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PubMed2005

The influence of a change in medicare reimbursement on the effectiveness of stage III or greater decubitus ulcer home health nursing care.

This study was designed to describe and evaluate the influence of a change in a Medicare reimbursement on the effectiveness of home health nursing care for stage III or greater decubitus ulcer patients. This health policy originated from the Balanced Budget Act (BBA) of 1997 and took its full effect with initiation of the Prospective Payment System (PPS) on October 1, 2000. A quantitative quasi-experimental design used OASIS data from the state of Virginia to evaluate 555 stage III or greater decubitus ulcer patients, age 65 or older. Comparisons were investigated between pre-PPS, 2000, and post-PPS, 2001, outcomes related to reported ulcer healing, lengths of stay, and discharge disposition. Results demonstrated significant differences for the outcomes studied. In addition, sanitation, ulcer healing, and discharge disposition were linked as predictors for length of stay. Results demonstrated that PPS has affected nursing care effectiveness for stage III or greater decubitus ulcer home health patients.

Aged↗
PubMed1998

An evaluation of current risk assessment scales for decubitus ulcer in general inpatients and wheelchair users.

OBJECTIVES: To study the components of two risk assessment scales for decubitus ulcer risk, Waterlow and Braden, and of the Chailey score for the same purpose. DESIGN: Experimental study of patients at risk of developing decubitus ulcers. SETTING: The West Midlands and Yorkshire. SUBJECTS: One hundred and fifty wheelchair users from the West Midlands and 9022 patients from a District General Hospital in York, the latter consisting of all admissions to the hospital in a four-month period. INTERVENTIONS: Braden, Chailey scores (wheelchair users) and Waterlow scores (all subjects) measured. MAIN OUTCOME MEASURES: Development of a pressure sore, receiver operating characteristic (ROC) curves. RESULTS: Waterlow outperformed Braden for classification of wheelchair patients with respect to decubitus ulcer. The Chailey score performed randomly in this group. The sensitivity and specificity as seen in ROC curves was different for Waterlow scores for wheelchair users and general patients, the latter being much better classified. Only three items out of 11 in the Waterlow score appeared to have any classification ability in the wheelchair group. CONCLUSIONS: Risk indicators used for general patients are probably poorly suited for wheelchair users. There is a need for large-scale predictive studies of wheelchair users and other groups to allow regression analysis of the subscales of risk indicators. From the provisional data of this study it appears that splitting patients by gender and into full- and part-time wheelchair users classifies almost as well the much more complicated risk assessment tools currently available.

Case-Control Studies↗
PubMed2004

Lightwand-assisted intubation of patients in the lateral decubitus position.

In some situations, patients need endotracheal intubation to maintain airway patency while they are constrained in the lateral position. In this study we compared lightwand-guided intubation of 120 randomly enrolled patients placed in the supine, right, or left lateral position. Group S patients were initially placed in the supine position, and subsequent to the artificial airway having been established they were turned to the lateral decubitus position. Group R patients were initially placed in a right decubitus position during induction and intubation. Group L patients were initially placed in a left decubitus position during induction and intubation. The duration of each intubation attempt, the total time to successful intubation, and the incidence of intubation-related intraoral injury, hemodynamic changes, and postoperative sore throat and hoarseness were recorded. Intubation took a similar length of time in the supine (14.5 +/- 13.4 s), left lateral (13.3 +/- 10.2 s), and right lateral positions (15.5 +/- 13.0 s) and resulted in a similar trend in hemodynamic changes. Patients in the lateral and supine positions revealed a comparable incidence of successful first-attempt intubation, sore throat, hoarseness, oral mucosal injury, and dysrhythmia. Insignificantly more esophageal intubations were performed in the lateral position in the first attempt at intubation; however, all patients were correctly intubated shortly after reattempting intubation. We concluded that lightwand-assisted intubation is easily performed and a similar technique may be used whether the patient is in a lateral, recumbent, or a supine position. This alternative technique should be practiced and is recommended for patients who must remain in a lateral position during intubation and surgery.

Adult↗
PubMed2001

Topical phenytoin treatment of stage II decubitus ulcers in the elderly.

OBJECTIVE: To compare the healing of stage II decubitus ulcers with topically applied phenytoin sodium with two other standard topical treatment procedures in a long-term care setting; and to assess the extent of systemic absorption after topical application in the phenytoin group. METHODS: Forty-seven nursing home patients with stage II decubitus ulcers were chosen for this study. The patients were matched for age, gender, and size and severity of wounds, and randomly assigned to each treatment group. Clinical assessment of decubitus ulcers was performed at the beginning of treatment and at each dressing change. Ulcers were examined for the presence of healthy granulation tissue, reduction in surface dimensions, and time to healing. Two phenytoin sodium plasma concentrations were to be obtained on all patients in the phenytoin group. RESULTS: Topical phenytoin therapy resulted in a shorter time to complete healing and formation of granulation tissue when compared with DuoDerm dressings or triple antibiotic ointment applications (p < or = 0.05). The mean +/- SD time to healing in the phenytoin group was 35.3 +/- 14.3 days compared with 51.8 +/- 19.6 and 53.8 +/- 8.5 days for the DuoDerm and triple antibiotic ointment groups, respectively. Healthy granulation tissue in the phenytoin group appeared within two to seven days in all subjects. Patients in the standard treatment groups required six to 21 days to produce new granulation tissue. Serum phenytoin sodium concentrations were nondetectable. No patient withdrew from the study secondary to adverse treatment effects. CONCLUSIONS: Both the phenytoin and standard treatment groups showed progress over the study period. However, the phenytoin group demonstrated more rapid results in all aspects of ulcer healing.

Administration, Topical↗
PubMed1986

The need for skin and muscle saving techniques in the repair of decubitus ulcers. A consecutive series of 72 patients and 100 ulcers over 5 years (1979/1984). A case report.

The authors report on a consecutive series of 72 patients during the period 1979-1984 presenting 100 important decubitus ulcers with a follow-up of at least one year. The repair of decubitus ulcers in paraplegic patients often requires a prolonged stay in hospital and multiple operations, since the lesions are frequently multiple. Local and general conditions make it imperative for the surgeon to choose a safe technique, with minimal tissue damage and above all leaving enough healthy skin and muscle for possible future repairs, especially in paraplegic patients. The various techniques are described according to the location of the decubitus ulcers. The following myocutaneous island flaps have been used: for sacral ulcers gluteus maximus flap; for ischial ulcers biceps femoris flap and for trochanteric ulcers tensor fascia lata flap. The authors insist on good long-term results with early social rehabilitation and prevention of recurrence, especially in paraplegic patients.

Adult↗
PubMed1994

[Surgical treatment of a long-term decubitus ulcer].

A 64-year-old male presented with a large decubitus ulcer of the sacrum which had not healed for thirteen years in spite of various conservative treatments. His primary disease was paraplegia following spondylitis. Although he was not ambulatory, he was able to manage a wheelchair. The decubitus, which had a 8 x 13 cm dead space, was successfully closed with a single operation using two fasciocutaneous flaps. The patient was discharged two months postoperatively. The medical cost of his treatment before and after the surgery was investigated. The expense including the surgery and postoperative care until discharge was five times more than the monthly cost of the preoperative period. These findings suggest that a decubitus ulcer which does not respond to conservative treatments for more than several months should be considered for a surgical management, as long as the patient's general condition permits an operation.

Aged↗
PubMedDate not supplied

[The surgical treatment of decubitus ulcers in patients with spinal cord trauma].

The paper summarizes experience in surgically treating decubitus in 429 patients with spinal cord injury. Main criteria for decubitus preparation for surgery, indications for various surgical interventions are defined. The outcomes of treatment are analyzed. The wound healed by first intention in 71% of patients and in 86% of patients within 3 months. Repeated surgery was required in 4.4% of patients. There is evidence that surgical intervention makes it possible to eliminate the existing decubituses in patients with spinal cord injury by score times more rapidly, to greatly improve the quality of their life and to increase survival.

Adult↗
PubMedDate not supplied

Topical application of insulin in the treatment of decubitus ulcers: a pilot study.

To test the hypothesis that there will be a significantly greater increase in the rate of healing of decubitus ulcers in subjects who receive topical insulin therapy than in subjects who receive other forms of therapy, a pilot study was conducted, utilizing a two-group before and after design. Decubitus ulcers of six experimental group subjects were treated with a topical application of ten units of regular insulin twice a day for five days; eight control group subjects received one of a variety of topical therapies other than insulin. Data were collected on all subjects for a 15-day period. Although generalizations cannot be based on the results of 14 subjects, data analysis showed that insulin was a safe and effective agent in the healing of small, uncomplicated decubitus ulcers. The results appear to warrant a more extensive study of the subject.

Administration, Topical↗
PubMed1979

[Effect of aerobic and anaerobic germs on the healing of decubitus ulcers].

Bacteriological examinations of decubitus ulcers were performed in 34 geriatric patients. A total of 179 wound swabs were analyzed for aerobic and anaerobic bacteria. The decubitus ulcers were divided into three groups according to wound healing: group A with progressive worsening, group B, stationary, and group C with healing within 10 weeks. The aerobic bacteria isolated from the three groups were significantly different (p less than 0.0001). In group A Pseudomonas aeruginosa was isolated in 88%, enterococci in 73% and Providentia in 34%, whereas in group B staphylococci were found in 69%, enterococci in 62% and E. coli in 32%. In group C staphylococci dominated with 91%, followed by enterococci (51%) and E. coli (25%). Anaerobic microorganisms were significantly (p less than 0.01) more frequent in decubitus ulcers with poor healing tendency (group A and B) than in healing ulcers (group C). These results suggest that bacterial growth on decubital ulcers significantly influences decubital ulcer healing. Furthermore, bacteriological examinations are of prognostic value and the results should be considered in treatment.

Aerobiosis↗
PubMed1992

Hemodynamic observation and treatment approach for patients with angina decubitus.

In order to investigate the mechanism and treatment of angina decubitus, 20 patients (18 men and 2 women aged 36-70 years) were studied during hospitalization. All patients were found to have an increased heart rate x systolic blood pressure product before the onset of angina decubitus, indicating that this type of angina pectoris belongs to the category of effort angina. Of the 11 patients investigated by continuous hemodynamic monitoring, 3 had significant progressive increases in pulmonary artery systolic pressure (PASP) and pulmonary artery diastolic pressure (PADP) before onset: their episodes of angina could not be completely controlled by digoxin and diuretics, but quickly subsided after beta blockers were added. Among the other 8 patients, PADP increased slightly in 5 and remained unchanged in 3 cases before onset: these patients had no manifestations of LV dysfunction, and beta blockers combined with coronary vasodilators produced satisfactory effects. These results indicate that LV failure is not a major factor in the pathogenesis of angina decubitus. The LV diastolic dysfunction seen in 8/11 cases may have been related to LV hypertrophy caused by long-term hypertension or chronic persistent ischemia.

Adrenergic beta-Antagonists↗
PubMed2003

[Rhabdomyolysis after nephrectomy in the lateral flexed decubitus position].

We report two cases of the rhabdomyolysis of the erector spine muscles occurring after nephrectomy in lateral flexed decubitus position. Case 1. A 39-year-old man (170-cm, 85-kg) underwent right nephrectomy for a right renal tumor. The patient was placed in a left flexed lateral decubitus position with a roll placed under the dependent iliac crest and upper half of the body was rotated backward for 6 h. The patient complained of severe left low back pain after the operation. On postoperative day 2, serum creatinine increased to 28,480 U.l-1 (MM 99%). Computed tomography scanning performed on postoperative day 4 showed hypodensity of the left erector spine muscles. Although the patient complained of severe pain, no other critical complications including renal failure occurred during the postoperative period. Case 2. A 59-year-old man (169-cm, 87-kg) was scheduled for right nephroureterectomy and partial resection of bladder for a right renal tumor. The patient was placed in a right flexed lateral decubitus position with a roll of towel and sponge placed under the dependent iliac crest for 8 hr. On postoperative day 1, CPK increased to 35,315 U.l-1 (MM 99%) and peaked at 55,760 U.l-1 (MM 99%) on postoperative day 2. Haptoglobin was administered and lactated Ringer and loop diuretics were administered. Fortunately the patient did not develop renal failure. Direct, prolonged pressure on the paravertebral muscle was the etiology of rhabdomyolysis in our cases. Although our cases were not severe and the complications were not induced, it must be kept in mind that excessive pressure in a limited area can damage the muscle during prolonged surgery.

Adult↗
PubMed2005

Closed femoral nailing in lateral decubitus position without a fracture table: a preliminary report of fifteen patients.

BACKGROUND: The use of a fracture table is standard for closed intramedullary nailing of femoral fractures. Instead of a fracture table, some clinicians have successfully performed this operation in the supine position via manual traction. Here, we present our experience performing this operation in the lateral decubitus position without a fracture table. METHODS: From December 2001 to November 2002, we consecutively performed closed intramedullary femoral nailing in 15 patients with low comminuted femoral shaft fractures in the lateral decubitus position without a fracture table. We used manual or joystick traction to approximate the fracture fragments and introduced a guide pin. A reaming procedure was done with serial reamers of increasing diameters to reduce the fracture fragments. Then, the nail was inserted along the guide pin. RESULTS: Six femora underwent Küntscher nailing and nine femora underwent interlocking nailing. Nine procedures were completed via joystick traction and six were completed via manual traction only. All fifteen procedures were completed without any changes in the other operative methods. The mean operation time was 55 minutes for Küntscher nailing and 118.3 minutes for interlocking nailing. The average union time was 5.8 months with 100% union. CONCLUSIONS: For low comminuted femoral shaft fractures, using manual or joystick traction in the lateral decubitus position without a fracture table is an alternative in closed femoral intramedullary nailing.

Adolescent↗
PubMed2006

[Pharmacokinetic simulation of high-dose administration of dexmedetomidine for decubitus treatment].

We used only dexmedetomidine to sedate a patient with Alzheimer disease, Parkinson's syndrome and emaciation for decubitus treatment in the prone position. The infusion rate of dexmedetomidine without a loading dose was increased until sufficient sedation was attained. The maximum plasma concentration and the plasma concentration in a stable state, which were calculated by pharmacokinetic simulation analysis, were 2.3 ng x ml(-1) and 1.5 ng x ml(-1), respectively. Respiration disorder did not occur and hemodynamic stability was preserved despite administration up to 11.5 mcg x kg(-1) x h(-1). An increase in the dose per weight was needed to increase the absolute dose because of emaciation. It was found by pharmacokinetic simulation analysis that the plasma concentration of dexmedetomidine required for decubitus treatment might be higher than the plasma concentration considered to be necessary for sedation in intensive care units. The simulation was conducted to administer dexmedetomidine, to estimate hemodynamic reaction, and to estimate the necessary plasma concentration. We conclude that dexmedetomidine is useful as an anesthetic agent for decubitus treatment in the prone position, although further investigations with regard to its safety are required.

Aged↗
PubMed2006

Orthopedic management of decubitus ulcers around the proximal femur.

Decubitus ulcers, commonly known as pressure ulcers or sores, represent localized areas of tissue necrosis. Despite increased awareness and use of preventive measures, these ulcers remain a major concern in the hospitalized and immobile patient population. When the hip joint becomes infected or the wound remains refractory to nonsurgical treatments, the orthopedic surgeon becomes involved in patient care. In this review, a brief overview of decubitus ulcers and their nonsurgical management is given, followed by a discussion of various flaps used in more extensive repairs. The major orthopedic procedures presented include proximal femoral resection (Girdlestone procedure), hip disarticulation, and hemipelvectomy. These surgeries retain an important position in managing complicated decubitus ulcers around the proximal femur.

Disarticulation↗
PubMed1991

[Decubitus ulcers in geriatrics--pathogenesis, prevention and therapy].

Magnitude and duration of interface pressure are the crucial etiological factors in the decubitus ulcer formation. Small amounts of interface pressure that exceed the average capillary pressure (range: 2.7 to 6.3 kPa) may lead to compression of the skin microcirculation and resultant tissue necrosis when a critical duration of interface pressure of more than 2 h is reached. The principles of decubitus ulcer prevention are derived from the pathophysiology of ulcer formation as noted: reduction of interface pressure below 3 kPa by bedding each at-risk patient on a 'super-soft' mattress and shortening the duration of interface pressure below 2 h. by turning of patients from the supine position to the right and left 30 degrees oblique back position every two hours. Decubitus ulcers typically show impaired wound healing. Conditions most conspicuously protracting normal wound healing are: tissue hypoxia, fibrin deposits, necrotic tissue, local infection, defective migration of keratinocytes, impaired general condition, etc. Based on these pathophysiological mechanisms, five therapeutical principles are proposed: complete relief of interface pressure, débridement of necrotic tissue, treatment of infection using systemical antibiotics, wet and air-permeable wound dressing, improvement of patient's general condition.

Aged↗
PubMedDate not supplied

Topical application of insulin in decubitus ulcers.

When a pilot study provided evidence that insulin may increase the rate of healing of decubitus ulcers, this study attempted to answer the question: Is topical insulin therapy an effective treatment regimen for decubitus ulcers? The experimental study utilized a two-group, before-after design. Twenty-nine geriatric subjects were randomly assigned to either the experimental or the control group. The single independent variable was the topical application of ten units of regular insulin (U.S.P.) twice daily. The dependent variable was the surface area of the decubitus ulcer measured in square millimeters. Rate of healing was defined as decrease in surface area over time. Data were also gathered on extraneous variables believed to influence the healing process. The F test was used to test the research hypothesis that experimental subjects would have an increased rate of healing. When comparison of group means on day seven and day 15 revealed no significant differences, the research hypothesis was rejected. Pearson product moment correlation procedures were utilized to determine if there were differences between extraneous variables and the rate of healing. Females healed significantly (p less than .05) more slowly than males. Also, there was a direct correlation between the number of days of treatment and the rate of healing.

Drug Evaluation↗
PubMed1979

Intact heel decubitus: an innovative treatment with a special cleansing sponge.

An innovative treatment of intact blue-black heel decubitus with a nonmedicated cleansing sponge was investigated. Forty-five patients over an 18-month period were identified with this type of decubitus and were treated tid for 21 days with a soak and massage of the heel. Analysis of variance was based on changes in size, color, and pliability of decubitus.

Analysis of Variance↗
PubMed1994

Right upper lobe atelectasis after upper urinary surgery in the lateral decubitus position--case report.

Pulmonary atelectasis is a known complication of urinary tract surgery performed in the lateral decubitus position. In 1946 Faulconer reported 8 cases of atelectasis associated with the use of the lateral decubitus position and elevated kidney rest. Several papers have indicated an influence of anesthesia and muscle relaxation as well as position in the development of atelectasis. We present a case of right upper lobe (RUL) atelectasis following left radical nephrectomy under general anesthesia in the right lateral decubitus position, successfully treated with saline lavage and bronchoscopic suction.

Anesthesia, General↗