DEHISCED STERNAL MUSCLE FLAP, DEHISCED LEG, ABDOMINAL WOUND CASE STUDY #1 DEHISCED STERNAL MUSCLE FLAP, DEHISCED LEG, ABDOMINAL WOUND In this case the multidisciplinary approach to wound care included both HBO and Negative Pressure Wound Therapy

55 years old Female Married 5 children 22 grandchildren Non-smoker The Patient 55 years old Female Married 5 children 22 grandchildren Non-smoker In this case the multidisciplinary approach to wound care included both HBO and Negative Pressure Wound Therapy

Coronary Artery Disease CO-MORBIDITIES Diabetic Hypertension Coronary Artery Disease Hyperlipidemia Probable Sleep Apnea Obesity Patient did not realize she had any of these co-morbidities.

Treatment Course Bypass Surgery 10/01 Dismissed from hospital 10/04 Sternal Wound and Donor Site Infection- Readmitted 10/28 Incision and debridement of leg and sternum - sternum removal 11/06 Closure of chest with muscle flap Debridement of leg wound 11/14 Transferred to NHS Clarkson Hospital 12/05 Hyperbaric Oxygen Treatments Initiated 12/06 Debridement of Sternal/chest/leg wounds - VAC Therapy Initiated 12/12 The patient arrived via ambulance at a local health care center and required emergency bypass surgery post acute MI. We will pick it up where NHS came in which was 12/5

Treatment Course Debridement of sternal and leg wounds - abdominal wound 01/13 STSG to sternal and leg wounds with VAC therapy 1/20 Transferred from acute care to sub-acute rehab unit 02/05

Sternal muscle flap and donor site are open sternum leg rectus TRANSFERRED TO NHS 12/05 Sternal muscle flap and donor site are open Lower leg is dehisced and infected The Infectious Disease Doctor said “cut the leg off” The sites all cultured positive for VRE.

STERNAL, RECTUS AND LEG WOUNDS IMPROVE QUICKLY 12/12 sternum leg rectus STERNAL, RECTUS AND LEG WOUNDS IMPROVE QUICKLY 12/12 Use of HBO and VAC therapy along with Multi-disciplinary approach The interdisciplinary approach coupled with state of the art wound care resulted in amazing results - quickly. The patient responded well to HBO, VAC therapy, IV antibiotics, and nutritional support.

STERNUM AND LEG GRANULATE ABDOMINAL WOUND DEBRIDED 01/13 rectus sternum abdomen STERNUM AND LEG GRANULATE ABDOMINAL WOUND DEBRIDED 01/13 Abdominal wound measures 15x10x4cm A small necrotic area distal to the rectus site was débrided and found to be necrotic beneath the surface. Clean granulated wound beds provided a perfect area for split thickness skin grafts. The rectus muscle was closing on it’s own.

SKIN GRAFT TO STERNUM AND LEG 1/20 abdomen SKIN GRAFT TO STERNUM AND LEG 1/20 VAC therapy replaced post skin graft for 5 days VAC was placed intraoperatively on the grafts - explain how and why this works. The abdominal wound continued to shrink in size.

COMPLETE TAKE ON SKIN GRAFTS TO LEG AND STERNUM 1/26 At first dressing change grafts have 100% take Grafts took 100%

ABDOMEN CONTINUES TO HEAL 2/5 Patient is transferred to Sub-acute rehab floor At this point, a calcium alginate rope was placed so that the patient and or family could perform dressing changes.

Physical and Occupational Therapy INTERDISCIPLINARY PLAN OF CARE Plastic Surgery General Surgery Infectious Disease Cardiology Pulmonary Medicine Endocrinology Nutrition Nursing Physical and Occupational Therapy Talk about what each service provided.

STERNUM PHOTOGRAPHIC REVIEW 2 1 3 4 5

RECTUS PHOTOGRAPHIC REVIEW 1 2 3 4

LEG PHOTOGRAPHIC REVIEW 2 1 3 4 5

ABDOMEN PHOTOGRAPHIC REVIEW 2 1 3

SHOULDER WOUND OSTEOMYLITIS REMOVAL OF HARDWARE CASE STUDY #2 SHOULDER WOUND OSTEOMYLITIS REMOVAL OF HARDWARE In this case the multidisciplinary approach to wound care included both HBO and Negative Pressure Wound Therapy

In Nebraska visiting family THE PATINET 39 Years Old Male 2 Children Non-Smoker In Nebraska visiting family She baby-sit her grandchildren in her home - while she was hospitalized grandchild #23 was born

Wound occurred when dirt biking CO-MORBIDITIES Healthy Young Man No co-morbidities Wound occurred when dirt biking Patient did not realize she had any of these co-morbidities.

Treatment Course Accident occurred Closed, grossly displaced clavicle fracture 11/10 Presented at ER 11/15 Surgical reduction/fixation with plate and 6 screws 11/24 Released from hospital without any problems 11/25 Presented with signs and symptoms of infection 11/29 Staph cultured – plate and screws noted to be dislodged IV antibiotics initiated 12/01 Plate and screws surgically removed Systemic reaction to Nafcillin and oral dicloxacillin 12/12 Released to home 12/20 Patient did not realize she had any of these co-morbidities.

Treatment Course Readmitted for further evaluation of non-healing wound 1/23 Surgical resection of mid third of clavicle with debridement of soft tissue infection Infectious disease consulted 1/30 Plastics called in – V.A.C. placed 2/2 Released with home care and V.A.C. 2/7 Clinic follow-up – V.A.C. discontinued-alginate initiated 2/14 IV antibiotics discontinued 2/21 Released from care-healed 2/28 Patient did not realize she had any of these co-morbidities.

Resection of Clavicle with debridement VAC placed 2/02 The Infectious Disease Doctor said “cut the leg off” The sites all cultured positive for VRE.

First VAC dressing change ABDOMEN At this point, a calcium alginate rope was placed so that the patient and or family could perform dressing changes. First VAC dressing change 2/05

Released to home with Home Care ABDOMEN Released to home with Home Care 2/07 V.A.C. therapy IV antibiotics At this point, a calcium alginate rope was placed so that the patient and or family could perform dressing changes.

Alginate dressing applied ABDOMEN First Clinic Follow Up 2/14 V.A.C. discontinued Alginate dressing applied At this point, a calcium alginate rope was placed so that the patient and or family could perform dressing changes.

IV antibiotics discontinued Clinic Follow up 2/21 IV antibiotics discontinued At this point, a calcium alginate rope was placed so that the patient and or family could perform dressing changes.

Hypergranulation area in center Removed with silver nitrate stick ABDOMEN Wound is closed  2/28 Hypergranulation area in center Removed with silver nitrate stick At this point, a calcium alginate rope was placed so that the patient and or family could perform dressing changes.

INTERDISCIPLINARY PLAN OF CARE Plastic Surgery Orthopedic Surgery Infectious Disease Nutrition Nursing Home healthcare Talk about what each service provided.

CLAVICLE PHOTOGRAPHIC REVIEW 3 1 2 4 5 6

Perineal cyst Necrotizing Component Radical Surgical Debridement CASE STUDY #3 Perineal cyst Necrotizing Component Radical Surgical Debridement In this case the multidisciplinary approach to wound care included both HBO and Negative Pressure Wound Therapy

THE PATINET 51 years old Female Single Smoker She baby-sit her grandchildren in her home - while she was hospitalized grandchild #23 was born

CO-MORBIDITIES Diabetic Hypertension Hyperlipidemia Probable Sleep Apnea Obesity Patient did not realize she had any of these co-morbidities.

Treatment Course Presented to Emergency Room with Perineal Cyst Infection Adult Onset Diabetes Mellitus Diagnosis Massive Infection with necrotizing features Emergency Surgery for debridement 1/16 Infectious Disease Consult 1/18 Plastic Surgery Consult V.A.C. Placement 1/24 Sub Acute Care Transfer 1/28 Released to Home 2/28 Healed 4/21 Patient did not realize she had any of these co-morbidities.

1/24 Vac placed 18cm – length 7cm – width 5cm tunnel @ 4:00 At this point, a calcium alginate rope was placed so that the patient and or family could perform dressing changes.

1/26 18cm length 5cm width 1cm undermining 0 tunnels At this point, a calcium alginate rope was placed so that the patient and or family could perform dressing changes.

At this point, a calcium alginate rope was placed so that the patient and or family could perform dressing changes. 2/14 12cm length 5cm width

2/19 10cm length 4cm width At this point, a calcium alginate rope was placed so that the patient and or family could perform dressing changes.

Released to Home 2/28 9cm length 4cm width At this point, a calcium alginate rope was placed so that the patient and or family could perform dressing changes. Released to Home 2/28 9cm length 4cm width

Clinic Follow-up 3/07 6cm length 4cm width At this point, a calcium alginate rope was placed so that the patient and or family could perform dressing changes. Clinic Follow-up 3/07 6cm length 4cm width

Normal Saline Moist dressings Clinic Follow-up 3/14 6cm length 3cm width V.A.C. discontinued Normal Saline Moist dressings At this point, a calcium alginate rope was placed so that the patient and or family could perform dressing changes.

Clinic Follow-Up 03/21 6cm length 3cm width At this point, a calcium alginate rope was placed so that the patient and or family could perform dressing changes. Clinic Follow-Up 03/21 6cm length 3cm width

Clinic Follow-Up 03/28 5cm length 3cm width At this point, a calcium alginate rope was placed so that the patient and or family could perform dressing changes. Clinic Follow-Up 03/28 5cm length 3cm width

Clinic Follow-Up 4/05 2.5cm length 2cm width At this point, a calcium alginate rope was placed so that the patient and or family could perform dressing changes. Clinic Follow-Up 4/05 2.5cm length 2cm width

Clinic Follow-Up 4/13 2cm length 2cm width At this point, a calcium alginate rope was placed so that the patient and or family could perform dressing changes. Clinic Follow-Up 4/13 2cm length 2cm width

4/21 Healed  Released from care At this point, a calcium alginate rope was placed so that the patient and or family could perform dressing changes. 4/21 Healed  Released from care

INTERDISCIPLINARY PLAN OF CARE Plastic Surgery General Surgery Infectious Disease Endocrinology Nutrition Nursing Home health care Talk about what each service provided.

Photographic Review Groin/peri-rectal Patient did not realize she had any of these co-morbidities.

4 2 1 3 At this point, a calcium alginate rope was placed so that the patient and or family could perform dressing changes. 8 5 6 7 9 11 10 12

Perirectal Abscess Necrotizing Component Radical Debridement CASE STUDY #4 Perirectal Abscess Necrotizing Component Radical Debridement In this case the multidisciplinary approach to wound care included both HBO and Negative Pressure Wound Therapy

62 year old Female Widow 2 Children The Patient 62 year old Female Widow 2 Children In this case the multidisciplinary approach to wound care included both HBO and Negative Pressure Wound Therapy

Adult Onset Diabetes Mellitus CO-MORBIDITIES Adult Onset Diabetes Mellitus Hypertension Hyperlipidemia Status Post hysterectomy related to cervical cancer with abdominal radiation therapy Obesity Nutritional Deficit Patient did not realize she had any of these co-morbidities.

Treatment Course Surgical debridement of necrotizing rectal-perineal abscess Performed at rural hospital 3/24 Further surgical debridement and diverting colostomy performed at rural hospital 3/25 Transferred to NHS Clarkson for Interdisciplinary care Infectious Disease Consult 3/26 Hyperbaric Oxygen Treatments Started Hyperalimentation for Nutrition Plastics Consulted Many organisms ¼ strength Betadine packs q8hours 3/30 Patient did not realize she had any of these co-morbidities.

Treatment Course Acute Renal Failure Atelectasis Bronchoscopy with Removal of Large Mucous Plug 4/5 Transferred from Intensive Care Unit to Floor Tube feeding initiated 4/10 V.A.C. Placed 4/13 Respiratory Arrest Ventilator Placement 4/21 Removed from Ventilator 4/23 Retention Sutures Placed in Wound 4/25 Patient Requested “No Code Status Last Dressing Change 4/27 Respiratory and Cardiac Arrest 5/1 Patient did not realize she had any of these co-morbidities.

Status Post Radical Debridement 4/13 Status Post Radical Debridement V.A.C. Placed At this point, a calcium alginate rope was placed so that the patient and or family could perform dressing changes.

First V.A.C. dressing Change At this point, a calcium alginate rope was placed so that the patient and or family could perform dressing changes. 4/16 First V.A.C. dressing Change

Hyperbaric Oxygen Treatments 4/18 NG tube feeding Hyperbaric Oxygen Treatments At this point, a calcium alginate rope was placed so that the patient and or family could perform dressing changes.

I.V. Antibiotics – Hyperbaric Oxygen Treatments At this point, a calcium alginate rope was placed so that the patient and or family could perform dressing changes. 4/23 V.A.C. continues I.V. Antibiotics – Hyperbaric Oxygen Treatments

Retention Sutures placed to encourage adhesion of skin flaps 4/25 Retention Sutures placed to encourage adhesion of skin flaps V.A.C. continues At this point, a calcium alginate rope was placed so that the patient and or family could perform dressing changes.

4/27 Multiple setbacks Renal Failure At this point, a calcium alginate rope was placed so that the patient and or family could perform dressing changes.

INTERDISCIPLINARY PLAN OF CARE Plastic Surgery General Surgery Infectious Disease Pulmonology Endocrinology Oncology Nutrition Nursing Social Services Physical Therapy Occupational Therapy Talk about what each service provided.

Peri-rectal Photographic Review Patient did not realize she had any of these co-morbidities.

3 1 2 At this point, a calcium alginate rope was placed so that the patient and or family could perform dressing changes. 4 5 6 7

Diabetic Foot Wound Radical Debridement Partial Bone Removal CASE STUDY #5 Diabetic Foot Wound Radical Debridement Partial Bone Removal In this case the multidisciplinary approach to wound care included both HBO and Negative Pressure Wound Therapy

The Patient 77 Year Old Woman Married 3 Children 9 Grandchildren 3 Great Grandchildren In this case the multidisciplinary approach to wound care included both HBO and Negative Pressure Wound Therapy

Peripheral Neuropathy CO-MORBIDITIES Breast Cancer Ongoing Chemotherapy Peripheral Neuropathy CAD CABG Patient did not realize she had any of these co-morbidities.

Treatment Course Admission related to acute infection left foot 9/20 Infectious Disease Consultation Orthopedic Consultation 9/21 Surgical Debridement of left foot 9/24 9/28 Plastic Surgery Consultation 10/1 V.A.C. Placed 10/3 Patient did not realize she had any of these co-morbidities.

Measures 5cm Length 2.5cm Width 4cm Depth Prior to first V.A.C. dressing change First Metatarsal debridement for osteo – bone exposed Measures 5cm Length 2.5cm Width 4cm Depth At this point, a calcium alginate rope was placed so that the patient and or family could perform dressing changes.

Measures 3.5cm Length 1.2cm Width 2cm Depth First V.A.C. Dressing Change I.V. antibiotic continue Hyperbaric Oxygen continues Measures 3.5cm Length 1.2cm Width 2cm Depth At this point, a calcium alginate rope was placed so that the patient and or family could perform dressing changes.

Measures 2cm Length 0.9cm Width <0.2cm Depth Last V.A.C. Dressing Change Patient dismissed to home with alginate dressing changes qod Measures 2cm Length 0.9cm Width <0.2cm Depth At this point, a calcium alginate rope was placed so that the patient and or family could perform dressing changes.

Physical and Occupational Therapy INTERDISCIPLINARY PLAN OF CARE Plastic Surgery Orthopedic Surgery Infectious Disease Pulmonary Medicine Endocrinology Nutrition Nursing Pedorthics Physical and Occupational Therapy Talk about what each service provided.

Photographic Review Foot Patient did not realize she had any of these co-morbidities.

At this point, a calcium alginate rope was placed so that the patient and or family could perform dressing changes. 1 2 3