I have a patient who had a failed mesh placement and a panniculectomy and who has developed at least three separate fistulas with a very large amount of output (3-4 L/24 hrs). Any suggestions? I am using an Eakin wound management pouch hooked up to wall suction.
A Retrospective, Descriptive Study of Sacral Ulcer Flap Coverage in Nonambulatory Patients with Hypoalbuminemia
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59 Abstract: Deep sacral pressure ulcers in nonambulatory hospitalized patients often are managed using surgical flaps. Reports about the effects of protein status on postoperative healing are inconsistent but surgery often is delayed until serum albumin levels normalize. Considering these conflicting data and the potential effects of delayed closure, the protocol at a Philippine national university hospital was changed to allow for early surgical reconstruction of sacral ulcers in hypoalbuminemic nonambulatory patients. A retrospective chart review was conducted to evaluate clinical outcomes of 16 nonambulatory patients (10 men, 6 women; average age 54 years, range 18 to 74) with moderate to severe hypoalbuminemia who underwent flap surgery for coverage of their Stage III or Stage IV sacral ulcers within a protocol of interdisciplinary care. Outcomes measured included the number of surgeries needed for coverage and wound complications encountered. Patient average albumin level before flap coverage was 21 g/L (range: 8 to 30 g/L), average sacral ulcer size was 10 cm x 10 cm, patients underwent an average of 2.56 procedures to achieve coverage, and average follow-up period was 11.25 months (range: 3 to 33 months, SD ± 10.4) after surgical closure. Of the 16 flaps, 15 (93.75%) were healed on final follow-up. Six patients (37.5%) had wound-related complications with more complications observed in the younger (<54 years old) patient group (r = 0.516; P = 0.039). Results suggest that with a system of interdisciplinary care and collaboration, sacral ulcer flap surgery can be performed in patients with moderate to severe hypoalbuminemia.
Please address correspondence to: Emmanuel P. Estrella, MD, Microsurgery Unit, Department of Orthopedics, University of the Philippines-College of Medicine, Philippine General Hospital, Taft Avenue, Manila, Philippines 1000; email: estee96@yahoo.com.
Pressure ulcer development is a problem in nonambulatory, hospitalized patients, with varying incidence across institutions. In a prospective cohort study1 of 286 bed- or wheelchair-bound patients age 55 years and older, 12.9% developed Stage II or Stage III pressure ulcers in a median of 9 days following admission. A retrospective study2 of 47 younger traumatic spinal cord injury patients admitted to a university hospital showed 42.5% developed pressure ulcers, 45% of which were Stage III or Stage IV. Surgical debridement and reconstruction have been recommended3,4 for severe pressure ulcers (Stage III and Stage IV), but several retrospective studies4-6 found impaired wound healing and ulcer recurrence, prompting recommendations for strict patient selection — ie, surgical candidates should be medically stable, well-nourished, and capable of participating in postoperative rehabilitation protocols.
Serum albumin, a basic screening test for protein status, is a gross indicator of patient’s nutrition and fluid balance.7 Although not as sensitive as prealbumin in detecting acute nutritional status change,7 its low cost and easy availability made it the biochemical test of choice for detecting malnutrition in the local setting. Reports on the role of albumin in wound healing are conflicting.
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If a pressure ulcer is repaired by using a flap but years later a wound opens in this area is a wound,new pressure ulcer or old pressure ulcer not healed(stage 4) ?
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