**4.1 Immediate debridement and amputation aiming at infection control**

Extremity ulcers in patients receiving HD are often difficult to heal. Nonetheless, patients with severely ischemic limbs due to maintenance HD are markedly increasing in number 1,2). They often require multiple surgeries because arteriosclerosis obliterans usually progresses, which causes other ischemic ulcers (Figures 2, 11, 12).

Fig. 11. (A) A patient with an ischemic foot due to maintenance HD developed necrosis of the left 2nd toe. (B) The ulcer was resolved by amputation. (C) However, he developed another site of necrosis with infection (arrow) on the third toe. (D) The patient underwent immediate debridement and osteotomy. (E)The wounds healed satisfactorily.

Complex Wounds in Patients Receiving Hemodialysis 133

necrosis. In our study, 14 patients underwent finger or limb amputation, with 9 due to

Fig. 13. (A) A 63-year-old man who suffered a burn visited our medical center 4 days after injury. He had received hemodialysis because of diabetes mellitus for 2 years. The blood access shunt in the left elbow, shown in the picture. On the first examination, the burn wound was covered with necrotic eschar with infection, and the patient showed burn wound sepsis with high fever. Debridement and free skin grafting were immediately

It is commonly believed that the development of ischemic limb ulcers in patients with CRF is influenced by underlying advanced diabetic microangiopathy 25). Although we have investigated severe extremity ulcers requiring surgical treatment, the present study indicates that the development of ulcers in patients with DM is not only associated with ischemia but is also strongly influenced by infection, because 11 of 13 patients with DM had infectious conditions such as gangrene, osteomyelitis, necrotizing fasciitis, and/ or sepsis. On the other hand, the development of ulcers in patients without DM was mainly due to ischemia and trauma. Only 2 patients developed MRSA sepsis originating from secondary

The interval from the start of HD to wound development in patients with was significantly shorter than that in those without DM. Generally, ulcers in patients with CRF and DM are thought to develop because of peripheral neuropathy, which reduces protective sensations 26). In addition, several investigators have reported incidences of peripheral arterial occlusive disease in patients receiving HD ranging from 2.5 to 19.0% 27, 28). Because of these neurovascular disorders, extremity ulcers develop more easily in patients with DM than in

performed. (B) The burn wound had resurfaced 3 weeks after surgery.

wound infection, and they underwent amputation.

those with other diseases.

A B

complicated sepsis and 5 due to dry necrosis associated with arteriosclerosis obliterans.

Fig. 12. (A) A case of Fournier's gangrene. A patient receiving HD due to DM developed progressive infection and necrosis of the scrotum and penis. (B) He underwent immediate debridement. (C)The wound was resurfaced with a mesh graft 2 weeks later. (D) However, necrosis of the penis progressed, and so the patient underwent amputation of the penis

Amputations of limbs or fingers are sometimes performed for these complex ulcers, because patients receiving HD are thought to present with immunocompromised conditions, and aggressive life-threatening infections such as sepsis require immediate surgical debridement in order to salvage the blood access line and their life (Figure 13). Only administrating antibiotics for the contaminated wound containing necrotic tissue is of no use and worsens the condition of patients, because antibiotic agents cannot reach the non-vascularized and infected necrotic mass. Immediate surgical debridement is the only recommended way to resolve these soft tissue infections (Figure 14) 23, 24). Surgical amputation is sometimes the only way to resurface these wounds, especially for some ischemic necrotic wounds including total finger or foot dry

C

Fig. 12. (A) A case of Fournier's gangrene. A patient receiving HD due to DM developed progressive infection and necrosis of the scrotum and penis. (B) He underwent immediate debridement. (C)The wound was resurfaced with a mesh graft 2 weeks later. (D) However, necrosis of the penis progressed, and so the patient underwent amputation of the penis

Amputations of limbs or fingers are sometimes performed for these complex ulcers, because patients receiving HD are thought to present with immunocompromised conditions, and aggressive life-threatening infections such as sepsis require immediate surgical debridement in order to salvage the blood access line and their life (Figure 13). Only administrating antibiotics for the contaminated wound containing necrotic tissue is of no use and worsens the condition of patients, because antibiotic agents cannot reach the non-vascularized and infected necrotic mass. Immediate surgical debridement is the only recommended way to resolve these soft tissue infections (Figure 14) 23, 24). Surgical amputation is sometimes the only way to resurface these wounds, especially for some ischemic necrotic wounds including total finger or foot dry

A B

D

necrosis. In our study, 14 patients underwent finger or limb amputation, with 9 due to complicated sepsis and 5 due to dry necrosis associated with arteriosclerosis obliterans.

Fig. 13. (A) A 63-year-old man who suffered a burn visited our medical center 4 days after injury. He had received hemodialysis because of diabetes mellitus for 2 years. The blood access shunt in the left elbow, shown in the picture. On the first examination, the burn wound was covered with necrotic eschar with infection, and the patient showed burn wound sepsis with high fever. Debridement and free skin grafting were immediately performed. (B) The burn wound had resurfaced 3 weeks after surgery.

It is commonly believed that the development of ischemic limb ulcers in patients with CRF is influenced by underlying advanced diabetic microangiopathy 25). Although we have investigated severe extremity ulcers requiring surgical treatment, the present study indicates that the development of ulcers in patients with DM is not only associated with ischemia but is also strongly influenced by infection, because 11 of 13 patients with DM had infectious conditions such as gangrene, osteomyelitis, necrotizing fasciitis, and/ or sepsis. On the other hand, the development of ulcers in patients without DM was mainly due to ischemia and trauma. Only 2 patients developed MRSA sepsis originating from secondary wound infection, and they underwent amputation.

The interval from the start of HD to wound development in patients with was significantly shorter than that in those without DM. Generally, ulcers in patients with CRF and DM are thought to develop because of peripheral neuropathy, which reduces protective sensations 26). In addition, several investigators have reported incidences of peripheral arterial occlusive disease in patients receiving HD ranging from 2.5 to 19.0% 27, 28). Because of these neurovascular disorders, extremity ulcers develop more easily in patients with DM than in those with other diseases.

Complex Wounds in Patients Receiving Hemodialysis 135

MRSA was isolated from almost all chronic wounds in patients with DM, which also suggested that HD-receiving patients with DM tend to bear multi-drug-resistant organisms,

The control of infection after aggressive debridement is the most important point to heal the wound and prevent the recurrence of infection. When initial debridement is insufficient and local infection recurs, further debridement is required. Wound infection cannot be controlled in the presence of necrotic tissue. If a patient shows relapsed wound infection without necrosis and foreign bodies remaining in the wound, cleansing the wound using continuous irrigation employing suction and irrigation system is recommended. This was also adapted for the treatment of osteomyelitis (Figure 15) 29). It is concluded that when a risk of recurring an infection remains after primary debridement, two-stage management, involving late second stage surgery included secondary debridement and stable

Fig. 15. (A) A patient receiving HD because of DM for 3 years developed osteomyelitis of the left big toe, and underwent debridement and wound closure. However, the soft tissue infection relapsed 5 days later. (B) He underwent secondary debridement and continuous irrigation, using a suction and irrigation system. (C) Three weeks later, the wound was covered with abundant granulation tissue with no infection. The wound closed

After the debridement of necrotic tissue, the wound bed needs to be prepared to receive either a graft or flap. 31) The resurfacing of wounds is one of the most important procedures, because such wounds will cause further infection, exudates, odors, and bleeding, which decrease the patient's quality of life. Chronic ulcers may sometimes prevent the patient from living at home. 32) Wound bed preparation has allowed uncomplicated wounds to heal quickly. 23, 33-37) The management of chronic wounds has progressed from assessing the

**5. Wound bed preparation for patients receiving HD** 

and, thus, strict infection control is required to prevent outbreaks.

reconstruction, should be considered.30)

spontaneously.

These infectious wounds often result in higher mortality rates because blood access shunts, especially when an artificial vessel is grafted, are easily infected. Bacteria from the wounds usually diffuse proximally along the subcutaneous flow of lymph or blood and can cause shunt infections, which lead to the loss of blood access channels and life-threatening sepsis. All our patients with infectious wounds (14 cases) required immediate debridement, including amputation to prevent such unfavorable general infections, because aggressive local inflammatory reactions had already developed (Figure 14). Thirteen of these patients had DM.

Fig. 14. (A) A 65-year-old man developed necrotizing fasciitis of the right leg, with pain and high fever. He had received hemodialysis because of diabetes mellitus for 1 year. The blood access shunt in the right elbow showed inflammation. Below-knee amputation was immediately performed. (B) A 52-year-old man developed a complex necrotic ulcer on the right foot with a high fever. He had received hemodialysis because of diabetes mellitus for 2 years. His blood access shunt in the left elbow also showed inflammation. Amputation of the fifth toe was immediately performed.

These infectious wounds often result in higher mortality rates because blood access shunts, especially when an artificial vessel is grafted, are easily infected. Bacteria from the wounds usually diffuse proximally along the subcutaneous flow of lymph or blood and can cause shunt infections, which lead to the loss of blood access channels and life-threatening sepsis. All our patients with infectious wounds (14 cases) required immediate debridement, including amputation to prevent such unfavorable general infections, because aggressive local inflammatory reactions had already developed (Figure 14). Thirteen of these patients had DM.

Fig. 14. (A) A 65-year-old man developed necrotizing fasciitis of the right leg, with pain and high fever. He had received hemodialysis because of diabetes mellitus for 1 year. The blood

B

A

access shunt in the right elbow showed inflammation. Below-knee amputation was immediately performed. (B) A 52-year-old man developed a complex necrotic ulcer on the right foot with a high fever. He had received hemodialysis because of diabetes mellitus for 2 years. His blood access shunt in the left elbow also showed inflammation. Amputation of

the fifth toe was immediately performed.

MRSA was isolated from almost all chronic wounds in patients with DM, which also suggested that HD-receiving patients with DM tend to bear multi-drug-resistant organisms, and, thus, strict infection control is required to prevent outbreaks.

The control of infection after aggressive debridement is the most important point to heal the wound and prevent the recurrence of infection. When initial debridement is insufficient and local infection recurs, further debridement is required. Wound infection cannot be controlled in the presence of necrotic tissue. If a patient shows relapsed wound infection without necrosis and foreign bodies remaining in the wound, cleansing the wound using continuous irrigation employing suction and irrigation system is recommended. This was also adapted for the treatment of osteomyelitis (Figure 15) 29). It is concluded that when a risk of recurring an infection remains after primary debridement, two-stage management, involving late second stage surgery included secondary debridement and stable reconstruction, should be considered.30)

Fig. 15. (A) A patient receiving HD because of DM for 3 years developed osteomyelitis of the left big toe, and underwent debridement and wound closure. However, the soft tissue infection relapsed 5 days later. (B) He underwent secondary debridement and continuous irrigation, using a suction and irrigation system. (C) Three weeks later, the wound was covered with abundant granulation tissue with no infection. The wound closed spontaneously.
