The Costs and Outcomes of Treating a Deep Pressure Ulcer in a Patient with Quadriplegia
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Subsequent 10-minute daily saline soaks were provided by a home care aid, followed by cleaning with ½ strength peroxide and the application of bacitracin ointment. A combine dressing and nonallergic tape were placed over the wound. This process was continued for 1 month until sutures were removed. Mr. K was reminded about the importance of avoiding pressure on the surgical area for 4 to 6 weeks after surgery. He returned to work 6 weeks after surgery with a motorized wheelchair and a silicone support pad. At 23 months, the pressure ulcer had not recurred (see Figure 1f). A review of insurance payments for this episode of care showed that the direct insurance cost for closing this pressure ulcer was $43,814 (see Table 2).
Pressure ulcers have been found on 5,000-year-old mummies in Egypt and continue to be an ever-present and resource-intensive problem within society. The time and resources required to manage and heal Stage III and Stage IV pressure ulcers are especially high.6
Traditionally, wounds have been managed to promote epithelialization by creating a moist wound environment. In the mid 20th century, the potential for moisture barrier dressings to reduce healing time, pain, scarring, and infection rates was realized.9 A current popular mode of wound management is the application of NPWT to the wound. The average healing time of Stage III and Stage IV trochanteric and trunk wounds averaging 22.2 cm2 using NPWT is 97 days; closure occurs as granulation tissue10 forms and becomes scar tissue. Because NPWT reduces edema through evacuation of water molecules, it also may remove low molecular weight proteins. The authors hypothesize that studies to ascertain the effect of NPWT on the risk of hypoproteinemia should be conducted, especially in patients with pressure ulcers. In addition, surgical approximation of the wound edges results in more durable tissue than the scar tissue that typically forms following secondary intention healing.7
In the 1970s, the need for more expedient and resilient skin coverage of large and/or deep wounds led to the development of tissue flap techniques. Tissue flaps involve detaching the tissue from its original site, transferring the tissue flap to the wound by advancement or rotation, and suturing the tissue flap to cover the wound. This major operative procedure is performed under general anesthesia7 and contraindicated in many elderly patients.
In the 1990s, a minimally invasive surgical technique that uses external skin expansion and dedicated wound care was introduced to close chronic and traumatic wounds. A clinical series11 of 125 patients with lower extremity wounds closed by external tissue expansion confirmed that tissue expansion stimulates angiogenesis. In vitro models12 also have demonstrated that tissue expansion increases the production of growth factors that include epidermal, fibroblast, transforming families, platelet-derived growth factor, and angiotensin II. A study13 of 20 patients subjected to breast reconstruction by means of tissue expansion indicated substantial mitotic activity, suggesting the formation of new tissue. Results of the recent study8 support 1- to 2-week healing and desired skin characteristics.