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Protocol Management of Late Stage Pressure Ulcers: a 5 year retrospecitive study of 101 consecutive patients with 179 ulcer
Kristin Hudak, MD1, David L. Larson, MD1, Kevin Simonelic, BS2.
1Medical College of Wisconsin, Milwaukee,, WI, USA, 2University of Miami, Miami, FL, USA.
PURPOSE: Pressure ulcers affect over a million adults, costing up to $40,000 per episode to treat. Despite reported recurrence rates between 12% and 82%, no standard protocol exists. Most studies examine small sample sizes with few reported outcomes and diverse treatment plans. While some authors suggest the necessity of adequate preoperative nutrition, others recommend a two-stage process: debridement, six weeks of intravenous antibiotics, followed by reconstruction. Our institution has a closed system whereby patients are treated by a single surgeon and treatment team. We use a standard surgical protocol: 1. surgery and immediate reconstruction, regardless of nutritional status, 2. intra-operative bone culture taken in a sterile manner to guide postoperative antibiotic use, and 3. hospital admission for three weeks of flat bed rest before starting a graduated sitting schedule. This study examines the effectiveness of this protocol in providing long term ulcer closure to a large group of patients.
METHODS: A retrospective chart review was performed on consecutive pressure ulcers patients treated surgically over a five-year period at a single-institution using the same protocol. A search of billing records by Current Procedural Terminology identified 101 patients with 179 ulcers. Data abstracted from the charts included demographics, co-morbidities, location and stage of ulcers, treatment history with outcomes and laboratory data. All patients had surgery and immediate reconstruction, regardless of nutritional status or osteomyelitis.
RESULTS: There were 79% male, 70% white, with a mean age of 49.4 years. A third were smokers. Of the 179 ulcers, 49.7% were ischial, 26.8% sacral, 19% trochanteric and 4.5% in other locations. Most were stage 4 (87.7%) while the remainder were stages 2 and 3. Primary closure was performed on 45.8% with the remainder receiving flap closure. Over two-thirds (67.7%) had operative bone cultures (52.1% positive). There was no correlation between positive bone cultures and recurrence (p=0.93). Overall recurrence rate was 16.8%--6.5% at 180 days, 13.6% at 360 days with mean recurrence at 435.9 days. New ulcer occurrence was 14.5%. Complication rate was 17.3%; only 5/32 were considered major, requiring an additional operation. The most common complication was suture-line dehiscence; less common complications included soft tissue infection and some flap necrosis. There was a statistically significant increase in prealbumin of 8.27 mg/L (CI 7.25-9.3) and albumin of 0.32 g/L (CI 0.24-0.40) from admission to discharge (p<0.0001). The admission prealbumin (p=0.2) and albumin (p=0.43) did not correlate with recurrence. The mean follow-up was 629 days.
CONCLUSION: The use of a standard clinical pathway for pressure ulcer treatment appears to improve long-term outcomes by decreasing variability in treatment. The validity of our protocol is supported by low recurrence and complication rates. Contrary to traditional beliefs, nutritional data at the time of operation does not predict outcome; with definitive closure of the wound, the nutritional markers improve significantly. Intra-operative bone cultures are the most valid method to diagnose and treat osteomyelitis. The results of the bone culture should not delay immediate definitive treatment.
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