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PubMed2001

Factors influencing the development of decubitus ulcers in critically ill surgical patients.

INTRODUCTION: Decubitus ulcers confer significant morbidity to critically ill patients. We sought to determine which patient factors contributed to the formation of decubitus ulcers in our critically ill patients, and hypothesized that these ulcers occurred most often in elderly patients with lengths of stay >7 days and high severity of illness. METHODS: This study was conducted prospectively in two phases. Phase I provided an initial analysis of patients who developed decubitus ulcers in the surgical intensive care unit (ICU) of New York Weill Cornell Center from January 1, 1993, to June 1, 1997. In phase II of the study, a comparison study was made for patients with ICU length of stay (ULOS) >7 days admitted to the same ICU from January 1, 1998, to August 31, 1998. Age, APACHE III score, systemic inflammatory response syndrome (SIRS score), multiple organ dysfunction syndrome (MODS) score, admission status, days without nutrition, ULOS, mortality, days to formation of decubitus ulcers, Cornell ulcer risk score, and other demographic features were recorded. Univariate and multivariate analysis of variance were performed to analyze independent risk factors for development of decubitus ulcers; p <.05. RESULTS: In phase I, 2,615 patients were admitted to surgical ICU over the study period. One hundred and one decubitus ulcers occurred (incidence 3.8%) during phase I, but the incidence of decubitus ulcers increased significantly over time to 9% (p <.01). Thirty-three decubitus ulcers occurred among the 412 patients (incidence 8.0%) during phase II. Multivariate analysis revealed that emergent admission (odds ratio [OR] 36.00, 95% confidence interval [CI] CI 0.2290-0.7694), age (OR 1.08, 95% CI 0.0026-0.0131), days in bed (OR 1.05, 95% CI -0.0013-0.0156, and days without nutrition (OR 0.51, 95% CI -0.1095--0.0334) were independent predictors of a decubitus ulcer. CONCLUSIONS: The incidence of decubitus ulcers is increasing in critically ill patients. Emergency ICU admission and ULOS >7 days in elderly patients confer significant risk for the formation of decubitus ulcers. Specific interventions targeting this high-risk population that may be instituted to decrease the incidence of decubitus ulcers include early nutrition, early mobilization, and possibly less noxious bedding surfaces.

APACHE↗
PubMed2004

Supine/left decubitus scanning: a valuable alternative to supine/prone scanning in CT colonography.

The purpose was to evaluate supine/left decubitus as an alternative to supine/prone scanning in computed tomographic colonography (CT colonography). Fifty patients were randomised to supine/prone, another 50 to supine/left decubitus scanning. Patients were scanned using a single-slice CT scanner. The colon was divided into eight segments. Comparisons of distension, breathing artefacts, residus and polyp detection were made between the two groups as well as between the different positions. Adequate distension was found in approximately 85, 97 and 95% of segments in the supine, prone and left decubitus positions, respectively. Combined scanning increased the percentage of adequate distension to 98.5% for prone-supine and 97.7% for left decubitus-supine scanning ( P<0.0005 compared to supine, P=0.001 compared to left decubitus and P=0.046 compared to prone scanning). Absence of residual material was found in approximately 62.7, 69.7 and 64% of segments in the supine, prone and left decubitus positions, respectively. Combined scanning increased this percentage to approximately 99% for both groups. No significant differences towards distension or residual material were found between combined supine-prone or supine-left decubitus scanning. In the supine-prone group, combined scanning additionally revealed four lesions and improved conspicuity in two cases of stalked polyps. In the supine-left decubitus group, combined scanning additionally revealed two lesions and improved conspicuity in one stalked polyp. There were significantly fewer breathing artefacts with left decubitus scanning than prone scanning ( P=0.005). A strong positive correlation was found between breathing artefacts and the age of patients in both patient groups. Colonic distension and preparation is improved by using supine and prone or supine and left decubitus scanning in combination, with a subsequent improved polyp detection. There were no significant differences between the two scanning protocols. Prone scanning, however, is hampered by breathing artefacts, especially in the elderly. Therefore, supine-left decubitus scanning is considered a valuable alternative to supine-prone scanning for the elderly.

Adult↗
PubMed2003

Autopsy-based assessment of extent and type of osteomyelitis in advanced-grade sacral decubitus ulcers: a histopathologic study.

CONTEXT: Decubitus ulcers constitute a serious medical problem, often encountered in association with hospitalization or institutionalization in senior citizens' or nursing homes. Potentially life-threatening sepsis has been reported to originate not only from soft tissue infection, but also from osteomyelitis as a complication of involvement of bone tissue in decubitus ulcers. OBJECTIVE: To assess the histopathology of osseous structures involved in grade IV decubitus ulcers. DESIGN: Autopsy-based histopathologic assessment of the presence and extent of osteomyelitis on os sacrum specimens from 28 deceased individuals with grade IV sacral decubitus ulcers using an undecalcified preparation following plastic embedding (staining with Goldner, Kossa modification, toluidine blue, and Giemsa). RESULTS: The histologic findings were classified in 4 types of pathomorphologic changes: type 1, decubitus ulcer confined to soft tissue, no inflammation (n = 7); type 2, decubitus ulcer involving bone, no inflammation (n = 7); type 3, decubitus ulcer involving bone, inflammation of soft tissue, no osteomyelitis (n = 1); and type 4, decubitus ulcer involving bone, presence of osteomyelitis (n = 13). Type 4 changes are further described as follows: type 4a, chronic osteomyelitis alone (n = 6); and type 4b, chronic and acute osteomyelitic changes (n = 7). More than half of the cases (n = 15) showed no inflammatory reaction within the medullary cavity (types 1-3). In all cases with osteomyelitis, inflammation was exclusively confined to the superficial parts of the os sacrum. Chronic osteomyelitis was seen in all cases in which osteomyelitis was present. In addition, mild acute osteomyelitic changes were observed in 7 cases. Severe liquefying osteomyelitis affecting deeper layers of the os sacrum was not found. Sepsis was present in 2 cases; in one of these cases, the decubitus ulcer was considered a possible source of infection. CONCLUSIONS: Our results provide evidence that in cases of grade IV decubitus ulcers, the macroscopic aspect and clinical imaging techniques may lead to an overestimation of the extent of osseous involvement. We suggest that the investigation of bone biopsies is not necessary in a considerable proportion of cases of grade IV decubitus ulcers in patients without sepsis, as the minor osseous alterations are of little consequence when establishing a therapeutic approach.

Aged↗
PubMed2000

[Hemodynamics of the lower extremities in patients with decubitus ulcers using the ultrasonic Doppler method].

Our clinical experience indicates that decubitus ulcers with tissue loss/necrosis extending beyond the subcutaneous fat in aged patients are liable to become refractory and that most of these patients experience a cold feeling/cyanosis in the lower extremities. In order to determine the relationship between the severity of the decubitus ulcers and the hemodynamics in the lower extremities, we conducted a blood flow test using the ultrasonic Doppler method on the lower extremities in patients. Sixty-eight inpatients (38 men, 30 women, with an average age of 80.5 +/- 7.6 years old) were selected. B-mode tomographs were obtained with an ultrasonic diagnostic apparatus. The power Doppler method was used to measure blood flow rate, vascular lumen diameter, and intravascular blood flow at the dorsalis pedis artery, posterior tibial artery, peroneal artery furcation, and femoral artery. The subjects were divided into three groups: patients without decubitus ulcers; patients with mild to moderate decubitus ulcers of IAET Classification grade I-III; and patients with severe decubitus ulcers (IAET Classification grade IV), and the measurements were compared among the groups. The results revealed a tendency for the vascular lumen to become narrowed and intravascular blood flow to be reduced at all sites as decubitus ulcers increased in severity and showed the hemodynamics in the lower extremities to be particularly poor in the severe group. We measured the hemodynamics in the lower extremity with the ultrasonic Doppler method from the viewpoint of decubitus ulcer prevention and found differences in blood flow in the lower extremities according to the severity of decubitus ulcers. A reduction in blood flow in the lower extremities is considered to indirectly indicate a susceptibility to decubitus ulcers and to serve as a sign of its exacerbation. We consequently considered the test to be useful and concluded that deterioration of hemodynamics due to the progress of arteriosclerosis is one of the causes of decubitus ulcer exacerbation.

Aged↗
PubMed1991

[The costs of decubitus].

In this article the costs of prevention and treatment of decubitus (bed sores) are calculated and an analysis is made of the structure of these costs. Using documented figures on the prevalence of decubitus in hospitals and nursing homes and of prices related to decubitus prevention and treatment as made in a hospital (University Hospital Utrecht, the Netherlands) in which decubitus is treated according to a strict protocol, total costs were calculated by extrapolation. Prevention of decubitus costs Dfl. 95,-per day per patient, treatment of decubitus stages I and II Dfl. 133,-and of stages III and IV up to Dfl. 175,-. These figures result in annual costs of Dfl. 223 million for prevention, Dfl. 125 million for treatment of stages I and II and of Dfl. 122 million for stages III and IV. Together with a mean occupation of hospital beds of 74% this amounts to a total of Dfl. 350 million per year for hospitals and a similar amount for nursing homes, or Dfl. 700 million in all. The costs of decubitus in home care are not known, but believed to be of the same order of magnitude. These figures apply to a total population of the Netherlands of 15 million. Extension of the hospital stay of the patients accounts for 65% of the costs, increase in attendance of nursing staff for 25% and all other actions (physical therapy, dietary adjustments, medication) for only 3%. Special beds cost about 7% of the total amount. The costs of prevention and treatment of decubitus are high (in hospitals and nursing homes alone approximately Dfl. 700 million per year) and tend to increase since the population is growing older and decubitus is occurring mainly in the older population. Only 7% of these costs are spent on the use of special beds. Since the costs of the leasing of these beds are usually not included in the hospital budgets, the financing of these important tools in prevention and treatment of decubitus is increasingly difficult.

Aged↗
PubMed2006

The effect of the lateral decubitus position on the intraocular pressure in anesthetized patients undergoing lung surgery.

BACKGROUND: Changing the body position alters the intraocular pressure (IOP). The aim of this study was to investigate the alteration in IOP of the eyes after a positional change from a supine position to a lateral decubitus position in anesthetized patients, in order to detect differences in IOP between the two eyes, possibly due to a gravity effect, in the lateral decubitus position. METHODS: IOP was measured in 20 patients undergoing lung surgery. IOP in both eyes was recorded prior to anesthesia in the supine position (baseline), after anesthetic induction but before tracheal intubation in the supine position, at the end of central venous catheterization in the Trendelenburg position, 5 min after a positional change to the lateral decubitus position, once every 30 min until the end of surgery in the lateral decubitus position, and 5 min after changing back to the supine position. RESULTS: The median IOP (16.3 mmHg; 25-75% percentile, 13-20 mmHg) in the dependent eye 5 min after changing to the lateral decubitus position increased significantly from the baseline median IOP (14.3 mmHg; 13-17.3 mmHg; P < 0.05). The increase in median IOP in the dependent eye persisted until the end of surgery in the lateral decubitus position (19 mmHg; 16.5-22.3 mmHg; P < 0.01 vs. baseline). The median IOP in the dependent eye was significantly higher than that in the non-dependent eye when anesthetized patients were placed in the lateral decubitus position (P < 0.01), and the mean differences in IOP between the eyes in the lateral decubitus position ranged from 2.9 to 4.1 mmHg. CONCLUSION: The IOP was higher in the dependent eye than in the non-dependent eye in anesthetized patients in the lateral decubitus position, and the IOP in the dependent eye increased in anesthetized patients compared with that in awakened and supine-positioned patients.

Adult↗
PubMed1993

[Effect of gentian violet on the elimination of methicillin-resistant Staphylococcus aureus (MRSA) existing in the decubitus region].

Methicillin-resistant Staphylococcus aureus (MRSA) is frequently isolated from skin lesions, such as in the decubitus region. There is a possibility that MRSA through these lesions can spread widely in a hospital. However, local treatment with most antibiotics and antiseptics (povidone-iodine) is not effective to eradicate MRSA from the infected decubitus. We have recently demonstrated that gentian violet (Gv) possessed a bactericidal effect against MRSA isolated from clinical specimens in vitro. This examination evaluated whether or not a topical ointment containing 0.1% Gv is effective to eradicate MRSA which existed in decubitus regions. Decubitus (14 clinical cases, ages 59-87 years) infected with MRSA were treated with 0.1% Gv-ointment once or twice daily after bathing in 0.1% Gv aqueous solution. Although all patients were treated with povidone-iodine and 9 out of 14 patients were given either local or systemic administration of antibiotics, those treatments were not effective to eradicate MRSA from decubituses. However, MRSA was not detectable in all cases within 34 days (average: 10.8 days +/- 2.7) after treatment with 0.1% Gv-ointment. The eradication of MRSA from decubitus areas tended to be delayed, depending upon the size and depth of decubituses (Grade III and IV) and complications such as diabetes mellitus. Skin irritability was not observed in any patients. These results suggest that 0.1% Gv-ointment is a useful material for the treatment of the MRSA-local wound infection. Treatment with Gv-ointment to MRSA-infected decubitus may exhibit a protective effect with regard to infection with MRSA in hospital.

Aged↗
PubMed1992

[Revision consensus prevention and treatment decubitus].

The text of the Consensus Meetings Prevention and Treatment of Decubitus (pressure sores; 1985 and 1986 respectively) was adapted to current insights into pathogenesis and treatment. This adaptation was important since the costs of the prevention and treatment of decubitus are enormous and decubitus tends to occur more often since the population is growing older. The so called anti-decubitus devices were grouped in 3 categories: 1. polyether foam mattresses, placed on top of the standard hospital mattresses (merely in prevention and in treatment of patients less than 85 kg), 2. polyether foam mattresses with or without special surface layout or simple alternating pressure air mattresses, replacing the standard hospital mattress (especially in patients greater than 85 kg) and 3. special beds and bed systems as low-air-loss beds and air-fluidized beds (only on strict indications such as thoracic operations and intensive treatments). The clinical manifestations of decubitus were classified in 4 stages: non-blanching erythema (1), blister (2), superficial decubitus (3) and deep decubitus (4). The existence of another form of pressure sores was identified: decubitus originating from operation or angiography tables, on which a deep necrosis develops, extending to form an abscess, erupting through the skin after 7-14 days. These ulcers are characterised by an impressive depth, usually to the underlying bones, but with vivid edges. The development of these sores is prevented in most cases by using a category 1 device on the tables mentioned.(ABSTRACT TRUNCATED AT 250 WORDS)

Bedding and Linens↗