Maricela123@gmail.com
Contributor
I need assistance in coding the following scenario.
PROCEDURE(S) PERFORMED: -
soft tissue debridement –
multiple local wound explorations –
biopsy of abdominal wall muscle and fascia
PRE-OPERATIVE DIAGNOSIS:
necrotizing soft tissue infection
end stage liver disease
POST-OPERATIVE DIAGNOSIS:
necrotizing myonecrosis
end stage liver disease
INDICATIONS FOR PROCEDURE:
68-year-old female with known end-stage liver disease who underwent a recent surgery with suprapubic catheter placement presents with a necrotizing soft tissue infection. Patient has been no complaint of abdominal pain for the past few days. Today while bathing her, her daughter noticed a foul-smelling wound at her previous suprapubic catheter location. The patient was taken to the ED for evaluation and found to have clinical evidence consistent with a necrotizing soft tissue infection. She was taken back to the operating room and found to have a necrotizing myonecrosis of the abdominal wall extending from the pubis up to her left chest wall. Given her extensive disease and underlying comorbidities it was determined that this was a nonsurvivable condition. A second surgeon was called to the OR to review the case and he independently agreed that this was nonsurvivable. As result, a discussion was had with the family explaining the findings and futile in this of any further care and the procedure was stopped and the patient was transported to the ICU with palliative care consult
DESCRIPTION OF PROCEDURE(S): The patient was placed in supine position on the operating table. General endotracheal anesthesia was induced without complication. The patient's perineum and abdomen were prepped and draped in usual sterile fashion. A surgical timeout was performed and the procedure began with exploring the suprapubic catheter wound. The surrounding skin and soft tissue was excised using Bovie electrocautery and the wound was discovered to track down to the pelvic wall musculature. Cultures were taken and the pelvic wall was examined and found to be grossly necrotic and extremely foul-smelling. Given this finding a separate incision was made in left lower quadrant and again soft tissue necrosis was discovered. A separate stick incision was then made higher along the abdominal wall on the left side and carried down to the musculature. The abdominal wall muscle at that site was again found to be necrotic, foul-smelling, with dish washer colored fluid consistent with a necrotizing myonecrosis infection. A fourth incision was then made on the left chest wall and again carried down to the fascia and muscle which was again found to be necrotic and foul-smelling consistent with necrotizing myonecrosis. Given these findings, it was evident that this patient had a nonsurvivable disease process and the operation was paused and the patient's status was discussed with her family. Given the severity of the patient's condition, it was decided to bring in another surgeon to examine the patient and the operative findings and give an additional opinion. Dr. Ricci was called in to the operating room, and the patient wounds were explored and the findings were reconfirmed independently. A biopsies of the abdominal wall from the separate wounds were taken and sent to microbiology and pathology for confirmation of the diagnosis. A separate incision was made on the patient's right abdominal wall and carried down to the fascia to determine if the disease process was bilateral. At that site the abdominal fascia was visualized and found to be uninfected. After consultation, it was confirmed that this patient had a nonsurvivable disease process and that continuing any operation would not result in any change in outcome of the patient's condition and was therefore futile. A discussion was again held with the patient's family and it was determined that the best course of action was to stop the operation, asked with the patient, allow her time to visit with her family, and consult palliative care postoperatively. The patient's wounds were then checked for hemostasis which was excellent and packed with Kerlix and covered with sterile ABDs and tape. She was then extubated and transported to the ICU in critical condition and palliative care consult was placed.
FINDING(S): necrotizing myonecrosis extending from the pubis to the left chest wall, Given the patients baseline health, end stage kidney disease, infection depth and extent of abdominal/chest/pelvic wall involvement this is a nonsurvivable disease process
COMPLICATIONS: none
SPECIMENS REMOVED: abdominal wall biopsy and cultures from pelvic muscle, abdominal muscle and chest wall
IMPLANTS/EXPLANTS: _ None
ESTIMATED BLOOD LOSS: minimal
PATIENT CONDITION: critical
PROCEDURE(S) PERFORMED: -
soft tissue debridement –
multiple local wound explorations –
biopsy of abdominal wall muscle and fascia
PRE-OPERATIVE DIAGNOSIS:
necrotizing soft tissue infection
end stage liver disease
POST-OPERATIVE DIAGNOSIS:
necrotizing myonecrosis
end stage liver disease
INDICATIONS FOR PROCEDURE:
68-year-old female with known end-stage liver disease who underwent a recent surgery with suprapubic catheter placement presents with a necrotizing soft tissue infection. Patient has been no complaint of abdominal pain for the past few days. Today while bathing her, her daughter noticed a foul-smelling wound at her previous suprapubic catheter location. The patient was taken to the ED for evaluation and found to have clinical evidence consistent with a necrotizing soft tissue infection. She was taken back to the operating room and found to have a necrotizing myonecrosis of the abdominal wall extending from the pubis up to her left chest wall. Given her extensive disease and underlying comorbidities it was determined that this was a nonsurvivable condition. A second surgeon was called to the OR to review the case and he independently agreed that this was nonsurvivable. As result, a discussion was had with the family explaining the findings and futile in this of any further care and the procedure was stopped and the patient was transported to the ICU with palliative care consult
DESCRIPTION OF PROCEDURE(S): The patient was placed in supine position on the operating table. General endotracheal anesthesia was induced without complication. The patient's perineum and abdomen were prepped and draped in usual sterile fashion. A surgical timeout was performed and the procedure began with exploring the suprapubic catheter wound. The surrounding skin and soft tissue was excised using Bovie electrocautery and the wound was discovered to track down to the pelvic wall musculature. Cultures were taken and the pelvic wall was examined and found to be grossly necrotic and extremely foul-smelling. Given this finding a separate incision was made in left lower quadrant and again soft tissue necrosis was discovered. A separate stick incision was then made higher along the abdominal wall on the left side and carried down to the musculature. The abdominal wall muscle at that site was again found to be necrotic, foul-smelling, with dish washer colored fluid consistent with a necrotizing myonecrosis infection. A fourth incision was then made on the left chest wall and again carried down to the fascia and muscle which was again found to be necrotic and foul-smelling consistent with necrotizing myonecrosis. Given these findings, it was evident that this patient had a nonsurvivable disease process and the operation was paused and the patient's status was discussed with her family. Given the severity of the patient's condition, it was decided to bring in another surgeon to examine the patient and the operative findings and give an additional opinion. Dr. Ricci was called in to the operating room, and the patient wounds were explored and the findings were reconfirmed independently. A biopsies of the abdominal wall from the separate wounds were taken and sent to microbiology and pathology for confirmation of the diagnosis. A separate incision was made on the patient's right abdominal wall and carried down to the fascia to determine if the disease process was bilateral. At that site the abdominal fascia was visualized and found to be uninfected. After consultation, it was confirmed that this patient had a nonsurvivable disease process and that continuing any operation would not result in any change in outcome of the patient's condition and was therefore futile. A discussion was again held with the patient's family and it was determined that the best course of action was to stop the operation, asked with the patient, allow her time to visit with her family, and consult palliative care postoperatively. The patient's wounds were then checked for hemostasis which was excellent and packed with Kerlix and covered with sterile ABDs and tape. She was then extubated and transported to the ICU in critical condition and palliative care consult was placed.
FINDING(S): necrotizing myonecrosis extending from the pubis to the left chest wall, Given the patients baseline health, end stage kidney disease, infection depth and extent of abdominal/chest/pelvic wall involvement this is a nonsurvivable disease process
COMPLICATIONS: none
SPECIMENS REMOVED: abdominal wall biopsy and cultures from pelvic muscle, abdominal muscle and chest wall
IMPLANTS/EXPLANTS: _ None
ESTIMATED BLOOD LOSS: minimal
PATIENT CONDITION: critical