Post-Operative Course
Post-operatively, the patient was transferred back to the ICU for close
monitoring for recurrent bleeding. The patient was continued on propofol
sedation to minimize movement in order to reduce rebleeding risk.
Mechanical DVT prophylaxis was utilized while pharmacologic options were
held given the high risk of rebleeding. D8 post-operative hemoglobin was
9.3. The following day (postoperative day 1) the hemoglobin was 8.9
without additional blood product administration. Post-operative packing
was left in the ITPW for 48 hours following the procedure. Subsequent
examination of the ITPW on D10 revealed a clean wound with no
significant bleeding. The wound was redressed with Xeroform, normal
saline moistened Kerlix, and covered with 2 ABD pads and a pressure
dressing. Dressing changes were performed daily by the general surgery
team. Daily examinations of the ITPW continued to show minimal oozing
from the wound base and no evidence of active bleeding.
Hemoglobin remained stable between 8.2-9.2 with no signs of recurrent
arterial bleeding. By D20, the wound exhibited signs of healing with
good granulation tissue along the medial aspect, (Figure 2A and B).
However, on D21, foul-smelling discharge was detected on ABD pads and a
wound investigation revealed sloughing tissue and decreased granulation
tissue. To address this finding, the dressing changes were increased
from once a day to twice a day and switched to VASH moistened Kerlix.
This change proved effective in improving the wound healing process.
On D28 wound assessment revealed a 17cm x 7.5cm x 3 cm wound with 40%
necrotic tissue down the length of the center of the wound with 60% red
moist granulation tissue along the sides with moderate sanguineous
drainage. The patient was discharged from the general surgery team on
D30, three weeks after wound exploration, with no evidence of rebleed
and overall improving wound appearance. The patient was discharged with
continued wound care at the patient’s assisted living facility, and a
general surgery clinic follow-up was scheduled 3 weeks after the
discharge date.
The patient was not able to follow up in the general surgery clinic at
the 3-week post-operative date. Unfortunately, he was subsequently
hospitalized for dyspnea secondary to ventilator-associated pneumonia
and COVID-19 pneumonia complications on 4/12. This hospitalization
offered the general surgery team the opportunity to re-evaluate his
wound status. Wound assessment of the right ischial tuberosity wound on
4/13 (D106) showed red, moist walls around the wound with good
granulation tissue. Slough covered the deep base of the wound and over
the boney prominence. There was moderate sanguineous drainage but no
signs of local infection, and wound edges were intact.