篇海報,這個案原本應該是骨科的,但他們堅持先處理壞死性筋膜炎,不過也學到皮下有air,不一定就是壞死性筋膜炎,若術前沒有CT,還真診斷不出來。

 今天也終於將blogger上照片顯示不出來的問題解決了,雖然是以很笨的方式重新一張一張貼,但若還是有遺漏的、或需訂正的,麻煩請告訴我,謝謝大家。

DSC03448

 

糖尿病患者以骨內氣體及皮下氣腫表現的沙門氏桿菌骨髓炎

游朝慶

台南市立醫院 外科

 

前言:

   當骨頭內在影像學上發現有空氣時(intraosseous gas),但又沒有骨頭傷害時(如骨折或開刀),須強烈懷疑是產氣性骨髓炎(emphysematous osteomyelitis),此外骨髓炎以皮下氣腫(subcutaneous emphysema)來表現的個案,文獻上非常少。下面介紹一個少見的案例,其為一54歲糖尿病患者診斷為左脛骨遠端產氣性骨髓炎,卻以左小腿及大腿的皮下氣腫來表現,組織培養顯示沙門氏桿菌(Salmonella group C2)。

個案報告﹕

   患者54歲男性,原住民,有糖尿病、高血脂、痛風及C肝等病史,於2個月前去南投打獵,因為動物的內臟不好保存,原住民習慣將捕獲的獵物現場剖肚,取出內臟生吃,但隔天就因為左髖部及膝蓋疼痛至本院急診求診,當時發燒到39.4度C、心跳103bpm,WBC正常,CRP:1.93,當時初步診斷為痛風性關節炎,因血糖高達549mg/dL,故因糖尿病控制不良住院。但關節痛仍然未改善,持續發燒,augmentin 無效,改為Ciprofloxacin ,HbA1C高達15.7%,故安排影像學檢查,X光無異常(如圖1):

clip_image002clip_image004

圖1:lt knee X-ray: Soft tissue swelling, anterior knee.

電腦斷層(CT)則可看到左大腿內側有一包空氣,左脛骨遠端骨頭內有一些空氣(圖2)。

clip_image006clip_image008

clip_image010clip_image012clip_image014clip_image016

圖2. CT: fasciitis with cellulitis of left thigh and arthritic arthropathy of bil knees.

  之後患者症狀漸漸改善,而隨後的blood culture培養出兩套 Salmonella group C2,患者於住院一周後出院,診斷為L't knee arthritis, gout arthritis & septic arthritis,Salmonella bacteremia

之後過了兩個月,患者又因左膝疼痛3天,在外面診所以痛風治療無效,到我們急診求診,來的時候,呈現出toxic signs,有點喘、血壓不高、微燒(37.3C),白血球18290並有band form:17%,其他data: CRP: 1.7, Blood gas: pH:7.416, HCO3:14.4, PCO2:22.9, BE:-8.2. Creat:1.7, BUN:49.6, ALT:92, AST:34, CPK:19, uric acid:8.3, sugar:229.

理學檢查為大腿下1/3疼痛,從左側鼠蹊至腳踝都有捻髮音(crepitus),X-Ray顯示左下肢有大量的氣體,懷疑有abscess(圖3),CT顯示左脛骨下1/3有骨髓內氣體,證實有骨髓炎,從左髖部到小腿有大量的皮下氣體,懷疑有壞死性筋膜炎(圖4),因懷疑敗血,建議膝上截肢(AK),但患者拒絕。

clip_image018clip_image020

圖3.Soft tissue swelling with emphysema over the right thigh, knee and lower leg

clip_image022clip_image024clip_image026clip_image028clip_image030clip_image032clip_image034

圖4. CT: intramedullary gas in the distal third of the femur bone, with extensive subcutaneous emphysema

  手術從大腿遠端外側進入,骨頭外側為正常、無膿瘍的表現,我們將脛骨遠端以氣鑽鑽開幾個洞,引流出白色無臭味的膿及氣體,並在左小腿及大腿內側做筋膜切開術,但卻無壞死性筋膜炎的表現。術中的培養結果仍然是Salmonella group C2,但血液培養沒長菌。

clip_image036clip_image038

圖5.OP finding ,第一及第二次手術

  抗生素醫感染科醫師建議使用Antibiotics treatment with Ciprofloxacin 200mg/vial 2 vial Q12H IV + Amoxicillin 1000mg+Clavulanate 200mg 1 vial q8h IVD

在經過兩次手術將傷口縫合後,患者於34天後出院。

結果:

  患者在門診追蹤1個月,並持續口服抗生素治療,傷口狀況良好。

討論:

   患者是台灣的原住民,常與族人一起打獵,並習慣和著鹽巴生吃獵物的內臟,其應該是沙門氏桿菌菌血症的原因。沙門氏桿菌很少會造成骨髓炎。在1981年,Ram等人發表說電腦斷層(CT)發現骨髓內氣體是骨髓炎的徵兆,在顱骨、脊椎、胸骨、肋骨外的骨頭上發現有骨內氣體,則幾乎可以診斷為產氣性骨髓炎,糖尿病及惡性腫瘤為常見的好發因子。因為這種病死亡率相當高(32%)以及常有併發症,尤其是患者同時有糖尿病,故積極的抗生素治療及手術介入是一定要的。

 

Salmonella Osteomyelitis with Intraosseous Gas and Subcutaneous Emphysema in the Patient with Diabetes

Chao-Chin Yu

Department of Surgery, Tainan Municipal Hospital

Introduction:

The presence of intraosseous gas in the absence of direct communication between bone and air, such as a compound fracture or recent surgery, is highly suggestive of emphysematous osteomyelitis. However there is rare osteomyelitis report with subcutaneous emphysema. We report a case of a 54-year-old male with diabetes mellitus who presented with emphysematous osteomyelitis of the left distal femur and subcutaneous emphysema of left thigh and calf. Specimen cultures in this case revealed a pure growth of Salmonella group C2.

Case Presentation:

The 54-year-old man with past medical history of poor controlled type 2 DM, hyperlipidemia, gout and hepatitis C was admitted through our emergency department due to left knee and hip joint pain for 8 hours. He was tachycardic (103bpm) and febrile (39.4C). Lab data showed normal white blood count, CRP:1.93, but high level of blood glucose level 549mg/dL, and HbA1c:15.7. Musculoskeletal soft tissue computed tomography (CT) showed fasciitis with cellulitis of left thigh and arthritic arthropathy of bil knees. He was diagnosed with gouty arthritis and septic arthritis and was treated with colchicines 0.5mg 1# qd and antibiotics. He was discharge 1week later after the symptoms improve. The following blood culture showed Salmonella group C2. The patient presented again to the emergency department 2months later with ongoing left knee pain for 3days, in vain with treatment of gout by clinic physician. He presented with toxic signs with dyspnea, dropped blood pressure, mild fever(37.3C) and leukocytosis(18290) with band form:17%. Lab data revealed: CRP: 1.7, Blood gas: pH:7.416, HCO3:14.4, PCO2:22.9, BE:-8.2. Creat:1.7, BUN:49.6, ALT:92, AST:34, CPK:19, uric acid:8.3, sugar:229. Physical exam showed local tenderness over lower third of left thigh and extensive crepitus extending from left groin to the left ankle. X-ray showed soft tissue tissue swelling with emphysema over lt thigh, knee and lower leg. Subsequent CT confirmed evidence of osteomyelitis with intramedullary gas in the distal third of the femur bone, with extensive subcutaneous emphysema involving the left hip, thigh and lower leg. Above knee amputation was suggested at first, but was refused by patient.

Through a lateral approach to the distal femur, penetration of bone was initially performed to drain the non-foul whitish intraosseous abscess and gas. The cortex of bone showed intact. Irrigation with H2O2 and debridement were performed. The fasciotomy of left thigh and calf was also done but no necrotizing fasciitis or abscess was found. Intraoperative cultures revealed Salmonella group C2. Blood cultures taken preoperatively showed no bacterial growth.

Antibiotics treatment with Ciprofloxacin 200mg/vial 2 vial Q12H IV + Amoxicillin 1000mg+Clavulanate 200mg 1 vial q8h IVD was suggested by Infection doctor. The wounds were open cared with normal saline moist gauze packing bid. After 2 subsequent surgeries, he was eventually discharged 34 days after admission.

Results:

The patient had been regularly followed up and received oral antibiotics in my OPD for 1months after discharge. The wound condition was good.

Discussion:

This patient is a Taiwanese aborigines. He hunt the boar with his clansman. Then they usually ate the raw organs of boar with salt which may be the source of salmonella bacteremia. Osteomyelitis is a rarely reported manifestation of Salmonella infection. In 1981, Ram et al. were first to describe the radiological finding of intraosseous gas as a sign of osteomyelitis on computed tomography (CT). When seen in the extra-axial skeleton, intraosseous gas is virtually pathognomonic for emphysematous osteomyelitis. Diabetes mellitus and malignancy are common predisposing factors. Aggressive antimicrobial and surgical intervention is required as emphysematous osteomyelitis is associated with high mortality (32%) and significant morbidity, especially in diabetic patients.

2016年3月19日 星期六

併有心臟衰竭的靜脈鬱滯性潰瘍患者

  今天又是全台灣大外科一年一次的大拜拜,順便也去貼了兩張海報。都只是個案報告。

順便測試google blogger部落格的圖片是否可恢復正常顯示(真的快被搞瘋了)

第一篇的中英文介紹如下:

DSC03449DSC03440

 

併有心臟衰竭的靜脈鬱滯性潰瘍患者
Venous Stasis Ulcers in the Patient with Heart Failure
游朝慶

台南市立醫院 外科

 

前言:

   靜脈性潰瘍(Venous ulcer),又被稱為鬱滯性潰瘍(stasis ulcer),是最常見的下肢潰瘍原因。其診斷需根據臨床表現,如靜脈不全、皮膚的變化或下肢水腫,其預後不好,常數年不會癒合。我們介紹一個個案,其兩下肢多處潰瘍、疼痛及水腫已四個月未癒合,我們在兩星期內就把潰瘍治療到接近癒合。

 

個案報告﹕

   62歲退休男性,有慢性心臟衰竭及中風已四年的病史,兩腳多處潰瘍及腫痛已四個月,此次因為兩腳紅腫熱痛,懷疑蜂窩性組織炎(cellulitis)及深層靜脈栓塞(Deep vein thrombosis)而從門診收住院。理學檢查:兩小腿下1/3有色素沉著(hyperpigmentation),嚴重凹陷性水腫(pitting edema),兩小腿紅腫痛,兩足部均可摸到脈搏,在右小腿有一3*4公分的傷口,並有濕性痂皮(wet eschar),在左小腿則有一巨大的15*10公分不規則淺傷口(如圖1),並有大量滲液。胸部有呼吸喘鳴聲(wheezing),實驗室檢查:WBC: 9810, Seg:87, Hb:13.0, plate:313K, BUN/Cr:23.5/1.2, Alb:2.9, Glu:114, CRP:9.25, Alb:2.9, T4:5.07, TSH:4.0756. EKG顯示有First degree AV block. 胸部X-ray: 心臟肥大、肺水腫(pulmonary edema)並有肋膜積水(如圖2)。周邊血管超音波排除了深層靜脈栓塞,但心臟超音波: chamber dilatation and generalized hypokinesis with impair global performance with ejection fraction : 35%.顯示嚴重心臟衰竭。

imageimage

圖1. hyperpigmentation over lower third of both calf, severe pitting edema, swelling, erythema, tenderness over bilateral calf, with chronic ulcer

image

圖2. cardiomegaly, pulmonary edema with pleural effusion

   因此診斷為心臟衰竭導致的下肢靜脈性潰瘍並鬱滯性皮膚炎,根據心臟科醫師建議,便開始使用大量利尿劑及低劑量dopamine療法,傷口則局部使用優碘粉(iodosorb powder),兩小腿抬高並綁上彈性繃帶。治療一禮拜後,wheezing改善後才去開刀房清創傷口(如圖3),患者在住了12天後出院。

imageimage

圖3.手術後,左小腿傷口已有局部癒合

 

結果

   患者在出院後一禮拜回診,此時傷口已縮小了7成(如圖4)。

最後診斷為CHF with pul edema with Venous stasis ulcers with cellulitis, bil lower legs, C6EsApPr

imageimage

圖4. OPD回診,兩小腿傷口已縮小

 

討論:

   靜脈不全導致的靜脈性潰瘍常常容易復發,且常常會持續數禮拜到數年,壓迫治療(使用彈性繃帶或彈性襪)是這種疾病的標準治療,治療6個月成功率約3-6成,治療1年成功率約7-8.5成,但傷口治療師永遠要記得引起靜脈潰瘍的其他原因,如肝硬化、心衰竭、深層靜脈栓塞、肥胖、腳外傷後(如骨折或手術)的後遺症、換過人工髖關節或膝關節、服用抗白血病的藥或其他會導致下肢水腫的藥。以這案例而言,利尿劑對於靜脈不全的水腫無效,但若是肝硬化或心衰竭所導致的下肢水腫,則利尿劑效果非常好。

 

 

Venous Stasis Ulcers in the Patient with Heart Failure

Chao-Chin Yu

Department of Surgery, Tainan Municipal Hospital

Introduction:

Venous ulcer, also known as stasis ulcer, is the most common etiology of lower extremity ulceration. The diagnosis of stasis ulcer was based on clinical criteria: venous insufficiency, cutaneous signs and/or severe leg edema. This prognosis of venous ulcer is poor. We report a case of bilateral leg chronic ulcers with pain and edema for 4months who nearly heals his ulcer in only 2 weeks.

Case Presentation:

The 62 year-old retired male with past history of chronic heart failure and old CVA for 4years is well until 2014/12/4 when he suffered from progressive swelling, erythema, pain, tire and heat over his bilateral legs. He was admitted via OPD under the initial suspicion of cellulitis and deep vein thrombosis. Physical examination shows hyperpigmentation over lower third of both calf, severe pitting edema, swelling, erythema, tenderness over bilateral calf and palpable pulses in both feet. A ulcer about 3*4cm with wet eschar 100% over right lower leg. The other huge shallow ulcer about 15*10cm with irregular shape and heavy discharge over left calf. Wheezing in chest was also noted. Lab data shows: WBC: 9810, Seg:87, Hb:13.0, plate:313K, BUN/Cr:23.5/1.2, Alb:2.9, Glu:114, CRP:9.25, T4:5.07, TSH:4.0756. EKG: First degree AV block. Chest X-ray: cardiomegaly, pulmonary edema with pleural effusion. Pheripheral vein sono on 12/6 shows no deep vein thrombosis. Cardiac echo on 12/8 shows four chamber dilatation and generalized hypokinesis with impair global performance with ejection fraction : 35%. Then we start lasix with low dose dopamine therapy by the suggestion of CV doctor. Besides, the wounds were treated with iodosorb powder topical use, legs elevation and compression therapy with elastic bandage under the diagnosis of venous stasis ulcers. He also received an operation for debridement on 12/11 after the wheezing improved. He was discharge on 8/16.

Results:

The patient was followed up in my OPD on 12/23. At that time, the huge ulcer of left leg showed about 70% reduction in wound area and near healed.

Discussion:

Venous ulcers are often recurrent, and open ulcers can persist from weeks to many years. Compression therapy is the standard of care for venous ulcers and chronic venous insufficiency. Success rates range from 30 to 60 percent at 24 weeks, and 70 to 85 percent after one year. However, wound care specialists should always keep in mind other possible causes of venous ulcers include liver cirrhosis, heart failure, deep venous thrombosis, obesity, after-effects of leg injury, homolateral artificial hip and knee joints, and consumption of anti-leukaemia or leg-edema-eliciting drugs.