Debridement washout

Can someone look at this op note and tell me what code you would use and how many units?

ize of Lesions: 85x50x12cm26-year-old woman who underwent a degloving injury due to her trauma. She developed necrosis of her skin had recurrent resection of the skin through the entire thigh circumferentially. This isn't been debrided last week. She has been washed out a few times. She returns operative for washout. I divided Dr. Moffett with plastic surgery to attend today and see what options we had for closure. Unfortunately there is a lot of the medial compartment muscles that are missing. There is no muscle left for particular flap. All the skin is missing. Her buttocks are intact, but we are uncertain if she has function of the right lower leg. She was taken off of sedation today but did not move the right leg despite moving the left one. Bottom line is perhaps amputation is on be best for her long-term.

Operative Note in Detail: Informed consent was obtained from family since she is intubated and sedated. She is brought from the ICU to the operative table placed on table in supine position. Her dressings were removed. The leg was prepped with Betadine circumferentially. We utilized the thigh drape. A timeout was called. She is on scheduled antibiotics. We began by manually examining the wound entirely. There is some small areas of necrosis that were removed bluntly. Should not require any use of cautery for bleeding. The skin distally by the knee and proximal by the hip was good. There were some small pockets was serous fluid that were opened and the pockets were drained. We then washed the entire leg with 6 L of saline with the Pulsavac. The femoral artery remains palpable, however the medial side of the quad is starting to cover this somewhat in sticking down. The central portion of the superficial femoral artery is still a little bit exposed. After washing the entire leg, we wrapped this with Kerlix soaked in Dakin's. It was wrapped with burn dressing and then a heavy Ace was used to hold this all in place. She was taken from the operating theater back to the the ICU in stable but critical condition.

Sign In or Register to comment.