Judith Reid, BSN, MS, CWCN, CWON, reidgraves@aol.com, Tri-State Memorial Hospital, Clarkston, WA

Jolene Tucker, RN, BSN, CWOCN, CFCN, jolene_tucker@msn.com, St. Joseph Regional Medical Center, Lewiston, ID

Jane Fore, MD, FAPWCA, FACCWS, Tri-State Memorial Hospital Wound Healing Center, Clarkston, WA

CLINICAL PROBLEM: Identifying cost-effective treatments for recalcitrantperistomal ulcers is challenging. We present a 70-year old male with multiple peristomal ulcerations resistant to current best practice treatments. His primary diagnosis is radiation colitis injury from prostate cancer treatment resulting in an anterior posterior resection and end ileostomy. A comparison of seven peristomal ulcer treatment regimens was calculated for cost and effectiveness.

The patient is morbidly obese with a pendulous pannus, uncontrolled diabetes mellitus type II, and history of coronary artery disease. Complications following partial colectomy and colostomy resulted in an ileostomy and a graft closing a major abdominal defect. He developed an enlarging parastomal herniaresulting in recurrent peristomal skin ulcerations. Partial and full thickness ulcers resulted from mechanical injury, leakage, chemical damage, and infections from an ill-fitted ostomy system.

The patient was fitted with a flat flexible 2 piece system. Skin complicationsinclude peristomal erythema, maceration, abnormal granulation, and fungal overgrowth. Other complications were increased cost for ostomy supplies due to frequent changes, and painful ulcerations.

CLINICAL APPROACH: Overall, ulcer management met with limited success despite multiple treatment regimens. Treatments included alginates, hydrocolloids, powdered polymer dressings, two collagen preparations, silver impregnated dressings and polyvinyl alcohol sponge with methylene blue and gentian violet. Positive wound cultures were treated with appropriate systemic and topical antibiotics. After following current best practices with limited success, treatment with 2-octyl cyanoacrylate monomer skin protection† was initiated. Progress toward deep tissue ulcers closure using the PUSH tool was seen within fourteen days.

Parastomal skin has maintained 100% complete closure for 4 months. He uses 2-octyl cyanoacrylate monomer skin protectant with each pouch change yielding a consistent wear-time of 3-5 days.

CONCLUSION: A comparative cost analysis of dressing acquisitions, and evidence of wound-healing progress over time was calculated. Significant healing and cost advantage was found with 2-octyl cyanoacrylate monomer skin protection application with each ostomy system change.

† Marathon® by Medline Industries, Inc.

REFERENCES:1. Peristomal Skin Complications: Best Practice for Clinicians. Wound, Ostomy and Continence Nurses Society (2007).2. Rolstad B, Erwin-Toth P. Peristomal skin complications: Prevention andManagement. Ostomy Wound Management. 2004; 50(9): 68-773. Ratliff CR, Scarano KA, Donovan AM, Colwell JC. Descriptive study ofperistomal complications. JWOCN. 2005; 32(1):33-37.4. Thomas DR, Rodeheaver GT, Bartolucci AA, et al. Pressure ulcer scale for healing: derivation and validation of the PUSH tool. Adv Wound Care. 1997;10:96-101.

COST COMPARISON OF TREATMENTS USED ONRECALCITRANT PERISTOMAL SKIN COMPLICATIONS

Initial Best Practice multiple therapies begin

Ulcers highly exudative with progress stalled

Ulcers Closed/Resurfaced

Ulcers Closed/Resurfaced

After initial treatment with 2-octyl cyanoacrylate monomer

DRESSING *COST/DRESSING EFFECT**

(Push Score Range During Use)

Calcium sodium alginate $2.34 11-9

Alginate +CMC+ionic silver $3.78 10-9

Thin hydrocolloid $0.86 11

Silicone based non-adherent foam $1.92 11

Transparent film $1.00 11

Powdered polymer dressings $6.43 11-7

Collagen powder/gel $3.03 11-7

Collagen Sheet $6.50 11-9

Silicone non-adherent contact layer $4.51 11-7

Polyvinyl alcohol sponge (PVA)+methylene blue+gentian violet $8.52 11-9

2-octyl cyanoacrylate monomer $7.23 9-0

* Costs calculated for supplies from this patients’ DME supplier for a single dressing to treat ulcers when used either alone or in combination with other dressings listed.

**PUSH TOOL 3.0 from the National Pressure Ulcer Advisory Panel. Measures wound healing by surface area, exudate and type of wound tissue. Scores range from 17 to 0 with 0 being closed/resurfaced.

Table I Cost Analysis and Effect using PUSH TOOL