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PubMed2005

Haemodynamic changes induced by hyperbaric bupivacaine during lateral decubitus or supine spinal anaesthesia.

BACKGROUND AND OBJECTIVE: Hypotension, the commonest side-effect of spinal anaesthesia, results from sympathetic denervation. This study compared patient positioning (supine vs. decubitus) on haemodynamic variables during spinal anaesthesia. METHODS: After intravenous crystalloid preloading with 5 mL kg(-1), hyperbaric bupivacaine 0.5% 2.5 mL was injected intrathecally at the L2-3 or L3-4 interspace. Patients were then randomly assigned to be positioned immediately supine and horizontal for 30 min (Group SUP, n = 12), or remained in the lateral decubitus position (fractured hip dependent) for 30 min (Group LAT, n = 14). Systolic blood pressure, mean arterial pressure, and loss of sensation of pinprick sensation were recorded prior to induction of spinal anaesthesia (baseline) and at 1, 2, 3, 5, 10, 15, 30, 45, 60, 90 and 120 min after intrathecal injection. RESULTS: In Group SUP, the percent maximum systolic blood pressure (36 +/- 13%) and percent maximum mean arterial pressure decreases (27 +/- 13%) were significantly greater (P < 0.05) than in Group LAT (30 +/- 8% and 23 +/- 11%, respectively). Additionally, there was a borderline significant delay in the time to maximum systolic blood pressure decrease in Group LAT (38 +/- 30 min) when compared with Group SUP (20 +/- 17 min, P = 0.06), while the total dose of ephedrine required in the SUP group (30 mg) was greater than that required in the LAT group (15 mg, P = 0.05). In Group LAT patients, the mean level of denervation on the operative side extended 2 dermatomes more cephalad than in Group SUP. CONCLUSIONS: Lateral positioning for spinal anaesthesia delays the onset of hypotension, while requiring smaller total doses of vasoconstrictors for blood pressure maintenance.

Aged↗
PubMed1996

The treatment of decubitus ulcers: a century of misinformation in the textbooks.

Decubitus ulcers are slow healing; in many cases they stagnate and fail to heal. Examination of the literature concerning decubitus ulcers reveals that there is a large body of treatments which have been suggested to stimulate the healing wound. This study examines the clinical effectiveness of the various treatments, and the scientific basis behind them. The treatments currently available are compared with those discussed in the literature over the last century, and common threads emerge which have a bearing on how literally one should accept the advice offered in current textbooks.

Anti-Infective Agents↗
PubMed2005

[Frequency of decubitus ulcer in patients of a university medical center. Combination of routine documentation and cross-sectional study].

BACKGROUND AND OBJECTIVE: Pressure ulcer is a relevant issue for quality management and cost containment of hospitals. Cross-sectional studies are the typical design to estimate the frequency of pressure ulcers. The derived point prevalence rate is not as good for a case related reference value as the period prevalence rate. The interdisciplinary pressure ulcer project at the University Clinics in Essen combined a routine documentation with a cross-sectional survey, thus providing both measurements for the first time. PATIENTS AND METHODS: The routine and computer-based collection of information about pressure ulcers started in March 2003, using the patient administration system medico//s from Siemens. Findings are presented from 49,904 admissions, starting on 91/03/2004, discharged by 31/03/2004. The mean age was 48.7 +/- 22.4 years; 51.2 % were males, 48.8 % females. Additionally, a decubitus team examined patients from randomly selected wards each work-day. The real period prevalence rate was calculated using the observed period prevalence rate, the sensitivity and the point prevalence rate. RESULTS: In the routine documentation, 700 pressure ulcers had been recorded from 49,904 inpatient cases (period prevalence rate 1.4 %). The decubitus team did 5,415 examinations and 294 times detected at least one pressure ulcer (point prevalence rate 5.4 %). Estimated results in three different period prevalence rates: 3.0 % using sensitivity of the routine documentation, 3.7 % using sensitivity stratified for departments, and 2.3 % using the point prevalence rate for cases with short, medium, and long length of stay. CONCLUSIONS: The project presents for the first time reference values for pressure ulcer frequency in university clinics. A comparison with international rates is hindered by unpublished sensitivity values. In view of the higher point prevalence rate of 10 % present in the literature, a period prevalence rate of 5 % is a realistic reference value.

Academic Medical Centers↗
PubMed2006

Moxifloxacin distribution in the interstitial space of infected decubitus ulcer tissue of patients with spinal cord injury measured by in vivo microdialysis.

We investigated the distribution of moxifloxacin in the interstitial space of normal and infected subcutaneous tissue in patients with spinal cord injury and decubitus ulcers using in vivo microdialysis. Drug concentrations achieved in serum, saliva, normal and infected tissues showed approximately parallel time profiles. The interstitial tissue fluids reached bactericidal levels for common bacteria found in infected skin lesions. Our findings suggest that moxifloxacin exhibits good and similar penetration into the interstitial space fluid in normal subcutaneous tissue and infected decubitus ulcers in patients with spinal cord injury.

Adult↗
PubMed2002

Lateral decubitus position for percutaneous nephrolithotripsy in the morbidly obese or kyphotic patient.

BACKGROUND AND PURPOSE: Morbidly obese or debilitated patients do not tolerate the prone position used for percutaneous nephrolithotripsy (PCNL) well and may suffer from severe cardiorespiratory compromise in this position. The purpose of this study is to demonstrate a simple way to overcome this difficulty. PATIENTS AND METHODS: Two morbidly obese patients, ages 48 and 32 years, with Body Mass Indices of 47.5 and 43.2 and a 68-year old patient severely debilitated by multiple cerebral infarctions, ischemic heart disease, and kyphosis suffered from relatively high renal stone burdens. For PCNL, the patients were placed in the lateral decubitus position. To obtain an anteroposterior projection in this position, the C-arm fluoroscopy unit was tilted to one side and the operating table to the other. Tract dilation, stone fragmentation, and fragment extraction were performed with the patient in this position. RESULTS: An attempt to perform PCNL in the prone position in the first patient was aborted because of severe hypoxemia and hypercarbia. In the lateral decubitus position, the procedures were easily performed in all patients without any complications. It was noted that by rotating the C-arm to a perpendicular position, it was possible to perform nephroscopy and use fluoroscopy simultaneously. CONCLUSION: We highly recommend using the lateral position for PCNL in morbidly obese patients and in patients suffering from kyphosis. This position is safe and convenient.

Adult↗
PubMed1989

Impaired migration of epidermal cells from decubitus ulcers in cell cultures. A cause of protracted wound healing?

Cultured epidermal cells of explants from decubitus ulcer edges showed significant (P less than 0.05) decreased maximal growth rate (range, 1.3-15.6%) and decreased area of outgrowth per explant (mean and SD, 1.6 +/- 1.7 mm2) when compared with explants obtained 4-5 cm distant from the ulcer edge (range, 46.7-68.8% and 4.6 +/- 2.7 mm2, respectively) and from healthy skin (range, 78.8-93.3% and 6.6 +/- 1.2 mm2, respectively). In contrast, epidermal cells in biopsies from the ulcer edge were significantly (P less than 0.05) more prevalent (range, 1.9-48.2%) as compared with biopsies of healthy skin (range, 3.1-5.1%). Therefore, the decreased growth rate and decreased area of outgrowth may be caused by a defective migration potential rather than an impaired mitotic activity. The latter seems to be normal, as demonstrated by the histomorphometry, which indicates the in vivo situation. Decreased migration potential of epidermal cells could explain the clinically observed protracted epithelialization of decubitus ulcers.

Adult↗
PubMed1977

Clindamycin for treatment of sepsis caused by decubitus ulcers.

Bacteremia was documented in 19 (76%) of 24 patients with sepsis caused solely by decubitus ulcers, persisted in all but two, and was polymicrobial in 10 (42%). Obligate anaerobes were isolated from 12 patients (63%) and included Bacteroides fragilis in 11 (58%). Aerobes, primarily Proteus (21%) and Staphylococcus (16%), were isolated in nine patients (47%). Therapy was judged appropriate when the microbial isolates were susceptible in vitro to the antibiotic used. Nineteen patients received clindamycin plus gentamicin, which was considered appropriate for all but one patient. Four patients received cephalothin plus kanamycin, which was inappropriate for three patients. One patient received appropriate treatment with methicillin, gentamicin, and chloramphenicol. Patients who received appropriate antibiotics and had surgical intervention had the lowest mortality rate (14%); in those treated with appropriate antibiotics but without surgical intervention, the incidence of death was 67% (P less than 0.05). Patients who received inappropriate antibiotics, whether or not there was surgical intervention, had a 75% mortality rate (P less than 0.05). Surgical debridement and antibiotic therapy effective against aerobic as well as anaerobic bacteria are important factors in the treatment of sepsis caused by decubitus ulcers.

Aerobiosis↗
PubMed2002

Homicide by decubitus ulcers.

Traditionally, the only penalties for poor treatment of nursing home patients have been civil lawsuits against nursing homes and their employees by families, or fines and license suspension by government organizations. Recently, government agencies have become much more aggressive in citing institutions for the development of decubitus ulcers (pressure sores) in their patients. A few government institutions have concluded that in some cases, the development of ulcers with resultant death is so grievous that there should be criminal prosecution of the individuals and/or institutions providing care. A leader in this concept has been the State of Hawaii. In November 2000, the State of Hawaii convicted an individual of manslaughter in the death of a patient at an adult residential care home (a form of nursing home) for permitting the progression of decubitus ulcers without seeking medical help, and for not bringing the patient back to a physician for treatment of the ulcers.

Aged↗
PubMed1992

The management of decubitus ulcers by musculocutaneous flaps: a five-year experience.

Large decubitus ulcers can be treated by using many methods, including musculocutaneous flaps. Musculocutaneous flaps provide reliable, well-vascularized cover and often can be revised in patients with secondary recurrence. We have treated 30 patients with large decubitus ulcers during a 5-year period by using musculocutaneous advancement flaps of the gluteus maximus, the hamstring muscle, and the tensor fasciae latae. There were two complications treated by debridement with flap advancement in 1 patient and the use of another flap in the second patient. Four patients developed a recurrent ulcer, which was treated by reelevation and advancement of the original flap in all patients. The general management and overall results are presented.

Buttocks↗
PubMed1985

Physico-mechanical aspects of decubitus prevention.

Reviewed is the theory of tissue deformation as cause of decubitus, as developed in cooperation with two Dutch Rehabilitation Institutes and two Dutch Rehabilitation Research Institutes. Also reviewed are the conditions of the prevention of decubitus concerning the support of the human body in the lying situation. The consequences of the new anti-deformation theory for the lying-support are discussed. A classification is given of the existing lying-down support systems. Examples of the three categories of existing lying-down support systems are given and discussed in general.

Gravitation↗
PubMed1983

Successful management of decubitus ulcers by the general surgeon.

Decubitus ulcers were handled by an aggressive routine of early wide excision and immediate advancement-rotation flaps of the thigh under antibiotic coverage. Of 23 patients referred for decubitus ulcers in two years, 20 were so managed, with primary healing in 15 and secondary healing in an additional four. There has been one recurrence, one operative death, and two late deaths.

Follow-Up Studies↗
PubMed2005

Pseudoangiosarcomatous squamous cell carcinoma of skin arising adjacent to decubitus ulcers.

Pseudoangiosarcomatous, or pseudovascular, squamous cell carcinoma of skin is an unusual form of acantholytic (adenoid, pseudoglandular) squamous cell carcinoma that mimics the histolopathologic appearance of angiosarcoma. We report a case of pseudoangiosarcomatous squamous cell carcinoma arising adjacent to decubitus ulcers. The histopathologic examination of a wedge biopsy specimen revealed infiltrative cords of neoplastic cells that formed interanastomosing channels imitating angiosarcoma. Immunohistochemical staining was negative for the endothelial markers (CD31, CD34, and factor VIII-related antigen) and positive using cytokeratin antibodies (AE1/AE3 and 34 betaE12). Because of metastatic disease, palliative measures were undertaken and the patient died four months later. To our knowledge, our patient is the first with pseudoangiosarcomatous squamous cell carcinoma of skin developing within decubitus ulcer.

Aged↗
PubMed1979

Skin oxygen tension as a function of imposed skin pressure: implication for decubitus ulcer formation.

Pressure is a crucial factor in the formation of decubitus ulcers. To elucidate the effect of imposed skin pressure, a new cutaneous oxygen sensor was used to measure the skin oxygen tension under increasing pressure upon skin tissue at "hard sites" (bony prominences) and at "soft sites" (muscle-padded areas). At hard sites the skin oxygen tension fell rapidly under increasing pressure (y = 90.9--0.39. X; r = 0.98) from an initial value of 86.4 +/- 10.6 to 20.2 +/- 12.1 mm Hg under an imposed skin pressure load of 175 gm/cm 2. At soft sites a pressure load of 175 gm/cm 2 decreased the skin oxygen tension only from 82.9 +/- 5.8 to 71.4 +/- 10.0 mm Hg. These results may explain why hard sites (bony prominences) are preferential areas for decubitus ulcer formation.

Adolescent↗
PubMed1983

Decubitus ulcer prevention: a new investigative method using transcutaneous oxygen tension measurement.

Sacral skin oxygen tension, measured by a noninvasive technique in ten healthy subjects, remained in the normal range when they were lying on a "super-soft" mattress or in the 30 degrees lateral position. Therefore, these methods are effective in decubitus ulcer prevention. Skin oxygen tension measurement allows immediate assessment of the efficacy of measures to prevent decubitus ulcers.

Adolescent↗
PubMed1999

Invasive ductal carcinoma of the male breast expanding from pacemaker pocket decubitus.

After twenty-five years of therapy with different unifocal pacemaking systems, an 84-year old male patient developed a nonseptic pacemaker decubitus. A rare incidental finding of invasive ductal carcinoma of the right mammary gland was surgically treated by a generous excision of the tumor and by consecutive modified radical mastectomy. According to published literature, the association of invasive ductal carcinoma arising from a pacemaker pocket decubitus and followed by curative treatment has not been previously reported. We do conclude that pacemaker generators in close relationship to the mammary gland should be considered with suspicion.

Aged↗
PubMed1983

Compensation filtration for decubitus radiography during double-contrast barium enema examinations.

Lateral decubitus images obtained during double-contrast barium enema examinations may be difficult to interpret because of the large difference in density between the various parts of the radiographs. Several types of filters are described which can be used to rectify this problem, thus improving the quality of the decubitus radiographs and achieving a slight reduction in radiation exposure.

Barium Sulfate↗
PubMed1986

Neonatal tension pulmonary interstitial emphysema in bronchopulmonary dysplasia: treatment with lateral decubitus positioning.

Persistent foci of tension pulmonary interstitial emphysema (TPIE) may represent a clinically significant threat to the neonate with bronchopulmonary dysplasia. A 5-year experience with 21 cases of TPIE is reported. These patients were treated with lateral decubitus positioning (LDP). The emphysematous side was placed down approximately 70% of the time for an average of slightly over 3 days. Progress was followed by serial chest radiographs. The overall success rate of LDP was 90%. Respiratory status either improved or remained stable in all responding neonates, and no proved complications were observed. The authors recommend lateral decubitus positioning as the initial treatment of choice in managing neonatal tension pulmonary emphysema.

Bronchopulmonary Dysplasia↗
PubMed2001

Influence of head-down and lateral decubitus neck flexion on heart rate variability.

The purpose of this study was to examine the response of heart rate variability (HRV), a noninvasive index of autonomic control, to head-down neck flexion (HDNF), which engages both otoliths and neck muscle afferents, and to lateral decubitus neck flexion (LNF), in which neck afferents are activated, whereas otolith afferent input is not. HRV and forearm blood flow were evaluated in participants lying prone, during HDNF, lying in the lateral decubitus position, and during LNF. Compared with the prone position, HDNF resulted in lower high-frequency (46.9 +/- 7.1 vs. 62.3 +/- 6.2) and higher low-frequency (53.1 +/- 7.1 vs. 37.7 +/- 6.2) power, expressed as normalized units, along with higher low-frequency-to-high-frequency ratio (1.65 +/- 0.3 vs. 0.78 +/- 0.2), whereas LNF resulted in no alterations in HRV indexes. Furthermore, there were no significant differences in forearm blood flow or vascular resistance among any of the positions. Our data suggest that otolith organs influence autonomic modulation of the heart, supporting previous studies reporting that HDNF elicits increased sympathetic outflow. These data further suggest that HDNF results in a parasympathetic withdrawal from the heart in addition to sympathetic activation.

Adult↗