Gangrene in the PCP setting

Uvod. Gangrena je stanje koje se karakteriše nekrozom i odumiranjem tkiva, čiji je najčešći uzrok loša cirkulacija krvi. Neblagovremeno prepoznata i lečena, može imati fatalan ishod. Kod dijabetičara predstavlja jednu od najtežih komplikacija koja, u osnovi, ima hronično lošu glikoregulaciju. U razvijenim društvima predstavlja vodeći uzrok amputacija sa posledičnom invalidnošću i povećanom stopom mortaliteta. Takođe, utiče najpre na kvalitet života pacijenata, kao i na zdravstvene i socijalne sisteme. Prikaz slučaja. Zapuštena vlažna gangrena desnog stopala kod pacijenta starosti 63 godine, dugogodišnjeg insulinzavisnog dijabetičara poreklom iz ruralne oblasti. Na predlog izabranog lekara da se hospitalizuje, pacijent zahteva da se sprovede kućno lečenje. Debridman hronične rane započinje se alginatnim oblogama sa srebrom, uz peroralnu i lokalnu antibiotsku terapiju. Lečenje se nastavlja čišćenjem rane i primenom antibiotske masti, te odstranjivanjem kalusa oštrim debridmanom da bi se već u fazi značajnog povlačenja i zarastanja hronične rane upotrebile i hidrofilne obloge od poliuretanske pene. Nakon šesnaestomesečnog lečenja postiže se zarastanje hronične rane uzrokovane vlažnom gangrenom desnog stopala. Zaključak. Pacijenta je lečio tim opšte medicine, pri čemu savremena sredstva za lečenje hroničnih rana značajno ubrzavaju zarastanje rana i mogu se primenjivati i u primarnoj zdravstvenoj zaštiti. Vremenski dugo i teško lečenje je bilo posledica pacijentovih nezadovoljavajućih socioepidemioloških i ekonomskih uslova i, najvažnije, odbijanja pacijenta da sa lekarom uspostavi potpunu saradnju koja je preduslov uspešnog lečenja. U sistemu zdravstvene zaštite primarna zdravstvena zaštita čini njen nezamenljiv deo ne samo u sprečavanju nastanka gangrene, već i u samom lečenju. Ključne reči: vlažna gangrena, hronična rana, autolitički debridman, primarna zdravstvena zaštita. Abstract


Introduction
Gangrene is a potentially deathly condition and its most distinctive feature is necrosis of the body part with poor circulation. The most common cause of the artery occlusion, with subsequent ischemia and then necrosis, especially in diabetics, are atherosclerosis, injuries, frostbites, burns, bacterial infections. Smoking is also an important risk factor for poor circulation. Gangrene may also appear in some hematologic diseases, such as polycitemia. 1 Gangrene may be dry, wet, and gas 1 , and among them, wet form is the most common one. Pathophysiology of the wet gangrene is explained by complex neuro-ischemic processes, followed by the loss of protective sensibility. Skin injuries and ulcerations are the infection entry points. It may also develop if the dry gangrene gets infected. 2,3 The wet gangrene causes the affected tissue to be edematous, macerated, foul smelling, painful, putrid, and is often followed by high fever. The development of the wet and gas gangrene is very rapid due to the circulating toxins which may cause sepsis with a fatal outcome. On the other hand, dry gangrene develops rather slowly. If the treatment isn`t timely, the amputation of the affected extremity may be the only therapeutic solution. The gangrenous process usually affects distal extremity parts, but it may also affect internal organs. The costs of treatment and subsequent disability due to amputation are a huge financial burden for all health systems, even those in developed countries. The modern compresses, used for the treatment of chronic wounds, enable autolytic debridement of the wound based on the concept of wet wound healing. They speed up the epithelization, angiogenesis, and synthesis of the connective tissue, provide adequate gas exchange between the wound and its surrounding, prevent the penetration of the microorganisms into the wound. Their removal is atraumatic and painless 4 . A part of the wide range of these compresses is alginate-argent ones, as well as hydrophilic polyurethane compresses. They interact with the wound.
Alginates with silver come from sea algae and they are made of mannuronic acid and anion polysaccharides and impregnated with argent ions. In contact with the wound the gel is being formed and it enables autolytic debridement of the wound, while the argent ions have a strong antimicrobial effect.
Hydrophilic polyurethane compresses are multilayered. Their inner component is very absorbent and it sucks up the wound exudate. Its out layer is water and bacteria resistant but it permeates gas exchange. 4 These compresses may be easily used in the primary care setting. Besides, family members may be trained for their application, if the wound is superficial, without bone tissue being affected. This is very useful, especially in rural and areas without public health nursing. Njihovom upotrebom značajno se skraćuje vreme potrebno za lečenje, jednostavne su za upotrebu, te donose značajne uštede zdravstvenom sistemu kao i pacijentima, čineći proces zarastanja znatno bržim 5,6,7 .
Physical examination: the patient is alert, oriented in time, space and person, afebrile, eupnoeic, moves only within the confines of his bed, with the normal musculoskeletal constitution; the skin and mucose are a bit paler and he looks very sick.
His head is of normal configuration, non-tender to palpation and percussion; the neck is cylindric and moves actively and passively in all directions; no noticeable overload of the big neck blood vessels, carotid puls palpable, on both sides; thyroid gland is in its place and shows no signs of enlargement.
His chest is cylindric, no deformities, moves symmetrically during breathing and lungs are clear to auscultation.
Regular heart rhythm, no murmurs, ictus cordis in its regular position, BP 220/120 mmHg, HR 80 bpm. Abdomen flat, soft, non-tender to palpitation, liver edge and spleen not felt, kidney percussion non-tender; extremities are of normal configuration.
The big toe of his left foot was amputated in 2012, due to gangrene. At the moment, his right foot and the lateral side of the distal part of the right lower leg are affected by the wet gangrene, with a very foul smell. His blood sugar level, on this home visit, is 13.4 mmol/l. His lower legs are hardly moveable. The patient was informed of the urgency of being transported to the regional hospital for further evaluation and treatment, The patient refused the suggestion and asked to be treated at home. His at-home treatment started at the beginning of October 2018. His diabetes was poorly regulated and the correction of antidiabetic therapy was suggested, which he also refused, but was willing to correct his antihypertensive therapy. The angiotensin 2 receptor blockers (ARBs) were introduced twice daily, diuretic, selective betablocker, acetylsalycilic acid, and alpha-lipoic acid. The newly introduced antihypertensive therapy led to the regulation of his blood pressure. During the following visit, the patient complained of dyspnoea attacks in the evening hours. He felt they were connected to the use of ARBs, so he stopped using them. So the new antihypertensive drugs were introducedthe fixed combination of perindopril and indapamide (maximum dose) in the morning, and calcium channel blocker, pamida ujutru u maksimalnoj dozi i antagonist kalcijumovih kanala 20 mg uveče. Ovu terapiju pacijent prihvata, navodi da je dobro toleriše i redovno koristi. U daljim kontrolama krvni pritisak postepeno dostiže normalne vrednosti. Pacijent uvedene selektivne betablokatore i acetilsalicilnu kiselinu smatra za nepotrebne i samoinicijativno ih isključuje iz terapije. Uprkos hronično lošoj glikoregulaciji i na kontrolama konstantno visokim vrednostima glikemije koja se kretala između 13 i 14mmol/l, pacijent za sve vreme lečenja nije dozvolio korekciju antidijabetesne terapije. Pristupa se i lečenju vlažne gangrene desnog stopala najpre čišćenjem rane dostupnim sredstvima, fiziološkim rastvorom i povidon jodom. Predloženo da se debridman vlažne gangrene započne alginatnim oblogama sa srebrom, što pacijent prihvata. Zbog raširene infekcije idesnog stopala, započeta je peroralna antibiotska terapija klindamicinom 600 mg dva puta dnevno na dvanaest sati i u trajanju od dve nedelje. Debridmanom hronične gangrenozne rane alginatnim oblogama sa srebrom od sredine oktobra do sredine novembra 2018. godine, postiže se uklanjanje nekrotičnog i macerisanog tkiva. Sredinom novembra 2018. lečenje rane se nastavlja topikalnom antibiotskom terapijom, najpre ciprofloksacinom a zatim fusidinskom kiselinom uz redovno čišćenje i previjanje rane.
Krajem decembra 2018. primetno je povlačenje gangrene te formiranje kalusa na ivicama hronične rane, te je postignuta potpuna pokretljivost pacijenta. U nastavku lečenja, tokom 2019 godine. sprovodi se oštri debridman u kućnim uslovima radi uklanjanja kalusa sve do postizanja zarastanja i epitelizacije. Nezadovoljavajući socioepidemiološki uslovi i higijena stopala doprinose jako sporom i otežanom zarastanju. Krajem jula 2019. godine zbog znakova infekcije, lokalno se primenjuje betalaktamski antibiotik i ordinira peroralna antibiotska terapija Clindamycinom 600 mg dva puta dnevno. Radi bržeg zarastanja, krajem septembra 2019. godine debridman rane se sprovodi hidrofilnom poliuretanskom oblogom, dok se potpuno zarastanje hroničnog ulkusa-rane postiže početkom februara 2020. godine. Koža zadnjeg dela plantarne strane desnog stopala je suva i hiperkeratotična, te se pacijentu predočava potreba za prevencijom povređivanja i upotrebom sredstava za regeneraciju kože. 20 mg, in the evening. Over time, the patient accepted the therapy, tolerated it well, and used it regularly. Further BP measurements showed normal BP values. The patient found selective beta-blocker and acetylsalicylic acid unnecessary, so he discontinued them by himself. Despite poor glycemic control, and values between 13-14 mmol/l he refused to make any changes in his antidiabetic therapy. Simultaneously, the treatment of the wet gangrene of the right foot was conducted. Initially, the wound was treated with saline solution and iodine. We also suggested the use of alginate-argent compresses for the debridement`s sake, which the patient gladly accepted. Due to the widespread infection of the right foot, we initiated the course of antibiotics orally (clindamycin, 600 mg, twice daily, for 14 days). The wound debridement, with the use of alginate-argent compresses, from mid October to mid November 2018, led to the removal of the necrotic and macerated tissue. Since mid November, the wound treatment was continued with the topical antibiotic application, using ciprofloxacin and then fusidic acid afterwards, with regular wound cleaning.
Since the end of December 2018, there was a noticeable withdrawal of the gangrenous tissue and callus started forming on the edges which enabled the patient to move with no difficulties. During 2019, in our home visits, we used the sharp debridement of the wound, constantly removing callous tissue until the wound started to heal. The unsatisfactory socio-epidemiologic conditions and foot hygiene contributed to the slow and difficult foot healing. By the end of July 2019, there was a new wound infection and we started the treatment with the topical use of beta-lactam antibiotics and peroral use of Clindamycin, 600mg, twice daily. In order to speed up the healing, we started the application of hydrophilic polyurethane compresses by the end of September 2019. The complete healing was achieved by the beginning of February 2020. The skin on the posterior part of the plantar side of the right foot was dry and hyperkeratose, so the patient was instructed to prevent skin damaging and use skin regeneration products.       Figure 5. Hydrophilic polyurethane coating accelerates the healing process. On Septembre 24 th , 2019. The coating is molded to the wound and matches its shape; sharp wound debridement is performed prior to the coating; the wound is noticeably smaller due to the formation of the granulation tissue which in time transforms into the scar which is mechanically stress proof 8 .
The antibiotic therapy we used was mostly empiric due to the reasons we mentioned before. 9,10 The education of the patients with high gangrene risk and the engagement of public health nursing are all part of the primary care services. The prevention and early spotting of the gangrenous wounds could hugely unburden the health system and ease the treatment. 11 Optimal glycemic control in diabetic patients is the best form of preventing complications. 12 The nurses` role is also very important because they could easily pass the information to a doctor on any skin changes in diabetic patients. It`s especially important for the rural areas where very often the physicians are not attainable on a daily bases. 13, 14 The introduction of the modern compresses for the debridement of the chronic wounds (alginate-argent ones at the beginning and polyurethane ones during the healing process) with the systemic and topical use of antibiotics stopped the further gangrene spread and eventually led to the wound healing. During the treatment, we also used the standard cotton gauze, but the possibility of continuous use of modern compresses and healing wound products could significantly speed up the healing process. The alpha-lipoic acid, which was introduced from the very beginning of the treatment, is one of the most potent antioxidants and has got an anti-inflammatory effect. 15,16 We are not really sure how much it contributed to wound healing, because the patient used it irregularly, which probably prolonged the treatment.

Conclusion
Treating chronic wounds with an advanced gangrene entails a holistic approach towards the patient, which includes the treatment of the main disease as well as the comorbidities. A patient`s willingness to cooperate is one of the most important prerequisites for the successful treatment. Even with the limited theraputic possibilities, unsatisfactory socio-epidemiologic conditions, rural environment, a full cooperation with the physician could significantly shorten the treatment process. Although the gangrene treatment is very difficult and complex we proved that PCPs are quite capable to treat patients with gangrene and diabetes successfully.