Milwaukee, Wis.; and Miami, Fla. From the Departments of Plastic Surgery and Physical Medicine and Rehabilitation, Medical College of Wisconsin, and the University of Miami School of Medicine.
Plast Reconstr Surg. 2012 Apr;129(4):897-904. doi: 10.1097/PRS.0b013e3182442197.
Despite a 12 to 82 percent pressure ulcer recurrence rate, no standard protocol exists for postoperative management. The authors reviewed a single surgeon's experience using a standard protocol: surgery and immediate reconstruction regardless of nutrition, intraoperative bone culture guiding postoperative antibiotic use, and hospital admission for 3 weeks of flat bedrest before graduated sitting.
A 5-year retrospective chart review was performed on consecutive surgically treated pressure ulcers. A search of billing records identified 101 patients with 179 ulcers. Data abstracted included demographics, comorbidities, location and stage of ulcers, treatment history with outcomes, and laboratory data.
Seventy-nine percent of the patients were men with a mean age of 49.4 years. Of 179 ulcers, 49.7 percent were ischial, 26.8 percent were sacral, and 19 percent were trochanteric; 87.7 percent of ulcers were stage 4. Primary closure was performed on 45.8 percent; others underwent flap closure. There was no correlation between positive bone cultures and recurrence or complications. The overall recurrence rate was 16.8 percent at a mean period of 435.9 days. New ulcer occurrence was 14.5 percent and the complication rate was 17.3 percent. Admission prealbumin and albumin did not correlate with recurrence or complication. Mean follow-up was 629 days.
A standard clinical pathway for pressure ulcer treatment improves long-term outcomes; the authors' protocol's validity is supported by low recurrence and complication rates. Nutritional data do not predict outcome. Intraoperative bone cultures are the most valid method of diagnosing osteomyelitis; results should not delay definitive treatment.
CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.
尽管压疮的复发率为 12%至 82%，但目前仍缺乏术后管理的标准方案。作者回顾了一位外科医生应用标准方案的经验：无论营养状况如何，均进行手术和即刻重建；根据术中骨培养结果指导术后抗生素使用；术后平卧位卧床 3 周，然后逐渐坐起。
对连续接受手术治疗的压疮患者进行了 5 年回顾性图表分析。通过查询计费记录，共识别出 101 例患者的 179 处压疮。提取的数据包括人口统计学资料、合并症、压疮部位和分期、治疗经过和结局，以及实验室数据。
79%的患者为男性，平均年龄为 49.4 岁。179 处压疮中，49.7%位于坐骨，26.8%位于骶骨，19%位于转子间；87.7%的压疮分期为 4 期。45.8%行一期缝合，其他患者行皮瓣修复。骨培养阳性与复发或并发症之间无相关性。平均随访 435.9 天，总体复发率为 16.8%。新发压疮发生率为 14.5%，并发症发生率为 17.3%。入院前前白蛋白和白蛋白与复发或并发症均无相关性。平均随访时间为 629 天。
采用标准的压疮治疗临床路径可改善长期结局；该作者方案的有效性得到了低复发率和低并发症率的支持。营养数据不能预测结局。术中骨培养是诊断骨髓炎最有效的方法；其结果不应延误确定性治疗。
临床问题/证据水平：治疗，IV。
