Abstract
Patients with pressure ulcers are generally older, have a long hospital stay and often have a variety of comorbidities. The decision to perform surgery for pressure ulcer management can be difficult because of concerns about the risk of postoperative complications.
The aim of this study was to analyse the relationship between comorbid conditions and surgical outcomes in order to guide patient selection for pressure ulcer surgery. In 57 patients, data on age, defect size, operating time, hospital stay, body mass index, surgical site, mobility state, cardiac ischaemic history, diabetes, renal failure, ventilator dependency, tracheostomy state, use of haemodilution therapy and cancer were evaluated using stepwise multiple logistic regression analysis to determine the relationships between variables.
There were no postoperative cardiac ischaemic events. Wound complications occurred in 8 patients (14%), pneumonia in 12 patients (21·1%) and mortality in 1 patient (1·7%). The risk of postoperative pneumonia increased 1·069‐fold in elderly patients (odds ratio = 1·069, P < 0·05) and increased 44·17‐fold in preoperative ventilator users (odds ratio = 44·17, P < 0·05). The risk of wound complication increased 1·012‐fold with the presence of a larger defect site (odds ratio = 1·012, P < 0·05) and increased 7·474‐fold in patients who received haemodilution therapy (odds ratio = 7·474, P < 0·05).
Our results indicate that most comorbid conditions did not significantly affect postoperative cardiopulmonary or wound complications. However, the risk of postoperative pneumonia increased in patients with ventilator use or old age, and the risk of wound complication increased in patients with a large defect size and in those who used haemodilution therapy.
Keywords: Comorbid condition, Complication, Operation risk, Pressure ulcer
Introduction
Pressure ulcers (PU) occur mainly in bedridden patients and are difficult to manage and treat once they develop. Patients who are unable to change their position because of spinal cord injury, cerebrovascular accident or general weakness are at a high risk of developing PU 1, 2. These patients are typically elderly, have a long hospital stay and often have multiple comorbidities 3.
When considering the risk of surgery, various comorbidities can increase the surgical risks to the patient as well as the complexity of the procedure for the physician. However, when PU are left without proper management, the general condition of the patient may worsen because of chronic infection, sepsis and metabolic abnormalities 4. Therefore, the determination of whether a patient should undergo surgery for PU is typically a challenging decision for the treating physician.
There have been a number of previous reports on the causes of PU and efforts to prevent them 5, 6, 7. However, to our knowledge, no previous studies have analysed the risk factors affecting postoperative outcomes.
The aim of this study was to investigate the relationship between various comorbidities and surgical outcomes to help identify high‐risk patients for PU surgery.
Materials and methods
The Institutional Review Board of our hospital approved this study. A retrospective chart review of patients who underwent PU surgery between January 2010 and June 2016 was conducted. A total of 57 patients (26 male, 31 female) were included in this study. Age, body mass index (BMI), surgical site, mobility state, operating time and length of hospital stay were determined for all patients.
In order to minimise surgical site‐related variability, only three areas where PU frequently occurs were included – the sacral, ischial and trochanteric areas 8, 9, 10 – and cases involving two or more surgical sites were defined as the multiple group, resulting in a total of four groups.
Mobility status was divided into four grades using the ‘Mobility status grading system for pressure ulcer patients’, a modified version of the ECOG scoring system 11 (Table 1). Grade I was defined as completely ambulatory, grade II as partially ambulatory and capable of all self‐care, grade III as bedridden but able to continue limited self‐care and grade IV as totally bedridden and unable to perform any self‐care.
Table 1.
Mobility status grading system for patients with pressure ulcer
| Grade | Mobility status |
|---|---|
| Grade I | Completely ambulatory |
| Grade II | Partially ambulatory and capable of all self‐care |
| Grade III | Bedridden but can carry out limited self‐care |
| Grade IV | Totally bedridden, cannot carry out any self‐care including changing position |
Comorbidities
Based on previous reports of risk factors related to surgery, we gathered information regarding the history of cardiac ischaemia 12, renal failure 13, ventilator use 14 and tracheostomy 15, which are known to be associated with postoperative cardiopulmonary risk. A history of angina or myocardial infarction was considered cardiac ischaemia, and patients who were currently receiving dialysis were considered to have renal failure. We also reviewed other risk factors that could be related to delayed healing, including the use of haemodilution therapy 16, diabetes 17, 18 and current or prior treatment with chemotherapy 19 or radiation 20 for cancer.
Surgical method and postoperative care
Surgery was performed using a fasciocutaneous flap with various forms of rotation and advancement. Postoperatively, postural changes were addressed every 2 hours, and an air mattress was employed for at least 4 weeks. The drain was removed after the volume of drainage was less than 30 cc per day, and the patient was discharged on the day following drain removal.
Surgical outcome
To assess postoperative cardiopulmonary and wound complications, cardiac ischaemic events, pneumonia, sepsis, mortality, haematoma formation, partial flap necrosis and wound infection were analysed.
Statistical analysis
One‐way analysis of variance was performed to compare the results between groups defined according to patients' surgical site and mobility state. Stepwise multiple logistic regression analysis was performed to investigate the relationship between age, defect size, operation time, hospital stay, BMI, surgical site, mobility state and comorbidities (history of cardiac ischaemia, use of haemodilution therapy, renal failure, diabetes, ventilator use, tracheostomy, cancer treatment) with pneumonia and wound complications. A P value < 0·05 was considered statistically significant. For significant predictors of pneumonia and wound complication, odd ratios with 95% confidence intervals (CI) were calculated as estimates of relative risk.
Results
A total of 57 patients (26 male, 31 female) were included in this study. The surgical sites included 36 sacral areas (63·2%), 9 ischial areas (15·8%), 3 trochanteric areas (5·2%) and 9 multiple sites (15·8%). Mobility state was classified as grade I in 5 patients (8·8%), grade II in 10 patients (17·5%), grade III in 11 patients (19·3%) and grade IV in 31 patients (54·4%) (Table 2).
Table 2.
Patient distribution according to surgical site and mobility state
| Total number of patients | 57 | |
|---|---|---|
| Gender | Male | 26 (45·6%) |
| Female | 31 (54·4%) | |
| Ulcer site | Sacral area | 36 (63·2%) |
| Ischial area | 9 (15·8%) | |
| Trochanteric area | 3 (5·2%) | |
| Multiple | 9 (15·8%) | |
| Mobility status | Grade I | 5 (8·8%) |
| Grade II | 10 (17·5%) | |
| Grade III | 11 (19·3%) | |
| Grade IV | 31 (54·4%) | |
Patient characteristics and the distribution of comorbidities are summarised in Table 3. Patients' mean age (range) was 61·28 (16–94) years, mean defect size was 107·56 (12–794) cm2, mean operating time was 187·49 (65–570) minutes, mean hospital stay was 33·02 (7–80) days, and mean BMI was 18·9 (10·9–33·1) kg/m2. The cohort included 6 patients with cancer (10·5%), 10 with tracheostomy (17·5%), 3 dependent on a ventilator (5·3%), 16 with diabetes (28·1%), 6 with renal failure (10·5%), 8 receiving haemodilution therapy (14%) and 3 with a history of cardiac ischaemia (5·3%).
Table 3.
Patient characteristics and distribution of comorbid disease
| Age (years) | 61·28 (16–94) |
| Defect size (cm2) | 107·56 (12–794) |
| Operating time (min) | 187·49 (65–570) |
| Hospital stay (days) | 33·02 (7–80) |
| BMI (kg/m2) | 18·9 (10·9–33·1) |
| Cancer (number) | 6 (10·5%) |
| Tracheostomy (number) | 10 (17·5%) |
| Ventilator dependency (number) | 3 (5·3%) |
| Diabetes (number) | 16 (28·1%) |
| Renal failure (number) | 6 (10·5%) |
| Use of haemodilution therapy (number) | 8 (14%) |
| Cardiac ischaemia history (number) | 3 (5·3%) |
Table 4 and Figure 1 summarise the comparison of continuous data (age, defect size, operating time, hospital stay) according to the surgical site.
Table 4.
Comparison of patient data according to surgical site
| Surgical site | Age (years) | Defect size (cm2) | Operating time (min) | Hospital stay (day) | BMI (kg/m2) |
|---|---|---|---|---|---|
| Sacral area | 61·86 | 72·86 | 153·53 | 25·14 | 19·31 |
| Ischial area | 53·11 | 67 | 229·44 | 13·11 | 22·4 |
| Trochanteric area | 64·67 | 123·67 | 226·67 | 20 | 18·45 |
| Multiple | 66 | 281·56 | 268·33 | 20·78 | 17·11 |
Figure 1.
Comparison of characteristics according to surgical site. Defect size was significantly larger in cases of multiple surgical sites than in patients with PU in the sacral and ischial areas (P < 0·05), and a longer operation time was required for multiple sites than for PU in the sacral area (P < 0·05). Age, hospital stay and BMI were not significantly different between the surgical sites.
Patients with multiple surgical sites had a significantly larger defect size (P < 0·05) compared to those with sacral and ischial surgical sites, and they had a significantly longer operating time than patients with sacral surgical sites (P < 0·05). However, age, hospital stay and BMI did not significantly differ between patients with different surgical sites.
The results of the comparisons according to mobility state are summarised in Table 5 and Figure 2. The grade III and grade IV groups had a significantly larger defect size than the grade I group (P < 0·05), and the operating time was significantly longer in the grade IV group than in the grade I group (P < 0·05). BMI was also significantly higher in the grade I and II groups than in the grade IV group (P < 0·05). There was no significant difference in age or hospital stay between the groups.
Table 5.
Comparison of patient data according to mobility state
| Mobility state | Age (years) | Defect size (cm2) | Operating time (min) | Hospital stay (day) | BMI (kg/m2) |
|---|---|---|---|---|---|
| Grade I | 72·6 | 48·6 | 147 | 15·6 | 25·59 |
| Grade II | 53·5 | 80·2 | 174 | 14·7 | 21·57 |
| Grade III | 64·64 | 143·91 | 185 | 25·55 | 18·19 |
| Grade IV | 60·77 | 113 | 199 | 37·2 | 17·32 |
Figure 2.
Comparison of results according to mobility state. Patients with grade III and grade IV had a significantly larger defect size than those with grade I mobility (P < 0·05), and the operating time was significantly longer in the grade IV group than in the grade I group (P < 0·05). BMI was also significantly higher in patients with grade I and II mobility than in those with grade IV mobility (P < 0·05). There was no significant difference in age or hospital stay between the groups.
There were no postoperative cardiac ischaemic events. A total of 8 patients (14%) developed wound complications, 12 patients (21·1%) developed pneumonia and 1 patient died (1·7%).
In the stepwise multiple logistic regression analysis, age and use of a ventilator were identified as factors associated with pneumonia (Table 6), with odds ratios of 1·069 and 44·17, respectively (both P < 0·05). The factors significantly related to wound complication were defect size and use of haemodilution therapy (Table 7), with odds ratios of 1·012 and 7·474, respectively (both P < 0·05).
Table 6.
Stepwise multiple logistic regression analysis for pneumonia
| P value | OR | 95% CI | |
|---|---|---|---|
| Age | 0·023 | 1·069 | 1·009–1·133 |
| Ventilator | 0·018 | 44·17 | 1·907–1023·174 |
CI, confidence interval; OR, odds ratio.
Table 7.
Stepwise multiple logistic regression analysis for wound complication
| P value | OR | 95% CI | |
|---|---|---|---|
| Defect size | 0·014 | 1·012 | 1·002–1·021 |
| Use of haemodilution therapy | 0·039 | 7·474 | 0·852–65·553 |
CI, confidence interval; OR, odds ratio.
Discussion
The development of various surgical methods to treat PU, as well as advances in anaesthesia and intensive care unit protocols, have improved the ease with which PU can be debrided and covered with flaps 21, 22. However, patients with PU often have a variety of comorbidities that can increase the risk of cardiopulmonary complications after surgery, and therefore, they often receive conservative care rather than surgery.
If PU is left untreated, problems related to the wound will persist and can become difficult for caregivers to manage. In terms of nutritional support, it is difficult to keep the patients' condition stable because the progression of PU and associated inflammation can further contribute to malnutrition 23. For this reason, the authors actively perform surgical treatment for patients in poor systemic condition, provided that consent is obtained from the patient or their caregiver before the procedure.
Many patients with surgical risk factors underwent surgery, and pneumonia was the most common postoperative complication. Approximately 21% of patients developed mild to severe pneumonia. However, the majority of these patients were in a bedridden state, and the limitation of their position because of the operation site may have been a factor affecting the risk of pneumonia. Among the factors included in stepwise multiple logistic regression analysis, advanced age and ventilator use were the only significant factors affecting the incidence of pneumonia. However, the odds ratio associated with age, 1·069, was not a higher risk to consider. By contrast, ventilator use was associated with a highly elevated risk (odds ratio 44·17). However, these patients were already known to be susceptible to pneumonia and were sufficiently informed of this risk before the surgery. Interestingly, tracheostomy was not a factor affecting pneumonia.
Wound complications occurred in 14% of patients, a lower rate than previously reported 8. Patients are at a relatively high risk of wound complications after PU surgery because of the difficulty in maintaining the postoperative position. Therefore, strict postoperative care must be maintained to prevent re‐operation because of wound complications. Stepwise multiple logistic regression analysis identified defect size and use of haemodilution therapy as factors having a significant effect on wound complications. The odds ratio of defect size was 1·012, indicating a minimal effect. The odds ratio of haemodilution therapy use was 7·474, indicating a more substantial risk elevation. If possible, medication was stopped prior to surgery, but the effects of this risk factor could not be completely eliminated.
No patients in our cohort had cardiac problems. The sole case of mortality involved a patient with pneumonia who deteriorated without resolution and died in a septic condition.
Notably, the operation time increased for surgeries involving multiple sites, but the duration of hospital stay was unchanged. Although the groups did not significantly differ, BMI was the lowest in patients with multiple PU sites. In combination with the finding of a larger defect size in patients with multiple sites, these observations suggest difficulty in nutrition balance. Similarly, in the comparison of patients according to their mobility state, bedridden patients had a longer operation time but no difference in the duration of hospitalisation. Bedridden patients also had a significantly lower BMI than ambulatory patients. In summary, even patients with extensive ulcers in a bedridden state or with involvement at multiple sites did not have an increased duration of postoperative care, and as previously reported, we expect that patients' nutritional profile can be improved by performing surgery for PU 8, 23.
The mobility status grading system presented in this paper may also have important implications. The depth of the PU wound is mainly assessed by the commonly known National Pressure Ulcer Advisory Panel (NPUAL) staging system 24. However, it is very important to evaluate a patient's mobility status as well as staging of the wound depth when planning the treatment of PU. A patient's mobility status may also affect their surgical or treatment plan as well as predictions concerning their prognosis and surgical outcome. Therefore, we need to evaluate the mobility status as well as staging of wound depth during the treatment of patients with PU. We hope that our grading system will be used actively in this regard.
This paper has some limitations. First, there may be more factors affecting an individual patient's condition besides the risk factors presented. Second, the number of patients was small. Third, it was a retrospective review. Fourth, this study was limited to a Korean population, so the results cannot be generalised to other ethnicities.
In conclusion, comorbidities such as a history of cardiac ischaemia, renal failure, tracheostomy, diabetes, chemotherapy and cancer; surgical site; mobility state; operating time; hospital stay; and BMI did not significantly affect postoperative cardiopulmonary or wound complications after surgical treatment of PU. However, the risk of developing pneumonia after surgery was greater in older patients and in those using a ventilator, and the risk of wound complications was higher in patients with a larger defect size and in those receiving haemodilution therapy.
These results suggest that high‐risk patients with comorbidities can be managed with active surgical treatment while remaining vigilant about the presence of risk factors, and active surgical treatment to cover a larger wound defect can be of great help in building up the general condition of the patient.
Acknowledgements
Institutional Review Board (Catholic Medical Center Office of Human Research Protection Program) approved this study.
The authors declare no conflict of interest.
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