Cocaine Use and Levamisole-Induced Vasculitis: A Multiple Case Study.

BACKGROUND: Levamisole is an immunomodulatory medication previously used to treat rheumatoid arthritis and some types of cancers; it was banned for use in humans in 2000 owing to its harmful side effects. Use of levamisole-laced cocaine is associated with a life-threatening syndrome characterized by a necrotizing purpuric rash leading to tissue destruction and necrotic wounds. This Clinical Challenges article summarizes our experience with the care of 2 adult women diagnosed with levamisole-related vasculitis. CASE: Case 1 is a 46-year-old woman who presented with joint pain in her hands and legs, along with bilateral ear pain, swelling, and bleeding. She was initially diagnosed with vasculitis and possible systemic lupus erythematosus. She experienced multiple recurrences and exacerbation of her condition over a period of months. She was ultimately diagnosed with levamisole-related vasculitis from recurrent cocaine use resulting in bilateral above the knee amputations. The second case is a 50-year-old woman who presented to our emergency department with redness and swelling of her bilateral lower extremities. She developed blisters and pustules that rapidly evolved into abscesses and red lesions over the course of several months. Her wounds also deteriorated despite topical therapy that occurred in a context of recurring use of cocaine. CONCLUSIONS: Our experience with these cases suggests that WOC nurses should consider levamisole-induced vasculitis in all patients presenting with unexplained vasculitis-type lesions, and particularly when these lesions occur in the context of known or suspected use of illicit substances such as cocaine. Given the absence of clinical guidelines for this increasingly prevalent condition, we recommend wound care based on principles of moist wound healing, combined with judicious use of therapies with antimicrobial activity and nonadherent dressings to reduce pain. Finally, we strongly recommend that care of these patients occurs as one part of a multidisciplinary care approach that focuses on cessation of the use of cocaine and all other illicit substances.

Broadening Our Bandwidth: A Multiple Case Report of Expanded Use of Telehealth Technology to Perform Wound Consultations During the COVID-19 Pandemic.

BACKGROUND: Managing patients during the coronavirus disease-2019 (COVID-19) pandemic, and the associated severe acute respiratory syndrome-related coronavirus-2 (SARS-CoV-2) in particular, required the nimble responsiveness for which WOC nurses are known. Problem-solving skills were needed to continue the level of WOC nursing services expected by patients, families, and professional colleagues, while reducing the hours we were physically present at our clinical facility. In order to respond to these demands, our team realized it must create an innovative approach to provide efficient, cost-effective consultations during this global crisis. This Challenges in Practice article summarizes our experience with use of telemedicine technologies to perform remote consultations within the acute care setting. CASES: Case 1 was a 52-year-old woman with a history of paraplegia. She had several pressure injuries but had not received topical care for these wounds prior to admission. A consultation for the WOC nurse was requested and performed via telehealth services on a day our team was working off-site. This case illustrates the process our team used to perform a virtual consultation and demonstrates how the use of images placed in the electronic medical record aided in developing an effective plan of care. Case 2 was a 48-year-old man who tested positive for COVID-19. He developed bilateral unstageable pressure injuries on his cheeks after being placed in the prone position for a prolonged period while critically ill. This case describes multiple technologic platforms used for telemedicine consults in a patient with COVID-19 requiring isolation. CONCLUSIONS: Remote consultation by WOC nurses was possible in our healthcare system because of previous experience using telemedicine technology and well-established collaborative relationships with providers and bedside nurses. By expanding our use of telemedicine technology, we were able to provide ongoing care to a patient without COVID-19 who had WOC consultation needs, and a patient with strict isolation demands due to COVID-19.

Telemedicine in a rural community hospital for remote wound care consultations.

BACKGROUND: We found that the number of patients requiring wound care consultation was increasing but the distance from our rural campus to the main campus acted as a barrier for timely consultations. Therefore, we implanted a telemedicine program, based on technology manufactured by VISICU (Baltimore, MD) used by intensive care and step-down unit patients in our health system. PROCESS: A wound consultation was performed with one certified WOC nurse in the remote facility and another certified WOC nurse at the patient's bedside to establish method reliability. Following this assessment of feasibility, we initiated a formal program for remote wound care consultations in March 2009. Fifty remote wound consults have been completed, resulting in an estimated savings of $5000. CONCLUSIONS: Limited evidence supports telemedicine for remote wound consultations; most literature is based on use of digital camera images or Web cam/computer programs. Our program uses a unique, real-time technology for remote wound care consultations. The potential cost-savings related to decrease in complications of wounds and the positive effects on patient progression and length of stay have not yet been measured. However, our initial experiences suggest that remote consultations using real-time telemedicine reduce delay between request for consultations and its completion, diminish transportation and nonproductive staff time costs, and are comparable to traditional face-to-face consultations.

Pressure Ulcers: Factors Contributing to Their Development in the OR.

The prevention of health care-associated pressure ulcers (HAPUs) is an important quality measure because HAPUs are considered a never event. The literature suggests that the prevalence rate of pressure ulcers is 8.5% or higher among patients who undergo surgical procedures that last longer than three hours. We performed a retrospective chart review to determine what factors contribute to the development of pressure ulcers in patients who undergo surgical procedures. The sample population included patients who acquired a pressure ulcer that was not present at admission and developed during their postoperative hospital stay. The project revealed consistent risk factors that may contribute to the development of pressure ulcers in patients who have undergone surgical procedures. These findings can drive the implementation of preventive measures to reduce the occurrence of HAPUs associated with surgical procedures.