Cost-effectiveness estimates of the Mwanza sexually transmitted diseases intervention

Abstract

fingers and his left forefoot. We have made several changes to our practice: after initial resuscitation we remove all peripheral venous lines and use central venous access only to reduce limb oedema and the risk of infecting compromised tissues; we use axillary arterial lines rather than radial, brachial, or femoral lines, which are associated with more severe distal ischaemia; we minimise the use of vasoconstricting inotropes; we use peritoneal dialysis followed by haemofiltration early in treatment; we involve members of the surgical team with an interest in peripheral limb injuries early on in treatment to assess limb damage; we do early fasciotomies for suspected compartment syndrome (do not delay because of disseminated intravascular coagulation or a high probability of death); we avoid debridement until the point of demarcation is clear; and we use intensive physiotherapy early in treatment to prevent contractures. We do not know whether the interstitial oedema released during fasciotomy is the cause or effect of small-vessel thrombosis and ischaemia. We postulate that early aggressive fasciotomy gives a compromised limb the best chance of reperfusion. Scrupulous haemostasis, careful wound dressing, and re-exploration mean that bleeding from fasciotomy sites is not a contraindication to surgery even if fully anticoagulated. We should no longer decide between life or limb, because we can successfully have both. Moreover, limb salvage should be done with reconstructive considerations in mind. Thus, early aggressive management of limb-threatening disorders together with life-saving resuscitation is essential if the long-term sequelae of multiple amputations are to be kept to a minimum.