Obstacles and opportunities for the multidisciplinary wound care team. A report for the clinical symposium on wound management.

On the last day of the 12th Annual Clinical Symposium on Wound Management, a panel of clinicians from various disciplines, and with diverse experience in wound management, discussed the challenges and rewards of being part of a multidisciplinary team caring for patients with wounds. Panelists included Sharon Baranoski, MSN, RN, CETN; C. Andrew Salzberg, MD; Marlys J. Staley, MS, PT; and David R. Thomas, MD, FACP. Elizabeth A. Ayello, PhD, RN, CS, CETN, was the moderator. An excerpt from this session is published here.

Vascularized muscle flaps and reoperative approach for complicated, dehisced sternal wounds in children.

Vascularized muscle flaps for treatment of mediastinitis and sternal wound dehiscence have become standard treatment practice, but triple-muscle flap reconstruction is reserved for the more complex wounds. The incisional approach for reoperation in such patients is controversial. We report an extremely ill infant, born at 38 weeks gestational age, who underwent an arterial switch procedure for transposition of the great arteries at 12 days of age. Sternal wound infection, dehiscence, mediastinitis, and extensive wound necrosis complicated the postoperative course. The cultured organism Enterobacter is a relatively rare cause for median sternotomy wound infection and was associated with massive postoperative hemorrhage. The infant underwent multiple debridements and at 2 months of age had reconstructive surgery with bilateral pectoralis major muscle advancement flaps combined with a rectus abdominis muscle flap. Three months postreconstruction the infant required reoperation to correct a stenosis at the site of the pulmonary artery anastomosis. This surgery was carried out through the previous median sternotomy scar because it was the safest, most direct approach and would also limit additional scarring. Long-term follow-up at 2 years of age shows a well-developed young boy with no limitations in growth and activity.

Predicting and preventing pressure ulcers in adults with paralysis.

A questionnaire mailed to all 2,295 members of the Eastern Paralyzed Veterans Association measured 45 potential risk factors for pressure ulcers. Logistic-regression analysis and Cox proportional-hazards analyses were used to identify the variables that were independently associated with pressure ulcers. The survey response rate was 42.2%. Among 15 risk factors from a previously published scale by the authors, 7 were independent predictors of pressure ulcer development: level of activity, level of mobility, complete spinal cord injury, urine incontinence or moisture, autonomic dysreflexia, pulmonary disease, and renal disease. In addition, 2 new variables added significant predictive value: being prone to infections that cause breathing problems and paralysis caused by trauma (as opposed to disease). Using these 9 risk factors, a new pressure ulcer risk assessment scale was designed specifically for persons with paralysis who are living in a community setting. It appears to be a more accurate method of predicting pressure ulcers than currently used risk assessment scales.

Surgical management of pressure ulcers.

Surgical management of pressure ulcers ranges from office or bedside debridement to formal debridement in the operating room for the more extensive necrosis. Closure of these wounds may be by advancement flap closure for the simple ulcers and by local muscle or myocutaneous flap closure for the more complex ulcers and defects. Some pressure ulcers recur following previous surgery or following conservative treatment. The simple recurrences can be managed by the use of simple techniques while the surgical options for the management of the more difficult recurrent ulcers are limited involving more complex surgery like sensate flaps, expanded flaps, free tissue transfers and fillet flaps.

Operative repair of pressure ulcers.

Surgical management of pressure ulcers ranges from débridement and advancement flap closure for simple ulcers to sensate flaps, expanded flaps, free-tissue transfers, and fillet flaps for more complex ulcers and defects. Some pressure ulcers recur following surgery or conservative treatment, and the surgical options for management of these difficult recurrent ulcers are limited. The geriatric population offers an even more difficult problem as patients suffer invariably from underlying medical and systemic diseases that may affect surgery or the rehabilitation program.

Recurrence of initial pressure ulcer in persons with spinal cord injuries.

Whether treated with surgery or by conservative, nonsurgical measures, pressure ulcers recur in 5% to 91% of spinal cord injured (SCI) patients. Factors other than the surgical technique used or the standard conservative management provided may be responsible. A retrospective study of 176 SCI patients with a history of one or more pressure ulcers was conducted at the Department of Veterans Affairs Medical Center at Castle Point, N.Y. Approximately 35% of patients who received either surgical or nonsurgical treatment had a recurrence. Patients who smoked and patients with diabetes or cardiovascular disease had higher recurrence rates.

Candida albicans infection of bilateral polyurethane-coated silicone gel breast implants.

We present a report of bilateral Candida albicans infection of polyurethane-coated silicone gel prostheses and an acute onset of unilateral capsular contracture 4 years after breast augmentation. The patient was treated by removal of implants, antibiotic irrigation of the capsule cavities, and immediate replacement with new implants. Following histopathologic diagnosis, the patient was treated with a course of fluconazole and remains symptom free at the 12-month follow-up.

Major risk factors for pressure ulcers in the spinal cord disabled: a literature review.

Pressure ulcers remain a dominant health problem for persons with spinal cord injury despite abundant published research describing risk factors. Although information on these factors is plentiful, its usefulness to the spinal cord disabled is limited by three problems. First, the sheer volume is overwhelming; more than 200 risk factors for pressure ulcers have been described in the published literature. For most health care professionals, finding, no less reading and evaluating, the hundreds of articles published on this topic would be difficult. Second, most studies focused on elderly patients in nursing homes. Pressure ulcer risk factors for the spinal cord disabled are often different from those for the elderly; yet many findings from studies of the elderly provide valuable information. Third, inadequate sample sizes often hamper the usefulness of research on the spinal cord disabled. Drawing valid conclusions from these small studies, especially concerning potential risk factors is difficult. To address these three problems, we critically evaluated the medical, nursing, and nutritional research literature that pertained to risk factors for pressure ulcer development. The purpose of this paper is to provide a review of published reports on the principal risk factors for pressure ulcers in persons with spinal cord injuries.

A new pressure ulcer risk assessment scale for individuals with spinal cord injury.

Each year, one-fourth of the 200,000 individuals with spinal cord injury in the United States develop pressure ulcers. No method currently exists, however, to accurately identify which of these individuals are at increased risk for development of pressure ulcers. We studied 219 spinal cord-injured patients, seen at a Veterans Affairs Medical Center, during a 6-yr period. Our goal was to develop a pressure ulcer risk assessment scale, specifically for persons with SCI. Each risk factor had to meet four criteria: (1) statistical association with pressure ulcer development; (2) biologically plausible mechanism; (3) literature support; (4) improved prediction. Among the 219 spinal cord-injured patients evaluated, 176 (80.4 percent) had a history of one or more pressure ulcers. Fifteen risk factors met the four criteria for inclusion into the risk assessment scale. They were as follows: restricted activity level, degree of immobility, complete spinal cord injury, urinary disease, impaired cognitive function, diabetes, cigarette smoking, residence in a nursing home or hospital, hypoalbuminemia, and anemia. Compared with the more general scales available, for quantifying the risk of pressure ulcer development, preliminary results suggest that this new scale is a significant improvement for the spinal cord-disabled.

Wound healing in partial-thickness burn wounds treated with collagenase ointment versus silver sulfadiazine cream.

During burn care the wounds must be repeatedly debrided of adherent and loose debris until the decision is made to surgically excise and graft the wound or to await epithelialization. Though native proteolytic enzymes in the skin or those produced by colonizing bacteria can speed eschar separation, the use of exogenous enzymes for wound debridement may accelerate wound cleaning and healing. Collagenase digests native and denatured collagen in necrotic tissue. This multicenter trial of 79 patients with partial-thickness wounds compared the efficacy of collagenase ointment applied with polymyxin B sulfate/bacitracin powder with the efficacy of standard topical antimicrobial therapy (control) in which silver sulfadiazine cream (1%) was used to debride paired burn sites. Patients selected for the study had two noncontiguous, partial-thickness, comparably sized, and anatomically similar burn wounds. Ages of patients ranged from 5 to 60 years (mean 33 years). The total body surface area burned ranged from 2% to 30% (mean 13.6%). Mean burn sizes used for study treatment were 366 cm2 (26 to 2310 cm2) for collagenase sites and 355 cm2 (26 to 2394 cm2) for control sites. Sites on each patient were randomly assigned to treatment with either collagenase or control. Endpoints were time to clean wound bed (absence of retained debris) and time to healing (complete epithelialization). The sites treated with collagenase cleaned in less time (mean 9.3 days) than the control sites (mean 11.6 days). Similarly the collagenase sites healed faster than the control sites (mean 19 vs 22.1 days).(ABSTRACT TRUNCATED AT 250 WORDS)

The effects of non-thermal pulsed electromagnetic energy on wound healing of pressure ulcers in spinal cord-injured patients: a randomized, double-blind study.

The objective of this randomized, double-blind study was to determine if non-thermal pulsed electromagnetic energy treatment significantly increases the healing rate of pressure ulcers in patients with spinal cord injuries. Subjects included volunteers admitted to a Veteran's Administration Hospital in New York over a 2 year period and consisted of 30 male spinal cord-injured patients, 20 with Stage II and 10 with Stage III pressure ulcers. Subjects were given non-thermal pulsed high-frequency electromagnetic energy treatment for 30 minutes twice daily for 12 weeks or until healed. The percentage of pressure ulcers healed was measured at one week. Of the 20 patients with Stage II pressure ulcers, the active group had a significantly increased rate of healing with a greater percentage of the ulcer healed at one week than the control group. After controlling for the baseline status of the pressure ulcer, active treatment was independently associated with a significantly shorter median time to complete healing of the ulcer. Stage III pressure ulcers healed faster in the treatment group but the sample size was limited. For spinal cord-injured men with Stage II pressure ulcers, active non-thermal pulsed electromagnetic energy treatment significantly improved healing.

Evaluation of ultrasound as a tool in the follow-up of patients with breast implants: a preliminary, prospective study.

We prospectively reviewed clinical findings in 93 patients with 154 silicone breast implants (SBIs), as well as ultrasound findings in 57 patients with 94 SBIs. Ultrasound findings of implant wall redundancy, combined with abnormal silicone echogenicity, correlated well with predicted and surgically confirmed SBI rupture. Age-related implant findings (i.e., length of time since implant placement) included capsular contracture, a variety of abnormal ultrasound findings, subjective reports of joint pain or fatigue, and a greater probability of rupture. Prospective screening of otherwise satisfied patients with SBIs raises concerns about the need for removal when satisfactory alternatives for maintaining breast size are limited. The ability to predict impending rupture will increase this dilemma.

Wound healing and wound management: focus on debridement. An interdisciplinary round table, September 18, 1992, Jackson Hole, WY.

A multidisciplinary panel of experts convened to discuss the basic concepts of prevention and treatment of pressure ulcers. Special emphasis was placed on four types of debridement: mechanical, surgical, autolystic, and enzymatic. Debridement of burns was also discussed. Team management by informed practitioners is vital to successful wound care and all treatments should be based on a holistic appraisal of patients and their individualized plans of care.