The Costs and Outcomes of Treating a Deep Pressure Ulcer in a Patient with Quadriplegia

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Author(s): 
Eli S. Schessel, MD; Ralph Ger, MD; and Robert Oddsen, ME

The tissue hooks of the external tissue expanders were inserted through the skin into deep subcutaneous tissue 2 to 3 cm from the wound margins and secured to the patient by encircling and tying the long ends of the previously untied sutures around the tissue expander. External tissue expanders were placed 2 to 3 cm apart (see Figure 1d) and combine dressings were placed between, under the ends and on top of the expanders, and held in place with Elastoplast (Smith & Nephew, London, UK). In general, clean wounds are evaluated every 2 days and contaminated wounds are evaluated daily; in Mr. K’s case, the wound was evaluated every 2 days. At that time, the tissue expanders were removed, the wound cleansed, debrided, and irrigated, and the untied sutures tied. If granulation tissue formation is insufficient to facilitate final closure, the process of suture and tissue expansion is repeated.

  On the fourth day post-expansion, a French catheter with multiple holes was placed subcutaneously for deep irrigation through the catheter twice per day for 5 days (see Figure 1e). Mr. K was discharged home on January 27, 2010. 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).

Discussion

  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.



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