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.