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Hi everyone, what would you recommend for an ulcer located on dorsal aspect of the foot with exposed tendons, extensive ulcer base and minimal exudate noted. This 80 year old lady refused to have her foot amputated.The Docs have ordered Iodosorb dressing daily. I was wondering if anyone has other suggestions on dressings since this lady is going under conservative management and Iodosorb can be expensive on the long run.

Cheerios.

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Miss Gangrene

With such extensive disease, it is unlikely that Iodosorb will be required in the long term, as if the patient continues to refuse amputation she is likely to become systemically unwell and die.

Otherwise you can try wet to moist saline packs 3-4 times a day. but I would be trying to help the patient realise the seriousness pf the situation.

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Stephen Tucker
Eastern Health
Podiatry Manager

My location

Stephen, thanks for your kind input. Basically the patient is bedridden and suffering from dementia as well. The family members are not keen on amputation as suggested by the orthopaedic Drs. Conservative treatment is the only way to go.
I disagree with Iodosorb dressing. My suggestion is to use Normgel or Tenderwet product.

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Miss Gangrene

Using Iodosorb will dry out the wound base where there is minimal exudate. Using a hydrogel such as Granugel or Purilon will maintain a moist environment. If the Iodosorb has been prescribed for antibacterial properties then try using Aquacel Ag as a secondary dressing. Possible problems with using Iodosorb over a long period is that it can affect thyroid function. Wound dressings in dementing patients is always a tricky one. There will be days when she will vehemently oppose any intervention and others where she will be more than co-operative, therefore your choice of dressing and frequency of change must also take these factors into account.

Generally the more frail and elderly the worse the surgical risk, but at the risk of offending others what would be the point of amputation if she is already bedbound? Potentially she may not survive the procedure, or post op recovery. I worked with such patients for a number of years. It is a very fine balance between managing the wound, the patient and the relatives, particularly if she is cared for at home.

If there is no possiblility that the wound will heal then this must be made clear to the relatives. This can then allow you to tackle why you are using particular dressings. Once it is accepted that the wound is of a terminal nature then you can generally use dressings such as a hydrocolloid which would allow less frequent changes, or even film dressings with absorbent padding. Using activated charcoal as a secondary will help minimise any odour.

Good luck with whatever wound dressings you decide. A case like this is where your 'people skills' will be probably be needed more than your Podiatry skills.

Nikki

Are they using the iodosorb to treat infection?, you did not mention the CRP level. What is the peripheral circulation like?

Helen Robins
Multidisciplinary Diabetic Foot and Ulcer Clinic
Montana Hospital
Pretoria, South Africa

Helen: the patient has reached to the stage for the limb amputation. Like what Nikki has said, the family member has decided not to proceed with the surgical procedure due to the fact that the elderly patient may not even survived the ordeal.

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Miss Gangrene

Sounds like it's not going to be a problem for very long either way. If the patient is that old and frail i can kind of see why they don't want to start chopping bits off. I would thing a moist dressing would be more comfortable than one which will dry the wound. Intrasite gel maybe?

This is why i switched to bio mechanics. My patients are rarely terminal even after i've seen them.

Best of luck :(

Robert

I think the 'stage for limb amputation' differs from hospital to hospital, country to country. In South Africa, the criteria for limb amputation may differ according to the facilities available etc etc. I am interested to hear from different clinics around the world on their criteria, is there consensus in other countries on this issue. I work in a clinic which often ends up with these patients who refuse amputation and sometimes, if we are lucky, save their limbs, in spite of dementia and other problems. The problems is always money and family/patient committment.

As far as dressings go I agree with all other submissions.

Helen

I would use Aquacell AG moistened on application to keep the wound moist and hopefully less painful. At the end of the day the main aim is comfort and to reduce the risk of infection.

Hi

Are you in Australia??

I would also recommend aquacel ag, but we have also had really good results with a honey dressing. Is it possible to show us a photo, a pic can tell you so much more. Dressings for these wounds are always expensive.
Also wondering if the community nurses are involved, as they often supply the dressings, as should the nursing home if the patient is in one.

Cheers

If it is a non infected chronic wound, a foam dressing like Biatain or polymem should do. This dressing will soak up the small amount of exudate and provide some protection to the area. A small amount of a hydrogel placed in the wound will also stop the wound drying out or help with the absorbtion of exudate. This type of dressing can be kept on for several days, depending on the amount of exudate breaking through.

Regards

Good advice from all responders.

Similar situations for me in previous years; used hydro gel topped with Acticoat silver dressing when suspicous of infections. Comfort and reducing infection risk were my main criteria, keeping family happy came second. Sadly, it's always been a waiting game until the pt leaves this earth.

Good luck